A nurse is caring for a client who is receiving TPN.

Exhibits

Which of the following actions should the nurse take?

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Notify provider to increase TPN rate/hr.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.

Obtain client weight twice daily.

Request a prescription for insulin.

Request an antibiotic to be administered.

Have 3 nurses verify the TPN solution prescription.

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Notify provider to increase TPN rate/hr.

Contraindicated

Rationale: Increasing the TPN rate without a clear medical indication can cause fluid overload and complications such as hyperglycemia or electrolyte imbalances, especially in a patient with an already abnormal potassium level.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.

Contraindicated

Rationale: The client's current oxygen saturation is 90%, which is low. Reducing oxygen delivery could further decrease oxygen saturation and exacerbate hypoxia.

Obtain client weight twice daily.

Anticipated

Rationale: Monitoring weight is important in clients receiving TPN to assess fluid balance, nutritional status, and to detect signs of fluid overload or dehydration.

Request a prescription for insulin.

Anticipated

Rationale: The client's fasting blood glucose level is elevated (140 mg/dL). Insulin therapy may be necessary to manage hyperglycemia, which can occur with TPN.

Request an antibiotic to be administered.

Anticipated

Rationale: The client has a fever, elevated WBC count, and signs of infection (productive cough with yellow sputum). Antibiotic therapy may be necessary to treat a suspected infection.

Have 3 nurses verify the TPN solution prescription.

Nonessential

Rationale: Typically, two nurses are sufficient to verify TPN prescriptions. While an additional nurse may add an extra layer of safety, it is not a standard practice and is considered nonessential unless specified by the facility's policy.

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Correct Answer is B

Explanation

A. Kussmaul respirations are associated with metabolic acidosis, such as diabetic ketoacidosis, not hypoglycemia.

B. Cool, clammy skin is a common sign of hypoglycemia, as the body responds to low blood glucose levels with sweating and skin changes.

C. Acetone breath is indicative of diabetic ketoacidosis, which is associated with hyperglycemia rather than hypoglycemia.

D. Increased urine output is often associated with hyperglycemia and diabetic ketoacidosis, not hypoglycemia.

A. Initiate a referral for the client to a home health agency. B. Remind the client of the importance of medication adherence. C. Tell the client to avoid places where there are large crowds of people. D. Instruct the client to avoid eating raw vegetables.

Correct Answer is A

Explanation

A. Referring the client to a home health agency demonstrates client advocacy by ensuring they receive the necessary support and resources for managing their condition at home.

B. While important, reminding the client about medication adherence is part of general health education rather than advocacy.

C. Advising the client to avoid large crowds is a precaution but does not directly address the need for additional support and resources.

D. Instructing the client to avoid raw vegetables is part of dietary advice but does not specifically support the client’s overall self-care at home.

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A nurse is caring for a client who is receiving TPN. Exhibits Which of the following actions should the nurse take? For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

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A nurse is caring for a client who is receiving TPN.

Exhibits

Which of the following actions should the nurse take?

For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.