Nokea
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
- A. Change the feeding apparatus every 24 hours.
- B. Use a higher volume of formula because the normal loss of the blood pressure.
- C. Slow the administration rate.
- D. Use a diluted formula, gradually increasing the volume and concentration.
- E. Anticipate changing to a lactose-free formula.
Correct Answer: A, C, D, E
Rationale: Changing the apparatus, slowing the rate, using diluted formula, and switching to lactose-free formula help manage diarrhea and distention.
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A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which of the following adverse effects?
- A. Bradycardia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Metoprolol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen implanted tunneled and cuffed central venous catheter is most appropriate for long-term IV therapy, blood products, and hyperalimentation due to its durability and reduced infection risk.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.
A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Serum calcium
- C. Serum glucose
- D. Serum cholesterol
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia due to potassium loss in urine. Monitoring serum potassium is critical to prevent arrhythmias or muscle weakness.