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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
- A. Change the PN infusion bag every 48 hr.
- B. Obtain a random blood glucose daily.
- C. Prepare the client for a central venous line.
- D. Administer the PN and fat emulsion separately.
Correct Answer: C
Rationale: The correct answer is C: Prepare the client for a central venous line. Parenteral nutrition (PN) with high dextrose concentrations can cause phlebitis and tissue damage if administered through a peripheral IV line. Therefore, a central venous line is appropriate for administering PN to prevent complications. Changing the PN bag every 48 hours (A) is important for infection control but not directly related to the administration method. Obtaining a random blood glucose daily (B) is important for monitoring glucose levels but does not address the administration method. Administering the PN and fat emulsion separately (D) is not necessary as they can be mixed in the same solution.
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A nurse is administering multiple types of ophthalmic drugs to a client. Which of the following actions should the nurse take?
- A. Hold the dropper 3 cm (1.2 in) away from the client's eye.
- B. Ask the client to close their eyes tightly after instilling each medication.
- C. Massage the client's eyelids for 2-3 seconds after instillation.
- D. Wait 5 min between the administration of each medication.
Correct Answer: D
Rationale: The correct answer is D: Wait 5 min between the administration of each medication. This is important to prevent dilution or interaction between the different ophthalmic medications. Administering multiple medications too close together can reduce the effectiveness of each medication. Holding the dropper at a specific distance (A) is not as critical as allowing time between administrations. Asking the client to close their eyes tightly (B) or massaging the eyelids (C) after instillation can disrupt the medication and should be avoided. Waiting for 5 minutes allows each medication to be properly absorbed before the next one is administered, ensuring optimal therapeutic effects.
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- A. The JEN Consultant
- B. Podcast League for Nursing
- C. Postnote ID # of Rights
- D. State Nurse Practice Acts
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice. Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses. Therefore, they are incorrect options.
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Physical therapist
- B. Speech-language pathologist
- C. Occupational therapist
- D. Social worker
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. Occupational therapists specialize in helping individuals regain skills needed for daily activities, such as using eating utensils. They focus on enhancing fine motor skills and cognitive abilities necessary for independent living. Referring the client to an occupational therapist will ensure a comprehensive approach to relearning utensil use. Physical therapists (A) focus on mobility and strength, not fine motor skills. Speech-language pathologists (B) address communication and swallowing issues, not utensil use. Social workers (D) assist with psychosocial support, not utensil retraining.
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
- A. The client speaks the same language as the nurse.
- B. The client has legal authority to do so.
- C. The client does not have a mental health condition.
- D. The client signed in the nurse's presence.
- E. The client was not coerced.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. B is essential as the client must have legal authority to give informed consent. D is crucial as the client's signature in the nurse's presence ensures authenticity. E is important to confirm that the client was not coerced. Choice A is incorrect as language proficiency does not determine consent validity. Choice C is incorrect as having a mental health condition does not automatically invalidate consent.
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.