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A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values indicates the TPN is effective?
- A. Albumin 3.5 g/dL
- B. Hemoglobin 8 g/dL
- C. WBC count 15,000/mm3
- D. Blood glucose 110 mg/dL
Correct Answer: D
Rationale: The correct answer is D. A blood glucose level of 110 mg/dL indicates that the TPN is effective in maintaining normal glucose levels. Hemoglobin level (choice B) is related to anemia and not directly indicative of TPN effectiveness. Albumin level (choice A) is a marker of nutritional status over a longer term and may not reflect immediate TPN effectiveness. White blood cell count (choice C) is related to infection or inflammation and is not a direct indicator of TPN effectiveness.
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A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?
- A. Flush the tube with 30 mL of sterile water before each feeding
- B. Administer the feeding using a large-bore syringe
- C. Keep the head of the bed elevated to 15 degrees
- D. Replace the feeding bag every 24 hours
Correct Answer: A
Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.
A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?
- A. Bradycardia.
- B. Tachycardia.
- C. Nausea.
- D. Blurred vision.
Correct Answer: D
Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.
A nurse is caring for a client who has heart failure and a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Increased shortness of breath.
- B. Decreased peripheral edema.
- C. Increased jugular venous distention.
- D. Increased heart rate.
Correct Answer: B
Rationale: The correct answer is B: Decreased peripheral edema. Furosemide is a diuretic that helps in reducing fluid overload in clients with heart failure by increasing urine output. A decrease in peripheral edema indicates that the medication is effectively removing excess fluid from the body. Choices A, C, and D are incorrect because they do not indicate an improvement in the client's condition. Increased shortness of breath, increased jugular venous distention, and increased heart rate are all signs of worsening heart failure and would not be expected findings when furosemide is effective.
A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will monitor my blood sugar level once a week.
- B. I will exercise every day even if my blood sugar is low.
- C. I will eat snacks rich in carbohydrates if my blood sugar drops.
- D. I will avoid sugary foods to prevent my blood sugar from rising.
Correct Answer: C
Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.
A healthcare professional is preparing education material for a client. Which of the following techniques should the professional use in creating material?
- A. Emphasize important information using bold lettering.
- B. Use a 7th-grade reading level.
- C. Avoid using cartoons in the material.
- D. Use words with three or four syllables.
Correct Answer: B
Rationale: The correct answer is to 'Use a 7th-grade reading level.' This ensures that the material is accessible to most clients by keeping the language simple and easy to understand. Emphasizing important information using bold lettering (Choice A) can be helpful but may not enhance overall readability. Avoiding cartoons (Choice C) is not a universal rule and can sometimes make the material more engaging. Using words with three or four syllables (Choice D) can make the material difficult to comprehend for many clients.