pcc2 final practice q
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? a-hypotension b-crackles upon lung auscultation c-thirst d-polyuria
b
The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply. a) Bites from ticks or deer flies b) Inhalation of bacterial spores c) Through a cut or abrasion in the skin d) Direct contact with an infected individual e) Sexual contact with an infected individual f) Ingestion of contaminated undercooked meat
b,c,f
Which intervention should the nurse try for a client who exhibits signs of sleep disturbance? a) Administer sleeping medication before bedtime. b) Ask the client each morning to describe the quality of sleep during the previous night. c) Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle d) Provide the client with normal sleep aids, such as pillows, back rubs, and snack
d
A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular distension, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? a-air embolism b-hypervolemia c-hyperglycemia d-sepsis
b
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 35 seconds. On the basis of the prothrombin time, the nurse anticipates which prescription? a) Adding a dose of heparin sodium b) Holding the next dose of warfarin c) Increasing the next dose of warfarin d) Administering the next dose of warfarin
b
A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 2 hours delay. The nurse should do which of the following actions? a-adjust infusion rate to catch up over next hour b-make sure infusion rate is infusing at ordered rate c-increase infusion rate to catch up over next few hrs d-adjust to full blast so it can catch up on time
b
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? a-decrease PN rate to 60 nl/hr b-start 0.9% NS at 30 ml/hr c-maintain present infusion rate d-discontinue PN
a
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? a-turn head to right b-inhale deeply, hold it, bear down c-breathe normal d-exhale slowly and evenly
b
The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? a) An air vent b) Tinted tubing c) An in-line filter d) A microdrip chambe
40) C - Rationale: The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.
Nurse Russell is preparing to give a total parenteral nutrition using a central line. Place the following steps for administration in the correct order?1. Connect the tubing to the central line. 2. Regulate the electric infusion pump at the ordered rate. 3. Maintain aseptic technique when handling the injection cap. 4. Check the solution for cloudiness, particles, or a change in color. 5. Prime the IV tubing through an infusion pump. 6. Select and flush the correct tubing and filter.
465312
The nurse checks the laboratory result for a serum digoxin level that was prescribed for a client earlier in the day and notes that the result is 2.4 ng/mL. The nurse should take which immediate action? a) Check the client's last pulse rate. b) Notify the health care provider (HCP). c) Record the normal value on the client's flow sheet. d) Administer the next dose of the medication as scheduled.
b
A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? a-time of last dressing change b-tightness of tuning connections c-clint's temp d-exp date on bag
c
Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold? a-minimizes muscle spasms b-prevents hemorrhages c-increases circulation d-reduces discomfort
c
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? a) Remove the intravenous (IV) line. b) Run a solution of 5% dextrose in water. c) Run normal saline at a keep-vein-open rate. d) Obtain a culture of the tip of the catheter device removed from the client.
c
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? a-10%dextrose in water b-5%dextrose in water c-5%dextrose in NS d-5%dextrose in lactated ringer solution
a
A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat globules at the top of the solution. The nurse ensure to do which of the following actions? a-takes another bottle of solution b-runs it under warm water c-rolls the bottle of solution gently d-shake the bottle solution vigorously
a
A patient receiving parenteral nutrition is administered via the following routes except: a-subclavian line b-central venous catheter c-PICC line d-PEG tube
a
The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? a) Initiate the intravenous line without the use of a pump. b) Contact the electrical maintenance department for assistance. c) Plug in the pump cord in the available plug above the room sink. d) Use an extension cord from the nurses' lounge for the pump plug
b
The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? a) Placing a safety knot in the safety device straps b) Safely securing the safety device straps to the side rails c) Applying safety device straps that do not tighten when force is applied against them d) Securing so that two fingers can slide easily between the safety device and the client's skin
b
The nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. which interventions should the nurse perform? a) Place the client in a prone position b) Approach the client from the left side c) Encourage deep breathing and coughing d) Discourage bending down e) Orient the client to his environment f) Administer a stool softener
b,d,e,f
. A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? a) Prepare to administer an antidote. b) Draw a sample for type and crossmatch and transfuse the client. c) Draw a sample for an activated partial thromboplastin time (aPTT) level. d) Draw a sample for prothrombin time (PT) and international normalized ratio (INR)
d
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? a-high grade fever, chills, decreased urination b-fatigue, increased sweating, and heat intolerance c-course dry hair, weakness, fatigue d-thirst, blurred vision, and diuresis
d
A client receiving parenteral nutrition (PN) complains of shortness of breath and shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse determines that the client is experiencing which complication of PN therapy? a-air embolism b-hypervolemia c-hyperglycemia d-pneumothorax
d
A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take would be to: a) remove the raised skin because the blister has already broken b) wash the area with soap and water to disinfect it c) apply a weakened alcohol solution to clean the area d) clean the area with normal saline solution and cover it with a protective dressing
d
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? a-right side, with head higher than feet b-right side, with head lower than feet c-left side, with head higher than feet d-left side, head lower than feet
d
A nurse is conducting a follow-up home visit to a client who has been discharged with a parenteral nutrition(PN). Which of the following should the nurse most closely monitor in this kind of therapy? a-BP&temp b-BP&pulse rate c-height&weight d-temp&weight
d
A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensure the availability of which medical equipment before hanging the solution? a-glucometer b-dressing tray c-nebulizer d-infusion pump
d
The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? a) Every 2 hours b) Every 3 hours c) Every 4 hours d) Every 30 minutes
d
