a client receiving total parenteral nutrition tpn is experiencing nausea and vomiting what is the nurses first action
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?

Correct answer: D

Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.

2. In the critical care unit, which client should receive the most care hours by a registered nurse (RN)?

Correct answer: C

Rationale: The client with a newly fractured femur and soft wrist restraints should receive the most care hours as they have physical limitations due to the fracture and mental limitations due to being restrained. This client requires continuous monitoring, support, and frequent assessments to prevent complications. Choices A, B, and D do not have the same level of physical and mental care needs as the client with the newly fractured femur and soft wrist restraints.

3. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

4. A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

Correct answer: C

Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.

5. A 66-year-old woman is retiring and needs health insurance. To which agency should the employee health nurse refer her?

Correct answer: B

Rationale: The correct answer is B: Medicare. Medicare is the federal health insurance program for individuals aged 65 and older, so it is the most suitable option for the 66-year-old woman retiring. Medicaid (choice A) is a state and federally funded program for low-income individuals and families, not specifically for retirees. COBRA (choice C) allows employees to continue their employer-sponsored health insurance for a limited time after leaving employment. Private insurance (choice D) refers to health insurance plans purchased directly from private insurance companies.

Similar Questions

An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?
An older adult client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses