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 caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my digoxin if my pulse is less than 50 beats per minute.
- B. I will take this medication with fiber to prevent constipation.
- C. I will increase my dose if my vision becomes blurred.
- D. I will notify my provider if I experience muscle weakness.
Correct Answer: D
Rationale: Rationale for Correct Answer (D):
The correct answer is D because muscle weakness is a potential sign of digoxin toxicity. It is crucial for the client to notify the provider immediately to prevent serious complications. This statement indicates an understanding of the teaching regarding digoxin therapy.
Summary of Incorrect Choices:
A: Incorrect. Taking digoxin with a pulse less than 50 beats per minute can lead to bradycardia and toxicity.
B: Incorrect. Taking digoxin with fiber may decrease its absorption, reducing its effectiveness.
C: Incorrect. Blurred vision is a sign of digoxin toxicity, and the dose should be decreased, not increased.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.'
- B. You should avoid intercourse to prevent injury to your vagina.'
- C. Women your age experience thickening of the vaginal tissue.'
- D. Your symptoms are likely due to decreasing estrogen levels.'
Correct Answer: D
Rationale: The correct answer is D: "Your symptoms are likely due to decreasing estrogen levels." This response is correct because vaginal dryness and itching are common symptoms of vaginal atrophy, which is often caused by decreased estrogen levels in older adult women. The nurse's acknowledgment and explanation of this physiological change can help the client understand the root cause of her symptoms and guide further discussion on appropriate treatment options, such as hormone therapy or vaginal moisturizers.
Choice A is incorrect because it dismisses the client's discomfort without addressing the underlying cause. Choice B is incorrect as it provides potentially harmful advice without addressing the issue. Choice C is incorrect as it inaccurately describes the condition of vaginal tissue in older women.
A nurse is caring for a client who has a full-thickness burn. Which of the following actions should the nurse take?
- A. Implement fluid restriction.
- B. Provide humidified oxygen.
- C. Administer antibiotic medications.
- D. Administer acyclovir orally.
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. Full-thickness burns can compromise the client's ability to breathe due to airway swelling and damage. Providing humidified oxygen helps support respiratory function by improving oxygenation and reducing the risk of hypoxia. Implementing fluid restriction (A) is not appropriate as burn patients typically require increased fluid intake to prevent dehydration. Administering antibiotic medications (C) may be necessary to prevent infection but is not the priority in this scenario. Administering acyclovir orally (D) is used to treat viral infections, not full-thickness burns.
A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
- A. Pad the upper two side rails of the client's bed.
- B. Keep a padded tongue blade at the client's bedside.
- C. Maintain peripheral IV access.
- D. Teach assistive personnel how to apply restraints.
Correct Answer: C
Rationale: The correct answer is C: Maintain peripheral IV access. This is important for clients with seizure disorders as they may require immediate administration of medications during or after a seizure. IV access allows for quick drug delivery.
Choice A is incorrect because padding the bed rails is not a standard intervention for seizure disorder.
Choice B is incorrect because a padded tongue blade is not necessary for managing seizures.
Choice D is incorrect because teaching assistive personnel to apply restraints is not a recommended intervention for clients with seizure disorders.
In summary, maintaining peripheral IV access is crucial for prompt medication administration during seizures, while the other choices are not directly related to managing seizures in this context.