Nokea
A nurse is caring for a client receiving TPN. Which of the following actions should the
nurse take? For each potential nursing intervention, click to specify if the potential intervention
is anticipated, nonessential, or contraindicated for the client.
- A. Request a prescription for insulin
- B. Request for an antibitic to be administered
- C. Decrease the client's oxygen to 1.5 L/min via nasal canula
- D. Have 3 nurses verify the TPN solution prescription
- F. Notify the provider to increase TPN rate/hr
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
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A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?
- A. The dietitian will provide you with the best food choices to manage your diabetes.'
- B. I understand that the dietary choices can seem overwhelming.'
- C. I can assist you with making a list of foods you like for the dietitian.'
- D. Managing your diabetes will require you to make accommodations.'
Correct Answer: C
Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.
Choice A is incorrect as it does not actively involve the client in decision-making. Choice B acknowledges the client's feelings but does not directly engage them in the process. Choice D focuses on the client's responsibilities but does not promote active participation.
A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following statements should the nurse include in the teaching?
- A. Depress the canister after you inhale.'
- B. Exhale fully before bringing the inhaler to your lips.'
- C. Use peroxide to clean the mouthpiece of your inhaler.'
- D. Do not shake your inhaler before use.'
Correct Answer: B
Rationale: The correct answer is B: "Exhale fully before bringing the inhaler to your lips." This statement is important because exhaling fully before inhaling the medication helps to ensure maximum delivery of the medication into the lungs. By exhaling fully, the client creates more space in the lungs for the medication to reach the lower airways effectively.
Choice A is incorrect because depressing the canister after inhaling would not allow the medication to reach the lungs. Choice C is incorrect as peroxide is not recommended for cleaning inhaler mouthpieces. Choice D is incorrect because shaking the inhaler before use is necessary to ensure proper mixing of the medication for effective delivery.
Which of the following actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increase in dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The correct actions for the nurse to take are A, B, D, and E. A - anticipating client prep for cardiac catheterization is important for timely intervention. B - assisting with a continuous heparin infusion helps prevent blood clot formation during the procedure. D - anticipating an increase in metoprolol dosage is necessary to manage cardiac workload during the procedure. E - obtaining a prescription for NPO status is crucial to prevent complications during the procedure. Choices C (encouraging ambulation) and F (requesting an antibiotic prescription) are not directly related to preparing for cardiac catheterization and may not be necessary in this context.
A nurse is providing teaching to a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: Correct Answer: C. Increase water intake and use bulk-forming laxatives.
Rationale: Increasing water intake helps soften stool, easing constipation in IBS-C. Bulk-forming laxatives add fiber to stool, improving bowel movements. Stimulant laxatives (A) can lead to dependency. Avoiding fiber-rich foods (B) worsens constipation. A low-carbohydrate diet (D) may exacerbate constipation.
A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
- A. Temperature of 37.9° C (100.2° F)
- B. Pallor in the affected extremity
- C. Bruising around the incisional site
- D. Urine output 150 mL over 4 hr
Correct Answer: B
Rationale: The correct answer is B: Pallor in the affected extremity. Pallor in the affected extremity post arterial revascularization could indicate compromised blood flow, potentially leading to ischemia or thrombosis. This is a critical finding that requires immediate intervention to prevent further complications such as tissue necrosis or limb loss.
Incorrect choices:
A: Temperature elevation may indicate infection, but it is not an immediate concern postoperatively.
C: Bruising around the incisional site is common after surgery and may not require immediate intervention unless there are signs of excessive bleeding.
D: Urine output of 150 mL over 4 hr is within normal limits and not a priority concern in this context.