Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?
A. Hypertension and crackles
B. Fever and chills
C. Excessive thirst and urination
D. Shakiness and diaphoresis
This question is an excerpt from Nurse Dive's nursing test bank - RN Ati fundamental of nursing proctored exam. Take the full exam now
Full Explanation
a. Hypertension and crackles:
While hypertension can be associated with various conditions, such as cardiovascular diseases or stress, it is not directly related to the cessation of TPN infusion.
Crackles in the lungs are often indicative of fluid accumulation or inflammation, commonly seen in conditions like pneumonia or heart failure. They are not typically associated with the interruption of TPN infusion.
b. Fever and chills:
Fever and chills can be symptoms of infection or inflammatory processes in the body. However, they are not specifically related to the interruption of TPN infusion.
In the context of TPN cessation, the focus would be on metabolic changes rather than infectious processes.
c. Excessive thirst and urination:
Excessive thirst and urination are classic symptoms of hyperglycemia, which can occur when TPN, particularly if it contains a high glucose concentration, is abruptly interrupted.
When TPN infusion stops, there is no longer a continuous supply of glucose to the body, leading to increased blood glucose levels and subsequent polyuria (excessive urination) and polydipsia (excessive thirst) as the body tries to eliminate excess glucose.
d. Shakiness and diaphoresis:
Shakiness and diaphoresis (excessive sweating) are classic symptoms of hypoglycemia, which can occur if TPN, particularly if it contains a high concentration of insulin, is abruptly interrupted.
TPN solutions often contain glucose and insulin to maintain proper blood glucose levels. If the infusion is stopped suddenly, there may be a rapid decline in blood glucose levels, leading to hypoglycemia, which manifests as shakiness, diaphoresis, confusion, and other neuroglycopenic symptoms.
Similar Questions
When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?
A. Contact the pharmacy and confirm that the dosage is safe to administer.
Contacting the pharmacy might be a good step in some cases, but if the nurse has identified a dosage that is three times higher than usual, it's crucial to address this directly with the prescribing provider first.
B. Ask another nurse to verify that the dosage is appropriate for the client
Asking another nurse to verify is a reasonable step, but ultimately, it's the responsibility of the nurse who identifies the discrepancy to take action.
C. Inform the charge nurse and administer the dose of the medication the provider prescribed.
Informing the charge nurse and administering the dose without questioning the provider's order could potentially put the client at risk if the dosage is indeed too high.
D. Contact the provider to question the dosage.
Contacting the provider to question the dosage is the most appropriate immediate action. It's crucial to seek clarification from the provider regarding the unusually high dosage to ensure the safety and well-being of the client. This step ensures that the client receives the correct and safe medication dosage.
Full Explanation
A. Contacting the pharmacy might be a good step in some cases, but if the nurse has identified a dosage that is three times higher than usual, it's crucial to address this directly with the prescribing provider first.
B. Asking another nurse to verify is a reasonable step, but ultimately, it's the responsibility of the nurse who identifies the discrepancy to take action.
C. Informing the charge nurse and administering the dose without questioning the provider's order could potentially put the client at risk if the dosage is indeed too high.
D. Contacting the provider to question the dosage is the most appropriate immediate action. It's crucial to seek clarification from the provider regarding the unusually high dosage to ensure the safety and well-being of the client. This step ensures that the client receives the correct and safe medication dosage.
A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).
A. Measurement of residual urine after urination
Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound
An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention
Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family
Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen
routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.
Full Explanation
A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.
Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
A. Elevate the head of the bed no more than 45°.
The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Use a transfer device to lift the client up in bed.
Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massage the skin over the client's bony prominences.
Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Apply cornstarch to keep sensitive skin areas dry.
Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
Full Explanation
A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.