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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Family visits should be limited to 30 minutes per day to minimize their exposure.

A It should be worn consistently by the nurse caring for the client with the radiation implant to monitor their radiation exposure. Giving it to the oncoming nurse at the end of the shift is not appropriate because it does not provide real-time monitoring of radiation exposure for the nurse during their shift.

C. Soiled linens should be kept in the room until the radioactive source is removed to prevent the spread of contamination

D. One should never touch it directly; instead, use long-handled forceps and place it in a lead-lined container for safe disposal.

A. Client report of nausea B. Serosanguineous drainage C. Muscle twitching D. Client report of incisional pain

Correct Answer is C

Explanation

C. Muscle twitching post-thyroidectomy can indicate hypocalcemia, a common complication due to inadvertent damage or removal of the parathyroid glands during surgery. Hypocalcemia can lead to neuromuscular irritability, including muscle twitching, tingling, or tetany.

A Nausea is a common postoperative symptom and can be caused by anesthesia, pain medications, or changes in gastrointestinal function. While uncomfortable, nausea alone is typically not an urgent concern

B Serosanguineous drainage (thin, pink-tinged fluid) from the surgical incision is expected in the early postoperative period. It indicates normal wound healing and does not usually require urgent attention

D. Routine incisional pain does not typically require urgent reporting unless accompanied by other concerning symptoms.

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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 caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?

A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?

A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?

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.