A nurse is caring for a client with gingivitis in the clinic.

Exhibits

Which of the following client statements indicates to the nurse the teaching was effective?

A. Hang the TPN solution to gravity to infuse: TPN solutions are typically administered using an infusion pump to control the rate of infusion accurately. Hanging the solution to gravity is not recommended because it may lead to inconsistent flow rates and inaccurate delivery of nutrients.
B. Titrate TPN solution to blood pressure: TPN solutions are not titrated based on blood pressure.

The composition and rate of TPN infusion are typically determined by the client's nutritional needs and metabolic status, not blood pressure.

C. Monitor the client's weight daily: Monitoring the client's weight daily is essential when administering TPN to assess for fluid balance, nutritional status, and response to therapy. Changes in weight can indicate fluid retention, dehydration, or changes in nutritional status, which may require adjustments to the TPN regimen.
D. Obtain the client's blood glucose level weekly: Blood glucose levels should be monitored frequently in clients receiving TPN, as hyperglycemia is a common complication. Weekly monitoring may not be sufficient to detect and manage hyperglycemia promptly. Therefore,
blood glucose levels are typically monitored more frequently, such as multiple times daily or according to institutional protocols.

A. The client had a decreased neutrophil count before the medication was administered: This finding may be expected in a client undergoing cytotoxic chemotherapy and receiving filgrastim to stimulate neutrophil production. It is not an indication for an incident report.
B. The client had chemotherapy 12 hr before the medication was administered: The timing of chemotherapy administration is not typically a reason to complete an incident report unless it conflicts with specific medication guidelines or protocols.
C. The vial was out of the refrigerator for 2 hr before the medication was administered:

Filgrastim should be stored in the refrigerator and protected from light. Allowing the medication vial to be out of the refrigerator for an extended period may compromise its stability and effectiveness, potentially leading to adverse effects or reduced efficacy. Therefore, this finding warrants completion of an incident report.
D. The client reported feeling nauseous after the medication was administered: Nausea is a known side effect of filgrastim and is not typically an indication for completing an incident report unless it is severe or persistent and requires intervention.