A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?

Low-grade fever

Fatigue

Anorexia

Hypoactive bowel sounds

Answer and Explanation

The Correct Answer is A

A. Low-grade fever: A low-grade fever could indicate an infection or other complications related to TPN or bowel surgery, and it is crucial to report this to the healthcare provider.
B. Fatigue: While fatigue is a common symptom, it is less urgent compared to a potential infection.
C. Anorexia: Anorexia is a concern but is not as immediate as a fever.
D. Hypoactive bowel sounds: This is expected after extensive bowel surgery and may not be as urgent as signs of infection.

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Correct Answer is C

Explanation

A. Vomiting: Vomiting is a common symptom associated with metabolic acidosis but is not a compensatory mechanism. It can lead to further electrolyte imbalances and dehydration.
B. Tachycardia: Tachycardia can occur as a response to acidosis but is not a direct compensatory mechanism for metabolic acidosis.
C. Deep rapid breathing: This is the correct choice. Deep rapid breathing, or Kussmaul respirations, is a compensatory mechanism for metabolic acidosis. It helps to expel carbon dioxide, thereby reducing acidity in the blood.
D. Watery diarrhea: Diarrhea can contribute to electrolyte imbalances and may exacerbate acidosis but is not a compensatory response by the body.

A. Fluid restriction B. Furosemide (Lasix) C. Calcium carbonate (Tums) D. Magnesium oxide (MagOx)

Correct Answer is B

Explanation

A. Fluid restriction: Fluid restriction is not indicated for high serum magnesium levels. It is generally used for conditions like heart failure or renal impairment, but not specifically for managing hypermagnesemia.
B. Furosemide (Lasix): This is the correct choice because furosemide is a diuretic that can help promote the excretion of excess magnesium through the urine. It is an appropriate treatment for hypermagnesemia, which is indicated by the elevated serum magnesium level.
C. Calcium carbonate (Tums): This option is incorrect as calcium carbonate is typically used to treat hypomagnesemia (low magnesium levels) or to bind excess phosphate, not to manage elevated magnesium levels.
D. Magnesium oxide (MagOx): This is not suitable because magnesium oxide would increase the magnesium level further, not decrease it. It is used to supplement magnesium in cases of deficiency, not to treat hypermagnesemia.

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A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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