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A client receiving total parenteral nutrition reports nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?
- A. Check the client's blood glucose
- B. Check the client's vital signs
- C. Report the findings to the health care provider
- D. Slow down the rate of infusion
Correct Answer: A
Rationale: Nausea, abdominal pain, and thirst in a TPN client suggest hyperglycemia, so checking blood glucose is the best action. Vital signs , reporting , or slowing infusion are secondary without glucose confirmation.
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A client with Alzheimer disease is admitted to the hospital. The client's adult child says to the nurse, 'I really want to continue caring for my mother at home, but she has become agitated and restless at night. I am awake most of the night, feel exhausted, and do not know what to do.' What is the best response by the nurse?
- A. Do not let your mother take naps in the afternoon.'
- B. Our social worker can discuss supportive options with you.'
- C. We can ask the health care provider for medication that will help your mother sleep.'
- D. Your mother should be cared for in a skilled nursing facility.'
Correct Answer: B
Rationale: Referring to a social worker provides access to resources like respite care or home support, addressing the caregiver's exhaustion. Limiting naps or medication may help but are narrow, and suggesting a facility dismisses the caregiver's wishes.
In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?
- A. call the health care provider
- B. check fetal heart load
- C. put the client in knee-chest position
- D. turn the client to the side
Correct Answer: C
Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.
The nurse has just received the shift report. Which one of the following clients should be seen first?
- A. A 14-year-old one day post-appendectomy with a WBC of 6500
- B. A 5-year-old three days post-fracture of the right tibia with a temperature of 101° Fahrenheit
- C. An 11-month-old admitted during the previous shift with dehydration and a hematocrit of 40
- D. An 8-week-old admitted four hours earlier with sub-sternal retractions and an oxygen saturation of 90%
Correct Answer: D
Rationale: Answer D is correct. There is nothing in answer A that indicates the client is unstable. Answer B is a good choice, but the client three days post-fracture may have a slight temperature, so he should be seen second. Answer C is also a good choice, but if the infant with dehydration is stable, the 8-week-old with respiratory distress (sub-sternal retractions and low oxygen saturation) is the most critical and should be seen first.
The nurse is repairing new prescriptions from the health care provider. Which prescription would require further clarification?
- A. Atorvastatin for hyperlipidemia in a client with angina pectoris
- B. Bupropion for smoking cessation in a client with emphysema
- C. Cyclobenzaprine for muscle spasms in a client with hepatitis
- D. Metronidazole for trichomoniasis in a client with Crohn disease
Correct Answer: C
Rationale: Cyclobenzaprine is contraindicated in hepatic impairment due to hepatitis, as it is metabolized by the liver, requiring clarification. Other prescriptions (A, B, D) are appropriate for the conditions.
The licensed practical nurse (LPN) is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?
- A. 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives
- B. 55-year-old ambulatory client with exacerbation of chronic bronchitis and an elevated hematocrit level
- C. 72-year-old client who had coronary stent placement 2 days ago and has an elevated temperature
- D. 80-year-old client who had surgical repair of a fractured hip 4 days ago
Correct Answer: D
Rationale: An 80-year-old post-hip surgery client is at highest DVT risk due to age, immobility, and recent surgery. Smoking and contraceptives , elevated hematocrit , and stent with fever carry risks but are less immediate.