Nokea
A client with acute pancreatitis is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Serum glucose
- C. Serum triglycerides
- D. Serum calcium
Correct Answer: C
Rationale: In a client with acute pancreatitis receiving total parenteral nutrition (TPN), the nurse should monitor serum triglycerides closely. Acute pancreatitis can lead to fat malabsorption, making the client susceptible to hypertriglyceridemia. Monitoring serum triglycerides is crucial to prevent complications such as hyperlipidemia. While monitoring serum potassium, glucose, and calcium levels is also essential in various conditions, in this scenario, the primary concern is the risk of developing hypertriglyceridemia due to fat malabsorption.
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A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement?
- A. Notify the healthcare provider.
- B. Review the client's medication history.
- C. Prepare the client for thyroid function tests.
- D. Initiate seizure precautions.
Correct Answer: A
Rationale: In a scenario where a client with hyperthyroidism is not responding to medications, the nurse's priority action should be to notify the healthcare provider. This is important because the client may require immediate intervention, such as adjusting the treatment plan or exploring alternative therapies. Reviewing the client's medication history (choice B) may be relevant but not as urgent as involving the healthcare provider. While preparing the client for thyroid function tests (choice C) may be necessary as part of the evaluation process, it is not the most immediate action to take. Initiating seizure precautions (choice D) is not directly related to the non-responsiveness of medications in hyperthyroidism and is not a priority in this situation.
Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?
- A. I am having pain in my lower back when I move my legs
- B. My throat hurts when I swallow
- C. I feel sick to my stomach and am going to throw up
- D. I have a headache that gets worse when I sit up
Correct Answer: D
Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.
In a client with liver cirrhosis admitted with ascites and jaundice, which laboratory value is most concerning to the nurse?
- A. Serum albumin of 3.0 g/dl
- B. Bilirubin of 3.0 mg/dl
- C. Ammonia level of 80 mcg/dl
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An elevated ammonia level of 80 mcg/dl is most concerning in a client with liver cirrhosis because it may indicate hepatic encephalopathy, a serious complication. Serum albumin, though low, is expected in cirrhosis and contributes to ascites. Bilirubin elevation is common in liver disease but may not be the most concerning in this case. Prothrombin time is typically prolonged in liver disease but may not be as acute as an elevated ammonia level suggesting hepatic encephalopathy.
When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?
- A. Stridor
- B. Nausea
- C. Headache
- D. Pruritus
Correct Answer: A
Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.
When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?
- A. Hold the thermometer in place.
- B. Place the disposable pad under the buttocks.
- C. Instruct the client to breathe deeply.
- D. Return the probe to the charger.
Correct Answer: A
Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.