A client receiving total parenteral nutrition (TPN) reports nausea and dizziness. What action should the nurse take first?

Correct Answer: B

Rationale: In this scenario, the most appropriate action for the nurse to take first when a client receiving TPN reports nausea and dizziness is to check the client's vital signs and blood pressure (Option B). Checking the client's vital signs and blood pressure is crucial to assess the client's current physiological status and to determine if the symptoms of nausea and dizziness are related to any potential hemodynamic changes or complications. This immediate assessment can help the nurse identify any potential issues that require prompt intervention. Checking the client's blood glucose level (Option A) is important in clients receiving TPN, but in this situation of acute symptoms of nausea and dizziness, assessing vital signs takes priority. Decreasing the infusion rate of TPN (Option C) may be a necessary intervention, but it should be based on a comprehensive assessment that includes vital signs and blood pressure. Administering antiemetic medication as prescribed (Option D) may provide symptomatic relief, but it is essential to assess the client's vital signs first to ensure that the client's condition is stable and that the medication is safe to administer. In an educational context, it is critical for nurses to prioritize assessments based on the client's immediate needs and symptoms. Understanding the rationale behind each option helps nurses develop clinical reasoning skills to provide safe and effective patient care.

Correct Answer: D

Rationale: In the context of a client with a suspected pulmonary embolism (PE), the nurse's priority intervention should be to prepare the client for a CT scan (Option D). A CT scan is the gold standard diagnostic test for confirming the presence of a pulmonary embolism. Timely diagnosis is crucial in initiating appropriate treatment and preventing potential complications such as cardiopulmonary collapse. Administering anticoagulant therapy (Option A) is a common treatment for PE, but it should not be initiated without a confirmed diagnosis. Elevating the head of the bed (Option B) is important for optimizing respiratory function in patients with respiratory distress, but it is not the priority over confirming the diagnosis. Checking the client's oxygen saturation (Option C) is important for assessing respiratory status, but it does not address the immediate need for diagnostic confirmation in a suspected PE case. In an educational context, this question highlights the importance of prioritizing interventions based on the urgency of the situation. It reinforces the significance of diagnostic tests in guiding appropriate treatment decisions and emphasizes the critical role of nurses in advocating for timely and accurate diagnostic procedures to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Report any unusual bleeding or bruising. Rationale: 1. **Correct Answer Explanation (C)**: Enoxaparin is an anticoagulant medication used to treat and prevent blood clots like deep vein thrombosis. One of the main side effects of anticoagulants is the risk of bleeding. Therefore, it is crucial for the nurse to educate the client to report any signs of unusual bleeding or bruising promptly. This teaching is essential for the client's safety and to prevent complications associated with anticoagulant therapy. 2. **Incorrect Answer Explanation**: - A) Rotate injection sites to avoid bruising: While rotating injection sites is a good practice for some medications, it is not the priority teaching point for a client on enoxaparin. The risk of bleeding and bruising is more critical than injection site rotation. - B) Administer the injection in the abdomen only: While enoxaparin is typically administered in the abdomen, this option does not address the crucial aspect of monitoring for bleeding or bruising. - D) Avoid contact sports to prevent injury: While it is generally advisable to avoid contact sports when on anticoagulant therapy, this option does not address the immediate need to monitor for potential side effects like bleeding. 3. **Educational Context**: Understanding the importance of patient education in medication management is critical for nurses. In the case of anticoagulant therapy, teaching patients about potential side effects like bleeding and bruising is essential for early detection and prevention of complications. Nurses play a crucial role in empowering patients to manage their conditions effectively through education and support. By emphasizing the need to report any unusual bleeding or bruising, the nurse ensures that the client is informed about a critical aspect of their medication regimen, promoting patient safety and optimal outcomes.

Correct Answer: C

Rationale: In the context of a client with a colostomy being discharged, the most important teaching for the nurse to provide is to empty the ostomy pouch when it is one-third full, which is option C. This is crucial for maintaining skin integrity, preventing leakage, and ensuring proper functioning of the colostomy. By emptying the pouch at the appropriate time, the client can avoid potential complications such as skin irritation, leakage, and discomfort. Option A, changing the ostomy bag daily, is incorrect as it is not necessary to change the entire bag daily unless there is a specific issue. This practice can be wasteful, costly, and may increase the risk of damaging the peristomal skin. Option B, avoiding gas-producing foods like broccoli, is important for some individuals with colostomies to minimize gas and odor, but it is not the most critical teaching point for discharge. It is more of a dietary recommendation rather than a fundamental aspect of colostomy care. Option D, using a skin barrier to protect the surrounding skin, is essential for preventing skin breakdown and irritation; however, it is not as critical as ensuring timely emptying of the ostomy pouch. While using a skin barrier is important, it is a preventive measure rather than a direct action that impacts the functionality of the colostomy. In an educational context, understanding the proper care of a colostomy is vital for nurses working with clients who have undergone ostomy surgery. By prioritizing teachings like timely pouch emptying, nurses can help clients maintain independence, quality of life, and prevent complications related to their colostomy.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Bradycardia of 50 beats per minute. Digoxin is a medication commonly prescribed for heart failure because it helps the heart beat stronger and pump more blood. However, one of the potential side effects of digoxin toxicity is bradycardia, a slow heart rate. A bradycardic heart rate of 50 beats per minute in a client taking digoxin can be indicative of toxicity and can lead to serious complications like life-threatening arrhythmias. Option B) Heart rate of 110 beats per minute is incorrect because it is within the normal range and not a concerning finding in a client with heart failure on digoxin. Option C) Respiratory rate of 16 breaths per minute is also within normal limits and does not directly relate to digoxin toxicity. Option D) Blood pressure of 130/80 mmHg is also within normal range and not a priority finding in this context. Educationally, this question highlights the importance of recognizing signs of digoxin toxicity in clients with heart failure. Nurses must be vigilant in monitoring heart rates in patients on digoxin to prevent adverse effects and provide timely interventions. Understanding the side effects and implications of medications used in heart failure management is crucial for safe and effective nursing practice.