A client is receiving total parenteral nutrition (TPN). The nurse enters the room and discovers that the container only has 15 minutes of solution left.
She calls the pharmacy and is told that the next bag will not be available for another hour.
What must the nurse do next?
Call the MD.
Give the patient a high-protein snack.
Hang a bag of 10% dextrose solution (D10W).
Flush the line when complete and wait for the pharmacy to supply the next bag.
The Correct Answer is C
Choice A rationale
While it is important to inform the physician about the delay in the TPN solution, the immediate priority is to maintain the patency of the central venous catheter and prevent hypoglycemia. Calling the MD should occur after taking steps to address the immediate risk.
Choice B rationale
Giving the patient a high-protein snack will not address the immediate issue of the TPN running out and the risk of hypoglycemia associated with the abrupt cessation of a high-glucose solution. TPN provides a significant amount of glucose, and suddenly stopping it can lead to a drop in blood sugar.
Choice C rationale
Hanging a bag of 10% dextrose solution (D10W) is the most appropriate immediate action. This will provide a continuous source of glucose to prevent hypoglycemia while waiting for the new TPN bag from the pharmacy. D10W is often used as a bridge solution in this situation. Normal blood glucose levels are typically 70-110 mg/dL.
Choice D rationale
Flushing the line and waiting for the pharmacy to supply the next bag without infusing any solution puts the patient at significant risk for hypoglycemia and can also lead to catheter occlusion. Maintaining a continuous infusion, even of D10W, is crucial. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The side-lying position with the head of bed at 30 degrees does not optimally align the nasal passages with the esophagus, increasing the risk of the NGT entering the trachea. Proper alignment facilitates easier and safer insertion into the stomach.
Choice B rationale
The tripod position is typically used for patients experiencing respiratory distress to maximize lung expansion. It does not provide the necessary head and neck alignment for safe nasogastric tube insertion.
Choice C rationale
Sitting the patient in an upright position, ideally between 45 to 90 degrees, uses gravity to aid the passage of the NGT down the esophagus. This position also allows the patient to cough effectively if the tube inadvertently enters the trachea.
Choice D rationale
Hyperextending the patient's head during NGT insertion can close off the esophagus and open the trachea, significantly increasing the risk of misplacement of the tube into the respiratory tract. The neck should be flexed forward with the chin to the chest during insertion.
Correct Answer is B
Explanation
Choice A rationale
Canned tuna and salmon, while sources of protein and omega-3 fatty acids, are not particularly high in potassium. Clients taking potassium-wasting diuretics need foods rich in potassium to replace the electrolytes lost through increased urination.
Choice B rationale
Oranges and bananas are excellent sources of potassium. Potassium is an essential electrolyte that is often depleted by potassium-wasting diuretics like furosemide or hydrochlorothiazide. Consuming these fruits helps maintain adequate potassium levels, which are crucial for cardiac function and muscle contraction. The normal range for serum potassium is typically 3.5-5.0 mEq/L.
Choice C rationale
Dried fruits, such as apricots and raisins, are high in potassium. However, the question asks what the nurse *should* include, and while dried fruits are beneficial, fresh fruits like oranges and bananas are often more readily available and consumed in larger quantities.
Choice D rationale
Cow's milk contains potassium but is not specifically emphasized for clients on potassium-wasting diuretics. Other food sources like fruits and vegetables generally provide a more direct and often higher concentration of potassium without the added phosphorus and calcium found in milk, which may be considerations for some individuals.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.