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 ["B","D","E"]

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This indicates infiltration as fluid accumulates in the surrounding tissue, causing the skin to appear pale and tight.
C. The vein is firm and cord-like: This is typically a sign of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a sign of infiltration where fluid has leaked out of the vein into the surrounding tissue.
E. Warmth at the insertion site: This can indicate infiltration or inflammation, depending on other symptoms present.

A. The client who takes medications for occasional anxiety B. The client admitted with a mild pleural effusion C. The client who has had diarrhea for the past 48 hours D. The client admitted with an acute renal injury E. The client admitted for treatment of asthmatic bronchitis

Correct Answer is ["C","D"]

Explanation

A. The client who takes medications for occasional anxiety: Anxiety medications are not typically associated with metabolic acidosis.
B. The client admitted with a mild pleural effusion: A mild pleural effusion is more related to fluid accumulation and respiratory issues rather than metabolic acidosis.
C. The client who has had diarrhea for the past 48 hours: Prolonged diarrhea can lead to loss of bicarbonate, resulting in metabolic acidosis.
D. The client admitted with an acute renal injury: Acute renal injury impairs the kidneys' ability to excrete acids and can lead to metabolic acidosis.
E. The client admitted for treatment of asthmatic bronchitis: Asthmatic bronchitis typically involves respiratory issues rather than metabolic acidosis.

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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

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Correct Answer is ["B","D","E"]

Explanation

The nurse identifies that which of the following clients is at risk for developing metabolic acidosis? (Select All That Apply)

Correct Answer is ["C","D"]

Explanation

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