Nokea
A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important?
- A. Assessing blood glucose as directed.
- B. Changing the IV dressing each day.
- C. Checking the IV site for redness.
- D. Performing appropriate hand hygiene.
Correct Answer: D
Rationale: Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose and the IV site are important, but preventing infection takes priority.
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A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate?
- A. Increase the fiber and water in your diet.
- B. Reduce fat to less than 30% each day.
- C. Report dry mouth and increased sweating.
- D. Lorcaserin may cause loose stools in a few days.
Correct Answer: A
Rationale: This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this. Reducing fat is important with orlistat, not lorcaserin. Dry mouth may occur, but loose stools are associated with orlistat.
A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.)
- A. Attempt to dislodge the clog by instilling a cola product.
- B. Determine if any of the medications come in a liquid form.
- C. Flush the tube before and after administering medications.
- D. Administer medications with a feeding pump.
- E. Try to flush the tube with 30 mL of water and gentle pressure.
Correct Answer: B,C,E
Rationale: If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube with water. Cola products should not be used unless water is ineffective. To prevent future problems, determine if medications can be dispensed in liquid form and flush the tube with water before and after medication administration.
A client is discussing weight loss medications with the nurse. Which statement by the nurse is most appropriate?
- A. Only over-the-counter medications are available.
- B. There are three drugs currently approved for this.
- C. The patient operation is available in a reduced-dose over-the-counter formulation.
- D. Prescription medications are not effective for weight loss.
Correct Answer: B
Rationale: There are three drugs available by prescription for weight loss, including orlistat (Xenical). The other statements are incorrect as over-the-counter options are limited, and prescription medications can be effective.
A client is receiving bolus feedings through a Dobbloff tube. What action by the nurse is most important?
- A. Auscultate lung sounds after each feeding.
- B. Check tube placement before each feeding.
- C. Check tube placement every 8 hours.
- D. Weigh the client daily on the same scale.
Correct Answer: B
Rationale: For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will not prevent misplacement issues. Weighing the client is important to determine if nutritional goals are being met.
Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because'I just have to know how much she weighs.' What action by the client's nurse is most appropriate?
- A. Make an anonymous report to the charge nurse.
- B. State,'That is a violation of client confidentiality.'
- C. Walk away and ignore the other nurse's behavior.
- D. Document the incident in the client's chart.
Correct Answer: B
Rationale: Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.