RN Adult Medical Surgical Online Practice 2023 A Flashcards
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse’s priority?
1. Temperature 38.4 C (101.1 F)
2. Increased respiratory secretions
3. Fluid intake of 200 mL in the prior 8 hr
4. Limited range of motion
Increased respiratory secretions
CORRECT
Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. Clients who have ALS may experience respiratory muscle weakness and dysphagia, and excessive respiratory secretions can impair the ability to clear the airway, which increases the client’s risk for aspiration.
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?
1. Obtain the client’s vital signs
2. Describe the blood transfusion procedure to the client
3. Check for the type and number of units of blood to administer.
4. Initiate a peripheral IV line
Check for the type and number of units of blood to administer
According to evidence-based practice, the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the client’s medication administration record.
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?
1. Place a padded tongue blade at the client’s bedside
2. keep the side rails lowered on the client’s bed
3. Maintain the client’s bed at hip level o above
4. Ensure that the client has a patent IV.
Place a padded tongue blade at the client’s bedside.
INCORRECT
The nurse should never insert a padded tongue blade in the client’s mouth because it can cause injury or occlude the client’s airway.
Keep the side rails lowered on the client’s bed.
INCORRECT
The nurse should keep two or three side rails up on the client’s bed to prevent falls.
Maintain the client’s bed at hip level or above.
INCORRECT
The nurse should keep the client’s bed in the lowest position to prevent falls.
Ensure that the client has a patent IV.
CORRECT
The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.
A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
- Sedimentation rate
- Hematocrit
- Calcium
- Acid phosphatase
Sedimentation rate
CORRECT
An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.
Hematocrit
INCORRECT
Hematocrit levels are not altered by inflammatory processes such as osteomyelitis.
Calcium
INCORRECT
A client who has a bone fracture can have an alteration in calcium levels due to bone remodeling, but alterations in calcium levels do not indicate an inflammatory process.
Acid phosphatase
INCORRECT
Acid phosphatase levels are altered in a client who has prostate disease. Phosphorus levels have an inverse relationship with calcium levels. Neither phosphorus nor acid phosphatase indicates an inflammatory disorder.
A nurse is preparing to present a program about the prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.)
- Follow a smoking cessation program.
- Maintain an appropriate weight.
- Eat a low-fat diet.
- Increase fluid intake.
- Decrease intake of complex carbohydrates.
Follow a smoking cessation program. (CORRECT)
Smoking cessation is an important lifestyle modification to prevent atherosclerosis.
Maintain an appropriate weight. (CORRECT)
Preventing obesity through diet and exercise can help to prevent atherosclerosis.
Eat a low-fat diet. (CORRECT)
Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis.
Increase fluid intake. (INCORRECT)
Increasing intake of fruits, vegetables, and grains can prevent atherosclerosis.
Decrease intake of complex carbohydrates. (INCORRECT)
Decreasing intake of simple sugars and sweetened foods and increasing complex carbohydrates, such as fiber, can reduce the risk of heart disease.
A nurse is caring for a client who has a potassium level of 3 mEq/L (normal range: 3.5 to 5 mEq/L). Which of the following assessment findings should the nurse expect?
- Positive Trousseau’s sign
- 4+ deep tendon reflexes
- Deep respirations
- Hypoactive bowel sounds
Positive Trousseau’s sign:
INCORRECT
Trousseau’s sign is associated with hypocalcemia, not hypokalemia.
2+ deep tendon reflexes:
INCORRECT
Deep tendon reflexes may be normal or diminished in hypokalemia. A 2+ reflex is within the normal range.
Deep respirations:
INCORRECT
Hypokalemia can lead to shallow breathing due to muscle weakness, not deep respirations.
Hypoactive bowel sounds:
CORRECT
Hypokalemia can result in decreased gastrointestinal motility, leading to hypoactive or absent bowel sounds.
A nurse is providing teaching for a female client who has recurrent urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?
Take tub baths daily.
Drink at least 1 L of fluid daily.
Wear underwear made of nylon.
Void before and after intercourse.
Take tub baths daily. (INCORRECT)
The client should take showers instead of tub baths to prevent bacteria present in bath water from entering the urethra.
Drink at least 1 L of fluid daily. (INCORRECT)
The client should drink 2 to 3 L of fluid daily to keep her urine dilute and to flush bacteria out of the urinary tract.
Wear underwear made of nylon. (INCORRECT)
The nurse should encourage the client to wear underwear made of cotton, which provides improved airflow through the perineal area. Underwear made from nylon traps moisture and provides an opportunity for bacterial growth.
Void before and after intercourse. (CORRECT)
The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and helps prevent the occurrence of infection.
A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?
Obtain a sputum sample.
Administer antipyretics.
Provide hand hygiene education.
Initiate airborne precautions.
Obtain a sputum sample. (INCORRECT)
The nurse should obtain a sputum sample to identify the microorganisms that are causing the client’s illness. However, there is another action that the nurse should take first.
Administer antipyretics. (INCORRECT)
The nurse should administer antipyretics to treat the client’s fever. However, there is another action that the nurse should take first.
Provide hand hygiene education. (INCORRECT)
The nurse should provide hand hygiene education. However, there is another action that the nurse should take first.
Initiate airborne precautions. (CORRECT)
This client is exhibiting manifestations of tuberculosis. The greatest risk in this situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.
A nurse is providing teaching to a client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching?
“It is an expected effect to sleep through the day when taking this medication.”
“Your constipation will be lessened as you develop a tolerance to the medication.”
“You should void every 4 hours to decrease the risk of urinary retention.”
“If you experience ringing in your ears, your dose will need to be reduced.”
“It is an expected effect to sleep through the day when taking this medication.” (INCORRECT)
The nurse should instruct the client to report oversedation, which increases the risk for respiratory depression.
“Your constipation will be lessened as you develop a tolerance to the medication.” (INCORRECT)
The nurse should instruct the client that constipation is an adverse effect of opioid analgesics and can be managed by increasing intake of fiber.
“You should void every 4 hours to decrease the risk of urinary retention.” (CORRECT)
The nurse should instruct the client to void at least every hour to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.
“If you experience ringing in your ears, your dose will need to be reduced.” (INCORRECT)
Many medications, including aspirin and aminoglycosides, can cause ringing in the ears, but this is not an adverse effect of opioid analgesics.
A nurse is providing teaching to a female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?
“Taking my daily progesterone should improve my symptoms.”
“A risk factor for my condition is obesity.”
“I should limit my daily fluid intake.”
“I will switch my morning cup of coffee to hot tea.”
“Taking my daily progesterone should improve my symptoms.” (INCORRECT)
Topical estrogen, not progesterone, can improve blood circulation to the perineal area and enhance the tone of the periurethral muscles for a client who has experienced menopause.
“A risk factor for my condition is obesity.” (CORRECT)
Excess weight creates increased abdominal pressure that can result in stress incontinence.
“I should limit my daily fluid intake.” (INCORRECT)
The client should maintain an adequate intake of water for proper kidney function and hydration.
“I will switch my morning cup of coffee to hot tea.” (INCORRECT)
A client who has stress incontinence should avoid caffeine intake because it is a bladder irritant. Many tea and coffee beverages contain caffeine.
A nurse is assessing a group of clients for indications of role changes. The nurse should identify which of the following clients is at risk for experiencing a role change:
A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose.
A client who had a cholecystectomy and is starting on a modified-fat diet.
A client who has Crohn’s disease and is experiencing diarrhea three times a day.
A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.
“A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose.” (INCORRECT)
The client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose can remain independent and active and is not at risk for experiencing a role change.
“A client who had a cholecystectomy and is starting on a modified-fat diet.” (INCORRECT)
The client who had a cholecystectomy with a diet change can remain independent and active and is not at risk for experiencing a role change.
“A client who has Crohn’s disease and is experiencing diarrhea three times a day.” (INCORRECT)
The client who has Crohn’s disease and is experiencing diarrhea can remain independent and active and is not at risk for experiencing a role change.
“A client who has multiple sclerosis and is experiencing progressive difficulty ambulating.” (CORRECT)
The nurse should identify that the progression of neurologic disease, such as multiple sclerosis, can lead to a role change as the client becomes less independent.
A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse’s priority to report to the provider?
Temperature 37.2° C (99° F)
Blood pressure 100/70 mm Hg
Weight loss
Restlessness
Temperature 37.2° C (99° F) (INCORRECT)
An increased temperature is nonurgent because it is an expected finding for a client who has just completed dialysis. The increase is caused by the dialysis machine slightly warming the blood. Therefore, the nurse should identify another finding as the priority to report.
Blood pressure 100/70 mm Hg (INCORRECT)
A decrease in blood pressure is nonurgent because it is an expected finding for a client who has just completed dialysis. The decrease is a result of the removal of excess fluid from the client’s blood. Therefore, the nurse should identify another finding as the priority to report.
Weight loss (INCORRECT)
Weight loss is nonurgent because it is an expected finding for a client who has just completed dialysis. The weight loss is a result of the removal of excess fluid from the client’s blood. Therefore, the nurse should identify another finding as the priority to report.
Restlessness (CORRECT)
Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can indicate that the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client’s blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.
A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?
“It’s like a curtain closed over my eye.”
“This sharp pain in my eye started 2 hours ago.”
“I’ve been having more and more difficulty seeing over the last few weeks.”
“I seem to have more problems seeing different colors.”
“It’s like a curtain closed over my eye.” (CORRECT)
A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.
“This sharp pain in my eye started 2 hours ago.” (INCORRECT)
Clients who have a retinal detachment may report seeing sudden flashes of light or floating dark spots, but retinal detachment is usually painless.
“I’ve been having more and more difficulty seeing over the last few weeks.” (INCORRECT)
Retinal detachment usually has a sudden onset rather than a gradual decline in vision over weeks.
“I seem to have more problems seeing different colors.” (INCORRECT)
Clients who have cataracts experience a loss in color perception. However, this is not a manifestation of retinal detachment.
A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?
Monitor the client’s temperature every 4 hr.
Insert an indwelling urinary catheter for the client.
Request the client’s bathroom to be cleaned three times each week.
Place a box of latex gloves just outside the client’s room.
Monitor the client’s temperature every 4 hr. (CORRECT)
The nurse should monitor the temperature of a client who has neutropenia every 4 hours because the client’s reduced leukocyte count greatly increases the risk for infection.
Insert an indwelling urinary catheter for the client. (INCORRECT)
The nurse should avoid the insertion of an indwelling urinary catheter for a client who has neutropenia because it can significantly increase the risk of infection.
Request the client’s bathroom to be cleaned three times each week. (INCORRECT)
The nurse should ensure that the client’s room and bathroom are cleaned at least once each day, rather than three times each week, to decrease the client’s risk for infection.
Place a box of latex gloves just outside the client’s room. (INCORRECT)
The nurse should keep a dedicated box of disposable gloves inside the client’s room to decrease the risk of contamination, which can lead to infection.
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse’s priority?
Loosen the clothing around the client’s neck.
Check the client’s pupillary response.
Turn the client to the side.
Move furniture away from the client.
Loosen the clothing around the client’s neck. (INCORRECT)
The nurse should loosen any restrictive clothing the client is wearing to prevent injury, but there is another action that is the priority in this situation.
Check the client’s pupillary response. (INCORRECT)
The nurse should perform neurologic checks after the seizure to monitor the client’s recovery, but this is not the immediate priority action.
Turn the client to the side. (CORRECT)
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.
Move furniture away from the client. (INCORRECT)
The nurse should move furniture away from the client to prevent self-injury. However, this action is not the priority compared to ensuring the client’s airway is protected.
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?
PaCO₂ 56 mm Hg (35 to 45 mm Hg)
pH 7.50 (7.35 to 7.45)
HCO₃⁻ 18 mEq/L (21 to 28 mEq/L)
PaO₂ 130 mm Hg (80 to 100 mm Hg)
PaCO₂ 56 mm Hg (35 to 45 mm Hg) (CORRECT)
A client who has COPD retains PaCO₂ due to the weakening and collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange, causing the PaCO₂ to increase above the expected reference range.
pH 7.50 (7.35 to 7.45) (INCORRECT)
A client who has COPD typically will have a pH less than 7.35 due to poor gas exchange resulting from elevated PaCO₂ and HCO₃⁻ levels, along with low oxygen levels, for an extended period of time.
HCO₃⁻ 18 mEq/L (21 to 28 mEq/L) (INCORRECT)
A client who has COPD will generally have elevated HCO₃⁻ levels as a compensatory response from the kidneys due to chronic respiratory acidosis, leading to a retention of HCO₃⁻ in the blood and an increase in pH over time.
PaO₂ 130 mm Hg (80 to 100 mm Hg) (INCORRECT)
A client who has COPD typically has a low oxygen level due to the weakening and collapse of the alveolar sacs, which decreases the area available in the lungs for gas exchange. A PaO₂ of 130 mm Hg indicates hyperoxia, which is not typical in COPD patients.
A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?
Increase intake of foods containing calcium.
Alternate application of heat and cold to the affected joints.
Keep the affected extremities elevated.
Limit movement of the affected joints.
Increase intake of foods containing calcium. (INCORRECT)
While adequate calcium intake is important to prevent bone loss, this action does not directly reduce pain. The client should consume a balanced diet high in nutrients, such as protein, vitamins, and iron, to promote tissue repair.
Alternate application of heat and cold to the affected joints. (CORRECT)
The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. Cold applications can relieve joint swelling, while heat can decrease joint stiffness and pain.
Keep the affected extremities elevated. (INCORRECT)
Elevating the affected extremities does not relieve the painful inflammation caused by rheumatoid arthritis, which is an autoimmune inflammatory disease. Elevation can help manage pain in clients with peripheral vascular disease, but it is not effective for rheumatoid arthritis.
Limit movement of the affected joints. (INCORRECT)
Although exercising affected joints can be painful, regular exercise is important to prevent stiffness and maintain joint function.
A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?
Check laboratory values for recent hemoglobin and hematocrit levels.
Establish a peripheral IV line for possible transfusion.
Call the laboratory to obtain a stat platelet count.
Obtain vital signs.
Check laboratory values for recent hemoglobin and hematocrit levels. (INCORRECT)
While checking hemoglobin and hematocrit levels is important to assess the need for blood product replacement, there is another action the nurse should take first.
Establish a peripheral IV line for possible transfusion. (INCORRECT)
Although initiating a peripheral IV line for saline or blood administration is essential, there is another action the nurse should take first.
Call the laboratory to obtain a stat platelet count. (INCORRECT)
Checking for a low platelet count is crucial since it indicates potential problems with blood clotting. However, there is another priority action the nurse should take first.
Obtain vital signs. (CORRECT)
The first action the nurse should take using the nursing process is to assess the client’s vital signs. A client with portal hypertension can develop esophageal varices, which are fragile and can rupture, leading to significant blood loss and shock. Obtaining vital signs provides critical information about the client’s condition that aids in decision-making.
A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?
Flush the line before administering antibiotics.
Position the client in Trendelenburg to obtain measurements.
Have the client bear down when readings are obtained.
Place a pressure bag around the flush solution.
Flush the line before administering antibiotics. (INCORRECT)
An arterial line is not appropriate access for administering antibiotics. The nurse should use the arterial line to obtain arterial blood gas samples and monitor hemodynamic pressures.
Position the client in Trendelenburg to obtain measurements. (INCORRECT)
The most appropriate positioning for a client while recording values from an arterial line is supine with the head of the bed elevated up to 60°.
Have the client bear down when readings are obtained. (INCORRECT)
Accurate readings from an arterial line cannot be obtained by having the client bear down since this action temporarily increases arterial pressure.
Place a pressure bag around the flush solution. (CORRECT)
The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line. This helps maintain a consistent flow of the flush solution into the arterial line.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse’s priority?
Moderate serosanguinous drainage on the dressing
Calcium 9.5 mg/dL (9 to 10.5 mg/dL)
Temperature 38.9° C (102° F)
Decreased bowel sounds
Moderate serosanguinous drainage on the dressing (INCORRECT)
Moderate serosanguinous drainage on the dressing is nonurgent because it is an expected finding for a client who is postoperative following a thyroidectomy. Therefore, there is another finding that is the nurse’s priority.
Calcium 9.5 mg/dL (9 to 10.5 mg/dL) (INCORRECT)
A serum calcium level of 9.5 mg/dL is nonurgent because it is within the expected reference range. The nurse should monitor the client for hypocalcemia following a thyroidectomy; however, there is another finding that is the nurse’s priority.
Temperature 38.9° C (102° F) (CORRECT)
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.
Decreased bowel sounds (INCORRECT)
Decreased bowel sounds are nonurgent because it is an expected finding for a client who is postoperative following a thyroidectomy due to general anesthesia. Therefore, there is another finding that is the nurse’s priority.
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?
Flex the foot every hour when awake.
Place a pillow under the knee when lying in bed.
Lower the leg when sitting in a chair.
Ensure the leg is abducted when resting in bed.
Flex the foot every hour when awake. (CORRECT)
The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.
Place a pillow under the knee when lying in bed. (INCORRECT)
The nurse should instruct the client to avoid placing pillows under the knee to prevent flexion contractures.
Lower the leg when sitting in a chair. (INCORRECT)
The nurse should instruct the client to elevate the leg when sitting in a chair to reduce edema and pain.
Ensure the leg is abducted when resting in bed. (INCORRECT)
The nurse should instruct the client to keep the operative leg in a neutral position when resting in bed to prevent dislocation of the knee.
A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?
“Ginkgo biloba relieves nausea for people who have vertigo.”
“Taking ginkgo biloba will help relieve your joint pain.”
“Ginkgo biloba can cause an increased risk for bleeding.”
“Taking ginkgo biloba decreases the risk of migraine headache.”
“Ginkgo biloba relieves nausea for people who have vertigo.” (INCORRECT)
Ginger root is a supplement that treats nausea caused by vertigo. Ginger root’s actions are similar to that of the antiemetic ondansetron in that both medications block serotonin receptors in the medulla.
“Taking ginkgo biloba will help relieve your joint pain.” (INCORRECT)
Glucosamine is a supplement that treats joint pain by reducing inflammation and promoting the body’s ability to make cartilage and synovial fluid.
“Ginkgo biloba can cause an increased risk for bleeding.” (CORRECT)
Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.
“Taking ginkgo biloba decreases the risk of migraine headache.” (INCORRECT)
Feverfew decreases the risk of migraine headache, as well as the intensity of manifestations, when taken prophylactically. Its actions are not well understood, but it is known that feverfew can decrease platelet aggregation and can increase the risk for bleeding.
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Insert a padded tongue blade.
Apply oxygen.
Restrain the client.
Loosen restrictive clothing.
Insert a padded tongue blade. (INCORRECT)
The nurse should not insert anything into the client’s mouth during the seizure. A tongue blade can create a choking hazard and cause injury to the client’s teeth and mouth.
Apply oxygen. (INCORRECT)
Clients who experience a tonic-clonic seizure can become hypoxic for brief intervals and may be offered oxygen in the postictal phase, but supplemental oxygen is not usually necessary.
Restrain the client. (INCORRECT)
The nurse should not restrain the client in any way during the seizure but should instead clear the area of objects close to the client to prevent injury.
Loosen restrictive clothing. (CORRECT)
The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.
A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?
Airbone
Droplet
Contact
Protective environment
Airborne (CORRECT)
Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster.
Droplet (INCORRECT)
Droplet precautions are required for clients who have infections due to micro-organisms that live in droplets but do not remain suspended in air for lengthy periods of time, such as influenza, rubella, pneumonia, streptococcal pharyngitis, pertussis, and mumps.
Contact (INCORRECT)
Contact precautions are required for clients who have infections that spread via direct contact or contact with the environment, such as vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, respiratory syncytial virus, scabies, and infections with Clostridium difficile.
Protective environment (INCORRECT)
Some clients who are immunocompromised require a protective environment.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?
Check the client’s blood glucose according to facility mealtimes.
Contact the provider to clarify the prescription.
Request for meals to be provided for the client.
Hold the prescription until the client is no longer NPO.
Check the client’s blood glucose according to facility mealtimes. (Incorrect)
Rationale: TPN contains a high amount of glucose, leading to the potential for hyperglycemia. The nurse should monitor blood glucose levels according to a scheduled protocol (e.g., every 6 hours) rather than mealtimes, especially since the client is NPO.
Contact the provider to clarify the prescription. (Correct)
Rationale: The client’s NPO status indicates that mealtimes are not applicable. Therefore, the nurse should clarify the prescription related to blood glucose monitoring or management.
Request for meals to be provided for the client. (Incorrect)
Rationale: An NPO status means that the client cannot have food or fluids by mouth. Meals cannot be reintroduced without a provider’s prescription, and there’s no indication that this client’s NPO status has changed.
Hold the prescription until the client is no longer NPO. (Incorrect)
Rationale: The nurse should continue to monitor blood glucose levels on a set schedule due to the glucose content in TPN, regardless of the client’s NPO status.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?
Keep the line open with 0.9% sodium chloride until the new bag arrives.
Administer dextrose 10% in water until the new bag arrives.
Flush the line and cap the port until the new bag arrives.
Decrease the infusion rate until the new bag arrives.
Keep the line open with 0.9% sodium chloride until the new bag arrives. (Incorrect)
Rationale: Infusing 0.9% sodium chloride can alter the client’s blood glucose levels, potentially causing harm.
Administer dextrose 10% in water until the new bag arrives. (Correct)
Rationale: TPN solutions contain high concentrations of dextrose. Administering dextrose 10% or 20% in water helps prevent a significant drop in the client’s blood glucose level.
Flush the line and cap the port until the new bag arrives. (Incorrect)
Rationale: The nurse should maintain an open IV line with an appropriate solution to avoid fluctuations in blood glucose levels.
Decrease the infusion rate until the new bag arrives. (Incorrect)
Rationale: Continuing to infuse IV fluids with the correct solution is necessary to prevent alterations in the client’s blood glucose levels.
A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the nurse expect?
Stone fragments in the urine
Fever
Decreased urine output
Bruising on the lower abdomen
Stone fragments in the urine (Correct)
Rationale: ESWL aims to break the calculi into fragments that can pass down the ureter, into the bladder, and through the urethra during voiding. After the procedure, the nurse should strain the client’s urine to confirm the passage of stones.
Fever following ESWL (Incorrect)
Rationale: Fever after ESWL can indicate a complication, possibly from micro-organisms associated with an underlying urinary tract infection or pyelonephritis.
Decreased urine output (Incorrect)
Rationale: A decrease in urine output following ESWL may indicate a complication caused by stone fragments obstructing urine flow.
Bruising on the lower abdomen (Incorrect)
Rationale: Bruising typically appears on the lower back or flank of the affected side due to the shock waves directed toward the body during the ESWL procedure.
