Nokea
A newly hired nurse is caring for a client who is receiving prescribed total parenteral nutrition (TPN) therapy. The nurse preceptor should intervene if the newly hired nurse?
- A. wears a surgical mask while changing the client's central vascular access dressing.
- B. obtains the client's capillary blood glucose every four to six hours.
- C. spikes and primes a new bag of TPN without an inline filter.
- D. continues the infusion via an infusion pump while the client is receiving a computed tomography scan.
Correct Answer: C
Rationale: TPN requires an inline filter to prevent infusion of particulate matter or air emboli. Not using a filter (C) is unsafe and requires intervention. Wearing a mask (A), checking glucose (B), and continuing infusion during a CT scan (D) are appropriate or not inherently unsafe.
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The nurse is assessing a client who was just diagnosed with acute pyelonephritis. Which of the following findings should the nurse expect to observe? Select all that apply.
- A. Costovertebral angle tenderness
- B. Jugular venous distention
- C. Fever and chills
- D. Urinary retention
- E. Dysuria
Correct Answer: A,C,E
Rationale: Pyelonephritis causes costovertebral angle tenderness, fever, chills, and dysuria due to kidney inflammation and infection.
The nurse reviews the lab values of a client and notes a serum sodium level of 125 mEq/L (mmol/L) [Reference range: 135-145 mEq/L (mmol/L)]. Which conditions does the nurse recognize as potential causes of this laboratory abnormality? Select all that apply.
- A. syndrome of inappropriate antidiuretic hormone (SIADH)
- B. diabetes Insipidus
- C. addison's disease (adrenal insufficiency)
- D. psychogenic polydipsia
- E. salt water drowning
Correct Answer: A,C,D
Rationale: SIADH causes water retention, diluting sodium. Addison's disease reduces aldosterone, leading to sodium loss. Psychogenic polydipsia causes excessive water intake, diluting sodium.
The nurse is reviewing the assessment data for a client with acute glomerulonephritis (AGN). Which of the following would be an expected finding?
- A. Ketonuria
- B. Hematuria
- C. Polyuria
- D. Glycosuria
Correct Answer: B
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation.
The nurse has obtained a physician's order to obtain a clean catch urine specimen from a client. The nurse should instruct the client to obtain the urine sample
- A. from the first stream of urine from the bladder.
- B. midstream from the bladder.
- C. from the final stream of urine from the bladder.
- D. by emptying the entire volume of urine in the specimen cup.
Correct Answer: B
Rationale: Midstream urine collection minimizes contamination for accurate testing.
The nurse is caring for a client who prescribed a 40 mEq potassium chloride capsule for hypokalemia. The client reports difficulty swallowing capsules. Which action should the nurse take when administering this medication?
- A. Sprinkle the contents of the capsule onto a spoonful of soft food.
- B. Have the client chew the capsule prior to swallowing.
- C. Sprinkle the contents of the capsule into a cup of warm water.
- D. Put the capsule under the client's tongue and have it dissolve.
Correct Answer: A
Rationale: Potassium chloride capsules can be opened and the contents sprinkled onto a small amount of soft food, such as applesauce, to aid swallowing. Chewing the capsule (B) could cause irritation or release the medication too quickly. Dissolving in warm water (C) is not recommended as it may affect the medication's stability. Sublingual administration (D) is not appropriate for potassium chloride.