Nokea
A client who is receiving a tube feeding around the clock.
Which of the following nursing actions is MOST appropriate?
- A. Rinse the bag and change the formula every four hours.
- B. Rinse the bag and change the formula every shift.
- C. Change the bag and formula every shift.
- D. Rinse the bag and change the formula every two hours.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
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The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions should the nurse prioritize?
- A. Encourage early ambulation.
- B. Administer pain medication as needed.
- C. Keep the affected leg in adduction.
- D. Monitor the incision for drainage.
Correct Answer: A
Rationale: Early ambulation prevents complications like thrombosis and promotes recovery. Options B, C, and D are secondary or incorrect.
Which of the following medication orders needs further clarification?
- A. Darvocet (propoxyphene/acetaminophen) $65 \mathrm{mg} \mathrm{q} \mathrm{4-6} \mathrm{hr} \mathrm{PRN}$
- B. Nembutal (pentobarbital) $100 \mathrm{mg}$ at bedtime
- C. Coumadin (sodium warfarin) $10 \mathrm{mg}$
- D. Estrace (estradiol) $2 \mathrm{mg}$ q day
Correct Answer: C
Rationale: Coumadin 10 mg lacks a route (e.g., oral) and frequency, requiring clarification. Darvocet , Nembutal , and Estrace are complete orders.
The nurse is caring for a client with chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results should the nurse report immediately?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high, risking hypertension or thrombosis with epoetin alfa. Options B, C, and D are expected or normal.
A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
- A. This Test is performed by sticking my finger and measuring the results.
- B. This Test needs to be performed in the morning before I eat breakfast.
- C. This Test indicates how well my blood sugar has been controlled the past 6-8 weeks.
- D. I must follow my diet carefully for several days before the Test .
Correct Answer: C
Rationale: when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC
The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
- A. An 18-month-old with respiratory syncytial virus.
- B. A 4-year-old with Kawasaki disease.
- C. A 10-year-old with Lyme's disease.
- D. A 16-year-old with infectious mononucleosis.
Correct Answer: A
Rationale: acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children