Nokea
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions isn't appropriate?
- A. Monitor serum blood glucose during infusion.
- B. Obtain the client's weight daily.
- C. Infuse 0.9% sodium chloride if the solution is not available.
- D. Verify the solution with another RN prior to infusion.
Correct Answer: C
Rationale: Correct Answer: C - Infuse 0.9% sodium chloride if the solution is not available.
Rationale: TPN is a specialized form of nutrition that must be administered precisely as prescribed to prevent complications. Infusing 0.9% sodium chloride instead of the prescribed TPN solution can lead to imbalanced nutrient intake and electrolyte disturbances. It is crucial to follow the prescribed TPN regimen accurately to meet the client's specific nutritional needs.
Incorrect Choices:
A: Monitoring serum blood glucose during infusion is appropriate to ensure the client's glycemic control while on TPN.
B: Obtaining the client's weight daily is important to assess fluid status and adjust the TPN prescription as needed.
D: Verifying the TPN solution with another RN prior to infusion is a standard safety practice to prevent errors in administration.
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A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
- A. Instruct the client to sit on a rubber ring when seated in a chair.
- B. Raise the head of the client's bed to a 90° angle.
- C. Place pillows between the client's knees when in a side-lying position.
- D. Use moisturizing lotion while massaging the client's bony prominences.
Correct Answer: C
Rationale: The correct answer is C: Place pillows between the client's knees when in a side-lying position. Placing pillows between the knees helps maintain proper alignment of the hips and spine, preventing the development of pressure ulcers and improving comfort for the client. Choice A is incorrect as sitting on a rubber ring does not directly address the client's hemiplegia. Choice B is incorrect because raising the head of the bed to a 90° angle may not be suitable for a client with hemiplegia due to potential issues with positioning and pressure distribution. Choice D is incorrect as using moisturizing lotion while massaging bony prominences is not a specific intervention for hemiplegia care.
A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
- A. Remove one of the weights.
- B. Tie knots in the ropes near the pulleys to shorten them.
- C. Increase the elevation of the affected extremity.
- D. Reapply the weights to ensure proper traction.
Correct Answer: D
Rationale: The correct action for the nurse to take is to reapply the weights to ensure proper traction. This is crucial to maintain the intended pulling force required for the skeletal traction to be effective in realigning the fractured bone. If the weights are resting on the floor, it means that the traction is not being applied as intended, which can lead to ineffective treatment and potential complications. Removing a weight (choice A) would decrease the traction force, tying knots in the ropes (choice B) would alter the mechanics of the system, and increasing the elevation of the extremity (choice C) would not address the issue of weights resting on the floor. Therefore, the best course of action is to reapply the weights to ensure proper traction and alignment of the fractured bone.
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
- A. Loss of hearing
- B. Paresthesia
- C. Muscle wasting
- D. Changes in vision
Correct Answer: B
Rationale: The correct answer is B: Paresthesia. Pernicious anemia leads to Vitamin B12 deficiency, causing nerve damage and paresthesia (tingling or burning sensation). This poses a risk to the client's safety as it can affect their balance and coordination, increasing the risk of falls and injuries. Loss of hearing (A), muscle wasting (C), and changes in vision (D) are potential manifestations of pernicious anemia but do not directly pose a risk to safety like paresthesia.
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
- A. Propranolol
- B. Dobutamine
- C. Mannitol
- D. Chlorpromazine
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce cerebral edema by drawing water out of brain tissue. This helps decrease intracranial pressure in clients with head injuries. Propranolol (A) is a beta-blocker used for hypertension, not specifically for intracranial pressure. Dobutamine (B) is a beta-adrenergic agonist used for cardiac support, not for intracranial pressure. Chlorpromazine (D) is an antipsychotic medication and does not address intracranial pressure. In summary, Mannitol is the appropriate choice for managing increased intracranial pressure due to its osmotic diuretic properties.
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?
- A. Increase phosphorus intake.
- B. Decrease carbohydrate intake.
- C. Decrease protein intake.
- D. Increase potassium intake.
Correct Answer: C
Rationale: The correct answer is C: Decrease protein intake. In nephrotic syndrome, there is increased protein loss in the urine, leading to hypoalbuminemia and edema. Decreasing protein intake helps reduce the workload on the kidneys and minimizes protein loss in the urine, supporting management of the condition. Increasing phosphorus intake (choice A) is not recommended as it can worsen kidney function. Decreasing carbohydrate intake (choice B) and increasing potassium intake (choice D) are not directly related to managing nephrotic syndrome.