Nursing Elites

1. The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?

• A. Serum potassium
• B. Blood glucose
• C. Serum sodium
• D. Serum calcium

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the increased risk of hyperglycemia associated with TPN infusion. Elevated blood glucose levels can lead to complications such as hyperglycemia, which can be harmful to the client. While monitoring serum potassium (Choice A), serum sodium (Choice C), and serum calcium (Choice D) are also important aspects of care, when specifically considering TPN administration, blood glucose monitoring takes precedence due to the potential for significant complications related to glucose imbalances.

2. A healthcare professional is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the professional include?

• A. Urticaria
• B. Ptosis
• C. Nausea
• D. Hematuria

Correct answer: A

Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. It presents as raised, red, itchy welts on the skin. Ptosis is drooping of the upper eyelid and is not typically associated with allergic reactions. Nausea is a gastrointestinal symptom that can occur with various conditions but is not specific to allergic reactions. Hematuria, which is the presence of blood in the urine, is not a typical manifestation of an allergic reaction.

3. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?

• A. “Get up and change positions slowly.”
• B. “Avoid eating aged cheese and smoked meat.”
• C. “Report any unusual bruising or bleeding to the doctor immediately.”
• D. “Eat the same amount of foods that contain vitamin K every day.”

Correct answer: A

Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.

4. A client with an NG tube is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

• A. Rinse the feeding bag with water between feedings
• B. Tell the client to keep the head of the bed elevated at least 30°
• C. Make sure the enteral formula is at room temperature
• D. Wipe the top of the formula can with alcohol

Correct answer: B

Rationale: The correct answer is to tell the client to keep the head of the bed elevated at least 30°. Elevating the head of the bed prevents aspiration of the enteral formula, which is a priority in caring for a client with an NG tube. This action helps in reducing the risk of complications such as pneumonia. Choices A, C, and D are incorrect. While rinsing the feeding bag, ensuring the enteral formula temperature, and maintaining cleanliness are important aspects of enteral feeding care, the priority is to prevent aspiration by keeping the head of the bed elevated. These actions can be implemented after ensuring the client's safety by maintaining the correct bed position.

5. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

• A. Infuse hypotonic IV fluids.
• B. Implement a fluid restriction.
• C. Increase sodium intake.
• D. Administer sodium polystyrene sulfonate.

Correct answer: A

Rationale: The correct answer is to infuse hypotonic IV fluids. In hypernatremia, there is an elevated sodium concentration in the blood, and diluting it with hypotonic fluids helps to lower the sodium levels. Implementing a fluid restriction or increasing sodium intake would worsen hypernatremia by further concentrating sodium in the body. Administering sodium polystyrene sulfonate is used for treating hyperkalemia, not hypernatremia.

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