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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. Place the client in Sims' position for catheter insertion.
- B. Verify the amount of TPN solution the client is receiving every 4 hr.
- C. Use clean technique when changing the catheter dressing.
- D. Prepare the client for a chest x-ray to verify catheter placement.
Correct Answer: D
Rationale: A chest x-ray confirms correct catheter placement for TPN administration.
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A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?
- A. Elevated ammonia
- B. Elevated lipase
- C. Prolonged PT/INR
- D. Decreased albumin
Correct Answer: B
Rationale: Elevated lipase is a specific marker of pancreatitis.
The client reports having trouble getting to sleep at night.
A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?
- A. Remain in bed until you fall asleep.
- B. Keep the television volume low while you are trying to fall asleep.
- C. Sleep longer hours on the weekend.
- D. Establish a daily exercise routine.
Correct Answer: D
Rationale: A daily exercise routine promotes better sleep patterns.
A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?
- A. Puffed rice cereal
- B. Tomato juice
- C. Bran muffin
- D. Cottage cheese
- E. None
- F. None
Correct Answer: C
Rationale: Bran muffins are high in fiber, which promotes bowel regularity and indicates understanding.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
The preschooler has manifestations of respiratory syncytial virus.
A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?
- A. Administer fluconazole to the preschooler.
- B. Monitor the preschooler's urine for protein.
- C. Request an x-ray of the preschooler's neck.
- D. Initiate droplet precautions.
Correct Answer: D
Rationale: Droplet precautions prevent RSV transmission.