Nokea
A nurse is planning care for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Serum calcium level
- B. Blood glucose level
- C. Serum albumin level
- D. Serum sodium level
Correct Answer: C
Rationale: The correct answer is C, Serum albumin level. Monitoring the serum albumin level helps assess the nutritional effectiveness of total parenteral nutrition (TPN). Serum albumin is a protein that reflects the long-term nutritional status of a patient. Serum calcium level (choice A) is not directly related to TPN effectiveness. Blood glucose level (choice B) is important to monitor in diabetic patients but is not the primary indicator of TPN efficacy. Serum sodium level (choice D) is more related to fluid balance and electrolyte status rather than the effectiveness of TPN.
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What is the best intervention for a patient experiencing hypoxia?
- A. Administer oxygen
- B. Reposition the patient
- C. Provide humidified air
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.
A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1500 mL per day
- B. Avoid massaging the affected extremity to relieve pain
- C. Avoid applying cold packs to the client's affected extremity
- D. Elevate the client's affected extremity when in bed
Correct Answer: D
Rationale: The correct instruction for a client with DVT is to elevate the affected extremity when in bed. Elevation helps reduce swelling by promoting venous return. Limiting fluid intake could lead to dehydration and is not recommended. Massaging the affected extremity can dislodge a clot, leading to serious complications. Applying cold packs can cause vasoconstriction and should be avoided in DVT.
Which electrolyte imbalance should be closely monitored in a patient receiving digoxin?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor glucose levels
Correct Answer: A
Rationale: Corrected Rationale: Potassium levels should be monitored closely in a patient receiving digoxin to avoid hypokalemia. Digoxin can increase the risk of developing life-threatening arrhythmias in the presence of low potassium levels. Monitoring sodium, calcium, or glucose levels is not specifically necessary for patients on digoxin, making choices B, C, and D incorrect.
A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?
- A. Dry, hacking cough
- B. Bounding peripheral pulses
- C. Decreased urinary output
- D. Weight loss of 1 kg in 24 hours
Correct Answer: C
Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.
What is the priority nursing intervention for a patient with hyperkalemia?
- A. Administer calcium gluconate
- B. Administer insulin
- C. Administer sodium bicarbonate
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.