A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.'
- B. I will obtain the client's weight every other day.'
- C. I will monitor the client's blood glucose level every 8 hours.'
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given.'
Correct Answer: A
Rationale: Correct Answer: A - "I will hang a new bag of TPN and IV tubing every 24 hours."
Rationale: Changing the TPN bag and tubing every 24 hours is crucial to prevent contamination and infection. TPN is a high-risk solution that can support bacterial growth. Changing the bag and tubing decreases the risk of infection and ensures the client receives fresh and uncontaminated TPN.
Summary of Incorrect Choices:
B: Obtaining the client's weight every other day is important for adjusting the TPN formula but does not demonstrate an understanding of the procedure like changing the bag and tubing.
C: Monitoring the client's blood glucose level every 8 hours is important for assessing tolerance to TPN but does not directly relate to the procedural aspect of TPN administration.
D: Increasing the rate of TPN infusion to ensure the correct amount is given is not safe practice and can lead to complications. The rate should be prescribed by the healthcare provider and not arbitrarily increased.
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The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time
- B. Complete an incident report if a client vomits after taking a medication
- C. Inform clients about the action of each medication prior to administration
- D. Read medication labels at least two times prior to administration
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is important for promoting patient safety and informed consent. By educating clients about their medications, nurses empower them to be active participants in their own care and help prevent medication errors. Option A is incorrect because preparing medications for multiple clients simultaneously can increase the risk of errors. Option B is incorrect as vomiting after medication administration should be reported to the healthcare provider, not necessarily as an incident report. Option D is incorrect as reading medication labels only once may lead to oversight of important information.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group
- B. Determine the roles of individual family member
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This should be the first action because understanding each family member's roles can help identify their needs, strengths, and how they can support each other. By determining roles, the nurse can establish a foundation for building effective coping strategies and addressing specific concerns within the family unit.
Incorrect choices:
A: Refer the family to a grief support group - This could be beneficial later on, but it's important to first understand the family dynamics and individual roles.
C: Encourage the family to assign specific tasks to individual family members - Assigning tasks may not address the underlying emotional needs of the family members.
D: Assist the family to establish a daily routine - While routines can be helpful, understanding roles is crucial for tailoring the routine to the family's specific situation.
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Use a face shield with a mask when providing care to the client
- C. Tell the client, 'You seem to be very upset.'
- D. Engage the panic alarm
Correct Answer: C
Rationale: The correct answer is C. When a client is aggravated, pacing, and speaking loudly, it is important to acknowledge their feelings. By telling the client, "You seem to be very upset," the nurse shows empathy and validates the client's emotions. This can help de-escalate the situation by demonstrating understanding and openness to communication. It also allows the nurse to assess the client's needs and concerns effectively.
Choice A is incorrect as initiating seclusion protocol should only be considered for extreme cases where the client poses a danger to themselves or others. Choice B is unnecessary in this situation as it does not address the client's emotional state. Choice D, engaging the panic alarm, is premature and could escalate the situation further.
Select the 5 actions the nurse should take.
- A. Increase the flowrate of the maintenance IV fluid
- B. Have the charge nurse notify the provider
- C. Place the client in a Trendelenburg position.
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix
- F. Administer oxygen at 10 L/min via nonrebreather face mask
Correct Answer: B, C, D, E, F
Rationale: The correct actions (B, C, D, E, F) are based on managing a prolapsed umbilical cord during labor. B is crucial for timely intervention by involving the provider. C (Trendelenburg position) helps alleviate pressure on the cord. D (upward pressure) helps relieve compression on the cord. E aims to prevent cord compression. F (oxygen) supports fetal oxygenation. A is incorrect as increasing IV flowrate isn't a priority. G is not provided.