Nokea
The nurse is caring for a client who is receiving total parenteral nutrition and has a prescription for an intravenous intralipid infusion. What intervention should the nurse implement before hanging the intralipid infusion?
- A. Refrigerate the bottle of solution.
- B. Add 100 mL normal saline to the infusion bottle.
- C. Place an in-line filter on the administration tubing.
- D. Check the solution for separation or an oily residue.
Correct Answer: D
Rationale: Intralipids provide nonprotein calories and prevent or correct fatty acid deficiency. The nurse checks the solution for separation or an oily appearance because this can indicate a spoiled or contaminated solution. Refrigeration renders the intralipid solution too thick to administer. Because they can affect the stability of the solution, the nurse avoids injecting additives into the intralipid infusion. Furthermore, an in-line filter is not used because it can disrupt the flow of solution by becoming clogged.
You may also like to solve these questions
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
- A. Myasthenic crisis is present.
- B. Cholinergic crisis is present.
- C. This result is a normal finding.
- D. This result is a positive finding.
Correct Answer: B
Rationale: An edrophonium test may be performed to determine whether increasing weakness in a client with previously diagnosed myasthenic is a result of cholinergic crisis (overmedication) with anticholinesterase medications or myasthenic crisis (undermedication). Worsening of the symptoms after the test dose of medication is administered indicates a cholinergic crisis.
The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?
- A. Obtain isopropyl alcohol to add to the bath water.
- B. Allow 5 minutes for the child to soak in the bath water.
- C. Have cool water available to add to the warm bath water.
- D. Warm the water to the same body temperature as the child's.
Correct Answer: C
Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.
The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites?
- A. Loose but intact pin sites
- B. Clear drainage from the pin sites
- C. Purulent drainage from the pin sites
- D. Redness and swelling around the pin sites
Correct Answer: B
Rationale: A small amount of clear drainage ('weeping') may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted, the primary health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.
The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client. When administering the IV potassium chloride, which action should the nurse take?
- A. Inject it as a bolus.
- B. Use a filter in the IV line.
- C. Dilute it per medication instructions.
- D. Apply cool compresses to the IV site.
Correct Answer: C
Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compresses would constrict the blood vessel, which could possibly be more irritating to the vein.
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?
- A. To avoid driving a car for at least 2 weeks
- B. Not to be fitted for a prosthesis for at least 3 months
- C. To avoid sitting for long periods for at least 2 weeks
- D. To report any elevation in temperature to the primary health care provider
Correct Answer: D
Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.