Nokea
Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?
- A. White blood cell count
- B. Serum electrolyte levels
- C. Arterial blood gas levels
- D. Hemoglobin and hematocrit levels
Correct Answer: B
Rationale: Serum electrolyte levels are critical to monitor in a client receiving TPN because TPN solutions contain high concentrations of glucose and electrolytes, which can lead to imbalances such as hyperkalemia, hypokalemia, or hyponatremia. These imbalances can cause serious complications, including cardiac dysrhythmias or neurological issues. While white blood cell count, arterial blood gas levels, and hemoglobin and hematocrit levels are important, they are not as directly related to the immediate risks associated with TPN administration as electrolyte levels.
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A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
- A. Raise the head of the bed.
- B. Loosen restrictive clothing.
- C. Remove the pillow and raise the padded side rails.
- D. Position the client on the side with the head flexed forward.
Correct Answer: D
Rationale: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?
- A. Monitoring the temperature
- B. Monitoring the blood pressure
- C. Inspecting the anterior fontanel for bulging
- D. Monitoring the specific gravity of the urine
Correct Answer: C
Rationale: Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.
A client diagnosed with obsessive-compulsive rituals often misses the unit's morning activities because of a bed-making ritual. What nursing action would be therapeutic?
- A. Verbalize tactful, mild disapproval of the behavior.
- B. Discuss the social implications of the behavior with the client.
- C. Help the client to make the bed so that the task can be finished quicker.
- D. Offer reflective feedback, such as, 'I see that you have made your bed several times.'
Correct Answer: D
Rationale: Reflective feedback acknowledges the client's behavior. Verbalizing disapproval and discussing social implications would increase the client's anxiety and reinforce the need to perform the ritual. The client is usually aware of the implications of the behavior. Helping with the ritual is nontherapeutic and also reinforces the behavior.
A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care?
- A. Assist the client in identifying supportive strategies.
- B. Initiate the possibility of placing the baby up for adoption.
- C. Stress the need for Alcoholics Anonymous (AA) meetings.
- D. Encourage the client to continue counseling after the birth.
- E. Encourage the client to participate in her rehabilitation care.
- F. Minimize communication with codependent family members.
Correct Answer: A,C,D,E
Rationale: The nurse provides supportive care by encouraging the client to participate in care and to identify coping strategies. Counseling needs to continue after the infant is born. Communication with family members is important but not when they are supporting the addiction. It is not appropriate to suggest adoption.
Which action should the nurse implement as part of care for a client after a bone biopsy?
- A. Monitoring the vital signs once per day.
- B. Keeping the area in a dependent position.
- C. Administering intramuscular opioid analgesics.
- D. Monitoring the site for swelling, bleeding, or hematoma formation.
Correct Answer: D
Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The vital signs are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position will increase the risk for bleeding. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.