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 had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate independently.
- B. Turn the client by log rolling with a turning sheet.
- C. Position the client in a high Fowler’s position.
- D. Apply a heating pad to the lower back.
Correct Answer: B
Rationale: The correct answer is B: Turn the client by log rolling with a turning sheet. After a lumbar laminectomy, it is essential to prevent twisting or bending at the waist to avoid damaging the surgical site. Log rolling with a turning sheet maintains proper alignment of the spine. Encouraging independent ambulation (A) may put strain on the surgical area. Positioning in a high Fowler's position (C) may increase pressure on the surgical site. Applying a heating pad (D) can lead to increased inflammation and potential burns.
A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
- A. Take the sample from the outer edge of formed stool.
- B. Wear sterile gloves when collecting the sample.
- C. Collect three samples from a single bowel movement.
- D. Discard samples that contain urine.
Correct Answer: D
Rationale: The correct answer is D: Discard samples that contain urine. This is crucial because urine can interfere with the accuracy of the fecal occult blood test results, leading to false positives. By discarding samples that contain urine, the nurse ensures the reliability of the test.
A: Taking the sample from the outer edge of formed stool is not necessary for a guaiac smear sample.
B: Wearing sterile gloves is important for infection control but not specifically for collecting a guaiac smear sample.
C: Collecting three samples from a single bowel movement is not standard practice for fecal occult blood testing and may not be necessary.
E, F, G: No further options provided.
A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?
- A. Twist at the waist when standing from a seated position.'
- B. Use a raised toilet seat to maintain your hips above your knees.'
- C. Apply a heating pad to the operative hip to decrease pain.'
- D. Move your stronger leg first when using a walker.'
Correct Answer: B
Rationale: The correct answer is B: Use a raised toilet seat to maintain your hips above your knees. This is important post-total hip arthroplasty to prevent hip dislocation. By keeping the hips above the knees, it reduces stress on the hip joint.
Incorrect choices:
A: Twisting at the waist can strain the hip joint post-surgery.
C: Applying heat can increase inflammation and risk of infection.
D: Moving the stronger leg first can lead to uneven weight distribution, increasing the risk of falls.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
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A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
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- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
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