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The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?
- A. Increase the rate to get the volume caught up before discontinuing.
- B. Stop the infusion as ordered.
- C. Taper infusion gradually.
- D. Hang 5% dextrose.
Correct Answer: C
Rationale: Rationale for Correct Answer (C - Taper infusion gradually):
1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances.
2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances.
3. Increasing the rate may cause fluid overload or hyperglycemia.
4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.
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Which piece of data will the nurse use for “B” when using SBAR?
- A. Having chest pain
- B. Pulse rate of 108
- C. History of angina
- D. Oxygen is needed
Correct Answer: C
Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.
The organization of a patients care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice?
- A. It is based on the participation of clinicians without a team leader.
- B. It is based on clinicians of varied backgrounds integrating their separate plans of care.
- C. It is based on communication and cooperation between disciplines.
- D. It is based on medical expertise and patient preference with the support of nursing.
Correct Answer: B
Rationale: Interdisciplinary collaboration involves clinicians from different backgrounds integrating their separate plans of care, ensuring a holistic approach to patient care. This fosters a comprehensive understanding of the patient's needs and individualized care. In contrast, multidisciplinary practice involves clinicians working independently without integrating their plans, potentially leading to fragmented care.
Choice A is incorrect as interdisciplinary collaboration does have a team leader to coordinate and facilitate communication among team members.
Choice C is incorrect because while communication and cooperation are essential in interdisciplinary collaboration, the key distinction is the integration of different perspectives and plans of care.
Choice D is incorrect as interdisciplinary collaboration goes beyond just medical expertise and patient preference, involving professionals from various disciplines working together to address all aspects of patient care.
A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following?
- A. Static stage
- B. Latent stage
- C. Viral set point
- D. Window period
Correct Answer: C
Rationale: The correct answer is C: Viral set point. The viral set point refers to the stable level of HIV in the body after the initial infection. This state indicates a balance between viral replication and the immune response. The other choices are incorrect because: A) Static stage implies no change, which is not the case with HIV levels fluctuating; B) Latent stage refers to a period of inactivity, not the stable state described; D) Window period is the time between infection and detectable antibodies, not the equilibrium state described.
The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patients risk of hypercalcemia?
- A. Stool softeners are contraindicated.
- B. Laxatives should be taken daily.
- C. Consume 2 to 4 L of fluid daily.
- D. Restrict calcium intake.
Correct Answer: C
Rationale: Rationale: Option C is correct because adequate hydration helps prevent hypercalcemia by promoting the excretion of excess calcium in the urine. This reduces the risk of calcium buildup in the blood. Consuming 2 to 4 liters of fluid daily ensures proper hydration, which is crucial for patients at risk for hypercalcemia. Stool softeners (Option A) are not contraindicated and can help prevent constipation, which may be a side effect of some cancer treatments. Laxatives (Option B) should not be taken daily as they can lead to dehydration and electrolyte imbalances. Restricting calcium intake (Option D) is not the primary intervention for preventing hypercalcemia; rather, maintaining adequate hydration is key.
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
- A. Increasing fluid intake
- B. Dribbling of urine
- C. Voiding in small amounts
- D. Voiding within 6 hours of catheter removal
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection.
A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal.
C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem.
D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.