Nokea
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) will be started. The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
You may also like to solve these questions
The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation?
- A. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant
- B. Lateral curvature to the spine noted on examination of a 10-year-old girl
- C. Presence of an S3 heart sound in a 2-year-old
Correct Answer: B
Rationale: Lateral curvature of the spine in a 10-year-old suggests scoliosis, which requires further evaluation to prevent progression. A rounded chest in infants is normal due to developing lungs, and an S3 heart sound can be normal in young children.
The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?
- A. I should avoid alcohol intake with this new medication.
- B. I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L).
- C. I should read the labels on all foods I eat, including those that say 'sugarless'.
- D. This medication will help me lose weight.
Correct Answer: D
Rationale: Glyburide stimulates insulin release to lower blood glucose but does not promote weight loss; it may cause weight gain. Avoiding alcohol, reporting hypoglycemia, and checking food labels are correct actions, indicating understanding.
The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is
- A. Discuss the need for genetic counseling
- B. Inform them that combined therapy is seldom effective
- C. Prepare for the child's permanent disfigurement
- D. Suggest that total blindness may follow surgery
Correct Answer: A
Rationale: Discuss the need for genetic counseling. The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring.
A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?
- A. Correction with laser surgery
- B. Eye drops in the affected eye
- C. Measurement of intraocular pressure
- D. Patching of the unaffected eye
Correct Answer: D
Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.
The nurse is contributing to a staff education program about non-pharmacological pain management techniques for newborns and infants. Which of the following techniques should the nurse include in the program? Select all that apply.
- A. Allow a newborn to suck on a gloved finger dipped in sucrose solution during a circumcision
- B. Apply a cold pack to a newborn’s heel 30 minutes before performing a heel stick
- C. Assist the parent to hold a newborn skin-to-skin during an IM injection
- D. Offer a pacifier to an infant while performing venipuncture
- E. Swaddle an infant while leaving the affected arm unwrapped during an IV dressing change
Correct Answer: A,C,D,E
Rationale: Sucrose sucking, skin-to-skin contact, pacifier use, and swaddling reduce pain perception in infants. Cold packs are not recommended for newborns due to risk of tissue damage and ineffective pain relief in this context.