Nursing Elites

1. What is the most likely complication for a client receiving TPN who suddenly develops tremors, dizziness, and diaphoresis?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The correct answer is D, Hypoglycemia. When a client receiving TPN suddenly develops tremors, dizziness, and diaphoresis, it is indicative of hypoglycemia. TPN provides a high concentration of glucose, and if it is abruptly stopped or the infusion rate is reduced, it can lead to hypoglycemia. Choices A, B, and C are incorrect as they do not directly correlate with the symptoms described in the scenario. Fluid volume overload typically presents with edema and hypertension, sepsis with fever and increased heart rate, and hyperglycemia with polyuria, polydipsia, and blurred vision.

2. A nurse is caring for four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?

• A. A client who is postoperative following a laminectomy and is receiving IV PCA
• B. A client who has dysphagia and does not recognize his family
• C. A client who has COPD and is going home with oxygen
• D. A client who has colon cancer and will undergo a hemicolectomy

Correct answer: D

Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible. Choices A, B, and C do not typically require TPN. Choice A is managing postoperative pain with IV PCA, choice B is likely to need alternative feeding methods due to dysphagia, and choice C is going home with oxygen for COPD management, which does not directly relate to the need for TPN.

3. During which stage of life is it most critical to build bone mass to prevent osteoporosis?

• A. Infancy
• B. Early childhood
• C. Adolescence
• D. Young adulthood

Correct answer: C

Rationale: Adolescence is the most critical stage for building bone mass, which plays a significant role in preventing osteoporosis in later life. During adolescence, approximately 45% of adult bone mass is formed. Although bone mass can be built during infancy, early childhood, and young adulthood, it is not as significant as during adolescence, making choices A, B, and D incorrect. Therefore, focusing on adequate nutrition and physical activity during adolescence is vital for long-term bone health.

4. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

• A. Stay with the client for the first 15 minutes of blood administration
• B. Stay with the client for the entire period of blood administration
• C. Run the infusion at a faster rate during the first 15 minutes
• D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

5. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?

• A. Tell her family that probably she can’t hear them
• B. Talk loudly so that Wendy can hear you
• C. Tell her family who are in the room not to talk
• D. Speak softly then hold her hands gently

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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