Nokea
While a client is receiving TPN, it is MOST important for the nurse to monitor
- A. vital signs and level of consciousness.
- B. arterial blood gases and liver enzymes.
- C. serum glucose and electrolytes.
- D. skin turgor and daily weights.
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.
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After abdominal surgery, a client has a nasogastric tube attached to low suctioning.
- A. What is the most appropriate nursing intervention for a client with a nasogastric tube who becomes nauseated with decreased gastric secretion flow?
- B. Irrigate the nasogastric tube with distilled water.
- C. Aspirate the gastric contents with a syringe.
- D. Administer an antiemetic medicine.
- E. Insert a new nasogastric tube.
Correct Answer: B
Rationale: Nausea and decreased flow suggest possible NG tube obstruction. Aspirating gastric contents with a syringe confirms tube placement (pH 0-4) and checks for blockages, addressing the cause of symptoms. Irrigation should use normal saline after placement confirmation, and antiemetics or tube replacement do not assess tube function.
A client on a psychiatric unit is glaring across the room and pointing a finger at empty space and yelling. What is the nurse's best response to the client's behavior?
- A. Say to him, 'There is no one there. Keep your voice down.'
- B. Escort the client to his room
- C. Restrain the client
- D. Offer PRN haloperidol (Haldol) as ordered
Correct Answer: B
Rationale: Escorting the client to a quieter space de-escalates agitation and ensures safety, addressing potential psychosis calmly.
During a prenatal visit, a client states: 'I have been very nauseated during my first trimester, and I don't understand the reason.' Which of the following responses by the nurse is BEST?
- A. You are nauseated because of the fatigue you are feeling.'
- B. The nausea is due an increase in the basal metabolic rate.'
- C. The nausea is caused by a secondary elevation in the hormones produced by the endocrine system.'
- D. If you eat different kinds of foods, you won't be nauseated.'
Correct Answer: C
Rationale: during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.