Nokea
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Hemoglobin A1c.
- C. Platelet count.
- D. Serum creatinine.
Correct Answer: A
Rationale: TPN can cause electrolyte imbalances, particularly hyperkalemia or hypokalemia
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The nurse is caring for patients on the surgical floor and has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.
- B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.
- C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.
- D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.
Correct Answer: D
Rationale: Strategy: Think ABCs. (1) does not indicate acute bleeding, small amount of blood (2) expected outcome (3) indicates resolution (4) correct-risk for peritonitis, should be assessed for further symptoms of infection
A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions?
- A. Elevate the head of the bed 30-45°.
- B. Place a pillow behind the patient's knees.
- C. Elevate the knee gatch on the bed 30°.
- D. Lie the client supine with a small pillow under the head.
Correct Answer: A
Rationale: would reduce stress on suture line and provide for comfort
An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
The nurse should
- A. decrease the IV rate to 20 cc/h and notify the physician.
- B. decrease the IV rate to 100 cc/h and continue to monitor the client.
- C. discontinue the IV and start oxygen at 6 L/min.
- D. assess for infiltration of the IV solution.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
A client is scheduled for an intravenous pyelogram (IVP).
Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
- A. A fat-free meal the evening prior to the examination and radiopaque tablets at bedtime.
- B. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
- C. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
- D. Explaining the importance of following directions regarding voiding during the Test .
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) fat-free meal is associated with a gall bladder series (2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter (3) correct-because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the Test
An older man is seen in the outpatient clinic for treatment of an acute attack of gout.
- A. Which nursing intervention is most beneficial for decreasing pain during ambulation in a client with gout?
- B. Perform passive range-of-motion exercises before walking.
- C. Encourage partial weight bearing while ambulating.
- D. Immobilize the extremity between activities.
- E. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: Partial weight bearing reduces pressure and stress on the affected joint, alleviating gout-related pain during ambulation. Passive exercises may worsen pain, immobilization increases stiffness, and restricting walking does not address pain management during necessary movement.