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The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following findings would indicate a complication of TPN therapy?
- A. Weight gain of 0.5 kg in 24 hours.
- B. Blood glucose level of 200 mg/dL.
- C. Temperature of 99°F (37.2°C).
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia, a common TPN complication due to high dextrose content, requiring insulin adjustment or rate change. Weight gain (A) is expected, low-grade fever (C) is nonspecific, and normal urine output (D) is unremarkable.
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A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101°F (38.3°C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?
- A. Insulin
- B. Hydrocortisone
- C. Potassium
- D. Hypotonic saline
Correct Answer: B
Rationale: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal - not hypotonic - saline solution.
B.C underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7 °C.
Potential complication that can be possibly developed will be:
- A. Sepsis
- B. Hypovolemic
- C. Pain
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Infection, such as sepsis, is a serious complication of skin grafting due to the risk of microbial invasion at the graft site.
Which statement describes factors that help build personal power in an organization?
- A. Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success
- B. Goals are met with the use of networking, mentoring, and coalition building
- C. High visibility and formal power are maintained with a confrontational style
- D. Credibility to one's position is enhanced when professional dress and demeanor are employed
Correct Answer: B
Rationale: Networking, mentoring, and coalition building are positive uses of personal power to meet goals.
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowlers
- D. Side-lying with head flat
Correct Answer: C
Rationale: Semi-Fowlers. Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion, helping to manage increased intracranial pressure.
The incidence of spinal cord defects/ neural tube defects such as meningomyelocele
The incidence of spinal cord defects/ neural tube defects such as meningomyelocele has decreased because
- A. prenatal diagnosis by ultrasound and treatment in the uterus.
- B. maternal ingestion of folic acid prior and during pregnancy.
- C. decreased incidence of smoking and alcohol use during pregnancy.
- D. genetic testing prior to pregnancy.
Correct Answer: B
Rationale: Folic acid supplementation reduces neural tube defects by supporting neural tube closure.