A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as an adverse effect of TPN
2+ deep tendons reflexes
Casual blood glucose 100 mg/dl
Potassium 4.8 mEq/L
2+ peripheral pitting Edema
The Correct Answer is D
TPN is a form of nutrition given intravenously to provide essential nutrients when a client is unable to consume an adequate oral diet. One of the potential adverse effects of TPN is fluid overload, which can manifest as peripheral edema. The presence of 2+ peripheral pitting edema indicates the accumulation of excess fluid in the tissues. It is important for the nurse to monitor the client's fluid balance closely and assess for signs of fluid overload, such as edema, to prevent complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinary retention: While urinary retention can be a side effect of meperidine and other opioids, it is not the priority assessment before administering the medication. Urinary retention is a concern but is not immediately life-threatening compared to other potential side effects of opioids, such as respiratory depression. Assessing urinary retention is important, but it is not the primary concern in this situation.
B. Vomiting: Vomiting can also be a side effect of opioids, including meperidine. While it is essential to assess for vomiting and its potential impact on the client's overall condition, it is not the priority assessment before administering the medication. Vomiting can be managed, and the nurse should address it as needed. However, the priority assessment is one that can affect the client's immediate safety and well-being, such as respiratory rate and potential respiratory depression.
C. Respiratory rate: This is the correct answer. The priority assessment before administering meperidine is the client's respiratory rate. Opioids can cause respiratory depression, leading to reduced breathing and inadequate ventilation. Monitoring the respiratory rate allows the nurse to detect any signs of respiratory distress or inadequate breathing, enabling them to intervene promptly to prevent serious complications.
D. Level of consciousness: While assessing the client's level of consciousness is essential for overall assessment and monitoring, it is not the priority assessment before administering meperidine. Respiratory depression due to opioid use can occur even when the client is conscious. However, if respiratory depression occurs, it can lead to a decrease in consciousness and potentially unconsciousness, making the assessment of respiratory rate more critical to prevent such complications.
Correct Answer is ["B","E"]
Explanation
The nurse should monitor the following laboratory tests to determine the effectiveness of epoetin alfa:
B. Hemoglobin: Epoetin alfa is a medication used to treat anemia by stimulating red blood cell production. Monitoring hemoglobin levels can help assess if the medication is effectively increasing red blood cell production and improving anemia.
E. Iron: Iron is essential for red blood cell production. Monitoring iron levels can help determine if the client has adequate iron stores to support the increased production of red blood cells stimulated by epoetin alfa.
The other options listed, A. Thyroid-stimulating hormone, C. Blood glucose, and D. Alanine aminotransferase, are not directly related to the effectiveness of epoetin alfa in treating anemia. Thyroid-stimulating hormone is related to thyroid function, blood glucose is related to blood sugar control, and alanine aminotransferase is related to liver function. While these tests may be important for monitoring the overall health of the client, they are not specific indicators of the effectiveness of epoetin alfa.
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