Nokea
During the first 24 hours after total parenteral nutrition (TPN) therapy is started.
The nurse should
- A. monitor vital signs every two hours.
- B. determine urinalysis results.
- C. evaluate blood glucose levels.
- D. compare weight with the previous readings.
Correct Answer: C
Rationale: Strategy: Determine how each assessment relates to TPN. (1) inappropriate (2) inappropriate (3) correct-total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content; important to monitor glucose levels (4) appropriate, but not a priority
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An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?
- A. Agitation, grandiose delusions, euphoria, difficulty concentrating.
- B. Difficulty in decision-making, preoccupation with self, distorted perceptions.
- C. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
- D. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer: A
Rationale: characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
- A. A postoperative appendectomy client who is complaining of incisional pain.
- B. A diabetic client who had a cardiac catheterization in the early AM.
- C. A postoperative cholecystectomy client who is complaining of incisional pain.
- D. A client with congestive heart failure who underwent diuresis in the hospital.
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
A client who has a strong family history of breast cancer tells the nurse that she is taking a drug to prevent breast cancer. The nurse expects the drug that she is receiving is:
- A. Tamoxifen (Nolvadex)
- B. Cyclophosphamide (Cytoxan)
- C. Estrogen (Premarin)
- D. Doxorubicin (Adriamycin)
Correct Answer: A
Rationale: Tamoxifen is used for breast cancer prevention in high-risk individuals due to its anti-estrogenic effects. Cyclophosphamide and Doxorubicin are chemotherapy drugs, not preventive, so B and D are incorrect. Estrogen can increase breast cancer risk, making C incorrect.
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
- A. You should ask your physician for a different drug.
- B. The physician will probably add another drug to your regimen.
- C. You should stop taking the medication if it is not effective.
- D. It takes two to four weeks for Paxil to be effective.
Correct Answer: D
Rationale: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.