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Total parenteral nutrition(TPN), is one of the home therapies being used for Chelsea Mann, 35, with acute ulcerative colitis causing massive diarrhea. She and her family will need instruction about:
- A. caring for the central catheter.
- B. how to mix the TPN solution.
- C. fixing malfunctions occuring in the IV pump.
- D. teaching the neighbors how to care for her.
Correct Answer: A
Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.
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Sue is having a minor procedure performed. Which type of anesthesia is most likely to be used?
- A. General.
- B. Epidural.
- C. Regional.
- D. Conscious sedation.
Correct Answer: D
Rationale: Conscious sedation is often used for minor procedures.
How can a nurse manager best improve hand-off communication among the staff? (SATA)
- A. Attending hand-off rounds to coach and mentor.
- B. Conducting audits of staff using a new template.
- C. Creating a template of topics to include in the report.
- D. Utilizing the SHARE model as a tool for standardizing hand-off reports and other critical communication.
Correct Answer: D
Rationale: The correct answer is D because utilizing the SHARE model helps standardize hand-off reports and communication.
1. S stands for Situation: providing context.
2. H stands for History: outlining relevant information.
3. A stands for Assessment: sharing assessment findings.
4. R stands for Recommendation: suggesting actions.
5. E stands for Explanation: clarifying any questions.
This model ensures all necessary information is communicated effectively. A, B, and C are incorrect because attending hand-off rounds, conducting audits, and creating templates may not ensure standardized communication like the SHARE model does.
The nurse is caring for a client with trigeminal neuralgia. To assist the client with nutrition needs, the nurse should:
- A. Offer small meals of high calorie soft food.
- B. Assist the client to sit in a chair for meals.
- C. Provide additional servings of fruits and raw vegetables.
- D. Encourage the client to eat fish, liver and chicken.
Correct Answer: A
Rationale: Soft foods minimize facial muscle movement, reducing pain.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
- A. Complete set of vital signs
- B. Palpation and auscultation of the abdomen
- C. Brief neurologic assessment
- D. Initiation of pulse oximetry
Correct Answer: C
Rationale: A brief neurologic assessment helps quickly identify potential brain injuries or other neurological deficits.
A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct Answer: C
Rationale: The correct answer is C because excessive alcohol consumption can raise blood pressure. Step 1: Alcohol can lead to hypertension. Step 2: Limiting alcohol intake is crucial in managing hypertension. Step 3: Choices A, B, and D promote healthy behaviors that help control blood pressure. Summary: Choice C is incorrect as it goes against hypertension management, while choices A, B, and D align with lifestyle modifications for hypertension.