Nokea
A primary health care provider prescribes lipids (fat emulsion) for a client who is receiving total parenteral nutrition (TPN). The nurse should explain to the client that the fat emulsion is administered for which reason?
- A. To provide essential fatty acids
- B. As a supplement to fluid intake
- C. To decrease the risk of phlebitis
- D. Infused during the night in place of TPN
Correct Answer: A
Rationale: Lipids are a brand of intravenous fat emulsion administered to clients who are at risk for developing an essential fatty acid deficiency, such as those receiving TPN. Fat emulsions help meet caloric and nutritional needs that cannot be met by glucose administration alone. Fat emulsions are not administered to increase the amount of body fluids and they do not decrease the incidence of phlebitis. Fat emulsions neither replace TPN nor do they require infusion during the night.
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Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
- A. Hyperresonance.
- B. Tympany.
- C. Dullness.
- D. Flatness.
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.
A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications?
- A. Anaphylactic reaction.
- B. Circulatory overload.
- C. Sepsis.
- D. Acute hemolytic reaction.
Correct Answer: B
Rationale: Difficulty breathing, elevated blood pressure, and cough suggest circulatory overload, a transfusion complication due to fluid volume excess.
The nurse is teaching a client with a new diagnosis of epilepsy about safety precautions. Which of the following instructions should be included?
- A. Avoid driving until seizures are controlled.
- B. Take baths instead of showers.
- C. Use a microwave instead of a stove.
- D. Sleep on a low bed with side rails.
Correct Answer: A, D
Rationale: Avoiding driving and using a low bed with rails prevent injury during seizures.
A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply.
- A. Fish
- B. Eggs
- C. Milk
- D. Nuts
- E. Grains
Correct Answer: D,E
Rationale: The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are incomplete proteins with the highest biological value. Nuts and grains are the only options that are not complete proteins. Foods such as meat, fish, milk, and eggs are complete proteins, which are not recommended for the client with chronic kidney disease.
The nurse is teaching a client with a new diagnosis of multiple sclerosis about safety precautions. Which of the following instructions is most important?
- A. Use assistive devices to prevent falls.
- B. Take medications at bedtime only.
- C. Avoid hot baths or showers.
- D. Limit physical activity to prevent fatigue.
Correct Answer: A
Rationale: Using assistive devices prevents falls, a critical safety concern in multiple sclerosis due to muscle weakness or coordination issues.