Nokea
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze
You may also like to solve these questions
Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and aiding breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective.
A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
- A. Pad sharp surfaces to avoid minor trauma when walking.
- B. Assess for spontaneous petechiae in the extremities.
- C. Keep the room darkened.
- D. Check for blood in the urine.
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.
A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect?
- A. The ventricular rate is increasing.
- B. The absent pulse is now palpable.
- C. The number of premature ventricular contractions is decreasing.
- D. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
Correct Answer: C
Rationale: Amiodarone treats ventricular arrhythmias. A decrease in PVCs indicates the drug is stabilizing the cardiac rhythm, its desired effect.
A client with end-stage cancer is receiving morphine for pain. The family is concerned about addiction. The nurse should explain that:
- A. Addiction is not a concern in terminal illness.
- B. Morphine will be tapered to prevent addiction.
- C. Addiction is common but manageable.
- D. Morphine should be avoided to prevent addiction.
Correct Answer: A
Rationale: In terminal illness, addiction is not a concern, as the priority is pain control to ensure comfort, and this explanation reassures the family.