Nokea
The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?
- A. Blood glucose of 200 mg/dL
- B. Weight gain of 1 pound in 24 hours
- C. Temperature of 99.8°F
- D. Dry, cracked lips
Correct Answer: A
Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.
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Which of the following is an expected finding in the assessment of a client with bulimia nervosa?
- A. Extreme weight loss
- B. Presence of lanugo over body
- C. Erosion of tooth enamel
- D. Muscle wasting
Correct Answer: C
Rationale: Bulimia nervosa involves recurrent binge eating followed by purging, often through vomiting, which exposes teeth to stomach acid, leading to enamel erosion. Extreme weight loss and lanugo are more characteristic of anorexia nervosa, and muscle wasting is not a primary feature of bulimia.
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
- A. Low birth weight
- B. Large for gestational age
- C. Preterm birth,but appropriate size for gestation
- D. Growth retardation in weight and length
Correct Answer: A
Rationale: Smoking during pregnancy restricts placental blood flow leading to low birth weight. Babies are not typically large and while preterm birth or growth retardation may occur low birth weight is the most consistent finding.
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of 'not feeling well.' At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
- A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- B. Ask him to dissolve three pieces of hard candy in his mouth
- C. Have him drink 4 oz of orange juice
- D. Monitor him closely until dinner arrives
Correct Answer: C
Rationale: Four ounces of orange juice will raise blood sugar to a normal level and sustain it until dinner, preventing hypoglycemia. The other options either raise blood sugar too high or are insufficient.
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.