Nokea
A nurse is caring for a client receiving TPN. What action should the nurse take?
- A. Monitor serum sodium levels daily.
- B. Check the client's capillary blood glucose level every 4 hr.
- C. Administer the solution at room temperature.
- D. Discontinue abruptly if the client reports nausea.
Correct Answer: B
Rationale: The correct answer is B: Check the client's capillary blood glucose level every 4 hr. This is crucial because TPN can cause hyperglycemia due to its high glucose content. Monitoring blood glucose levels helps in detecting and managing hyperglycemia.
Incorrect answers:
A: Monitoring serum sodium levels is not directly related to TPN administration.
C: Administering the solution at room temperature is not necessary for TPN administration.
D: Discontinuing TPN abruptly can lead to serious complications; it should be gradually tapered off.
Overall, monitoring blood glucose levels is essential in TPN therapy to prevent complications related to hyperglycemia.
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A nurse is teaching a newly licensed nurse about the purpose of a CA 125 test. Which of the following statements should the nurse include in the teaching?
- A. A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer.
- B. A CA 125 test is used to detect pregnancy.
- C. A CA 125 test is used to diagnose cervical cancer.
- D. A CA 125 test is used to screen for prostate cancer.
Correct Answer: A
Rationale: The correct answer is A: A CA 125 test is used to monitor a client's progress during treatment of ovarian cancer. This is because CA 125 is a biomarker that is commonly elevated in ovarian cancer patients. Monitoring CA 125 levels helps healthcare providers assess the effectiveness of treatment and detect any recurrence of the disease.
Choice B is incorrect because a CA 125 test is not used to detect pregnancy. Choice C is incorrect because a CA 125 test is not used to diagnose cervical cancer; it is primarily associated with ovarian cancer. Choice D is incorrect because a CA 125 test is not used to screen for prostate cancer; it is specific to ovarian cancer.
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
- A. C-reactive protein
- B. Erythrocyte sedimentation rate (ESR)
- C. White blood cell count
- D. Hematocrit
Correct Answer: B
Rationale: The correct answer is B: Erythrocyte sedimentation rate (ESR). ESR is a common test used to monitor inflammation levels in rheumatoid arthritis (RA) patients. Aspirin is an anti-inflammatory medication, so monitoring ESR can help assess the effectiveness of the treatment. A decrease in ESR levels indicates a reduction in inflammation, suggesting that the aspirin is working. The other choices (A, C, D) are not specific to monitoring the effectiveness of aspirin in RA. C-reactive protein and white blood cell count are general markers of inflammation and infection, not specific to RA. Hematocrit measures red blood cell levels, which are not directly related to the effectiveness of aspirin in treating RA.
A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
- A. I may eat 10 ounces of lean protein each day
- B. I will limit my sodium intake.
- C. I will increase my intake of fruits and vegetables.
- D. I will avoid fried foods and processed meats.
Correct Answer: A
Rationale: The correct answer is A: "I may eat 10 ounces of lean protein each day." This statement indicates a need for further teaching because consuming 10 ounces of lean protein daily may lead to excessive protein intake, which can strain the kidneys and potentially worsen hypertension. Clients with hypertension should limit protein intake and focus on lean sources in moderation. Choices B, C, and D are correct as they align with a heart-healthy diet by limiting sodium intake, increasing fruits and vegetables, and avoiding fried foods and processed meats, respectively.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.