A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?
Uses the TPN IV tubing to administer the client's next dose of antibiotics
Plans for a check of the client's fingerstick glucose level every 6 hr
Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved
Schedules a bag and tubing change for 24 hr after the start of the infusion
The Correct Answer is A
Rationale:
A. Uses the TPN IV tubing to administer the client's next dose of antibiotics: TPN lines should never be used for administering other medications or fluids because this increases the risk of contamination, infection, and incompatibility reactions. TPN requires dedicated IV access to maintain sterility and prevent complications such as sepsis.
B. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose regularly is essential during TPN administration because high dextrose concentrations can cause hyperglycemia. Checking every 4–6 hours aligns with safe monitoring practices and does not require intervention.
C. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Slowly titrating the TPN rate helps the client adjust to the high glucose content and reduces the risk of hyperglycemia or fluid overload. This demonstrates safe and appropriate administration practice.
D. Schedules a bag and tubing change for 24 hr after the start of the infusion: Changing the TPN solution and tubing every 24 hours is consistent with infection control guidelines. This action maintains sterility and prevents microbial growth, reflecting proper technique.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Place the client in supine position: The supine position is not ideal for paracentesis. The procedure is typically performed with the client sitting upright on the edge of the bed or in a high Fowler’s position, allowing fluid to collect in the lower abdomen and reducing the risk of organ puncture.
B. Ensure the client has a full bladder: A full bladder increases the risk of bladder puncture during paracentesis. Clients are usually asked to void before the procedure to minimize this risk and promote safety.
C. Obtain a creatinine level: While kidney function may be relevant to overall health, measuring creatinine is not required specifically for paracentesis. The procedure focuses on removing ascitic fluid and assessing for infection or other complications, not directly on renal function.
D. Weigh the client: Weighing the client before the procedure establishes a baseline to evaluate the amount of fluid removed and monitor changes in fluid status. Pre- and post-procedure weights help assess effectiveness and detect complications such as hypotension or fluid shifts.
Correct Answer is A
Explanation
Rationale:
A. "You have the right to decide who receives information.": Clients have the legal and ethical right to confidentiality regarding their medical care under HIPAA and patient privacy regulations. Respecting the client’s decision about who can receive health information reinforces autonomy and ensures that the nurse supports the client’s rights in healthcare decision-making.
B. "Your partner can be a great source of support for you at this time.": While acknowledging the potential benefits of support is empathetic, this statement does not address the client’s request for privacy. It may inadvertently pressure the client to share information, which could violate confidentiality and autonomy.
C. "Is there a reason you don't want your partner to know about your procedure?": Asking for justification may make the client feel challenged or judged. The client is not required to explain their choice, and pressing for reasons can undermine trust and respect for their privacy.
D. "The provider will be tactful when talking to your partner.": This statement assumes the provider will communicate with the partner and disregards the client’s expressed wishes. It could lead to disclosure against the client’s consent, violating confidentiality and patient rights.
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