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The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
- A. Blood glucose of 140 mg/dL
- B. White blood cell count of 8000/mm³
- C. Serum potassium of 3.8 mEq/L
- D. Serum calcium of 7.8 mg/dL
Correct Answer: D
Rationale: The correct answer is D: Serum calcium of 7.8 mg/dL. This finding indicates hypocalcemia, which can lead to life-threatening cardiac arrhythmias. Low calcium levels can be caused by TPN administration or poor calcium absorption following bowel resection. Immediate intervention may include administering IV calcium gluconate.
A: Blood glucose of 140 mg/dL is within the normal range and not an immediate concern.
B: White blood cell count of 8000/mm³ is within the normal range and does not require immediate intervention.
C: Serum potassium of 3.8 mEq/L is within the normal range and does not pose an immediate threat.
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A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
- A. It dissolves blood clots
- B. It prevents the blood from clotting
- C. It thins the blood
- D. It decreases the risk of infection
Correct Answer: B
Rationale: The correct answer is B: It prevents the blood from clotting. Warfarin works as an anticoagulant by inhibiting the production of certain clotting factors in the liver. This prevents the formation of blood clots and reduces the risk of conditions like deep vein thrombosis or stroke. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones. Choice C is misleading as it does not actually "thin" the blood but affects its ability to clot. Choice D is unrelated to the mechanism of action of warfarin.
When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?
- A. Instill the medication quickly
- B. Insert the needle slowly
- C. Select a large, deep muscle mass
- D. Use a short, small gauge needle
Correct Answer: C
Rationale: The correct answer is C: Select a large, deep muscle mass. This is because using a large, deep muscle mass ensures proper absorption and distribution of the medication, reducing the risk of tissue damage or irritation.
Rationale:
1. Instilling the medication quickly (Choice A) can cause discomfort and increase the risk of tissue trauma.
2. Inserting the needle slowly (Choice B) can also lead to pain and discomfort for the patient.
3. Using a short, small gauge needle (Choice D) may not reach the deep muscle mass and can cause inadequate absorption of the medication.
In summary, selecting a large, deep muscle mass ensures optimal medication delivery and minimizes discomfort and tissue damage compared to the other choices.
A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client¢â‚¬â„¢s teaching plan?
- A. Avoid all forms of sugar
- B. Check blood glucose levels once a week
- C. Rotate insulin injection sites
- D. Monitor urine ketone levels
Correct Answer: C
Rationale: The correct answer is C: Rotate insulin injection sites. This instruction is crucial to prevent lipohypertrophy, which can lead to inconsistent insulin absorption. By rotating injection sites, the client ensures proper insulin absorption and prevents complications. Checking blood glucose levels once a week (B) is not frequent enough for proper diabetes management. Avoiding all forms of sugar (A) is an outdated approach, as moderation is key. Monitoring urine ketone levels (D) is not as reliable as blood ketone testing for assessing diabetic ketoacidosis risk.
Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
- A. Avoiding the administration of high levels of oxygen for extended periods.
- B. Administering a sedative at bedtime to slow the client's respiratory rate.
- C. Removing the nasal cannula during the night to prevent oxygen buildup.
- D. Running oxygen through a hydration source prior to administration.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. High levels of oxygen over a prolonged period can lead to oxygen toxicity.
2. Oxygen toxicity can cause lung damage and respiratory distress.
3. To prevent oxygen toxicity, it is crucial to monitor and limit the duration and amount of oxygen administered.
4. Therefore, avoiding the administration of high levels of oxygen for extended periods is the most effective intervention to prevent oxygen toxicity.
Summary of other choices:
B: Administering a sedative does not address the root cause of oxygen toxicity and can mask symptoms.
C: Removing the nasal cannula at night can lead to hypoxia and is not a safe practice.
D: Running oxygen through a hydration source does not prevent oxygen toxicity and is not a recognized intervention.
The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?
- A. Daily intake and output
- B. Skin turgor
- C. Daily weight
- D. Vital signs every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Daily weight. Daily weight is the most important data to assess fluid status in a client with pneumonia as weight changes can indicate fluid retention or loss, a crucial aspect in managing pneumonia. Skin turgor (B) is more indicative of hydration status, not overall fluid balance. Daily intake and output (A) is important but does not provide a direct measure of fluid status. Vital signs (D) are important for monitoring overall health but do not directly assess fluid status.