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1. A client with Crohn's disease is receiving parenteral nutrition. Which of the following interventions should the nurse not include in the care of this client?
- A. Remove the parenteral nutrition solution from the refrigerator 2 hours before infusion.
- B. Remove unused parenteral nutrition after 12 hours of use.
- C. Monitor daily laboratory values and report abnormalities as needed.
- D. Monitor the flow rate of the parenteral nutrition carefully and adjust it if necessary.
Correct answer: B
Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.
2. A client is following Seventh-Day Adventist dietary laws. Which of the following dietary guidelines should the nurse include in the plan of care?
- A. Replace salt with pepper when seasoning food.
- B. Request that coffee is removed from meal trays.
- C. Offer pork with two meals per week.
- D. Provide a high-protein snack between meals.
Correct answer: B
Rationale: Seventh-Day Adventists typically avoid stimulants like caffeine, so requesting that coffee be removed from meal trays is appropriate. Choice A is incorrect because it does not specifically relate to Seventh-Day Adventist dietary guidelines. Choice C is incorrect as pork is generally avoided in Seventh-Day Adventist dietary laws. Choice D is incorrect as it does not address the specific dietary preferences of Seventh-Day Adventist clients.
3. After consuming a meal high in fat, the _____ releases _______ to aid in digestion.
- A. stomach, acid
- B. liver, bile
- C. pancreas, bicarbonate
- D. gallbladder, bile
Correct answer: D
Rationale: The gallbladder releases bile into the small intestine to help digest fats. Bile emulsifies fats, breaking them down into smaller droplets for easier digestion. The stomach primarily releases gastric acid, the liver produces bile but stores it in the gallbladder, and the pancreas secretes bicarbonate to neutralize stomach acid in the small intestine. Therefore, choices A, B, and C are incorrect.
4. The correct temperature to store vaccines in a refrigerator is:
- A. between -4 deg C and +8 deg C
- B. between 2 deg C and +8 deg C
- C. between -8 deg C and 0 deg C
- D. between -8 deg C and +4 deg C
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
5. Myxedema coma is a life-threatening complication of long-standing and untreated hypothyroidism with one of the following characteristics.
- A. Hyperglycemia
- B. Hypothermia
- C. Hyperthermia
- D. Hypoglycemia
Correct answer: A
Rationale: Myxedema coma is associated with hypothermia, not hyperthermia. Therefore, the correct characteristic of myxedema coma is hypothermia. This condition is a medical emergency that requires prompt recognition and intervention to prevent serious complications. The presence of hyperglycemia is not a defining characteristic of myxedema coma, making choice A the correct answer in this case. Hyperthermia and hypoglycemia are not typically seen in myxedema coma and are not consistent with the clinical presentation of this condition.
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