Nokea
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
- A. monitor daily weights and intake and output
- B. monitor serum electrolytes and glucose levels daily
- C. change IV tubing every 48 hours or per facility protocol
- D. change the IV site dressing every 24 hours or per facility protocol
- E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.
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Which of the following factors increase the risk of developing deep vein thrombosis (DVT)? Select all that apply.
- A. Being underweight
- B. Smoking
- C. Having surgery
- D. Taking oral contraceptives
- E. High-protein diet
- F. Immobility
Correct Answer: B,C,D,F
Rationale: DVT risk factors include smoking (B), surgery (C), oral contraceptives (D), and immobility (F). Underweight (A) and high-protein diet (E) are not significant risks.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.
A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?
- A. Disturbed body image related to major changes in the structure and function of the larynx
- B. Ineffective airway clearance related to excess mucus in airway, due to surgical procedure
- C. Imbalanced nutrition less than body requirement related to the inability to have food intake, due to dysphagia
- D. Impaired verbal communication related to inability to talk, due to removal of larynx
Correct Answer: B
Rationale: Ineffective airway clearance is the priority post-laryngectomy due to the risk of mucus obstruction in the new airway (stoma), which can be life-threatening.
When caring for the child with autistic disorder, the nurse should:
- A. Take the child to the playroom to be with peers
- B. Assign a consistent caregiver
- C. Place the child in a ward with other children
- D. Assign several staff members to provide care
Correct Answer: B
Rationale: A consistent caregiver provides stability and reduces anxiety in a child with autism.
The nurse is caring for a client with a tracheostomy tube in place. During tracheostomy care, the nurse accidentally dislodges the tube. Which of the following actions should the nurse take FIRST?
- A. Insert a new tracheostomy tube immediately.
- B. Call for assistance from the respiratory therapist.
- C. Attempt to reinsert the dislodged tube.
- D. Cover the stoma with a sterile dressing.
Correct Answer: A
Rationale: immediate reinsertion of a tracheostomy tube is critical to maintain airway patency