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

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Correct Answer is D

Explanation

D. This practice is recommended as a safety precaution to minimize the risk of radioactive contamination following treatment with radioactive isotopes. It helps to ensure that any residual radioactivity is contained and not inadvertently spread, which is particularly important in shared or public bathrooms.

A The recommended distance is typically at least 1 meter (approximately 3 feet), although specific guidelines may vary depending on the type and dose of radiation used.

B. The use of cloth handkerchiefs versus disposable tissues does not significantly affect radiation safety. The focus should be on minimizing contamination and ensuring proper disposal of any tissues or materials that come into contact with bodily fluids.

C. While managing incontinence appropriately is important for comfort and hygiene, it is not directly related to radiation safety. Clients should use standard incontinence products as needed, ensuring proper disposal and hygiene practices.

A. Measure blood glucose every 2 hr. B. Instruct the client to lie flat C. Instruct the client to expect tingling in their extremities. D. Limit the client's fluid intake.

Correct Answer is B

Explanation

B. After a lumbar puncture, instructing the client to lie flat on their back for a period of time (often 1-2 hours) helps prevent complications such as headaches due to CSF leakage and promotes proper sealing of the puncture site.

A Monitoring blood glucose every 2 hours is not typically necessary immediately following a lumbar puncture unless the client has pre-existing diabetes or there are specific indications to monitor glucose levels

C Tingling in the extremities is not an expected or normal occurrence following a lumbar puncture. It could indicate neurological complications such as nerve irritation or damage, which would require prompt assessment and intervention.

D. The nurse should encourage adequate hydration unless contraindicated by the client's medical condition or specific post-procedure instructions.

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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 providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication the client is no longer infectious?

A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

Exhibits A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?

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.