Exhibits

Which of the following actions should the nurse take?

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Obtain client weight twice daily.

Have 3 nurses verify the TPN solution prescription.

Request a prescription for insulin.

Request an antibiotic to be administered.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.

Notify provider to increase TPN rate/hr.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Obtain client weight twice daily

Anticipated: This intervention is anticipated. Monitoring the client's weight is crucial when they are receiving Total Parenteral Nutrition (TPN) to assess for fluid status, nutritional adequacy, and response to therapy. It helps in adjusting TPN rates and managing fluid balance.

Have 3 nurses verify the TPN solution prescription

Anticipated: Verifying TPN solution prescription by multiple nurses is a critical safety measure to prevent errors in TPN administration, which can have serious consequences. This ensures that the TPN solution matches the prescribed order in terms of content, concentration, and rate.

Request a prescription for insulin

Anticipated: Given the client's hyperglycemia (fasting blood glucose of 140 mg/dL) and potential exacerbation by TPN administration (which can be rich in glucose), requesting insulin is appropriate. Insulin helps manage blood glucose levels and prevent hyperglycemia, especially important in clients with diabetes or those on TPN.

Request an antibiotic to be administered

Anticipated: The client presents with signs of infection (fever, productive cough, yellow sputum) and crackles auscultated in the lungs, indicating a possible respiratory infection. Requesting antibiotics is essential to treat the infection promptly and prevent further complications.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula

Nonessential: The client is currently receiving 2 L/min oxygen via nasal cannula with an oxygen saturation of 90%. Decreasing the oxygen flow may compromise oxygenation further, especially given the crackles and productive cough. It is more appropriate to maintain or potentially increase oxygen support based on the client's oxygen saturation.

Notify provider to increase TPN rate/hr

Contraindicated: The client has diarrhea (3 episodes in the past 4 hours) and an abdominal distension, which may indicate gastrointestinal intolerance to TPN. Increasing the TPN rate could exacerbate diarrhea and worsen fluid and electrolyte imbalances. It is important to address the underlying cause of diarrhea and abdominal symptoms before considering any increase in TPN rate.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A Breathing exercises can help improve lung function and oxygenation. However, the specific type of breathing exercise is crucial. Emphysema typically involves air trapping due to loss of elasticity in the lungs, so teaching a breathing exercise with a longer exhalation phase (to facilitate complete exhalation and prevent air trapping) would be more beneficial than emphasizing a longer inhalation phase.

B. Fluid restriction is not typically indicated for clients with emphysema. It is more relevant for conditions where fluid overload can exacerbate symptoms (like congestive heart failure). In emphysema, maintaining adequate hydration is important to keep secretions thin and more manageable for clearing.

C.Incentive spirometry is used to help promote deep breathing and prevent atelectasis (lung collapse) by encouraging the client to take slow, deep breaths. However, incentive spirometry is typically more useful for clients recovering from surgery or immobilized clients rather than for those with emphysema.

D. The use of oxygen therapy at 2 L/min is a standard intervention for clients with emphysema who have low oxygen levels, as it helps maintain proper oxygenation. It is crucial to manage oxygen levels carefully to prevent complications such as hypoxia or pulmonary hypertension while avoiding excessive oxygen, which may reduce the patient's drive to breathe.

A. "My parent has type 2 diabetes mellitus." B. "I wish my family was more supportive of my decision." C. "I am not very good about taking prescribed medication." D. "I had symptoms of asthma when I was a child."

Correct Answer is C

Explanation

C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.

A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.

B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.

D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Exhibits Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Obtain client weight twice daily

Have 3 nurses verify the TPN solution prescription

Request a prescription for insulin

Request an antibiotic to be administered

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula

Notify provider to increase TPN rate/hr

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

Correct Answer is C

Explanation

A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching?

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?

Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Exhibits

Which of the following actions should the nurse take?

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.