A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Hypertension and crackles

Fever and chills

Excessive thirst and urination

Shakiness and diaphoresis

Answer and Explanation

The Correct Answer is D

a. Hypertension and crackles:

While hypertension can be associated with various conditions, such as cardiovascular diseases or stress, it is not directly related to the cessation of TPN infusion.

Crackles in the lungs are often indicative of fluid accumulation or inflammation, commonly seen in conditions like pneumonia or heart failure. They are not typically associated with the interruption of TPN infusion.

b. Fever and chills:

Fever and chills can be symptoms of infection or inflammatory processes in the body. However, they are not specifically related to the interruption of TPN infusion.

In the context of TPN cessation, the focus would be on metabolic changes rather than infectious processes.

c. Excessive thirst and urination:

Excessive thirst and urination are classic symptoms of hyperglycemia, which can occur when TPN, particularly if it contains a high glucose concentration, is abruptly interrupted.

When TPN infusion stops, there is no longer a continuous supply of glucose to the body, leading to increased blood glucose levels and subsequent polyuria (excessive urination) and polydipsia (excessive thirst) as the body tries to eliminate excess glucose.

d. Shakiness and diaphoresis:

Shakiness and diaphoresis (excessive sweating) are classic symptoms of hypoglycemia, which can occur if TPN, particularly if it contains a high concentration of insulin, is abruptly interrupted.

TPN solutions often contain glucose and insulin to maintain proper blood glucose levels. If the infusion is stopped suddenly, there may be a rapid decline in blood glucose levels, leading to hypoglycemia, which manifests as shakiness, diaphoresis, confusion, and other neuroglycopenic symptoms.

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Correct Answer is A

Explanation

A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.

A. Wash the tablet off with alcohol and place it in a clean medication. B. Use the tablet's packaging to pick it up from the counter. C. Discard the tablet and obtain another dose of medication. D. Place the tablet directly into a medication cup.

Correct Answer is C

Explanation

A. Washing the tablet off with alcohol and placing it in a clean medication may not effectively remove all potential contaminants and could alter the medication. It's safer to discard it.
B. Using the tablet's packaging to pick it up may not guarantee that the tablet is still clean or free from contamination.
C. Discarding the tablet and obtaining another dose of medication is the safest and most appropriate action. This ensures that the client receives a clean and uncontaminated dose of medication.
D. Placing the tablet directly into a medication cup without any further cleaning is not recommended, as it could introduce potential contaminants into the client's medication.

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A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Nursing Test Bank

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