Nokea
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply.
- A. Place the solution on an IV pump at the prescribed rate.
- B. Monitor blood glucose every six (6) hours.
- C. Weigh the client weekly, first thing in the morning.
- D. Change the IV tubing every three (3) days.
- E. Monitor intake and output every shift.
Correct Answer: A,B,E
Rationale: TPN requires an IV pump for precise delivery, frequent glucose monitoring due to high dextrose content, and intake/output monitoring to assess fluid balance. Weekly weights and tubing changes every 3 days are less critical or incorrect.
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The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented?
- A. Encourage fluids orally.
- B. Administer 10% saline solution IVPB.
- C. Administer antidiuretic hormone intranasally.
- D. Place on seizure precautions.
Correct Answer: D
Rationale: Severe hyponatremia (110 mEq/L) increases seizure risk due to cerebral edema. Seizure precautions are the priority to ensure safety. Oral fluids or ADH may worsen hyponatremia, and 10% saline is not standard.
The client with a continent urinary diversion is being discharged. Which discharge instructions should the nurse include in the teaching?
- A. Have the client demonstrate catheterizing the stoma.
- B. Instruct the client on how to pouch the stoma.
- C. Explain the use of a bedside drainage bag at night.
- D. Tell the client to call the HCP if the temperature is 99°F or less.
Correct Answer: A
Rationale: A continent urinary diversion (e.g., Indiana pouch) requires periodic catheterization of the stoma. Demonstrating this ensures the client can manage it. Pouching and drainage bags are for incontinent diversions, and a 99°F fever is not concerning.
Which nursing intervention is most appropriate when the nurse is changing the appliance of the client's ileal conduit?
- A. When you remove the appliance, let the urine drip into a container.
- B. When you remove the appliance, insert a tampon into the stoma.
- C. When you remove the appliance, press a gloved finger over the stoma.
- D. When you remove the appliance, pinch the stoma with two fingers.
Correct Answer: C
Rationale: Pressing a gloved finger over the stoma prevents urine leakage during appliance changes, maintaining hygiene and skin integrity.
Which information should the nurse include when explaining the management of the client's urolithiasis? Select all that apply.
- A. Increase fluid intake to 3 liters per day.
- B. Strain all urine to collect stones for analysis.
- C. Take prescribed analgesics for pain relief.
- D. Avoid all dairy products to prevent stone formation.
- E. Follow a low-sodium diet to reduce stone risk.
- F. Report fever or chills immediately.
Correct Answer: A,B,C,F
Rationale: Increasing fluid intake, straining urine, taking analgesics, and reporting fever or chills are key management strategies for urolithiasis to promote stone passage and prevent complications.
If this client's condition is similar to that of others in the oliguric phase of renal failure, the nurse would anticipate the client's urine output to be within what range?
- A. 50 to 100 mL/hour
- B. 100 to 150 mL/hour
- C. 500 to 1,000 mL/day
- D. 100 to 500 mL/day
Correct Answer: D
Rationale: The oliguric phase of renal failure is characterized by a urine output of 100–500 mL/day, reflecting significantly reduced kidney function.