Nokea
The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is appropriate for the nurse to take to correct the problem?
- A. Readjust the solution to infuse the desired amount.
- B. Continue the infusion at the current rate, but run the next bottle at an increased rate.
- C. Double the infusion rate for 2 hours.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is appropriate when a TPN infusion is behind schedule, as adjusting rates without an order can cause complications like hyperglycemia or circulatory overload. Continuing at the current rate or doubling the rate is unsafe. CN: Pharmacological and parenteral therapies; CL: Synthesize
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Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic?
- A. Applying moist heat to the flank area.
- B. Administering meperidine (Demerol).
- C. Encouraging high fluid intake.
- D. Maintaining complete bed rest.
Correct Answer: B
Rationale: Meperidine, an opioid, provides the most effective relief for the severe pain of renal colic by directly addressing pain pathways.
A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for:
- A. Footdrop.
- B. Knee swelling and pain.
- C. Tingling in the arm.
- D. Absence of the Achilles reflex.
Correct Answer: C
Rationale: Thoracoscopy positioning (lateral decubitus) can compress nerves in the arm, causing tingling due to brachial plexus injury. Footdrop or Achilles reflex issues are unrelated to this position.
The nurse is planning a staff development conference about measures to reduce medication errors. It would be appropriate for the nurse to state which actions may help reduce medication errors? Select all that apply.
- A. Timely medication reconciliation
- B. Delay documentation of medication administration to the end of the shift
- C. Delegate medication transcription to unlicensed assistive personnel (UAP)
- D. Limit the use of verbal orders to emergent situations
- E. Place medication dispensing systems in high-traffic areas
Correct Answer: A,D
Rationale: Timely reconciliation and limiting verbal orders reduce errors; delayed documentation, UAP transcription, and high-traffic dispensing systems increase error risk.
A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. In the immediate postoperative phase, the nurse should:
- A. Prevent nausea and vomiting.
- B. Maintain a patent airway.
- C. Provide frequent oral hygiene.
- D. Establish a way for the client to communicate.
Correct Answer: B
Rationale: Maintaining a patent airway is the priority in the immediate postoperative phase for a client with a wired jaw, as swelling or secretions could obstruct the airway. While the other interventions are important, airway management is the most critical.
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.