A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

Correct Answer: D

Rationale: The correct answer is D, Serum albumin. Serum albumin levels are a good indicator of the nutritional effectiveness of total parenteral nutrition (TPN). Monitoring serum albumin levels helps assess the client's overall protein status and nutritional adequacy. Choices A, B, and C are not direct indicators of the effectiveness of TPN therapy. Serum calcium levels may be affected by other factors, blood glucose monitoring is more relevant for clients with diabetes or those receiving insulin therapy, and serum protein is not as specific as serum albumin in evaluating TPN effectiveness.

Correct Answer: D

Rationale: The correct answer is to apply a hydrocolloid dressing. For a stage 2 pressure injury, maintaining a moist environment is crucial for healing. Hydrocolloid dressings help achieve this by promoting autolytic debridement and creating a barrier against bacteria while allowing the wound to heal. Applying a dry dressing (Choice A) may not provide the necessary moisture for healing. Cleansing the wound with normal saline (Choice B) is essential, but a hydrocolloid dressing is more specific for promoting healing in this case. Performing debridement as needed (Choice C) is not typically indicated for stage 2 pressure injuries, as they involve partial-thickness skin loss without slough or eschar.

Correct Answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

Correct Answer: A

Rationale: The correct answer is A: 'To reduce nausea and vomiting.' Antiemetics are medications used to prevent or alleviate nausea and vomiting. While they may indirectly help with appetite by reducing the unpleasant symptoms that can lead to decreased food intake, their primary purpose is not to increase appetite (Choice B). Choice C, 'To treat nausea caused by chemotherapy,' is partly correct as antiemetics are commonly used to manage chemotherapy-induced nausea, but this is not their exclusive purpose. Choice D, 'To treat allergic reactions,' is incorrect as antiemetics are not primarily used for treating allergic reactions.

Correct Answer: C

Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.

Correct Answer: A

Rationale: Administering oxygen is the best initial nursing intervention for a patient with suspected pulmonary embolism because it helps address hypoxia, a common complication of this condition. Oxygen therapy can improve oxygenation and support vital organ function. Administering anticoagulants (Choice B) is a treatment option for confirmed pulmonary embolism but not the initial intervention. Repositioning the patient (Choice C) and checking oxygen saturation (Choice D) are important assessments but do not address the immediate need to improve oxygenation in a patient with suspected pulmonary embolism.

Correct Answer: B

Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.

Correct Answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

Correct Answer: A

Rationale: The correct answer is A, Bradycardia. Bradycardia, or a slower than normal heart rate, is a classic sign of digoxin toxicity. Digoxin is a medication commonly used to treat heart conditions, but an excess of digoxin in the body can lead to toxicity. This toxicity can manifest as various symptoms, with bradycardia being one of the most common ones. Hypertension (high blood pressure) and tachycardia (fast heart rate) are not typical signs of digoxin toxicity. Tachypnea, which refers to rapid breathing, is also not a common sign of digoxin toxicity.