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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Log roll the client onto the operative side: After hip replacement surgery, the client should avoid lying directly on the operative side to prevent dislocation of the new joint. The client should be log rolled onto the unaffected side instead, using proper body alignment.
B. Keep client's affected heel on the bed: The heel of the affected leg should not be placed flat on the bed to prevent pressure ulcers and promote proper alignment. The nurse should ensure that the affected leg is elevated and properly supported.
C. Use an elevated toilet seat: Using an elevated toilet seat is essential for a client after hip replacement surgery. It helps the client avoid excessive flexion of the hip joint, which can increase the risk of dislocation or complications in the immediate postoperative period.
D. Perform internal and external rotation exercises of the hip: Internal and external rotation exercises should be avoided immediately after a total hip replacement as they can put the joint at risk for dislocation. The focus should be on maintaining proper alignment and performing safe range-of-motion exercises.
Correct Answer is A
Explanation
A. Frothy sputum: Frothy sputum, particularly pink or blood-tinged, is a classic sign of pulmonary edema, which is common in left-sided heart failure. The left side of the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and causing this symptom.
B. Bradycardia: In left-sided heart failure, tachycardia (elevated heart rate) is more commonly seen as the heart tries to compensate for decreased cardiac output, not bradycardia (slow heart rate).
C. Warm skin: In left-sided heart failure, the skin may feel cool and clammy due to poor circulation and reduced cardiac output. Warm skin is not a typical finding in this condition.
D. Jugular vein distention: Jugular vein distention is more indicative of right-sided heart failure, where there is a backup of blood in the venous system. Left-sided heart failure primarily causes symptoms related to pulmonary congestion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.