Nokea
The nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The nurse plans on taking which appropriate action?
- A. Inserting an indwelling urinary catheter.
- B. Weighing the client in the morning before the first void.
- C. Placing a mask on the client before changing the central line dressing.
- D. Establishing continuous cardiac monitoring.
Correct Answer: B
Rationale: Weighing the client daily (B) monitors fluid balance and nutritional status, critical for TPN management. Catheters (A), masks (C), and cardiac monitoring (D) are not routinely required unless indicated.
You may also like to solve these questions
The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. Pantoprazole
- B. Ciprofloxacin
- C. Lactulose
- D. Loperamide
Correct Answer: B
Rationale: Ciprofloxacin, an antibiotic, is used to treat bacterial peritonitis. Pantoprazole reduces acid, lactulose treats hepatic encephalopathy, and loperamide slows motility, none of which address peritonitis directly.
The nurse is caring for a 26-year-old patient who cannot meet their nutritional needs by mouth. The interdisciplinary team decided inserting an NG tube for enteral feedings would be best. After inserting the tube, the nurse knows which of the following is the most accurate way to verify the placement of the tube?
- A. Aspiration of stomach contents
- B. pH verification of the aspirate
- C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ)
- D. Visualization on an X-ray
Correct Answer: D
Rationale: X-ray visualization (D) is the most accurate method to confirm NG tube placement, ensuring it is in the stomach and not the lungs.
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
- A. I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish.
- B. I should slowly introduce high-fiber foods in my diet.
- C. I must always wear a pouch over my stoma.
- D. I should clean the skin around my stoma with rubbing alcohol.
Correct Answer: D
Rationale: Using rubbing alcohol (D) can irritate the skin around the stoma. Options A, B, and C are appropriate for colostomy care.
The nurse is caring for a postoperative client who underwent abdominal surgery and is receiving patient-controlled analgesia (PCA) with morphine for pain management. The nurse notes that the client is sedated but still complaining of severe pain. What is the most appropriate action for the nurse to take?
- A. Increase the PCA dosage
- B. Administer a non-opioid analgesic
- C. Discontinue PCA and Administer Intramuscular (IM) Morphine
- D. Notify the healthcare provider
Correct Answer: D
Rationale: Notifying the provider (D) is appropriate when the client is sedated yet in severe pain, indicating potential PCA inadequacy or complications requiring reassessment.
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
- A. Supine
- B. Right lateral
- C. Sitting position with legs dangling off the edge of the bed
- D. Left lateral
Correct Answer: B
Rationale: Right lateral positioning (B) applies pressure to the biopsy site, minimizing bleeding risk post-liver biopsy.