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The nurse is monitoring a client who was recently prescribed total parenteral nutrition (TPN). Which action should the nurse take when obtaining a fingerstick glucose reading of 425 mg/dL (24.28 mmol/L)?
- A. Stop the TPN.
- B. Administer insulin.
- C. Notify the primary health care provider.
- D. Decrease the flow rate of the TPN.
Correct Answer: C
Rationale: Hyperglycemia is a complication of TPN, and the nurse should report abnormalities to the primary health care provider. Options 1, 2, and 4 are not done without a primary health care provider's prescription.
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The nurse provides information to a client diagnosed with insulin-dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (4 mmol/L) should the nurse include in the information? Select all that apply.
- A. Hunger
- B. Sweating
- C. Weakness
- D. Nervousness
- E. Cool clammy skin
- F. Increased urinary output
Correct Answer: A,B,C,D,E
Rationale: Hypoglycemia is characterized by a blood glucose level less than 70 mg/dL (4 mmol/L). Clinical manifestations of hypoglycemia include hunger, sweating, weakness, nervousness, cool clammy skin, blurred vision or double vision, tachycardia, and palpitations. Increased urinary output is a manifestation of hyperglycemia.
The nurse is monitoring a client diagnosed with a ruptured appendix for signs of peritonitis. The nurse should assess for which manifestations of this complication? Select all that apply.
- A. Bradycardia
- B. Distended abdomen
- C. Subnormal temperature
- D. Rigid, boardlike abdomen
- E. Diminished bowel sounds
- F. Inability to pass flatus or feces
Correct Answer: B,D,E,F
Rationale: Peritonitis is an acute inflammation of the visceral and parietal peritoneum, the endothelial lining of the abdominal cavity. Clinical manifestations include distended abdomen; a rigid, boardlike abdomen; diminished bowel sounds; inability to pass flatus or feces; abdominal pain (localized, poorly localized, or referred to the shoulder or thorax); anorexia, nausea, and vomiting; rebound tenderness in the abdomen; high fever; tachycardia; dehydration from the high fever; decreased urinary output; hiccups; and possible compromise in respiratory status.
A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure is not effective?
- A. Code cart
- B. A small-bore needle
- C. Extra-large drainage bottle
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Empyema is the collection of pus within the pleural cavity. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion. A small-bore needle would not effectively allow exudate to drain. Options 1 and 3 are also unnecessary.
A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?
- A. Dull and aching pain in the costovertebral area
- B. Aching and cramplike pain throughout the abdomen
- C. Pain that is sharp and radiating posteriorly to the spinal column
- D. Pain that is excruciating, wavelike, and radiating toward the genitalia
Correct Answer: D
Rationale: The pain of ureteral colic is caused by movement of a stone through the ureter and is sharp, excruciating, and wavelike, radiating to the genitalia and thigh. The stone causes reduced flow of urine, and the urine also contains blood because of the stone's abrasive action on urinary tract mucosa. Stones in the renal pelvis cause pain that is a dull ache in the costovertebral area. Renal colic is characterized by pain that is acute, with tenderness over the costovertebral area.
The nurse is caring for a client who has been placed in skin traction. Which action by the nurse provides for countertraction to reduce shear and friction?
- A. Using a footboard
- B. Providing an overhead trapeze
- C. Slightly elevating the foot of the bed
- D. Slightly elevating the head of the bed
Correct Answer: C
Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in skin traction (which is applied to a leg), the foot of the bed is elevated. Option 3 provides a force that opposes the traction force effectively without harming the client. A footboard, an overhead trapeze, or elevating the head of the bed is not used to provide countertraction.