Nokea
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose level of 180 mg/dL.
- B. Temperature of 100.4°F (38°C).
- C. Weight gain of 1 kg in 24 hours.
- D. Potassium level of 3.8 mEq/L.
Correct Answer: B
Rationale: A temperature of 100.4°F suggests infection, a serious complication in TPN due to catheter-related bloodstream infections. Options A, C, and D are less urgent: hyperglycemia is common and manageable, rapid weight gain may indicate fluid overload, and potassium 3.8 mEq/L is normal.
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A low-purine diet is ordered for a client who has uric acid kidney stones. Which foods should the client avoid? Select all that apply.
- A. Eggs
- B. Chicken
- C. Liver
- D. Oats
- E. Lentils
- F. Lobster
Correct Answer: C,F
Rationale: Liver and lobster are high-purine foods, increasing uric acid production, which worsens uric acid kidney stones. Eggs, chicken, oats, and lentils are lower in purines and safer.
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
The nurse is teaching a client with a new diagnosis of hypertension about lisinopril (Prinivil). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report a persistent dry cough.
- C. Stop the medication if blood pressure is normal.
- D. Avoid regular blood pressure checks.
Correct Answer: B
Rationale: A persistent dry cough is a common lisinopril side effect, requiring reporting. Options A, C, and D are incorrect.
An 11-year-old boy with a minor head injury treated at the outpatient clinic.
The nurse determines that further teaching is necessary if the mother makes which of the following statements? dimensional visualization of the vertebral canal.'
- A. My son may have dizziness for 24 hours.'
- B. My son can drink carbonated beverages if he vomits.'
- C. My son may complain of nausea.'
- D. My son will probably have a headache.'
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) correct-unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours, should not get more intense
The nurse is administering digoxin to a 6-month-old infant. Which finding would cause the nurse to withhold the medication and notify the charge nurse or the physician?
- A. Apical heart rate of 85
- B. Appears lethargic
- C. Circumoral cyanosis
- D. Respiratory rate of 38
Correct Answer: A
Rationale: An apical heart rate below 100 in infants indicates bradycardia, a contraindication for digoxin due to toxicity risk, requiring withholding and reporting.