NCLEX Secrets - Level of Cognitive Ability
21. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of lb in 1 week. The nurse next assesses the client to detect the presence of which of the following?
a) thirst
b) polyuria
c) decreased blood pressure
d) crackles on auscultation of the lungs
22. A nurse is caring for a group of adult clients on an acute care medical-surgical unit. The nurse understands that which of the following clients would be the least likely candidate for parenteral nutrition (PN)?
a) a 66-year old client with extensive burns
b) a 42-year old client who has an open cholecystectomy
c) a 27-year old client with severe exacerbation of Crohn's disease
d) a 35-year old client with persistent nausea and vomiting from chemotherapy.
23. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, repalce immediate blood loss, and increase blood pressure?
a) 0.45% sodium chloride
b) 0.33% sodium chloride
c) 0.225% sodium chloride
d) lactated ringer's solution
24. The nurse is making initial rounds on the nursing unit to assess the conditon of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client?
a) infection
b) phlebitis
c) infiltration
d) thrombosis
25. The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking approximate steps to care for client, the nurse documents in the medical record that the client expericed:
a) phlebitis of the vein
b) infiltration of the IV lin
c) hypersensitivity to the IV solution
d) allergic reaction to the IV catheter material
NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE
21) D
- optimal weight gain on PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Options A and B are associated with hyperglycemia. Option C is likely to be noted in deficient fluid volume.
22) B
- parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods. Examples of these conditions include those of the clients identified in option A, C, and D. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or AIDS. The client with the open cholecystectomy is not a candidate because this client would resume regular diet within few days following surgery.
23) D
- the goal of therapy with this client is to expand intravascular volume as quickly as possible. Lactated ringer's (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in option A, B, and C would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.
24) C
- an infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. The other three options are likely to be accompanied by warmth at the site, not coolness.
25) A
- phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.
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NCLEX Secrets - Level of Cognitive Ability (Analysis 21-25)
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