Nokea
A client is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Measure the client's blood glucose level every 6 hours
- B. Change the TPN tubing every 24 hours
- C. Weigh the client weekly
- D. Administer the TPN through a peripheral IV line
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client receiving total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. This practice helps reduce the risk of infection in clients receiving parenteral nutrition. Measuring the client's blood glucose level every 6 hours is important for clients on insulin therapy or with diabetes, but it is not directly related to TPN administration. Weighing the client weekly is essential for monitoring fluid status and nutritional progress, but it is not specific to TPN care. Administering TPN through a peripheral IV line is incorrect because TPN solutions are hypertonic and can cause phlebitis or thrombosis if administered through a peripheral line; a central venous access is typically used for TPN administration.
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A client requests the creation of a living will. Which of the following actions should the nurse take?
- A. Schedule a meeting between the hospital ethics committee and the client
- B. Evaluate the client's understanding of life-sustaining measures
- C. Determine the client's preferences about post-mortem care
- D. Request a conference with the client's family
Correct Answer: B
Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.
A client is receiving intermittent enteral tube feedings and is experiencing dumping syndrome. Which of the following actions should the nurse take?
- A. Administer a refrigerated feeding.
- B. Increase the amount of water used to flush the tubing.
- C. Decrease the rate of the client's feedings.
- D. Instruct the client to move onto their right side.
Correct Answer: C
Rationale: Dumping syndrome is a condition that occurs when food moves too quickly from the stomach into the small intestine. Symptoms can include abdominal cramping, diarrhea, and sweating. To manage dumping syndrome in a client receiving enteral tube feedings, the nurse should decrease the rate of the feedings. This intervention helps slow down the movement of food through the gastrointestinal tract, reducing the symptoms. Administering a refrigerated feeding (choice A) or increasing the amount of water used to flush the tubing (choice B) are not appropriate actions for addressing dumping syndrome. Instructing the client to move onto their right side (choice D) is not a relevant intervention for managing dumping syndrome in this scenario.
A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?
- A. Chest pain.
- B. Muscle spasms.
- C. Cool, moist skin.
- D. Incisional pain.
Correct Answer: A
Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.
A client with a new prescription for furosemide should increase intake of which of the following?
- A. You should take this medication on an empty stomach.
- B. You should increase your intake of potassium-rich foods.
- C. You should take this medication at bedtime.
- D. You should avoid taking this medication with food.
Correct Answer: B
Rationale: The correct answer is B: 'You should increase your intake of potassium-rich foods.' Furosemide is a potassium-wasting diuretic, which means it can lead to low potassium levels in the body. Increasing intake of potassium-rich foods helps counteract this effect. Choices A, C, and D are incorrect because furosemide should not necessarily be taken on an empty stomach, at bedtime, or specifically avoided with food.
A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
- A. Chlamydia
- B. Human papillomavirus
- C. Candidiasis
- D. Herpes simplex virus
Correct Answer: A
Rationale: Chlamydia is the correct answer. Chlamydia is a sexually transmitted infection that is considered a nationally notifiable infectious disease, meaning healthcare providers are required to report cases to public health authorities. Reporting such cases is crucial for disease surveillance and implementing appropriate control measures. Human papillomavirus, Candidiasis, and Herpes simplex virus are not nationally notifiable infectious diseases and do not require mandatory reporting to the state health department.