Nokea
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.'
- B. I will obtain the client's weight every other day.'
- C. I will monitor the client's blood glucose level every 8 hours.'
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given.'
Correct Answer: A
Rationale: Correct Answer: A - "I will hang a new bag of TPN and IV tubing every 24 hours."
Rationale: Changing the TPN bag and tubing every 24 hours is crucial to prevent contamination and infection. TPN is a high-risk solution that can support bacterial growth. Changing the bag and tubing decreases the risk of infection and ensures the client receives fresh and uncontaminated TPN.
Summary of Incorrect Choices:
B: Obtaining the client's weight every other day is important for adjusting the TPN formula but does not demonstrate an understanding of the procedure like changing the bag and tubing.
C: Monitoring the client's blood glucose level every 8 hours is important for assessing tolerance to TPN but does not directly relate to the procedural aspect of TPN administration.
D: Increasing the rate of TPN infusion to ensure the correct amount is given is not safe practice and can lead to complications. The rate should be prescribed by the healthcare provider and not arbitrarily increased.
You may also like to solve these questions
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group
- B. Determine the roles of individual family member
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This should be the first action because understanding each family member's roles can help identify their needs, strengths, and how they can support each other. By determining roles, the nurse can establish a foundation for building effective coping strategies and addressing specific concerns within the family unit.
Incorrect choices:
A: Refer the family to a grief support group - This could be beneficial later on, but it's important to first understand the family dynamics and individual roles.
C: Encourage the family to assign specific tasks to individual family members - Assigning tasks may not address the underlying emotional needs of the family members.
D: Assist the family to establish a daily routine - While routines can be helpful, understanding roles is crucial for tailoring the routine to the family's specific situation.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Use a face shield with a mask when providing care to the client
- C. Tell the client, 'You seem to be very upset.'
- D. Engage the panic alarm
Correct Answer: C
Rationale: The correct answer is C. When a client is aggravated, pacing, and speaking loudly, it is important to acknowledge their feelings. By telling the client, "You seem to be very upset," the nurse shows empathy and validates the client's emotions. This can help de-escalate the situation by demonstrating understanding and openness to communication. It also allows the nurse to assess the client's needs and concerns effectively.
Choice A is incorrect as initiating seclusion protocol should only be considered for extreme cases where the client poses a danger to themselves or others. Choice B is unnecessary in this situation as it does not address the client's emotional state. Choice D, engaging the panic alarm, is premature and could escalate the situation further.
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.