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A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?
- A. Blood glucose level of 150 mg/dL.
- B. Blood pressure of 110/70 mm Hg.
- C. Serum albumin level of 3.5 g/dL.
- D. The client's temperature is 100.4°F (38°C).
Correct Answer: D
Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.
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The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in the Sims' position.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct Answer: C
Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.
The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
- A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
- B. Retake the blood pressure in the same arm, deflating the cuff slowly.
- C. Ask another healthcare provider to recheck the blood pressure to compare results.
- D. Obtain another blood pressure cuff and retake the blood pressure.
Correct Answer: B
Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
- A. Record the amount on the client's fluid output record.
- B. Encourage the client to increase oral fluid intake.
- C. Notify the healthcare provider of the findings.
- D. Palpate the client's bladder for distention.
Correct Answer: A
Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.
During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?
- A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
- B. The client tells the nurse that she does not have much of an appetite today.
- C. The nurse notes that there are numerous scatter rugs throughout the house.
- D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.
Correct Answer: C
Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.