“I should wait for X-ray confirmation before using the tube.” “I can confirm placement by auscultating over the epigastric area.” “I can mix liquid medications in with the tube feeding for administration.” “I will flush the tube with 20 to 30 mL of water every 4 hours during continuous tube feeding.” “I will observe the…
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
monitor daily weights and intake and output monitor serum electrolytes and glucose levels daily change IV tubing every 48 hours or per facility protocol change the IV site dressing every 24 hours or per facility protocol if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
The nurse is caring for a client newly diagnosed with diabetes type 2. The health care provider plans to start the client on a rapid-acting insulin. Which insulin does the nurse anticipate noting on the order?
Lantus Levemir Humalog Humulin 70/30
Along with traditional therapy, a client asks the nurse about alternative therapies for chronic pain. Which could the nurse provide to the client?
yoga acupuncture music therapy hypnosis
A 92-year-old male client with Alzheimer’s frequently experiences urinary incontinence. Which intervention should the nurse do first ?
apply a condom catheter insert an indwelling catheter apply a diaper offer the urinal every 2 hours
A client with a colostomy is experiencing mild diarrhea. Which instruction should the nurse give the client?
drink two 8-oz glasses of water eat two bananas eat five prunes eat a salad with vinaigrette dressing
A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?
drink orange juice to relieve discomfort drink extra milk to relieve discomfort avoid drinking from a straw rinse twice a day with antiseptic mouthwash
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
reduce fluid intake to 1,500 ml/day take a warm shower twice a day apply a tight binder around her breasts come in to see the physician immediately as this is abnormal
A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions?
move the client closer to the nursing station to allow close monitoring apply the restraint in compliance with hospital policy consult with a more experienced nurse on a course of action check on the client every 30 minutes to ensure her safety
The nurse on the inpatient memory care unit is caring for a client with Alzheimer’s who exhibits wandering behavior. The 24-hour observer calls the nurse to report that the client left the unit. It would be most appropriate for the nurse to take which of the following actions?
notify the family notify security along with a description of the client ask the observer in what direction the client headed ask other staff on the unit to assist in finding the client