A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to intervene?

Capillary blood glucose level 164 mg/dl.

Crackles in bilateral lower lobes

WBC count 13.000/mm

Right upper quadrant pa

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Capillary blood glucose level 164 mg/dl is appropriate. A capillary blood glucose level of 164 mg/dl is above the target range for blood glucose control. In a client receiving total parenteral nutrition (TPN), it's essential to monitor blood glucose levels closely, as hyperglycaemia can lead to complications. The nurse should intervene by notifying the healthcare provider and following the prescribed protocols for managing elevated blood glucose levels in a client with acute pancreatitis receiving TPN.

Choice B Reason:

Crackles in bilateral lower lobes is inappropriate. Crackles in the lungs could be indicative of fluid accumulation or inflammation, which can occur in various conditions. While it should be monitored, it may not require immediate intervention related to the TPN.

Choice C Reason:

WBC count 13,000/mm is inappropriate-. An elevated white blood cell count could be related to the acute pancreatitis itself or other factors. It might require further assessment and monitoring but may not be directly related to the TPN.

Choice D Reason:

Right upper quadrant pain is inappropriate- The client's right upper quadrant pain might be related to the acute pancreatitis or another cause, but it does not specifically indicate a need to intervene with the TPN at this moment.

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Correct Answer is A

Explanation

Choice A Reason:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.

Choice B Reason:

Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.

Choice C Reason:

Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.

Choice D Reason:

Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.

A. May operate a motor vehicle when no longer taking analgesics B. Increase Intake of fiber-rich foods. C. May place a small pillow under the head when sleeping. D. Take tub baths instead of showers

Correct Answer is A

Explanation

Choice A reason:

May operate a motor vehicle when no longer taking analgesics is appropriate. This option could still potentially be a concern. While the patient might not be taking analgesics, the halo device's restrictions on neck movement could still impact their ability to safely operate a motor vehicle. So, this option might still need clarification with the provider.

Choice B reason:

Increase Intake of fibre-rich foods. This option is not related to the use of a halo device. Increasing fibber intake is generally a positive dietary recommendation, and it doesn't directly pertain to the halo device or the patient's discharge instructions.

Choice C reason:

May place a small pillow under the head when sleeping. This option is incorrect because using a small pillow under the head when sleeping is a common practice for patients with halo devices. It helps to maintain proper alignment and reduce discomfort while sleeping.

Choice D reason:

Take tub baths instead of showers. This option is incorrect because taking tub baths instead of showers is a common recommendation for patients with halo devices. The halo device must be kept dry to prevent complications. Showering might increase the risk of water seeping into the halo vest, whereas taking a tub bath could help in maintaining dryness around the device.

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A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to intervene?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is A

Explanation

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