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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. Most nurses regard this conventional recording of the date, time, and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this?
- A. Discharge Summary
- B. Nursing Kardex
- C. Medicine and Treatment Record
- D. Nursing Health History and Assessment Worksheet
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.
3. Patients with congestive heart failure need to restrict their intake of:
- A. fiber
- B. sodium
- C. cholesterol
- D. saturated fat
Correct answer: B
Rationale: Patients with congestive heart failure need to restrict their intake of sodium. This restriction is crucial to prevent fluid retention, which can exacerbate the condition. While fiber is generally beneficial for heart health, sodium restriction is more critical in this scenario. Cholesterol and saturated fat intake should also be monitored, but sodium restriction takes precedence due to its direct impact on fluid balance.
4. You are an ostomy nurse and you know that colostomy is defined as:
- A. It is an incision into the colon to create an artificial opening to the exterior of the abdomen
- B. It is end to end anastomosis of the gastric stump to the duodenum
- C. It is end to end anastomosis of the gastric stump to the jejunum
- D. It is an incision into the ileum to create an artificial opening to the exterior of the abdomen
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
5. What is the rationale in the use of bag technique during home visits?
- A. It helps render effective nursing care to clients or other members of the family
- B. It saves time and effort of the nurse in the performance of nursing procedures
- C. It should minimize or prevent the spread of infection from individuals to families
- D. It should not overshadow concerns for the patient
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.
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