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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.
Correct Answer is D
Explanation
A. Independently disposing of the remaining medication may not be in compliance with facility policies and could potentially interfere with an investigation into how the medication was left unattended.
B. Returning the medication to the unit's stock for future use is not appropriate, as the vial is already open and its integrity may be compromised.
C. Administering the medication to other clients is absolutely not an option. This could lead to serious harm or even fatal consequences for the other clients involved.
D. When a nurse discovers an open vial of medication left unattended, it is a serious safety concern. The nurse should report the discrepancy immediately to the appropriate personnel or supervisor. This ensures that the situation is addressed promptly and that necessary actions are taken to prevent potential harm to clients.
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