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 D

Explanation

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

A. Blood in the tubing close to the insertion site B. Chills, fever, and generalized discomfort C. Pallor, sweating, and discomfort at the insertion site D. Dyspnea, headache, and increased blood pressure

Correct Answer is D

Explanation

A. Blood in the tubing close to the insertion site: This indicates a possible issue with the IV but not fluid overload specifically.
B. Chills, fever, and generalized discomfort: These symptoms may suggest an infection or reaction but are not specific to fluid overload.
C. Pallor, sweating, and discomfort at the insertion site: These could indicate a local reaction or issue with the IV site but not fluid overload.
D. Dyspnea, headache, and increased blood pressure: These symptoms are indicative of fluid overload, as the body reacts to excessive fluid with symptoms such as difficulty breathing (dyspnea), increased blood pressure, and headaches.

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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 D

Explanation

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Correct Answer is D

Explanation

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