Nokea
A nurse is caring for a client receiving TPN. Which of the following actions should the
nurse take? For each potential nursing intervention, click to specify if the potential intervention
is anticipated, nonessential, or contraindicated for the client.
- A. Request a prescription for insulin
- B. Request for an antibitic to be administered
- C. Decrease the client's oxygen to 1.5 L/min via nasal canula
- D. Have 3 nurses verify the TPN solution prescription
- F. Notify the provider to increase TPN rate/hr
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
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A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
- A. Wound tissue firm to palpation
- B. Dry brown eschar
- C. Light yellow exudate
- D. Dark red granulation tissue
Correct Answer: D
Rationale: The correct answer is D: Dark red granulation tissue. Granulation tissue is a sign of healing in a wound, indicating new blood vessels and collagen formation. Dark red color indicates good blood supply. A: Firm wound tissue can indicate infection or inadequate healing. B: Dry brown eschar is a sign of necrotic tissue, not healing. C: Light yellow exudate can indicate infection or inflammation.
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
- A. Limit the client's fluid intake.
- B. Measure blood glucose every 2 hr.
- C. Instruct the client to expect tingling in their extremities.
- D. Instruct the client to lie flat.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to lie flat. This is important to prevent post-lumbar puncture headache by promoting the closure of the dural puncture site. Lying flat helps reduce the risk of cerebrospinal fluid leakage and subsequent headache. Limiting fluid intake (A) is not necessary post-lumbar puncture. Monitoring blood glucose (B) is not directly related to lumbar puncture care. Expecting tingling in extremities (C) is not a common post-lumbar puncture symptom.
A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?
- A. Photophobia
- B. Bradycardia
- C. Intermittent headache
- D. Petechiae on the chest
Correct Answer: A
Rationale: The correct answer is A: Photophobia. Photophobia, or sensitivity to light, is a common symptom of meningitis due to inflammation of the meninges surrounding the brain and spinal cord. This occurs because bright light can worsen the headache associated with meningitis. Bradycardia and petechiae on the chest are not typical findings in meningitis. Intermittent headache is vague and not specific to meningitis.
A nurse is assessing a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowler’s position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. After a total hip arthroplasty, maintaining abduction of the affected extremity helps prevent dislocation of the hip prosthesis. This position helps stabilize the hip joint and reduces the risk of complications. Option B (Position the client in high Fowler's position) is incorrect as it does not directly address the postoperative care specific to a total hip arthroplasty. Option C (Encourage the client to cross their legs at the ankles) is incorrect because crossing legs can create pressure on the hip joint and increase the risk of dislocation. Option D (Have the client bend forward at the waist while sitting) is incorrect as this could also increase the risk of hip dislocation.
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in the lower legs, particularly around the medial malleolus due to poor circulation in chronic venous insufficiency. The pressure and pooling of blood in the veins can lead to tissue breakdown and ulcer formation in this area. Assessing the medial malleolus for the presence of a venous ulcer is crucial in managing the client's condition.
Incorrect Choices:
A: Tip of the toes - Venous ulcers are less likely to occur in this area as it is more distal and less affected by venous insufficiency.
C: Ball of the foot - Venous ulcers are more commonly found in the lower legs rather than the ball of the foot.
D: Heel of the foot - While ulcers can develop on the heel, they are less likely to be venous ulcers in chronic venous insufficiency compared to the medial malleol