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The nurse is preparing to hang a new TPN bag. Which step is essential to prevent infection?
- A. Use clean gloves during setup.
- B. Verify the solution with another nurse.
- C. Change the tubing every 48 hours.
- D. Administer through a peripheral line.
Correct Answer: B
Rationale: Verifying the TPN solution with another nurse ensures accuracy and prevents errors that could lead to infection or other complications. Clean gloves are insufficient (sterile technique is needed), tubing change frequency varies, and TPN is typically given via a central line. CN: Safety and infection control; CL: Synthesize
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An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?
- A. Giving the client a written exercise program.
- B. Explaining the exercise program to the client's spouse.
- C. Reassuring the client that he or she can do the exercise program.
- D. Tailoring a program to the client's needs and abilities.
Correct Answer: D
Rationale: Tailoring the exercise program to the client's needs and abilities ensures it is feasible and sustainable, promoting adherence.
A client on hemodialysis reports muscle cramps. The nurse should:
- A. Increase dialysate flow.
- B. Check electrolyte levels.
- C. Administer a diuretic.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Muscle cramps may indicate electrolyte imbalances, requiring lab assessment.
Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)?
- A. Limit caffeine intake to two cups of coffee per day.
- B. Do not lie down for 2 hours after eating.
- C. Follow a low-protein diet.
- D. Take medications with milk to decrease irritation.
Correct Answer: B
Rationale: Avoiding lying down for 2 hours after eating prevents reflux of stomach contents into the esophagus, a key strategy for managing GERD. The other options are incorrect or exacerbate symptoms.
A client with Buerger's disease smokes two packs of cigarettes a day. Smoking cessation is critical or the client may lose the affected extremity. When helping a client change behavior, it is important to know the client's:
- A. Ability to attend support groups
- B. Goals of the treatment
- C. Perception of the negative behavior
- D. Motivation
Correct Answer: D
Rationale: Motivation is critical for behavior change, such as smoking cessation in Buerger's disease, as it drives the client's commitment to quit. Understanding motivation (e.g., desire to avoid amputation) guides tailored interventions. Support groups, treatment goals, and perception are secondary to motivation.
The family of a client in hospice asks about stopping oral feedings. The nurse should explain that:
- A. Stopping feedings may reduce discomfort.
- B. Feedings must continue to prevent starvation.
- C. Oral feedings are required by law.
- D. Stopping feedings will hasten death.
Correct Answer: A
Rationale: Stopping oral feedings in hospice can reduce discomfort from fluid overload or aspiration, aligning with comfort-focused care.