Nokea
The nurse assesses a client receiving total parenteral nutrition (TPN) and fat emulsions. The nurse observes that the fat emulsion infusion is one hour behind schedule. The nurse should take which action?
- A. Adjust the infusion rate to make up the difference over the next hour, then revert the infusion rate back to the prescribed rate.
- B. Increase the infusion rate to ensure that the infusion finishes at the correct time.
- C. Ensure the fat emulsion infusion rate is infusing at the prescribed rate and maintain the rate at the prescribed rate.
- D. Stop the infusion and inform the primary health care provider (PHCP).
Correct Answer: C
Rationale: Fat emulsions must be infused at a steady, prescribed rate to prevent complications like fat overload syndrome. Adjusting or increasing the rate can be dangerous, and stopping the infusion is unnecessary unless there’s a specific issue.
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The nurse is caring for a client with advanced liver cirrhosis receiving prescribed medications. Which medications would the nurse clarify with the primary healthcare provider (PHCP)? Select all that apply.
- A. Isoniazid
- B. Valproic Acid
- C. Amiodarone
- D. Lithium
- E. Thiamine
Correct Answer: A,B,C
Rationale: Isoniazid, valproic acid, and amiodarone are hepatotoxic and can exacerbate liver damage in cirrhosis, requiring clarification with the PHCP. Lithium is not primarily hepatotoxic, and thiamine is often beneficial in cirrhosis to prevent Wernicke’s encephalopathy.
The following scenario applies to the next 1 items
The nurse is caring for a client in the outpatient clinic
Item 1 of 1
Nurses’ Note
35-year-female arrives at the clinic for reported loss of appetite and nausea. The client reports that she is not eating as much because she experiences palpitations, sweating, and dizziness about thirty minutes after she eats. She reports that she has not been adherent to the prescribed diet and her symptoms worsen when she eats something sweet and drinks cola.
Medical History
• Morbid obesity (BMI 42)
• Roux-en-Y procedure eight weeks ago
Complete the following sentence by choosing from the list of options. To prevent.........., the nurse should instruct the client ............. and ...........
- A. Pernicious anemia
- B. Dumping syndrome
- C. Lie down after meals
- D. Exercise after meals
- E. Avoid drinking with meals
- F. Eat food high in carbohydrates
- G. Eat food high in vitamin B12
Correct Answer: B,E
Rationale: Dumping syndrome (B) occurs post-Roux-en-Y due to rapid gastric emptying. Avoiding drinking with meals (E) slows digestion, reducing symptoms. Lying down after meals (C) can worsen symptoms and is not advised.
The nurse has instructed self-management strategies for a client diagnosed with gastroesophageal reflux disease (GERD). Which statement by the client would indicate a correct understanding of the teaching?
- A. It's much better for me to wear loose-fitting clothes right now.
- B. I stopped eating grilled chicken and now eat more ground hamburger.
- C. If I wake up with GERD symptoms, I should lower the head of my bed while sleeping.
- D. I should take my prescribed omeprazole after meals.
Correct Answer: A
Rationale: Loose-fitting clothes (A) reduce abdominal pressure, helping manage GERD. Hamburger (B) is high-fat and worsens reflux, lowering the bed (C) increases symptoms, and omeprazole (D) is taken before meals.
The nurse is reviewing a client's medical record, and it is noted that they have a positive Murphy sign. The nurse recognizes that this sign is elicited in which abdominal quadrant?
- A. Area A
- B. Area B
- C. Area C
- D. Area D
Correct Answer: C
Rationale: Murphy's sign, elicited by pain on palpation of the right upper quadrant (Area C) during inspiration, is associated with cholecystitis.
The nurse is caring for a client with appendicitis. Which of the following statements are correct regarding this condition? Select all that apply.
- A. McBurney's point tenderness is a sign of appendicitis
- B. Appendicitis is more common among males
- C. A low carbohydrate diet is a risk factor for appendicitis
- D. Diagnosis of appendicitis is confirmed by endoscopic retrograde cholangiopancreatography
- E. The client may have an elevated white blood cell count (WBC)
Correct Answer: A,E
Rationale: McBurney's point tenderness (A) and elevated WBC (E) are hallmark signs of appendicitis. It is not more common in males (B), low-carb diets (C) are not a risk factor, and ERCP (D) is not used for diagnosis.