Nokea
A nurse is preparing to administer intermittent lipid emulsion and notes a layer of fat floating in the IV solution bag. Which action should the nurse take?
- A. Shake the bag to mix the fat.
- B. Administer the bag of solution.
- C. Return the bag to the pharmacy.
- D. Turn the bag upside down one time.
Correct Answer: C
Rationale: Fat separation indicates instability; solution should be returned to pharmacy as it could cause fat embolism.
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A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?
- A. Aspiration
- B. Gastroesophageal reflux disease
- C. Peptic ulcer disease
- D. Dumping syndrome
Correct Answer: A
Rationale: Aspiration is the primary concern with dysphagia due to impaired swallowing reflexes.
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
- A. Place a cool cloth on the forehead.
- B. Elevate the head of the bed 30 degrees.
- C. Administer morphine 2 mg IV.
- D. Prepare for a lumbar puncture.
Correct Answer: B
Rationale: Elevating the HOB decreases intracranial pressure which may be causing the headache.
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
A nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis due to the risk of which complication?
- A. Hyperglycemia
- B. Disequilibrium syndrome
- C. Peritonitis
- D. Hyperphosphatemia
- E. The client experiences pain upon palpation of the epigastric region.
Correct Answer: A
Rationale: Maintaining dwell time prevents excessive glucose absorption from dialysate which could cause hyperglycemia.