Nokea
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
- A. Change the PN infusion bag every 48 hr.
- B. Obtain a random blood glucose daily.
- C. Prepare the client for a central venous line.
- D. Administer the PN and fat emulsion separately.
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line. Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (D) is not necessary as they can be mixed in the same solution.
You may also like to solve these questions
A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using restraints, which of the following actions must the nurse take first?
- A. Obtain a prescription for restraints from the provider.
- B. Explain the procedure to the client and their family.
- C. Attempt less restrictive alternatives.
- D. Document the indications for using wrist restraints.
Correct Answer: C
Rationale: Correct Answer: C - Attempt less restrictive alternatives.
Rationale: Before resorting to using restraints, the nurse must first try less restrictive measures to ensure the safety and well-being of the client. This includes interventions such as redirecting the client's behavior, providing distractions, or addressing the underlying cause of the behavior. By attempting less restrictive alternatives, the nurse can promote the client's autonomy and prevent the potential negative effects of using restraints.
Summary:
A: Obtaining a prescription for restraints is important, but it should not be the first step.
B: Explaining the procedure to the client and their family is important but does not address the immediate need for less restrictive alternatives.
D: Documenting the indications for using wrist restraints is necessary but does not address the need to explore other options first.
A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hr at a time.
- B. Instruct the client to take deep, rhythmic breaths.
- C. Apply an ice pack to the client's back for 1 hr.
- D. Remove distractions from the client's room.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to take deep, rhythmic breaths. Deep breathing helps promote relaxation, reduces muscle tension, and distracts the client from pain sensations. This can be an effective nonpharmacological pain relief method.
A: Encouraging the client to apply a heating pad for 2 hours at a time may exacerbate the pain if it's already mild.
C: Applying an ice pack for 1 hour may not be suitable for mild back pain as it is more effective for acute injuries.
D: Removing distractions may help, but it does not directly address the client's pain.
A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who has acute abdominal pain of 4 on a scale from 0 to 10
- B. A client who has pneumonia and an oxygen saturation of 96%
- C. A client who has a urinary tract infection and low-grade fever
- D. A client who has new onset of dyspnea 24 hr after a total hip arthroplasty
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client with new onset of dyspnea 24 hr after a total hip arthroplasty first because it could indicate a potential pulmonary embolism, a serious and life-threatening complication. Dyspnea post-surgery can be a sign of decreased oxygenation and impaired gas exchange, requiring prompt assessment and intervention to prevent further complications. Acute abdominal pain (A) can be distressing, but it is less urgent than potential respiratory compromise. Pneumonia with oxygen saturation of 96% (B) is stable and not immediately life-threatening. A urinary tract infection with low-grade fever (C) is also not as urgent as potential respiratory distress.
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
- A. The client takes an antihypertensive medication.
- B. The client has electrical wires secured to baseboards.
- C. The client wears rubber-sole shoes.
- D. The client's visual acuity is 20/40.
Correct Answer: A
Rationale: The correct answer is A because taking antihypertensive medication can lead to orthostatic hypotension, increasing fall risk. Choice B is incorrect as securing electrical wires actually reduces tripping hazards. Choice C is incorrect as rubber-sole shoes provide better traction. Choice D is incorrect as 20/40 visual acuity alone may not directly contribute to fall risk.