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.

Answer and Explanation

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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Correct Answer is ["B","E"]

Explanation

A. Place a tongue blade at the bedside: Inserting an object into the mouth during a seizure can lead to airway obstruction, dental injury, or harm to the client. The focus should be on ensuring the client’s safety and airway clearance without inserting any objects.

B. Dim the overhead lights: Dim lighting can help reduce external stimuli that might trigger a seizure. Bright or harsh lights can sometimes exacerbate seizures, so it’s important to create a calm environment that helps prevent further stimulation or agitation.

C. Assist the client to ambulate every 4 hr: Ambulation is not a priority during a seizure or in the immediate post-seizure period. The client’s safety should be ensured by limiting activities that could result in injury, such as walking, especially if they are at risk for more seizures.

D. Apply a warming blanket: Applying a warming blanket is not recommended, especially in the presence of meningitis, as it can increase the risk of hyperthermia. Meningitis can already cause fever, and adding heat may worsen the condition.

E. Have suction equipment at the bedside: Suction equipment should always be available for clients experiencing seizures. This ensures that any secretions or vomit can be cleared quickly to maintain a clear airway, which is essential during and after a seizure.

A. Partial pressure of CO2 50 mm Hg (35 to 45 mm Hg) B. Serum bicarbonate 9 mEq/L (21 to 28 mEq/L) C. Blood glucose 230 mg/dL (74 to 106 mg/dL) D. pH 7.5 (7.35 to 7.45)

Correct Answer is B

Explanation

A. Partial pressure of CO2 50 mm Hg (35 to 45 mm Hg): In DKA the partial pressure of CO2 decreases due to hyperventilation, which is the body’s compensatory mechanism to blow off CO2 and correct metabolic acidosis. A CO2 level of 50 mm Hg would suggest insufficient compensation.

B. Serum bicarbonate 9 mEq/L (21 to 28 mEq/L): In DKA, serum bicarbonate levels decrease due to the accumulation of ketoacids, leading to metabolic acidosis. A level of 9 mEq/L is significantly lower than the normal range and indicates the severity of acidosis.

C. Blood glucose 230 mg/dL (74 to 106 mg/dL): Blood glucose levels in DKA are typically much higher than 230 mg/dL. Blood glucose levels in DKA can exceed 250 mg/dL, often reaching 600 mg/dL or higher, due to insufficient insulin.

D. pH 7.5 (7.35 to 7.45): The pH in DKA is usually low, indicating acidosis. A pH of 7.5 is higher than the normal range, suggesting alkalosis, which is not consistent with DKA. Typically, the pH in DKA is below 7.35 due to metabolic acidosis.

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