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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.
Correct Answer is A
Explanation
A. Steak and scrambled eggs: Steak and scrambled eggs are excellent sources of heme iron, which is highly bioavailable and easily absorbed by the body. This choice reflects a good understanding of dietary sources rich in iron.
B. Cornmeal muffin and orange juice: While orange juice can enhance iron absorption due to its vitamin C content, cornmeal muffins are not a significant source of iron. This option does not indicate a strong understanding of iron-rich foods.
C. Cantaloupe and cottage cheese: Both cantaloupe and cottage cheese are low in iron content. This menu choice does not reflect an understanding of the best dietary sources of iron.
D. Strawberry pancakes and coffee: Strawberries have some iron, but not in significant amounts, and coffee can inhibit iron absorption due to its polyphenol content. This choice does not indicate an understanding of iron-rich foods.
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