Nokea
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings indicates a complication of TPN?
- A. Blood glucose of 200 mg/dL.
- B. Temperature of 99°F.
- C. Weight gain of 1 lb per week.
- D. Clear breath sounds.
Correct Answer: A
Rationale: Hyperglycemia (blood glucose of 200 mg/dL) is a common complication of TPN due to high dextrose content, requiring insulin adjustments.
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What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice?
- A. Justice: Equally dividing time and other resources among a group of clients
- B. Beneficence: Doing no harm during the course of nursing care
- C. Veracity: Fully answering the client's questions without any withholding of information
- D. Fidelity: Upholding the American Nurses Association's Code of Ethics
Correct Answer: C
Rationale: Veracity is accurately paired with fully answering the client's questions without withholding information, as it emphasizes truthfulness in nursing practice. Justice involves fair treatment, not just equal time ; Beneficence involves promoting good, not just avoiding harm ; Fidelity is about keeping promises, not specifically the ANA Code .
Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization?
- A. An opt out consent
- B. An implicit consent
- C. An explicit consent
- D. No consent at all is given
Correct Answer: B
Rationale: Implicit consent is given by the client's voluntary admission to an acute care facility, implying agreement to routine treatments and procedures necessary for their care, unless explicitly refused.
A client with a history of heart failure is prescribed lisinopril (Prinivil). The nurse should monitor the client for which of the following adverse effects?
- A. Hyperkalemia.
- B. Hypotension.
- C. Weight loss.
- D. Tachycardia.
Correct Answer: A, B
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia and hypotension.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.
When assessing a 2-month-old infant, the nurse feels a 'click' when abducting the infant's left hip. Which of the following should the nurse do next?
- A. Document the finding as normal for a 2-month-old.
- B. Check the lengths of the femurs to determine if they are equal.
- C. Instruct the mother to keep the leg in an adducted position.
- D. Reschedule the child for a follow-up assessment in 3 weeks.
Correct Answer: B
Rationale: A 'click' during hip abduction suggests developmental dysplasia of the hip, so checking femur lengths helps confirm asymmetry for further evaluation.