Nokea
A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?
- A. Use a 1.2 micron filter when infusing TPN with fat emulsions added.
- B. Allow 18 hr for the lipids to infuse when not mixed with the TPN solution.
- C. Change the TPN solution after 36 hr.
- D. Change the TPN tubing every 48 hr.
Correct Answer: D
Rationale: The correct answer is D: Change the TPN tubing every 48 hr. This is essential to prevent bacterial growth and infection, maintaining the integrity of the TPN solution. Regular tubing changes reduce the risk of contamination and ensure patient safety.
A: Using a 1.2 micron filter is not directly related to tubing changes and is not a primary concern for TPN administration.
B: Allowing 18 hr for lipids to infuse is not a standard practice and does not address the need for tubing changes.
C: Changing the TPN solution after 36 hr is not a standard guideline and may not be necessary unless specific factors indicate a need for a change.
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Where are most fat-digesting enzymes produced?
- A. small intestine
- B. gallbladder
- C. liver
- D. pancreas
Correct Answer: D
Rationale: The correct answer is D: pancreas. The pancreas produces most fat-digesting enzymes, such as lipase, which help break down fats in the small intestine. The liver produces bile, stored in the gallbladder, which aids in fat digestion but doesn't directly produce fat-digesting enzymes. The small intestine primarily absorbs nutrients rather than producing fat-digesting enzymes. Therefore, the pancreas is the main source of fat-digesting enzymes in the digestive system.
The nurse is caring for a patient with chronic kidney disease. Which of the following laboratory results should the nurse prioritize?
- A. Potassium level of 3.5 mEq/L
- B. Blood urea nitrogen (BUN) level of 18 mg/dL
- C. Serum creatinine level of 4.0 mg/dL
- D. Hemoglobin level of 12 g/dL
Correct Answer: C
Rationale: The correct answer is C: Serum creatinine level of 4.0 mg/dL. This is prioritized as high serum creatinine indicates impaired kidney function in chronic kidney disease. Elevated creatinine levels suggest decreased glomerular filtration rate, which is crucial in monitoring kidney function. Option A (Potassium level of 3.5 mEq/L) may be important due to the risk of hyperkalemia in kidney disease, but it is not as critical as monitoring kidney function. Option B (BUN level of 18 mg/dL) is within normal range and typically fluctuates based on diet and hydration status. Option D (Hemoglobin level of 12 g/dL) is important but not the priority in this case.
The nurse is performing pre-procedure teaching for a patient scheduled to undergo a liver biopsy. After listening to the information, the patient states, "I am so scareI just don't know if I can do this procedure." Which response is best?
- A. "The procedure will only last about 15 minutes."
- B. "Most patients say it feels similar to a punch in the shoulder."
- C. "You do not have to have the procedure."
- D. "I understand that you are afraiTell me more about your concerns."
Correct Answer: D
Rationale: The correct answer is D because it demonstrates empathy and active listening. By acknowledging the patient's fear and encouraging them to express their concerns further, the nurse can address specific fears and provide appropriate support. This approach helps build trust and rapport, leading to better patient outcomes.
A: Providing the duration of the procedure (choice A) may not effectively address the patient's underlying fear.
B: Comparing the sensation to a punch (choice B) may minimize the patient's concerns and not address the emotional aspect of their fear.
C: Telling the patient they do not have to have the procedure (choice C) could be misleading and may not be in the patient's best interest without further exploration of their concerns.
The nurse should urge a client with an ileoanal anastomosis to do perineal exercises four to six times a day for how many repetitions?
- A. 5
- B. 10
- C. 15
- D. 20
Correct Answer: C
Rationale: Perineal exercises help strengthen muscles and improve bowel control, typically recommended at 15 repetitions.
Regarding HCL:
- A. it inhibits pepsinogen.
- B. it helps in absorption of iron.
- C. it helps in absorption of vitamin B12.
- D. is secreted in response to sympathetic stimulation.
Correct Answer: B
Rationale: Step 1: HCL helps in the digestion of food by creating an acidic environment in the stomach.
Step 2: This acidic environment aids in the breakdown of food components, including iron.
Step 3: Iron absorption is enhanced in the presence of HCL.
Conclusion: Choice B is correct as HCL helps in the absorption of iron. Choices A, C, and D are incorrect as HCL does not inhibit pepsinogen, aid in absorption of vitamin B12, or secreted in response to sympathetic stimulation.