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During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?
- A. The client's oxygen saturation is 95%
- B. The client's blood pressure is 110/70 mm Hg
- C. The client has a temperature of 36.8°C (98.2°F)
- D. The client's heart rate is 88/min
Correct Answer: B
Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.
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A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 72 hours.
- B. Monitor the client's blood glucose every 4 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Use sterile technique when changing the central line dressing.
Correct Answer: D
Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.
A client is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Measure the client's blood glucose level every 6 hours
- B. Change the TPN tubing every 24 hours
- C. Weigh the client weekly
- D. Administer the TPN through a peripheral IV line
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client receiving total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. This practice helps reduce the risk of infection in clients receiving parenteral nutrition. Measuring the client's blood glucose level every 6 hours is important for clients on insulin therapy or with diabetes, but it is not directly related to TPN administration. Weighing the client weekly is essential for monitoring fluid status and nutritional progress, but it is not specific to TPN care. Administering TPN through a peripheral IV line is incorrect because TPN solutions are hypertonic and can cause phlebitis or thrombosis if administered through a peripheral line; a central venous access is typically used for TPN administration.
A nurse is caring for a client who has a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
- B. Increased urinary output.
- C. Blood pressure of 118/78 mm Hg.
- D. Decreased peripheral edema.
Correct Answer: A
Rationale: The correct answer is A. Weight loss of 0.5 kg (1.1 lb) in 24 hours is an indication that furosemide is effectively reducing fluid retention. This medication works by promoting diuresis, resulting in increased urine output, which could lead to weight loss. While increased urinary output (choice B) is a common effect of furosemide, weight loss is a more specific indicator of its effectiveness. Blood pressure (choice C) and decreased peripheral edema (choice D) can be influenced by various factors and are not direct indicators of furosemide's effectiveness in reducing fluid retention.
A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?
- A. Bradycardia.
- B. Tachycardia.
- C. Nausea.
- D. Blurred vision.
Correct Answer: D
Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.
A nurse is caring for a client who has osteoarthritis. Which of the following actions should the nurse take?
- A. Apply heat to inflamed joints
- B. Provide passive range-of-motion exercises
- C. Encourage prolonged use of NSAIDs
- D. Apply cold packs to the joints
Correct Answer: A
Rationale: Corrected Rationale: Applying heat to inflamed joints can help relieve pain in clients with osteoarthritis. Heat therapy can help improve blood circulation, relax muscles, and reduce stiffness. Choice B, providing passive range-of-motion exercises, may be beneficial for joint mobility but is not the first-line intervention for pain relief in osteoarthritis. Choice C, encouraging prolonged use of NSAIDs, should be done cautiously due to potential side effects and should be guided by a healthcare provider. Choice D, applying cold packs to the joints, is not recommended for osteoarthritis as cold therapy can worsen stiffness and discomfort in this condition.