Nokea
Which complication should the nurse monitor for?
- A. Contractions
- B. Increased fetal movement
- C. Hypertension
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (D) is also important but not typically a primary concern in this situation.
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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 eight 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
Rationale: The correct answer is A because hanging a new bag of TPN and IV tubing every 24 hours helps to prevent bacterial growth and contamination, ensuring the client's safety. TPN solutions are prone to bacterial contamination if left hanging for too long, so changing the bag and tubing every 24 hours is crucial.
Summary of incorrect choices:
B: Obtaining the client's weight every other day is important for monitoring the effectiveness of TPN therapy, but it does not specifically address the procedure for administering TPN.
C: Monitoring the client's blood glucose level every eight hours is essential for managing TPN therapy, but it does not directly relate to the procedure of administering TPN.
D: Increasing the rate of TPN infusion without proper authorization or assessment can lead to serious complications such as hyperglycemia or fluid overload, making this choice incorrect.
Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Instruct the client to avoid five vaccines
- B. Instruct the client to avoid foods high in purines
- C. Instruct the client to use mild soaps for cleansing skin.
- D. Gout
- E. Rheumatoid arthritis (RA)
- F. Systemic lupus erythematosus (SLE)
- G. ANA
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels and responds to dietary modifications. Monitoring uric acid ensures treatment effectiveness.
Which of the following actions should the nurse plan to take?
- A. Document the client's behavior every 15 minutes.
- B. Obtain a prescription for restraints within 4 hours.
- C. Release the restraints every 2 hours to assess circulation.
- D. Discontinue restraints only when the provider removes the order.
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation. Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted. Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at high volume
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices
- D. Assess the client for suicidal ideation
- E. Place the client in a room near the activity room
Correct Answer: B,D
Rationale: [
B: Asking the client about the content of their hallucinations is indicated to gather important information for assessment and treatment planning.
D: Assessing the client for suicidal ideation is crucial to ensure their safety and provide appropriate interventions.
A: Allowing the client to watch TV at high volume is contraindicated as it may exacerbate symptoms or disturb others.
C: Instructing the client on expected hygiene practices may not be a priority compared to assessing hallucinations and suicidal ideation.
E: Placing the client in a room near the activity room is not mentioned in the question and does not address the client's immediate needs.]