Nokea
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications?
- A. Hypostatic pneumonia.
- B. Pulmonary hypertension.
- C. Orthostatic hypotension.
- D. Fluid imbalances.
Correct Answer: D
Rationale: TPN can cause fluid imbalances due to high glucose and volume loads, requiring close monitoring of intake, output, and electrolytes.
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The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response?
- A. Do you often need help with food shopping?
- B. Let's discuss how we can solve this problem.
- C. Do you have any support systems for shopping?
- D. I wish I could but I don't have time to run errands.
Correct Answer: B
Rationale: The nurse's duty is to help the client; but in helping the client, the nurse's first action is to finish the assessment and then find immediate and long-term solutions to the problem. In options 1 and 3 the nurse asks a closed-ended question, which is unlikely to further nurse-client communication. Option 4 is inappropriate while failing to address the client's problem.
A client with a history of chronic kidney disease is admitted with hyperphosphatemia. The nurse should expect to administer which of the following medications?
- A. Calcium carbonate.
- B. Ferrous sulfate.
- C. Vitamin D.
- D. Potassium chloride.
Correct Answer: A
Rationale: Calcium carbonate binds phosphate in the gut to manage hyperphosphatemia.
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
You are having a nice dinner in a fancy restaurant. As you are eating, you hear the gentleman eating at the next table start to bang the table, hold his throat and forcibly cough. What should you do?
- A. Perform the Valsalva maneuver
- B. Encourage the person to continue coughing
- C. Perform the Heimlich maneuver
- D. Begin CPR and prepare for ACLS measures
Correct Answer: B
Rationale: Forcing coughing suggests a partial airway obstruction. Encouraging the person to continue coughing is the first step to dislodge the obstruction without invasive intervention.
The nurse is caring for a client who has just undergone a lumbar puncture. Which of the following interventions is most appropriate in the immediate post-procedure period?
- A. Encourage ambulation to prevent stiffness.
- B. Keep the client flat for 4-6 hours.
- C. Administer oral fluids immediately.
- D. Apply heat to the puncture site.
Correct Answer: B
Rationale: Keeping the client flat for 4-6 hours post-lumbar puncture reduces the risk of spinal headache due to cerebrospinal fluid leakage.