Nokea
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) will be started. The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
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A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?
- A. Teach the client how to cough up secretions
- B. Changes the tracheostomy trach ties
- C. Monitor for skin breakdown around the stoma
- D. Suction the tracheostomy when needed
Correct Answer: B
Rationale: Unlicensed assistive personnel should be able to perform routine tracheostomy care, such as changing trach ties, which is a standard, low-risk task.
Rehabilitation services begin:
- A. when the client enters the health care system.
- B. after the client requests rehabilitation services.
- C. after the client's physical condition stabilizes.
- D. when the client is discharged from the hospital.
Correct Answer: A
Rationale: Rehabilitation starts upon entry into the healthcare system to maximize recovery from the outset. Waiting for stabilization or discharge delays optimal intervention. Health Promotion and Maintenance
A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?
- A. Check the urethral catheter and drainage tubing
- B. Irrigate the catheter with 30 mL sterile normal saline
- C. Notify the registered nurse
- D. Remove and reinsert the next larger size catheter
Correct Answer: A
Rationale: Checking the catheter and tubing first ensures there are no kinks, blockages, or improper placements causing the leak, which is a non-invasive and logical initial step. Irrigation or removal requires further assessment, and notifying the RN is premature without initial troubleshooting.
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.
A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
- A. All lesions crusted
- B. Elevated temperature
- C. Rhinorrhea and coryza
- D. Presence of vesicles
Correct Answer: A
Rationale: All lesions crusted. The child is no longer contagious when all lesions are crusted over.