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A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?
- A. Verify the amount of TPN solution the client is receiving every 4 hr.
- B. Prepare the client for a chest x-ray to verify catheter placement.
- C. Place the client in Sims' position for catheter insertion.
- D. Use a clean technique when changing the catheter dressing.
Correct Answer: B
Rationale: A chest X-ray confirms proper central venous catheter placement, critical for safe TPN administration. Verifying solution, Sims' position, or clean technique are inappropriate.
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A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Sodium
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide can cause hypokalemia, so potassium levels must be monitored. Sodium, calcium, or magnesium aren't primarily affected.
A nurse is caring for a client who is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild bruising.
- B. The client's aPTT is 90 seconds.
- C. The client's blood pressure is 122/80 mm Hg.
- D. The client's urine output is 40 mL/hr.
Correct Answer: B
Rationale: An aPTT of 90 seconds (above therapeutic range of 60-80) suggests excessive anticoagulation, requiring reporting. Bruising, normal BP, and urine output are less urgent.
A nurse is caring for a client who is postoperative following a spinal fusion. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate with a back brace.
- B. Instruct the client to twist at the waist when turning.
- C. Apply a heating pad to the surgical site.
- D. Allow the client to sit for 2 hr at a time.
Correct Answer: A
Rationale: A back brace supports ambulation, promoting stability. Twisting risks injury, heating pads may increase swelling, and prolonged sitting strains the spine.
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following actions should the nurse take?
- A. Monitor the client for neck swelling.
- B. Instruct the client to resume a high-iodine diet.
- C. Apply a heating pad to the surgical site.
- D. Encourage the client to speak loudly to test vocal cords.
Correct Answer: A
Rationale: Neck swelling post-thyroidectomy could indicate hematoma or edema, requiring monitoring. High-iodine diets, heating pads, and loud speaking aren't appropriate.
A nurse is reinforcing teaching with a client who has a new prescription for escitalopram. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication at bedtime.
- B. I might sweat more while taking this medication.
- C. I need to avoid dairy products.
- D. I can expect my symptoms to go away right away.
Correct Answer: B
Rationale: Escitalopram can cause sweating, showing understanding. Timing is flexible, dairy isn't restricted, and symptom relief takes weeks.