Nursing Elites

1. While changing the linen on the client's bed, what should the nurse do?

• A. Hold the linen away from their body and clothing.
• B. Fold the linen neatly before placing it in the laundry.
• C. Wear clean gloves while handling the linen.
• D. Place the linen directly on the floor until the new linen is in place.

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

2. A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority?

• A. Extinguish the fire.
• B. Activate the fire alarm.
• C. Move clients who are nearby.
• D. Close all open doors on the unit.

Correct answer: B

Rationale: In a fire emergency, the nurse's priority is to activate the fire alarm. This action alerts others to the emergency, initiates the evacuation process, and ensures everyone's safety. Extinguishing the fire can be dangerous and should be left to trained personnel. Moving clients who are nearby might delay the activation of the alarm and can put the nurse and clients at risk. Closing all open doors on the unit is important to contain the fire but should not take precedence over alerting others through the fire alarm system.

3. During the physical assessment of a client, which technique should a nurse use when performing a Romberg's test?

• A. Touch the client's face with a cotton ball
• B. Apply a vibrating tuning fork to the client's forehead
• C. Have the client stand with arms at her sides and feet together
• D. Perform direct percussion over the area of the kidneys

Correct answer: C

Rationale: During a Romberg's test, the nurse assesses the client's balance. Having the client stand with arms at her sides and feet together is the correct technique. This position helps the nurse observe for swaying or loss of balance, indicating alterations in balance. Choices A and B are incorrect as they are not part of Romberg's test and do not assess balance. Choice D is also incorrect as direct percussion over the kidneys is not associated with a Romberg's test.

4. The healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which laboratory value should be monitored closely to assess for complications?

• A. Serum sodium
• B. Serum calcium
• C. Blood urea nitrogen (BUN)
• D. Blood glucose

Correct answer: D

Rationale: The correct answer is D: Blood glucose. Monitoring blood glucose levels is crucial for clients receiving total parenteral nutrition (TPN) due to the high glucose content in TPN solutions. TPN delivers essential nutrients, including glucose, directly into the bloodstream. Clients on TPN are at risk of developing hyperglycemia due to the concentrated glucose infusion. Therefore, close monitoring of blood glucose levels is necessary to detect and prevent hyperglycemia-related complications such as osmotic diuresis, hyperosmolarity, and electrolyte imbalances. While serum sodium, serum calcium, and blood urea nitrogen (BUN) levels are important parameters in various clinical scenarios, they are not specifically associated with TPN administration. These values are not the primary indicators to assess for complications in clients receiving TPN.

5. The healthcare provider is assessing a client diagnosed with rheumatoid arthritis. Which assessment finding would be most concerning?

• A. Morning stiffness
• B. Joint deformities
• C. Weight loss
• D. Fever

Correct answer: D

Rationale: Fever in a client with rheumatoid arthritis can indicate an underlying infection or a more serious systemic involvement, such as vasculitis or inflammation of internal organs. These conditions can lead to serious complications and require immediate medical attention. Joint deformities and morning stiffness are common manifestations of rheumatoid arthritis itself and may not be indicative of an acute issue. Weight loss can be seen in chronic inflammatory conditions like rheumatoid arthritis but is not as concerning as fever, which suggests an acute process requiring prompt evaluation and intervention.

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