Nokea
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has $300 \mathrm{~mL}$ of solution left. The nurse should:
- A. Continue the infusion until the remaining 300mL is infused
- B. Change the filter on the tubing and continue with the infusion
- C. Notify the physician and obtain orders to alter the rate of the solution
- D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution
Correct Answer: D
Rationale: TPN solutions should not hang for more than 24 hours due to infection risk. The nurse should discontinue the current bag, change the tubing, and hang a new bag. Continuing or altering the rate is unsafe.
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An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply.
- A. Use warm saline soaks four times per day to remove crusting.
- B. Apply topical antibiotic without touching the tip of the tube to his eye.
- C. Wash his hands after touching his eyes.
- D. Avoid touching his eyes.
- E. Observe isolation procedures and confine himself to his bedroom until the redness in the eye disappears.
Correct Answer: A,B,C,D
Rationale: Warm saline soaks, careful antibiotic application, hand washing, and avoiding eye contact prevent spread and promote healing. Isolation is unnecessary unless specified.
A client on a psychiatric care unit approaches the nurse and complains of muscle spasms in his neck, stiffness in other muscles, and that his eyes are rolling upward. The client had two p.r.n. doses of haloperidol (Haldol) in the last 6 hours. Of the drugs that have been ordered for the client as needed (see chart), the nurse should administer:
- A. Lorazepam (Ativan).
- B. Amantadine (Symmetrel).
- C. Diphenhydramine (Benadryl).
- D. Benztropine (Cogentin).
Correct Answer: D
Rationale: Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening. I.M. benztropine is the fastest and most effective drug for managing dystonia. Lorazepam is an antianxiety medication and is not effective for treatment of dystonia. Although amantadine and diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic symptoms.
The nurse should advise which of the following clients who is taking lithium to consult with the physician regarding a potential adjustment in lithium dosage?
- A. A client who continues work as a computer programmer.
- B. A client who attends college classes.
- C. A client who can now care for her children.
- D. A client who is beginning training for a tennis team.
Correct Answer: D
Rationale: Increased physical activity, such as tennis training, can lead to dehydration or electrolyte imbalances, which may affect lithium levels and increase toxicity risk, necessitating a dosage adjustment.
A 72-year-old client is referred for counseling. During the initial nursing assessment, the client denies the need for counseling. The nurse would agree with the client if she made which of the following comments?
- A. My doctor just put me on an antidepressant, and I'll be fine in a week or so.'
- B. My daughter sent me here. She's mad because I don't have the energy to take care of my grandkids.'
- C. Since I've gotten over the death of my husband, I've had more energy and been more active than before he died.'
- D. My son got worried because I made this silly comment about wanting to be with my husband in heaven.'
Correct Answer: C
Rationale: Increased energy and activity post-grief suggest the client is coping well, supporting her denial of needing counseling.
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
- A. Urinary pH
- B. Radial pulse
- C. Temperature
- D. Blood pressure
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.