Nokea
A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?
- A. Turn off the TPN for 30 minutes.
- B. Ensure a separate IV access route.
- C. Flush the CVC with normal saline.
- D. Check for compatibility with TPN.
Correct Answer: B
Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions.
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A client is brought into the emergency department after sustaining a possible closed head injury. Which assessment will the nurse perform first?
- A. Level of consciousness
- B. Pulse and blood pressure
- C. Respiratory rate and depth
- D. Ability to move extremities
Correct Answer: C
Rationale: The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option 2), followed by evaluation of the status of the cardiovascular and neurological systems.
A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply.
- A. Cardiac murmur
- B. Cardiac enlargement
- C. Cool pale skin over the joints
- D. White painful skin lesions on the trunk
- E. Small nontender lumps on bony prominences
- F. Purposeless jerky movements of the extremities and face
Correct Answer: A,B,E,F
Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
The nurse provides information to a client with a colostomy. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply.
- A. Parsley
- B. Yogurt
- C. Buttermilk
- D. Cucumbers
- E. Cauliflower
- F. Cranberry juice
Correct Answer: A,B,C,F
Rationale: The nurse should provide information about foods and measures that will prevent odor from a colostomy. Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors. Foods that cause flatus and thus odor, including broccoli, Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas, should be avoided.