Nokea
Which of the following actions is appropriate for the nurse to take?
- A. Add medication directly to enteral feeding
- B. Dissolve the medication together
- C. Use a syringe to allow the medications to flow by gravity
- D. Flush the NG tube with 5 ml water
Correct Answer: D
Rationale: The correct answer is D: Flush the NG tube with 5 ml water. This action is appropriate because flushing the NG tube with water helps prevent clogging and ensures proper medication administration. Adding medication directly to enteral feeding (choice A) can lead to tube clogging. Dissolving medications together (choice B) can alter their effectiveness. Using a syringe to allow medications to flow by gravity (choice C) may not be sufficient for complete administration. Flushing the NG tube with water (choice D) maintains tube patency. No further choices provided.
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Which finding should the nurse identify as a potential indication of increased intracranial pressure?
- A. Increasingly severe headache
- B. Bradycardia and hypertension
- C. Dilated, non-reactive pupils
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Increasingly severe headache is a common symptom of increased intracranial pressure due to brain tissue compression. Bradycardia and hypertension can occur as a result of increased intracranial pressure affecting the autonomic nervous system. Dilated, non-reactive pupils may indicate brainstem compression. Therefore, all of these findings are potential indications of increased intracranial pressure. Choices A, B, and C all individually point towards different manifestations of increased intracranial pressure, making them incorrect if considered in isolation.
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.
For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
- A. Assist the client with ambulation
- B. Inform the client to expect drowsiness
- C. Monitor for elevated temperature
- D. Assess for urinary retention
- E. Encourage the client to turn from side to side
Correct Answer: C,D,E
Rationale: Monitoring temperature, assessing urinary retention, and encouraging position changes are essential after epidural administration.
Which of the following interventions should the nurse include in the plan?
- A. Speak in a neutral tone when addressing the client.
- B. Force the client to take the prescribed medication.
- C. Encourage the client to discuss their delusions.
- D. Use humor to lighten the mood and build trust.
Correct Answer: A
Rationale: The correct answer is A: Speak in a neutral tone when addressing the client. This intervention is important as it helps maintain a calm and non-threatening environment, promoting effective communication with the client. Speaking in a neutral tone also conveys respect and understanding, which can help build trust and rapport.
Choice B is incorrect because forcing the client to take medication can lead to resistance and worsen the therapeutic relationship. Choice C may not be appropriate as encouraging a client to discuss delusions without proper training or expertise in addressing such issues could potentially exacerbate the situation. Choice D, using humor, may not be suitable in this context as it may not be well received by a client experiencing delusions.
Which of the following actions should the nurse take first?
- A. Review the client's allergy history.
- B. Monitor the client's temperature.
- C. Check the client's latest white blood cell(WBC) count.
- D. Explain the purpose of the medication to the client.
Correct Answer: A
Rationale: The correct answer is A: Review the client's allergy history. This should be done first to prevent potential harm to the client from allergic reactions. Knowing the client's allergy history helps the nurse identify any potential risks associated with administering medications. Monitoring temperature (B) and checking WBC count (C) are important but come after ensuring the safety of medication administration. Explaining the purpose of medication (D) is important but should be done after ensuring the client's safety.