Nokea
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create
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A client wakes up in the postanesthesia care unit and sees a drain with bright red fluid in it exiting from her total hip incision. She asks the nurse, 'Is this supposed to be there?' Which of the following represents the nurse's best response?
- A. œThe drainage is blood and fluid that must be drained out for healing.'
- B. œDon't worry about it. I will explain it when you are more awake.'
- C. œThis blood is being kept sterile and will be given back to you.'
- D. œI will give you something to make you sleep so you will not worry.'
Correct Answer: A
Rationale: Explaining that the drain removes blood and fluid for healing reassures the client and accurately describes the purpose of the drain in a total hip incision.
The nurse is teaching a client about a newly prescribed doxycycline. Which of the following statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication with milk or cheese.
- B. If I develop foul-smelling diarrhea I should contact my doctor.
- C. I need to wear sunscreen outdoors while taking this medication.
- D. I can stop this medication when I feel better.
- E. I should take this medication on an empty stomach.
Correct Answer: A,D
Rationale: Doxycycline should not be taken with dairy products like milk or cheese (Choice A) because calcium can bind to the medication and reduce its absorption. Choice D is incorrect because antibiotics like doxycycline should be taken for the full prescribed course to prevent resistance and ensure complete treatment. Choice B is correct; foul-smelling diarrhea could indicate a serious infection like Clostridium difficile. Choice C is correct; doxycycline causes photosensitivity, requiring sunscreen. Choice E is correct; taking doxycycline on an empty stomach improves absorption.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
The nurse is teaching a group of teenage boys who are on a baseball team about the risks of chewing tobacco. Which of the following should the nurse instruct the teenagers to report to their parents and physicians? Select all that apply.
- A. Dysphagia.
- B. Sessibility in the
- C. Unexplained mouth pain.
- D. Lump in the neck.
- E. Decreased saliva.
- F. White patch on the mucosa.
Correct Answer: C,D,F
Rationale: Chewing tobacco is a known risk factor for oral cancer and other oral health issues. Symptoms such as unexplained mouth pain, a lump in the neck, and white patches on the mucosa are concerning and could indicate serious conditions like oral cancer or precancerous lesions, requiring immediate medical attention. Dysphagia and decreased saliva are less specific and not directly linked to chewing tobacco risks in this context.
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate?
- A. Placing a pillow in the axilla so the arm is away from the body.
- B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.
- C. Immobilizing the extremity in a sling.
- D. Positioning a hand cone in the hand so the fingers are barely flexed.
- E. Keeping the arm at the side using a pillow.
Correct Answer: A,D
Rationale: Placing a pillow in the axilla (A) prevents adduction contractures, and a hand cone (D) maintains slight finger flexion to avoid claw-hand deformity. A sling or keeping the arm at the side may promote contractures, and elevating the hand above the elbow is less critical.