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The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following complications should the nurse assess for during the therapy? Select all that apply.
- A. Hyperglycemia
- B. Infection
- C. Air embolism
- D. Cardiac tamponade
- E. Dehydration
Correct Answer: A,B,C
Rationale: TPN risks include hyperglycemia (A) from high glucose content, infection (B) due to central line use, and air embolism (C) from improper line management. Cardiac tamponade (D) and dehydration (E) are less directly associated.
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The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question?
- A. Iron sucrose
- B. Enoxaparin
- C. Sucralfate
- D. Hydroxyurea
Correct Answer: B
Rationale: Enoxaparin, an anticoagulant, increases bleeding risk, which is concerning in a client with occult blood in the stool. Iron sucrose treats anemia, sucralfate protects the gastric mucosa, and hydroxyurea is not directly related to gastrointestinal bleeding.
The following scenario applies to the next 1 items
The nurse is caring for a client who presents with acute appendicitis
Item 1 of 1
History of Present Illness
19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting.
Vital Signs
• Oral temperature 101° F (38.3°C)
• Pulse 90/minute
• Respirations 18/minute
• Blood Pressure 110/66 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
• White blood cell count, 11,500 mm3 (5,000-10,000 mm3)
• Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL)
• BUN 26 mg/dL (10-20 mg/dL)
• Potassium 3.3 mEq/L (3.5-5 mEq/L)
Select two (2) findings from the clinical data that require immediate follow-up
- A. Oral temperature 101°F (38.3°C)
- B. White blood cell count, 11,500 mm³
- C. Creatinine, 0.9 mg/dL
- D. Nausea and vomiting
- E. Potassium 3.3 mEq/L
- F. BUN 26 mg/dL
- G. Reports of pain increasing while coughing
Correct Answer: A,D
Rationale: Fever (A) and nausea/vomiting (D) in appendicitis suggest ongoing inflammation or complications, requiring immediate follow-up to prevent rupture or peritonitis.
The nurse has provided medication instruction to a client prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication one hour after meals.
- B. I will remain upright for 30 minutes after taking this medicine.
- C. This medication will help with my peptic ulcer disease.
- D. I know this medication works when my nausea and vomiting are gone.
- E. I may dissolve this medication in warm water.
Correct Answer: A,D,E
Rationale: Sucralfate is taken 1 hour before meals, not after; it treats ulcers but does not primarily relieve nausea/vomiting; and it should not be dissolved in water. Remaining upright and ulcer treatment are correct.
The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention following the procedure?
- A. Administer analgesics to control pain
- B. Monitor for signs of infection
- C. Monitor for signs of hypovolemia
- D. Ensure that the ascitic fluid is sent to the lab for analysis
Correct Answer: C
Rationale: Monitoring for hypovolemia (C) is critical after paracentesis due to the risk of fluid shifts from removing large volumes of ascitic fluid.
The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action before the client's exam?
- A. Remove any medicated patches before the exam
- B. Instruct the client to empty their bladder right before the test
- C. Educate the client that they may experience a flushing sensation during the exam
- D. Assess the client for an implantable pacemaker
Correct Answer: C
Rationale: Educating about the flushing sensation (C) prepares the client for the common effect of IV contrast. Patches (A) are not routinely removed, emptying the bladder (B) is not critical, and pacemakers (D) are relevant for MRI, not CT.