A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)
Verify the solution with another RN prior to infusion.
Monitor serum blood glucose during infusion.
Increase the rate of infusion administration is delayed.
Infuse 0.9% sodium chloride if the solution is not available.
Obtain the client's weight daily.
Correct Answer : A,B,E
A. Verify the solution with another RN prior to infusion: To ensure patient safety, the TPN solution should be verified by two licensed healthcare providers before infusion. This helps prevent errors in administering the incorrect solution.
B. Monitor serum blood glucose during infusion: TPN contains high concentrations of glucose, which can lead to hyperglycemia. Monitoring blood glucose levels is essential to prevent complications such as hyperglycemia or hypoglycemia.
C. Increase the rate of infusion if the solution is delayed: The rate of infusion should not be increased to make up for a delayed start, as rapid infusion can lead to fluid overload or metabolic disturbances. The infusion rate should be adjusted based on medical guidelines and the provider's orders.
D. Infuse 0.9% sodium chloride if the solution is not available: If TPN is unavailable, the client should not receive just sodium chloride, as TPN is a complete nutrition solution. Alternative methods should be discussed with the healthcare provider, and the client should not be left without the required nutritional support.
E. Obtain the client's weight daily: Daily weight measurements are crucial to monitor fluid status and nutritional intake, especially when the client is receiving TPN, to ensure that the client is maintaining proper nutritional balance and avoiding complications like fluid retention.
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Related Questions
Correct Answer is C
Explanation
A. Hypotension: While hypotension can be a concern with opioid use, it is less immediately life-threatening compared to respiratory depression, which is the most dangerous side effect of morphine. Monitoring BP is important, but the priority is airway and breathing.
B. Bradycardia: Bradycardia is a possible side effect of morphine, but it does not usually present an immediate risk to the client's life unless it is severe. Respiratory depression poses a greater risk to the client’s oxygenation status.
C. Bradypnea: Bradypnea (slow breathing) is the most critical concern when a client is receiving morphine. Opioids like morphine can cause respiratory depression, which can be life-threatening. This should be the nurse's priority to assess and address immediately.
D. Pruritus: Pruritus (itching) is a common side effect of morphine, but it is not life-threatening. While it can be uncomfortable, it does not require immediate intervention compared to respiratory depression.
Correct Answer is ["30"]
Explanation
Calculation:
- Determine the concentration of the available lidocaine solution in milligrams per milliliter (mg/mL).
Available concentration = Total medication (mg) / Total volume (mL)
= 400 mg / 100 mL
= 4 mg/mL.
- Convert the desired dose from milligrams per minute (mg/min) to milligrams per hour (mg/hr).
1 hr = 60 min
Desired dose in mg/hr = 2 mg/min × 60 min/hr
= 120 mg/hr.
- Calculate the IV pump rate in milliliters per hour (mL/hr).
IV pump rate (mL/hr) = Desired dose (mg/hr) / Available concentration (mg/mL)
= 120 mg/hr / 4 mg/mL
= 30 mL/hr.
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