Nokea
The nurse is caring for a client receiving total parenteral nutrition (TPN), which was initiated twelve hours ago. The priority assessment for this client is which of the following?
- A. Urine output
- B. Oral temperature
- C. Weight
- D. Capillary blood glucose
Correct Answer: D
Rationale: TPN contains high concentrations of glucose, which can lead to hyperglycemia, especially in the early stages of administration. Monitoring capillary blood glucose is critical to detect and manage this potential complication.
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The health care provider (HCP) places an order to administer gentamicin intravenously to a client with acute diverticulitis. It is important the nurse knows that intravenous gentamicin is administered:
- A. Over one minute via IV push
- B. Over two minutes via IV push
- C. As an IV infusion over 15-20 minutes
- D. As an IV infusion over 30 minutes to two hours
Correct Answer: D
Rationale: Gentamicin (D) is administered as an IV infusion over 30 minutes to two hours to ensure safe delivery and minimize toxicity risks like nephrotoxicity.
The nurse is teaching a client about the newly prescribed medication, esomeprazole. Which statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication with meals.
- B. Long term use of this medication may increase my risk for osteoporosis.
- C. The medication will coat my ulcer so I can eat without pain.
- D. I will need frequent laboratory tests while taking this medication.
- E. I may need to take magnesium supplements while on this medication.
Correct Answer: A,C,D
Rationale: Esomeprazole should be taken before meals, not with them; it reduces acid but does not coat ulcers; and routine lab tests are not typically required. Osteoporosis risk and magnesium supplementation are valid concerns.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Notes
0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
Laboratory Results
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Insert a peripheral venous access device (VAD), obtain a stool specimen for culture and sensitivity (C & S), prepare the client for surgery, request an order for a clear liquid diet.
- B. Peritonitis, diverticulitis, appendicitis, gastroenteritis.
- C. Lung sounds, pulse, temperature, hemoglobin and hematocrit.
Correct Answer: B: Appendicitis; A: Insert a peripheral VAD, prepare the client for surgery; C: Temperature, pulse
Rationale: The clinical presentation (right lower quadrant pain, fever, leukocytosis, rigid abdomen) strongly suggests appendicitis (B). Inserting a VAD and preparing for surgery (A) are critical for anticipated appendectomy. Monitoring temperature and pulse (C) tracks infection and hemodynamic status.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply.
- A. Furosemide
- B. Neomycin
- C. Naproxen
- D. Lactulose
- E. Diazepam
Correct Answer: A,B,D
Rationale: Furosemide (A) manages ascites, neomycin (B) reduces gut ammonia production, and lactulose (D) treats hepatic encephalopathy. Naproxen (C) and diazepam (E) can worsen liver dysfunction or encephalopathy.
The nurse is caring for a client with cirrhosis of the liver who is receiving lactulose. Which of the following findings indicate a therapeutic response?
- A. Increased liver enzymes
- B. Increased level of consciousness
- C. Decreased urinary calcium
- D. Increased gastric pH
Correct Answer: B
Rationale: Lactulose reduces ammonia levels in cirrhosis by promoting its excretion, improving hepatic encephalopathy and thus increasing level of consciousness. Increased liver enzymes, decreased urinary calcium, and increased gastric pH are not therapeutic outcomes.