A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?
Sit the client upright.
Stop the TPN infusion.
Prepare to add insulin to the TPN infusion.
Turn the client on his left side.
The Correct Answer is B
Choice A reason: Sitting the client upright may help with respiratory symptoms if fluid overload or dyspnea occurs, but it does not address the underlying issue of rapid TPN infusion. It is a supportive measure, not a corrective action.
Choice B reason: Stopping the TPN infusion is the immediate and appropriate response to prevent complications such as hyperglycemia, fluid overload, and electrolyte imbalance. TPN must be administered at a controlled rate to avoid metabolic disturbances. Halting the infusion allows the nurse to reassess and notify the provider for further instructions.
Choice C reason: Adding insulin to the TPN solution is a preemptive measure used when hyperglycemia is anticipated or present. It is not a corrective action for rapid infusion and should only be done under provider orders with proper monitoring.
Choice D reason: Turning the client on the left side is a maneuver used in certain emergency situations, such as air embolism, but it is not relevant to TPN infusion rate issues. It does not mitigate the risks associated with rapid nutrient delivery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The lockout feature does not ensure adequate medication use. It is designed to prevent excessive dosing, not to encourage more frequent use. Patients are educated to self-administer based on pain levels.
Choice B reason: PCA pumps are patient-controlled and do not operate on a fixed schedule. The lockout interval is not a reminder tool but a safety mechanism to regulate dosing frequency.
Choice C reason: The lockout interval is a safety feature that prevents the patient from receiving another dose until a specified time has passed. This minimizes the risk of overdose and ensures safe administration of opioids or other analgesics.
Choice D reason: PCA pumps are designed for patient autonomy in pain control. Nurses monitor usage and effectiveness but do not control administration directly. The lockout feature is built into the device, not managed manually by nursing staff.
Correct Answer is D
Explanation
Choice A reason: While a glucose level of 500 mg/dL is elevated and common in HHS, it alone is not diagnostic. HHS is characterized by extreme hyperglycemia, hyperosmolarity, and absence of significant ketosis.
Choice B reason: Hypertension may be present in many conditions and is not specific to HHS. It does not help differentiate HHS from other hyperglycemic emergencies.
Choice C reason: Ketosis is a hallmark of diabetic ketoacidosis (DKA), not HHS. In HHS, insulin levels are sufficient to prevent ketosis but not enough to prevent hyperglycemia.
Choice D reason: A plasma osmolarity of 350 mOsm/L is elevated and indicative of HHS. This hyperosmolar state leads to profound dehydration and altered mental status, distinguishing HHS from DKA.
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