Nokea
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.
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A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
- A. Voiding of 350mL of concentrated urine in
- B. Irregular heart rate of 82 beats/min
- C. Pupils constricted and equal
- D. Respiratory rate of 8breaths/min
Correct Answer: D
Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention.
A: Voiding of 350mL of concentrated urine is not typically associated with morphine use.
B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine.
C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.
A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?
- A. Sinusitis
- B. Lymphadenopathy
- C. Anaphylaxis
- D. Angioedema
Correct Answer: A
Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications.
Summary of other choices:
B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis.
C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis.
D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Rationale:
1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty.
2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring.
3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care.
4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care.
Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.
When documenting subjective data, the nurse should do which of the following?
- A. Use the client’s own words placed in quotation marks.
- B. Paraphrase the information stated by the client.
- C. Validate the information with the client’s family prior to documentation.
- D. Record the information using nonspecific words.
Correct Answer: A
Rationale: The correct answer is A because using the client's own words in quotation marks ensures accurate representation of their subjective data. It maintains the integrity of the information provided by the client and improves communication between healthcare providers. Paraphrasing (choice B) may lead to misinterpretation or distortion of the client's statements. Validating with the client's family (choice C) may introduce bias or inaccurate information. Recording with nonspecific words (choice D) decreases the clarity and specificity of the documentation, which is essential for effective communication and decision-making in healthcare.
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient’s headache. Which action by the nurse is priority for this patient?
- A. Eliminate headache from the nursing care plan.
- B. Direct the nursing assistive personnel to ask if the headache is relieved.
- C. Reassess the patient’s pain level in 30 minutes.
- D. Revise the plan of care.
Correct Answer: C
Rationale: The correct answer is C: Reassess the patient's pain level in 30 minutes. This is the priority action as it allows the nurse to evaluate the effectiveness of the acetaminophen in relieving the patient's headache. By reassessing the pain level, the nurse can determine if the medication is working or if further intervention is needed.
A: Eliminating the headache from the care plan is not appropriate as the patient's comfort and pain relief should be a priority.
B: Directing the nursing assistive personnel to inquire if the headache is relieved is not thorough assessment and does not provide direct evaluation of the patient's pain level.
D: Revising the plan of care may be necessary based on the reassessment, but it is not the immediate priority compared to evaluating the patient's response to treatment.