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A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. The client's blood glucose is 120 mg/dL.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's weight increased by 0.5 kg overnight.
- D. The client reports mild discomfort at the IV site.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, possibly catheter-related, requiring reporting. Normal glucose, slight weight gain, and mild discomfort are less urgent.
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A nurse is reinforcing teaching with a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?
- A. Increase your intake of potassium-rich foods.
- B. Take the medication at bedtime.
- C. Monitor for leg cramps.
- D. Limit your fluid intake to 1 liter daily.
Correct Answer: C
Rationale: Hydrochlorothiazide can cause hypokalemia, leading to leg cramps, which should be monitored. Potassium intake may need adjustment, it's taken in the morning, and fluid limits aren't standard.
A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication in the morning.
- B. I might lose weight while taking this medication.
- C. I need to avoid tyramine-rich foods.
- D. I can expect my mood to improve right away.
Correct Answer: A
Rationale: Fluoxetine is taken in the morning to avoid insomnia, showing understanding. Weight changes vary, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Weight loss
- B. Decreased blood pressure
- C. Decreased skin turgor
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate pulmonary edema from fluid overload. Weight loss, low blood pressure, or poor skin turgor suggest dehydration, not overload.
A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Which of the following statements should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience insomnia while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You should expect immediate improvement in your symptoms.
Correct Answer: B
Rationale: Sertraline can cause insomnia, a key side effect to anticipate. It's taken flexibly, caffeine isn't restricted, and effects take weeks.
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
- A. Suction the tube every 2 hr.
- B. Secure the tube to the client's face.
- C. Monitor the client's cuff pressure daily.
- D. Reposition the client every 4 hr.
Correct Answer: B
Rationale: Securing the tube prevents dislodgement, ensuring airway safety. Suctioning is as needed, cuff pressure checks are frequent, and repositioning is every 2 hours.