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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. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:
- A. Interview the client for chief complaints and other symptoms
- B. Talk to the relatives to gather data about history of illness
- C. Do auscultation to check for chest congestion
- D. Do a physical examination while asking the client relevant questions
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
3. Which of the following is reflected in an ECG due to hypokalemia?
- A. Tall T waves and Pathologic Q wave
- B. Widening QRS Complex and U wave
- C. None of the above
- D. Both A and B
Correct answer: B
Rationale: Hypokalemia, a condition characterized by low levels of potassium in the blood, is reflected in an ECG by a widening QRS Complex and a U wave. This is because potassium plays a key role in the electrical activity of the heart, and its deficiency can lead to abnormalities in the heart's rhythm as represented by these specific changes on the ECG. Choice A is incorrect as tall T waves and pathologic Q waves are more commonly associated with hyperkalemia or myocardial infarction, respectively, rather than hypokalemia. Choices C and D are also incorrect as they do not accurately reflect the ECG changes caused by hypokalemia.
4. Being in contact with reality and the environment is a function of the:
- A. conscience
- B. ego
- C. id
- D. super ego
Correct answer: B
Rationale: Being in contact with reality and the environment is a function of the ego. The ego is responsible for mediating between the id's basic desires, the superego's idealistic standards, and the real world. The conscience (not listed as a choice) is related to feelings of guilt or moral responsibility. The id represents primal instincts, and the superego represents the internalized ideals and moral standards.
5. James wants to know the recommended intake for iron for his gender and age. Which of the following would provide the best answer for James?
- A. EAR
- B. UL
- C. RDA
- D. DV
Correct answer: C
Rationale: The Recommended Dietary Allowance (RDA) is the correct answer for James because it provides the daily intake level that meets the nutrient needs of most healthy individuals in a specific age and gender group. Choice A, EAR (Estimated Average Requirement), represents the average daily nutrient intake level estimated to meet the requirement of half the healthy individuals in a particular life stage and gender group. Choice B, UL (Tolerable Upper Intake Level), is the maximum daily intake unlikely to cause adverse health effects. Choice D, DV (Daily Value), is a general guide used for food labeling that represents how much a nutrient in a serving of food contributes to a daily diet based on a 2000-calorie daily intake.
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