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Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy?
- A. Glycosuria.
- B. A 1- to 2-pound weight gain.
- C. Decreased appetite.
- D. Elevated temperature.
Correct Answer: D
Rationale: An elevated temperature after the first few days of TPN may indicate a complication like infection, particularly catheter-related. Glycosuria can occur with TPN but is managed, a small weight gain is expected, and decreased appetite is not a direct complication. CN: Pharmacological and parenteral therapies; CL: Analyze
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A female receiving radiation therapy for lung cancer complains to the nurse that she is having difficulty sleeping. Which of the following nursing actions is most appropriate?
- A. Suggest the client stop watching television before bed.
- B. Assess the client's usual sleep patterns, amount of sleep, and bedtime rituals.
- C. Tell the client sleeplessness is expected with radiation therapy.
- D. Suggest that the client stop drinking coffee until the therapy is completed.
Correct Answer: B
Rationale: Assessing sleep patterns, amount of sleep, and bedtime rituals provides a comprehensive understanding of the client's insomnia, enabling tailored interventions.
A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive:
- A. Hydromorphone (Dilaudid) I.V.
- B. Diltiazem (Cardizem) PO.
- C. Meperidine (Demerol) I.M.
- D. Promethazine (Phenergan).
Correct Answer: A
Rationale: Severe pain requires a potent analgesic. Hydromorphone I.V. (A) provides rapid, effective pain relief. Diltiazem (B) is for cardiac conditions, not pain. Meperidine (C) is less preferred due to side effects, and promethazine (D) is for nausea, not pain.
Which of the following is the best way for the nurse to begin the preoperative interview?
- A. Walk in the client's room and ask, 'Are you Mrs. Smith?'
- B. Walk in the client's room, sit down, and take the client's blood pressure.
- C. Walk in the client's room, sit down, maintain eye contact, and introduce yourself.
- D. Walk in the client's room, and ask the client her name.
Correct Answer: C
Rationale: Introducing oneself while maintaining eye contact and sitting down establishes rapport and trust, creating a therapeutic environment for the interview. This approach prioritizes patient comfort and communication.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?
- A. Giving the client a written exercise program.
- B. Explaining the exercise program to the client's spouse.
- C. Reassuring the client that he or she can do the exercise program.
- D. Tailoring a program to the client's needs and abilities.
Correct Answer: D
Rationale: Tailoring the exercise program to the client's needs and abilities ensures it is feasible and sustainable, promoting adherence.