Nokea
A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?
- A. Vitamin E
- B. Vitamin A
- C. Vitamin C
- D. Vitamin D
Correct Answer: C
Rationale: Vitamin C is water-soluble, requiring regular intake as it's not stored in the body.
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A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?
- A. Manifestations of hypoglycemia
- B. Height of the IV pole
- C. IV insertion site
- D. The client's oral intake
Correct Answer: C
Rationale: Monitoring the IV insertion site is critical for TPN due to the high risk of infection and complications with central lines.
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
- A. The nurse administers the feeding through a syringe barrel by gravity.
- B. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
- C. The nurse allows the client to rest in a supine position during feeding.
- D. The nurse irrigates the NG tube with tap water after feeding.
Correct Answer: C
Rationale: Supine position during feeding increases aspiration risk; semi-Fowler's is recommended.
A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
- A. Increased collagen
- B. Increased muscle mass
- C. Decreased serum calcium
- D. Decreased circulation
Correct Answer: D
Rationale: Decreased circulation from immobility reduces tissue oxygenation, increasing pressure injury risk.
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.
A nurse is caring for a client who has capillary blood glucose 48 mg/dL. Which of the following findings should the nurse expect?
- A. Tremors
- B. Bradycardia
- C. Decreased appetite
- D. Flushed skin
Correct Answer: A
Rationale: Tremors are a common hypoglycemia symptom due to the body's stress response.