Nokea
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their 'chest hurts'. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
- A. Your client may be experiencing a fluid overload.
- B. Your client may be experiencing an embolus.
- C. Your client may be hyperglycemic.
- D. Your client may have an inadvertent pneumothorax.
Correct Answer: B
Rationale: Chest pain and dyspnea in a client receiving TPN suggest a possible embolus, such as a pulmonary embolism, which is a serious complication requiring immediate attention.
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A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?
- A. Clear, serous drainage.
- B. Bright red drainage of 50 mL in 2 hours.
- C. Slight swelling around the drain site.
- D. Drainage with a foul odor.
Correct Answer: B
Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.
A client with a history of pancreatitis is admitted with abdominal pain. The nurse should expect which of the following laboratory findings?
- A. Elevated amylase and lipase.
- B. Decreased white blood cell count.
- C. Elevated hemoglobin.
- D. Decreased blood glucose.
Correct Answer: A
Rationale: Elevated amylase and lipase are hallmark laboratory findings in pancreatitis due to pancreatic enzyme release.
Sexually transmitted diseases are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and to maintain the patient's confidentiality. The client's family cannot request release of medical information without the client's consent. A physician's order is not a substitute for a client's consent to release medical information in the absence of a communicable disease.
- A. Report the disease to the public health agency while maintaining confidentiality.
- B. Share the information with the client's family.
- C. Obtain a physician's order to release information.
- D. Disclose the information to the client's employer.
Correct Answer: A
Rationale: Reporting STDs to public health agencies is mandatory, but confidentiality must be maintained except in specific legal circumstances.
A client with a diagnosis of Parkinson's disease is prescribed levodopa-carbidopa (Sinemet). The nurse should teach the client that this medication works by:
- A. Reducing muscle spasms.
- B. Increasing dopamine levels in the brain.
- C. Blocking acetylcholine receptors.
- D. Decreasing serotonin levels.
Correct Answer: B
Rationale: Levodopa-carbidopa increases dopamine levels in the brain, helping to alleviate Parkinson's symptoms.
A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother?
- A. The neonate will need to be bottle-fed for the next few days.
- B. The condition typically is treated with I.V. antibiotic therapy.
- C. The client's uterus may become 'boggy,' requiring frequent massage and oxytocics.
- D. The client needs to remain in bed in a side-lying position as much as possible.
Correct Answer: B
Rationale: Endometritis is typically treated with I.V. antibiotics to address the infection.