Nokea
A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?
- A. Changing the TPN tubing and solution every 24 hours
- B. Monitoring the TPN infusion rate closely
- C. Keeping the head of the bed elevated
- D. Ensuring the solution is at room temperature before infusing
Correct Answer: A
Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.
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The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm reset button on the ventilator
Correct Answer: B
Rationale: When the high-pressure alarm on a ventilator goes off, the nurse's initial action should be to perform a quick assessment of the client's condition. This assessment helps in promptly identifying the cause of the alarm, such as mucus plugging, kinking of the tubing, or other issues. By assessing the client first, the nurse can determine the appropriate intervention needed to address the alarm. Choices A and D are incorrect because disconnecting the client from the ventilator or pressing the alarm reset button should not be the initial actions without assessing the client's condition. While calling the respiratory therapist for help could be beneficial, assessing the client's condition should be the nurse's priority to address the immediate concern.
The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?
- A. We will call the healthcare provider if the child develops acne.
- B. Our child should brush and floss carefully after every meal.
- C. We will skip the next dose if vomiting or fever occurs.
- D. When our child is seizure-free for 6 months, we can stop the medication.
Correct Answer: B
Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.
A nurse is reinforcing teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?
- A. 1 tbsp of soft margarine
- B. ½ oz of nuts
- C. 2 tbsp of peanut butter
- D. 1 oz of sunflower seeds
Correct Answer: C
Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.
When assessing a client for signs and symptoms of a fluid volume deficit, the nurse would be most concerned with which finding?
- A. Blood pressure of 90/60 mm Hg
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Urine output of 30 mL per hour
Correct Answer: A
Rationale: Corrected Rationale: A low blood pressure of 90/60 mm Hg is a significant finding indicating fluid volume deficit. In fluid volume deficit, the body tries to compensate by increasing heart rate (choice B) to maintain cardiac output. Respiratory rate (choice C) may increase as a compensatory mechanism, but it is not the primary concern in fluid volume deficit. Urine output (choice D) may decrease in response to fluid volume deficit, but it is a late sign and not the most concerning finding.
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
- A. Bleeding time
- B. Hemoglobin and hematocrit
- C. White blood cells
- D. Platelets
Correct Answer: B
Rationale: Corrected Hemoglobin and hematocrit levels should be monitored closely after blood transfusions to assess the effectiveness and identify any complications. Monitoring hemoglobin and hematocrit levels helps evaluate the patient's oxygen-carrying capacity and blood volume. While platelets are crucial for clotting, they are not typically affected immediately after a blood transfusion. White blood cell count monitoring is more relevant in assessing infection or immune response, not directly related to a blood transfusion. Bleeding time measures platelet function, which is not the primary concern immediately after a blood transfusion.