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 B

Explanation

A Furosemide is likely to cause hypotension rather than hypertension.

B. Limiting salt intake is highly recommended while on furosemide because excess sodium can cause the body to retain water, which can worsen fluid retention and undermine the effectiveness of the diuretic.

C. Checking the pulse is important for certain medications that can affect heart rate, like beta-blockers. However, furosemide is not typically associated with major effects on pulse rate.

D. While increasing potassium-rich foods such as cantaloupe can be beneficial in managing electrolyte balance, it does not specifically address a potential adverse effect of the medication.

A. Negative sputum cultures for acid-fast bacteria B. Positive Quantiferon-TB Gold test (negative) C. Mantoux skin test revealing an induration of less than 1 mm D. Client no longer coughing up blood-tinged sputum

Correct Answer is A

Explanation

A Sputum cultures for AFB are used to detect the presence of Mycobacterium tuberculosis, the bacteria causing TB. A negative result means that the sputum samples tested do not contain viable TB bacteria that can be transmitted to others. It indicates that the client's TB treatment has been effective in reducing the bacterial load to non-infectious levels.

B. The Quantiferon-TB Gold test is a blood test used to detect TB infection based on the immune response to TB antigens. A positive result indicates TB infection but does not differentiate between latent TB infection (not infectious) and active TB disease (potentially infectious).

C. The Mantoux tuberculin skin test (TST) is another test used to detect TB infection based on a delayed- type hypersensitivity reaction to TB antigens. An induration of less than 1 mm is considered negative and suggests that the client does not have a significant immune response to TB antigens, which could mean they are not infected with TB or the infection is not significant. This finding does not provide information on the client's infectiousness.

D. This indicates improvement in the client's symptoms, as coughing up blood-tinged sputum (hemoptysis) is a common symptom of active pulmonary TB. While improvement in symptoms is an important aspect of TB treatment, it does not directly indicate whether the client is no longer infectious. Infectiousness is primarily determined by microbiological tests such as sputum cultures for AFB.

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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 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?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

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?

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?

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?

A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?

A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?

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 assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?

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.