Nokea
A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?
- A. Fluid volume overload
- B. Sepsis
- C. Hyperglycemia
- D. Hypoglycemia
Correct Answer: D
Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.
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Which statement indicates understanding of a low-fiber diet?
- A. I can cut up carrots and celery sticks for my lunch.
- B. I will eat a bran muffin for my mid-morning snack.
- C. I will have oatmeal with skim milk for my breakfast.
- D. I should choose canned peaches for my fruit serving.
Correct Answer: D
Rationale: The correct answer is D because canned peaches are low in fiber compared to the other options provided. Option A contains high-fiber vegetables (carrots and celery), option B includes a bran muffin which is fiber-rich, and option C involves oatmeal which is also a good source of fiber. Therefore, choosing canned peaches aligns with a low-fiber diet.
You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:
- A. Take the blood pressure reading on both arms for comparison
- B. Listen to and identify the phases of Korotkoff sounds
- C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
- D. Observe procedures for infection control
Correct Answer: B
Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.
During the first 24 hours after the thermal injury, you should assess Sergio for:
- A. hypokalemia and hypernatremia
- B. hypokalemia and hyponatremia
- C. hyperkalemia and hyponatremia
- D. hyperkalemia and hypernatremia
Correct Answer: D
Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.
Integrated management for childhood illness is the universal protocol of care endorsed by WHO and is used by different countries worldwide, including the Philippines. In any case that the nurse classifies the child and categorizes the signs and symptoms in the PINK category, you know that this means:
- A. Urgent referral
- B. Antibiotic Management
- C. Home treatment
- D. Outpatient treatment facility is needed
Correct Answer: B
Rationale: When a child is classified under the PINK category in the Integrated Management of Childhood Illness (IMCI) guidelines, it signifies the need for antibiotic management. This category indicates severe signs and symptoms requiring immediate antibiotic treatment to address the underlying infection. Choices A, C, and D are incorrect because the PINK category specifically calls for urgent antibiotic management rather than urgent referral, home treatment, or outpatient treatment facility.
The nurse knows that after receiving the blood from the blood bank, it should be administered within:
- A. 1 hour
- B. 2 hours
- C. 4 hours
- D. 6 hours
Correct Answer: D
Rationale: Blood transfusions need to be administered promptly after receiving the blood from the blood bank to ensure patient safety and effectiveness. Waiting too long can lead to complications such as bacterial growth in the blood product, which can be harmful when infused. Administering the blood within 6 hours is crucial to prevent such risks. Choices A, B, and C are incorrect because waiting for 1, 2, or 4 hours respectively can increase the likelihood of complications associated with delayed transfusion.