Nokea
Which statement about total parenteral nutrition is true?
- A. Clients are at high risk for infection when they are getting TPN because they are immunocompromised.
- B. Clients are at high risk for hyperglycemia when they are getting TPN because they are diabetic.
- C. The client should perform the Valsalva maneuver when the nurse changes the TPN tubing.
- D. The client should perform the Valsalva maneuver when the nurse changes the TPN dressing.
Correct Answer: C
Rationale: The Valsalva maneuver is used when changing TPN tubing to prevent air embolism by increasing intrathoracic pressure.
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At a 6-month-old infant is being admitted from the emergency department with dehydration secondary to viral gastroenteritis. Which of the following room assignments is the most appropriate for this infant?
- A. A semiprivate room with an 8-year-old child who has had an appendectomy.
- B. A semiprivate room with a 10-year-old child with a dressed head injury.
- C. A private room.
- D. A semiprivate room with a 4-year-old child with leukemia.
Correct Answer: C
Rationale: Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room to prevent the spread of infection.
The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
- A. Ensuring that no lubricant is on the paddles
- B. Placing the charged paddles one at a time on the client's chest
- C. Holding the client's upper torso stable while the defibrillation is performed
- D. Assuring that all assisting personnel are clear of the client and the client's bed
Correct Answer: D
Rationale: Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of 'all clear.' For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.
You routinely use the PQRST method to assess pain. The PQRST method consists of:
- A. Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
- B. Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
- C. Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
- D. Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
When preparing a 3-year-old child for blood specimens to be drawn for laboratory testing, the nurse should?
- A. Explain the procedure in advance
- B. Explain why the blood needs to be drawn
- C. Use distraction techniques during the procedure
- D. Provide verbal explanations about what will occur
Correct Answer: C
Rationale: Distraction techniques are most effective for a 3-year-old during painful procedures like blood draws, as they have limited understanding of explanations. Simple preparation may help, but distraction is key.
After instructing a primiparous client who is breast-feeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she states which of the following?
- A. I should position the baby the same way for each feeding.'
- B. I should make sure the baby grasps the entire areola and nipple.'
- C. I should air dry my breasts and nipples for 10 to 15 minutes after the feeding.'
- D. I shouldn't use a hand breast pump if my nipples get sore.'
Correct Answer: A
Rationale: Varying the baby's position during feeding prevents nipple soreness, so using the same position indicates a need for further instruction.