Question

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). For which of the following findings should the nurse monitor as a potential complication of TPN?

Answer 1

Correct Answers:

Electrolyte imbalance

Rationale :

🔹 Total Parenteral Nutrition (TPN) is a highly concentrated solution of glucose, amino acids, electrolytes, vitamins, and lipids delivered directly into the bloodstream via a central line.

🔹 Because it bypasses normal digestion and absorption, there is a high risk of electrolyte imbalances (such as hypokalemia, hypophosphatemia, or hypomagnesemia), especially during initiation or adjustment of therapy.

🔹 The nurse must monitor daily labs (electrolytes, glucose, liver and renal function tests) to prevent complications.

🔹 Constipation, respiratory depression, and hypotension are not typical complications of TPN, but hyperglycemia, infection, and fluid/electrolyte disturbances are common concerns.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

A client who has hypothyroidism and is stuporous

Rationale :

🟦Stupor in hypothyroidism indicates myxedema coma, a life-threatening emergency. It requires immediate intervention to support airway, breathing, circulation, and administration of IV thyroid hormone.

🟦 The other clients—burn needing dressing, post-appendectomy with hypoactive bowel sounds, or nausea post-chemo—are stable and not immediately life-threatening.

🟦 In priority frameworks, Airway, Breathing, Circulation (ABC) and acute changes in level of consciousness take precedence.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Inspect the client's skin under the device every 8 hr.

Rationale :

🟩 Rationale: Buck’s traction is a skin traction, and the biggest risks are skin breakdown, impaired circulation, and neurovascular compromise.

🟩 The nurse must inspect skin regularly (every 8 hr or per protocol) to prevent complications.

🟩 The weights should never be released or removed by the nurse unless prescribed, as this defeats the purpose of continuous traction.

🟩 Circulation checks should be every 1–2 hr initially, not every 12 hr.

🟩 Range of motion is not performed on the affected limb while in traction, only on the unaffected extremities.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Dopamine

Rationale :

🟥 Dopamine is a vasopressor and inotropic agent that increases blood pressure, cardiac output, and renal perfusion in cases of shock.

🟥 Septic shock is characterized by systemic vasodilation and capillary leak, which must be counteracted with vasopressors after fluid resuscitation.

🟥 Nitroprusside is a vasodilator, which would worsen hypotension.

🟥 Diphenhydramine is an antihistamine, useful for allergic reactions, not septic shock.

🟥 Desmopressin is used for diabetes insipidus or certain bleeding disorders, not septic shock.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

“l am thankful there are no serious complications from this type of surgery.”

Rationale :

📝 Informed consent requires the client to understand risks, benefits, alternatives, and potential complications of the procedure.

📝 The client’s statement shows lack of awareness that serious complications can occur, such as infection, bleeding, or prosthesis failure.

📝 The nurse’s duty is to witness voluntariness and capacity, not to provide full teaching about the surgery.

📝 If gaps are noted, the nurse must contact the surgeon to clarify before consent can be validated.

📝 This ensures the client’s decision is informed, ethical, and legally sound.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Apply pressure to the lacrimal punctum for 1 min following administration.

Rationale :

👁️ Pressing on the lacrimal punctum blocks the nasolacrimal duct, preventing the medication from draining into the nasal mucosa/systemic circulation.

👁️ This reduces risk of systemic side effects, especially with meds like beta-blocker eye drops.

👁️ Correct placement is into the conjunctival sac, not directly onto the cornea.

👁️ The child should be kept in a comfortable position; forcing head tilt or long sitting is not needed.

👁️ Excess solution should be wiped away from the inner canthus outward, to avoid contamination.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

“Rh immune globulin is not necessary since this is your second pregnancy."

Rationale :

🩸 Rh immune globulin prevents maternal immune system from forming antibodies against Rh-positive fetal blood cells.

🩸 The client is Rh-negative (AB–) and delivered an Rh-positive infant (B+), putting her at risk for sensitization.

🩸 Administration within 72 hours postpartum is crucial to protect future pregnancies from hemolytic disease of the newborn.

🩸 Gravida and parity don’t matter—every exposure to Rh+ blood can sensitize the mother.

🩸 Baby does not need RhIG—only the Rh-negative mother receives it.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Egg whites

Rationale :

🥚 Egg whites provide lean protein without cholesterol or saturated fats.

🥚 Foods like beef liver, clams, and lobster contain high cholesterol, which worsens hyperlipidemia.

🥚 Teaching emphasizes avoiding organ meats, full-fat dairy, and shellfish, while choosing low-fat proteins, fruits, vegetables, and whole grains.

🥚 Substituting egg whites for yolks helps clients reduce dietary cholesterol intake.

🥚 This supports heart health and reduces the risk of atherosclerosis and cardiovascular disease.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Thyroid hormones

Rationale :

🔬 Lithium can interfere with the thyroid gland, causing goiter and hypothyroidism over time.

🔬 Baseline TSH and thyroid panel are required to monitor changes during therapy.

🔬 Nurses also check renal function and electrolytes, since lithium is excreted by the kidneys and toxicity risk rises if clearance is impaired.

🔬 Thyroid monitoring ensures early detection of hormonal changes before severe symptoms appear.

🔬 Clients may require dose adjustments or thyroid replacement therapy during long-term lithium use.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Social worker

Rationale :

🤝 Social workers coordinate psychosocial support services and can make direct referrals to family therapy or counseling.

🤝 They link clients with mental health providers, community resources, and support systems.

🤝 Occupational and recreational therapists focus on rehabilitation and leisure skills—not counseling.

🤝 A paramedical technologist provides diagnostic/technical support, not therapeutic referrals.

🤝 Social workers ensure clients get access to appropriate therapy and follow-up care.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). For which of the following findings should the nurse monitor as a potential complication of TPN?

2 :
A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

3 :
A nurse is caring for a client who has a femur fracture and is on bedrest with Bucks extension traction. Which of the following actions should the nurse take?

4 :
A nurse is caring for a school-age child who has a blood pressure of 88/50 mm Hg and develops septic shock. Which of the following medications should the nurse expect the provider to prescribe?

5 :
A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?

6 :
A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take?

7 :
A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2. para 2. and her blood type is AB negative. The newborn's blood type is B positive. Which of the following statements is appropriate?

8 :
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

9 :
A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose. which of the following laboratory values should the nurse evaluate?

10 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

QLexNursing

1 : A nurse is caring for a client who is receiving total parenteral nutrition (TPN). For which of the following findings should the nurse monitor as a potential complication of TPN?

2 : A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

3 : A nurse is caring for a client who has a femur fracture and is on bedrest with Bucks extension traction. Which of the following actions should the nurse take?

4 : A nurse is caring for a school-age child who has a blood pressure of 88/50 mm Hg and develops septic shock. Which of the following medications should the nurse expect the provider to prescribe?

5 : A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?

6 : A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take?

7 : A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2. para 2. and her blood type is AB negative. The newborn's blood type is B positive. Which of the following statements is appropriate?

8 : A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

9 : A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose. which of the following laboratory values should the nurse evaluate?

10 : A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

1 :
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). For which of the following findings should the nurse monitor as a potential complication of TPN?

2 :
A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

3 :
A nurse is caring for a client who has a femur fracture and is on bedrest with Bucks extension traction. Which of the following actions should the nurse take?

4 :
A nurse is caring for a school-age child who has a blood pressure of 88/50 mm Hg and develops septic shock. Which of the following medications should the nurse expect the provider to prescribe?

5 :
A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?

6 :
A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take?

7 :
A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2. para 2. and her blood type is AB negative. The newborn's blood type is B positive. Which of the following statements is appropriate?

8 :
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

9 :
A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose. which of the following laboratory values should the nurse evaluate?

10 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?