Nokea
The nurse is infusing total parenteral nutrition (TPN) through a peripherally inserted central catheter. The client's TPN was turned off for 1 hour for an MRI. Which action by the nurse is most appropriate for this client?
- A. notify the health care provider for further orders
- B. discard the volume of the TPN that should have been administered and make a note in the chart
- C. double the flow rate on the infusion for 1 hour to keep the TPN on schedule, and then resume the normal flow rate
- D. increase the flow rate on the infusion for two hours to keep the TPN on schedule, and then resume the normal flow rate
Correct Answer: A
Rationale: Notifying the provider ensures proper adjustment of TPN administration, as altering rates or discarding solution can cause metabolic imbalances.
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The doctor has prescribed Claratin (loratidine) for a client with seasonal allergies. The feature that separates Claratin from other antihistamines such as diphenhydramine is that the medication:
- A. Is nonsedating
- B. Stimulates appetite
- C. Is used for motion sickness
- D. Is less expensive
Correct Answer: A
Rationale: Loratadine (Claritin) is a second-generation antihistamine that is nonsedating, unlike first-generation antihistamines like diphenhydramine.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
- A. Russell's traction
- B. Buck's traction
- C. Halo traction
- D. Crutchfield tong traction
Correct Answer: C
Rationale: Halo traction is used for cervical fractures and can be maintained post-discharge for stabilization.
The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?
- A. Insert a straight catheter for residual
- B. Encourage oral intake of fluids
- C. Check perineum for swelling or hematoma
- D. Palpate bladder for distention and position
Correct Answer: D
Rationale: Palpating the bladder assesses for distention, which may indicate urinary retention, guiding further interventions without immediately resorting to invasive measures.
Which instruction would not be included in the discharge teaching of the client receiving chlorpromazine (Thorazine)?
- A. You will need to wear protective clothing or a sunscreen when you are outside.'
- B. You will need to avoid eating aged cheese.'
- C. You should carry hard candy with you to decrease dryness of the mouth.'
- D. You should report a sore throat immediately.'
Correct Answer: B
Rationale: Avoiding aged cheese is relevant for MAO inhibitors, not chlorpromazine, which does not interact with tyramine-containing foods.
A client is admitted with a tumor in the parietal lobe. Which symptoms would be expected due to this tumor's location?
- A. Hemiplegia
- B. Aphasia
- C. Paresthesia
- D. Nausea
Correct Answer: C
Rationale: The parietal lobe processes sensory information. A tumor here may cause paresthesia (abnormal sensations like tingling) due to disruption of sensory pathways.