A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Change the PN infusion bag every 48 hr.

Administer the PN and fat emulsion separately.

Prepare the client for a central venous line.

Obtain a random blood glucose daily.

Answer and Explanation

The Correct Answer is C

Rationale: Parenteral nutrition (PN) is a method of providing essential nutrients to the body through a central vein. PN is indicated for clients who cannot take oral or enteral nutrition due to intestinal failure or other conditions. PN requires a central venous line because the solution is hypertonic and can cause thrombophlebitis or damage to peripheral veins. A central venous line also allows for better monitoring of fluid balance and electrolyte levels.

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Correct Answer is D

Explanation

The nurse should identify that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPAA because it is not related to the client's care or treatment. The nurse should only share information with health care team members who are directly involved in the client's care or have a legitimate need to know.

A. Deliver a series of high-pitched sounds at random intervals. B. Hold an activated tuning fork against the client's mastoid process. C. Whisper a series of words softly into one ear. D. Place an activated tuning fork in the middle of the client's forehead.

Correct Answer is D

Explanation

Place an activated tuning fork in the middle of the client's forehead. The rationale for this answer is that Weber's test is used to assess for conductive or sensorineural hearing loss by comparing bone conduction in both ears. The nurse places an activated tuning fork in the middle of the client's forehead and asks if the sound is heard equally in both ears or louder in one ear.

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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPAA?

Correct Answer is D

Explanation

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

Correct Answer is D

Explanation

A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier?

A nurse is speaking with the partner of a client who is unconscious and has a do-not resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test?

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?