the client is npo and is receiving total parenteral nutrition tpn via a subclavian line which precautions should the nurse implement select one that d
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HESI Leadership and Management

1. The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select one that does not apply.

Correct answer: D

Rationale: Precautions for clients receiving TPN include placing the solution on an IV pump to control the rate, monitoring blood glucose levels to detect hyperglycemia, and monitoring intake and output to assess fluid balance. Changing the IV tubing every three days is not a standard precaution for clients receiving TPN via a subclavian line.

2. The nurse is caring for a client with hyperparathyroidism. Which of the following clinical manifestations is consistent with this condition?

Correct answer: B

Rationale: In hyperparathyroidism, there is an overproduction of parathyroid hormone, leading to increased calcium levels in the blood (hypercalcemia). This occurs as the parathyroid hormone stimulates the release of calcium from the bones and enhances calcium absorption in the intestines and kidneys. Therefore, the correct answer is hypercalcemia (Choice B). Hypocalcemia (Choice A) is not consistent with hyperparathyroidism, as this condition is characterized by high calcium levels. Hypokalemia (Choice C) and hyperphosphatemia (Choice D) are not typically associated with hyperparathyroidism and are not primary manifestations of this condition.

3. When implementing a new policy on the unit, what process should a nurse manager follow?

Correct answer: A

Rationale: When introducing a new policy on the unit, it is essential for the nurse manager to involve staff members in the decision-making process. This approach helps in gathering input and insights from the team, fostering a sense of ownership and commitment. By communicating the reasons behind the policy change, the nurse manager ensures transparency and promotes understanding among the staff, leading to buy-in and acceptance of the new policy. Choice B is incorrect because implementing a policy change without involving staff and explaining the rationale may lead to resistance or lack of understanding. Choice C is not ideal as delegation without active involvement and communication with the team may result in misunderstandings or incomplete implementation. Choice D lacks the crucial step of involving staff in the decision-making process, which is important for successful policy implementation and team engagement.

4. The healthcare provider is assessing a client with hypothyroidism. Which of the following clinical findings would the healthcare provider expect?

Correct answer: C

Rationale: Cold intolerance is a classic symptom of hypothyroidism. In hypothyroidism, the body's metabolic rate is decreased, leading to a reduced ability to regulate body temperature. As a result, individuals with hypothyroidism often feel cold, especially in their extremities. Tachycardia (A) is more commonly associated with hyperthyroidism due to the increased metabolic rate. Weight loss (B) is also a typical finding in hyperthyroidism, as the body burns calories at a faster rate. Diaphoresis (D), excessive sweating, is not a typical symptom of hypothyroidism.

5. A client is admitted to the ER with DKA. In the acute phase, the priority nursing action is to prepare to:

Correct answer: A

Rationale: Administering regular insulin intravenously is the priority nursing action in the acute phase of DKA. Insulin helps to lower blood glucose levels by promoting cellular uptake of glucose and inhibiting ketone production. Administering dextrose would be counterproductive as it can worsen hyperglycemia. Correcting acidosis is important but usually follows insulin administration. Applying an electrocardiogram monitor is not the priority action in the acute management of DKA.

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