Fundamentals Of Nursing NCLEX Quiz 47

1. A client is receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to identify the presence of which of the following?

Hypotension.

Crackles upon auscultation of the lungs.

Thirst.

Polyuria.

Normally. the weight gain of a client receiving PN is about 1-2 pound a week. A weight gain of five (5) pounds over a week indicates a client is experiencing fluid retention that can result to hypervolemia. Signs of hypervolemia includes weight gain more than desired. headache. jugular vein distention. bounding pulse. and crackles on lung auscultation.Option A: Hypertension. not hypotension is expected.Options C and D are associated with hyperglycemia.

Explanation

Normally. the weight gain of a client receiving PN is about 1-2 pound a week. A weight gain of five (5) pounds over a week indicates a client is experiencing fluid retention that can result to hypervolemia. Signs of hypervolemia includes weight gain more than desired. headache. jugular vein distention. bounding pulse. and crackles on lung auscultation.Option A: Hypertension. not hypotension is expected.Options C and D are associated with hyperglycemia.

2. A client is receiving nutrition via parenteral nutrition (PN). A nurse assess the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

High-grade fever. chills. and decreased urination.

Fatigue. increased sweating. and heat intolerance.

Coarse dry hair. weakness. and fatigue.

Thirst. blurred vision. and diuresis.

Signs of hyperglycemia include excessive thirst. fatigue. restlessness. blurred vision. confusion. weakness. Kussmaul’s respirations. diuresis. and coma when hyperglycemia is severe.Option A are signs of infection.Option B are signs of hyperthyroidism.Option C are signs of hypothyroidism.

Explanation

Signs of hyperglycemia include excessive thirst. fatigue. restlessness. blurred vision. confusion. weakness. Kussmaul’s respirations. diuresis. and coma when hyperglycemia is severe.Option A are signs of infection.Option B are signs of hyperthyroidism.Option C are signs of hypothyroidism.

3. A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has a bounding pulse. jugular distension. and weight gain greater than desired. The nurse determines that the client is experiencing which complication of PN therapy?

Air embolism.

Hypervolemia.

Hyperglycemia.

Sepsis.

The client’s sign and symptoms are consistent with hypervolemia. This happen when the client receives excessive fluid administration or administration of fluid too rapidly.

Explanation

The client’s sign and symptoms are consistent with hypervolemia. This happen when the client receives excessive fluid administration or administration of fluid too rapidly.

4. A client is receiving parenteral nutrition (PN) suddenly is having a fever. A nurse notifies the physician and the physician initially prescribes that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials?

Send them to the laboratory for culture.

Save them for a return to the manufacturer.

Return them to the hospital pharmacy.

Discard them in the unit trash.

When the client who is receiving PN has a high temperature. a catheter-related infection should be suspected. The solution and tubing should be changed. and the discontinued materials should be cultured for an infectious organism.

Explanation

When the client who is receiving PN has a high temperature. a catheter-related infection should be suspected. The solution and tubing should be changed. and the discontinued materials should be cultured for an infectious organism.

5. A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that there are redness and drainage at the insertion site. The nurse next assesses which of the following?

Time of last dressing change.

Allergy.

Client’s temperature.

Expiration date.

Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given. the temperature is the next item to assess.

Explanation

Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given. the temperature is the next item to assess.

6. A nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse ask the client to take which essential action during the tube change?

Turn the head to the right.

Inhale deeply. hold it. and bear down.

Breathe normally.

Exhale slowly and evenly.

The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tube changes. The nurse asks the client to take a deep breath. hold it. and bear down.Option A is incorrect because if the intravenous line is on the right. the client turns his or head to the left. This position increases intrathoracic pressure.Options C and D can cause the potential for an air embolism during the tube change.

Explanation

The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tube changes. The nurse asks the client to take a deep breath. hold it. and bear down.Option A is incorrect because if the intravenous line is on the right. the client turns his or head to the left. This position increases intrathoracic pressure.Options C and D can cause the potential for an air embolism during the tube change.

7. A client is being weaned off from parenteral nutrition (PN) and is given a go-signal to take a regular diet. The ongoing solution rate has been 120ml/hr. A nurse expects that which of the following prescriptions regarding the PN solution will accompany the diet order?

Decrease the PN rate to 60ml/hr.

Start 0.9% normal saline at 30 ml/hr.

Maintain the present infusion rate.

Discontinue the PN.

When a client begins eating a regular diet after a period of receiving PN. the PN is decreased slowly. PN that is terminated abruptly will cause hypoglycemia. Gradually decreasing the infusion rate allows the client to remain sufficiently nourished during the transition to a normal diet and prevents an episode of hypoglycemia.

Explanation

When a client begins eating a regular diet after a period of receiving PN. the PN is decreased slowly. PN that is terminated abruptly will cause hypoglycemia. Gradually decreasing the infusion rate allows the client to remain sufficiently nourished during the transition to a normal diet and prevents an episode of hypoglycemia.

8. A nurse is caring for a group of clients on a medical-surgical nursing unit. The nurse recognizes that which of the following clients would be the least likely candidate for parenteral nutrition?

A 55-year-old with persistent nausea and vomiting from chemotherapy.

A 44-year old client with ulcerative colitis.

A 59-year old client who had an appendectomy.

A 25-year old client with a Hirschprung’s Disease.

The client with an appendectomy is not a candidate because this client would resume a regular diet within a few days following the surgery.Options A. B. and D are incorrect because parenteral nutrition is indicated in these clients since their gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods.

Explanation

The client with an appendectomy is not a candidate because this client would resume a regular diet within a few days following the surgery.Options A. B. and D are incorrect because parenteral nutrition is indicated in these clients since their gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods.

9. A nurse is making initial rounds at the beginning of the shift and notice that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

10% dextrose in water.

5% dextrose in water.

5% dextrose in normal saline.

5% dextrose in lactated Ringer solution.

The client is at risk of hypoglycemia. Hence the nurse will hang a solution that has the highest amount of glucose until the new parenteral nutrition solution becomes readily available.

Explanation

The client is at risk of hypoglycemia. Hence the nurse will hang a solution that has the highest amount of glucose until the new parenteral nutrition solution becomes readily available.

10. A nurse is caring a client who disconnected the tubing of the parenteral nutrition from the central line catheter. A nurse suspects an occurrence of an air embolism. Which of the following is an appropriate position for the client in this kind of situation?

On the right side. with head higher than the feet.

On the right side. with head lower than the feet.

On the left side. with the head higher than the feet.

On the left side. with head lower than the feet.

Air embolism happens because of the entry of air into the catheter system. If it occurs. the client should be placed in a left-side-lying position with the head be lower than the feet. This position will lessen the effect of the air traveling as a bolus to the lungs by trapping it on the right side of the heart.

Explanation

Air embolism happens because of the entry of air into the catheter system. If it occurs. the client should be placed in a left-side-lying position with the head be lower than the feet. This position will lessen the effect of the air traveling as a bolus to the lungs by trapping it on the right side of the heart.