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The nurse is reviewing a client's chart and notes a discrepancy in the TPN order. Which action should the nurse take first?
- A. Adjust the infusion rate to match the order.
- B. Contact the prescribing physician for clarification.
- C. Continue the current infusion rate.
- D. Document the discrepancy in the client's chart.
Correct Answer: B
Rationale: Contacting the prescribing physician for clarification is the first action to resolve a discrepancy in a TPN order, ensuring safety and accuracy. Adjusting the rate, continuing the current rate, or documenting without clarification risks errors. CN: Safety and infection control; CL: Synthesize
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Which of the following diets would be most appropriate in the chronic obstructive pulmonary disease (COPD)?
- A. Low-fat, low-cholesterol diet.
- B. Bland, soft diet.
- C. Low-sodium diet.
- D. High-calorie, high-protein diet.
Correct Answer: D
Rationale: A high-calorie, high-protein diet supports nutritional needs in COPD, where energy expenditure is high and appetite may be low. Other diets are less specific to COPD requirements.
The nurse is assessing a client with hepatitis and notices that the AST and ALT levels have increased. Which of the following statements by the client requires further instruction by the nurse?
- A. I require increased periods of rest.
- B. I follow a low-fat, high carbohydrate diet.
- C. I eat dry toast to relieve my nausea.
- D. I take acetaminophen (Tylenol) for arthritis pain.
Correct Answer: D
Rationale: Acetaminophen (D) is hepatotoxic and should be avoided in hepatitis due to increased liver enzyme levels. Rest (A), a low-fat, high-carbohydrate diet (B), and dry toast for nausea (C) are appropriate.
The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Obtain the client's weight
- B. Ensure ABO type compatibility
- C. Infuse the platelets over 2 to 4 hours
- D. Verify completed consent for platelet transfusion
- E. Obtain pre-transfusion vital signs
Correct Answer: B,D,E
Rationale: Ensuring ABO compatibility prevents transfusion reactions, verifying consent ensures legal and ethical standards, and obtaining pre-transfusion vital signs establishes a baseline for monitoring. Platelet infusions are typically rapid (15–30 minutes), not 2–4 hours, and weight is not routinely required unless dosing is weight-based.
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
The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy?
- A. Acromegaly.
- B. Cushing's disease.
- C. Diabetes mellitus.
- D. Hypopituitarism.
Correct Answer: D
Rationale: Hypophysectomy can impair pituitary function, leading to hypopituitarism, with symptoms like fatigue, weakness, and hormonal deficiencies.