Nokea
A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself once a week.
- B. I should limit my fluid intake to 1 liter per day.
- C. I should report a weight gain of 2 pounds in one day.
- D. I should reduce my protein intake to prevent fluid retention.
Correct Answer: C
Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.
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A client, 12 hours postpartum, reports not having a bowel movement for 4 days. Which medication should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository.
- B. Magnesium hydroxide 30 ml PO.
- C. Famotidine 20 mg PO.
- D. Loperamide 4 mg PO.
Correct Answer: A
Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. The client's report of not having a bowel movement for 4 days indicates constipation, and Bisacodyl is a stimulant laxative that helps initiate bowel movements. Magnesium hydroxide is an antacid and osmotic laxative used for indigestion, not for constipation. Famotidine is an H2 receptor antagonist used to reduce stomach acid production and treat heartburn, not constipation. Loperamide is an antidiarrheal agent and would be contraindicated in a client experiencing constipation.
A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following actions should the nurse take?
- A. Give the medication as a bolus over 10 minutes.
- B. Dilute the medication before administration.
- C. Infuse the medication at a rate of 10 mEq/hr.
- D. Administer the medication undiluted.
Correct Answer: C
Rationale: The correct action the nurse should take when administering potassium chloride IV to a client with hypokalemia is to infuse the medication at a rate of 10 mEq/hr. This slow infusion rate is crucial to prevent the development of hyperkalemia, a potentially dangerous condition. Option A is incorrect because giving the medication as a bolus over 10 minutes can lead to adverse effects. Option B is incorrect as potassium chloride does not necessarily need to be diluted before administration in this scenario. Option D is incorrect as administering the medication undiluted can also increase the risk of hyperkalemia.
A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 72 hours.
- B. Monitor the client's blood glucose every 4 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Use sterile technique when changing the central line dressing.
Correct Answer: D
Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.
A nurse is planning assignments for a licensed practical nurse (LPN) during a staffing shortage. Which client should be delegated to the LPN?
- A. A client with an Hgb of 6.3 g/dl and a prescription for packed RBCs.
- B. A client who sustained a concussion and has unequal pupils.
- C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction.
- D. A client who fractured his femur yesterday and is experiencing shortness of breath.
Correct Answer: C
Rationale: The correct answer is C because the client postoperative following a bowel resection with an NG tube set to continuous suction requires routine postoperative care, which an LPN can manage. Choice A involves administering blood products, which typically requires assessment and monitoring by a registered nurse. Choice B indicates a potentially serious neurological condition that requires assessment by a higher-level provider. Choice D suggests a client experiencing respiratory distress, which requires immediate assessment and intervention by a registered nurse or physician.
A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?
- A. Witness the waste of the controlled substance by another nurse
- B. Dispose of the controlled substance by yourself
- C. Leave the controlled substance in the client's room for later use
- D. Document the administration and sign off at the end of the shift
Correct Answer: A
Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.