Nokea
A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?
- A. Administer the TPN solution separately from 0.9% sodium chloride
- B. Check for an allergy to eggs
- C. Discuss the TPN solution with the client
- D. Monitor for hypoglycemia
Correct Answer: B
Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.
You may also like to solve these questions
A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
- A. Feeling flushed and warm
- B. Abdominal fullness
- C. Swollen lips
- D. Metallic taste in the mouth
Correct Answer: C
Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.
A client with hepatic encephalopathy is being educated about their diet by a nurse. Which of the following food selections indicates that the client understands the teaching?
- A. A sandwich and a milkshake
- B. Rice with black beans
- C. Cottage cheese and tuna on lettuce
- D. A three-egg omelet with low-sodium ham
Correct Answer: B
Rationale: The correct answer is B: Rice with black beans. Clients with hepatic encephalopathy should limit protein intake to prevent the buildup of ammonia. Plant-based proteins are preferred over animal-based proteins in this condition. Rice with black beans provides a good balance of nutrients and is a suitable choice for a client with hepatic encephalopathy. Choices A, C, and D are incorrect because they contain animal-based proteins, which should be limited in clients with hepatic encephalopathy.
A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
- A. Drainage fluid is greenish-yellow
- B. Aspirate pH of 3
- C. Abdominal rigidity
- D. Air bubbles noted in the NG tube
Correct Answer: C
Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.
A child is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take with meals
- B. Take at bedtime
- C. Take with a glass of milk
- D. Take with a glass of orange juice
Correct Answer: D
Rationale: The correct answer is to take ferrous sulfate with a glass of orange juice. Vitamin C, found in orange juice, enhances iron absorption. Taking iron with milk (choice C) is not recommended as it reduces iron absorption. Taking it with meals (choice A) can hinder its absorption due to other food components. Taking it at bedtime (choice B) doesn't affect absorption but might cause gastrointestinal upset in some individuals.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.