Nokea
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?
- A. Manifestations of hypoglycemia
- B. Height of the IV pole
- C. IV insertion site
- D. The client's oral intake
Correct Answer: C
Rationale: Monitoring the IV insertion site is critical for TPN due to the high risk of infection and complications with central lines.
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A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
- A. Assist the client to low Fowler's position.
- B. Test the pH of gastric aspirate.
- C. Discard any residual gastric contents.
- D. Warm the feeding solution to body temperature.
Correct Answer: B
Rationale: Testing gastric aspirate pH confirms NG tube placement in the stomach (pH 1-4).
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
- A. To remove gastric acid that might cause dyspepsia
- B. To identify delayed gastric emptying
- C. To confirm the placement of the NG tube
- D. To determine the client's electrolyte balance
Correct Answer: B
Rationale: Measuring residual identifies delayed gastric emptying, reducing aspiration risk.
A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a significant risk from vomiting due to fluid and electrolyte loss.
A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a common complication of vomiting due to significant fluid loss.