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Questions 158

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Question 1 of 5

The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?

Correct Answer: A

Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.

Question 2 of 5

One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, 'It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.' The nurse's best response would be:

Correct Answer: B

Rationale: Focusing is an effective therapeutic strategy. This response, however, allows the client to 'defocus' off the topic of learning how to accept responsibility for his behavior and future growth. The nurse can educate the client about both the 'genetic risk' for the development of alcoholism and ways to make long-term healthy lifestyle changes. This response is inappropriately confrontational and condescending to the client. Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.

Question 3 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.

Question 4 of 5

The nurse is preparing to administer a dose of ondansetron (Zofran) for nausea. Which route is most appropriate for rapid onset?

Correct Answer: C

Rationale: Intravenous ondansetron provides the fastest onset for nausea relief, ideal in acute settings. Oral and sublingual routes are slower, and IM is less common.

Question 5 of 5

The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?

Correct Answer: A

Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.

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