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?

Plans for a check of the client's fingerstick glucose level every 6 hr

Schedules a bag and tubing change for 24 hr after the start of the infusion

Uses the TPN IV tubing to administer the client's next dose of antibiotics

Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved

Answer and Explanation

The Correct Answer is C

A. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose levels is essential for clients receiving TPN due to the risk of hyperglycemia. Checking glucose every 6 hours is a standard practice that helps ensure appropriate glycemic control, so this action is appropriate.

B. Schedules a bag and tubing change for 24 hr after the start of the infusion: It is standard practice to change the TPN bag and tubing every 24 hours to reduce the risk of infection and maintain sterility. This timing aligns with best practices for TPN administration, indicating no need for intervention.

C. Uses the TPN IV tubing to administer the client's next dose of antibiotics: Using the TPN line for additional medications, such as antibiotics, can lead to complications like incompatible drug interactions or infection. TPN should ideally be delivered through a dedicated line to prevent these risks, which necessitates intervention from the supervising nurse.

D. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Gradual escalation of the TPN infusion rate is important to prevent complications such as hyperglycemia. This action is appropriate, as it allows the body to adapt to the increased caloric intake safely.

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Correct Answer is D

Explanation

A. Premature Infant Pain Profile (PIPP): This scale is specifically designed for assessing pain in preterm infants and may not be suitable for a newborn delivered at 38 weeks of gestation.

B. FACES pain rating scale: This scale is typically used for older children who can understand and relate to facial expressions, making it inappropriate for assessing pain in newborns.

C. Visual analog scale (VAS): This scale is also not suitable for newborns, as it requires the ability to understand and interpret a continuous scale, which newborns cannot do.

D. Neonatal Infant Pain Scale (NIPS): This is the most appropriate choice for assessing pain in a newborn. It evaluates indicators such as facial expression, cry, breathing patterns, and extremity movement, making it suitable for this age group and context.

A. Ketorolac B. Acetaminophen C. Aspirin D. Ibuprofen

Correct Answer is B

Explanation

A) Ketorolac: Ketorolac is a potent nonsteroidal anti-inflammatory drug (NSAID) often used for severe pain. However, it can cause gastrointestinal irritation and bleeding, which poses a significant risk for a client with a history of peptic ulcers. Therefore, administering ketorolac would not be advisable in this situation.

B) Acetaminophen: Acetaminophen is an analgesic that does not have the gastrointestinal side effects associated with NSAIDs. It is a safer option for clients with a history of peptic ulcers, as it does not irritate the stomach lining and can effectively relieve headache pain without exacerbating ulcer-related complications.

C) Aspirin: Aspirin is another NSAID that can increase the risk of gastrointestinal bleeding, especially in individuals with a history of peptic ulcers. While it is effective for pain relief, its anticoagulant properties and irritation potential make it an unsuitable choice for this client.

D) Ibuprofen: Like other NSAIDs, ibuprofen can cause gastrointestinal issues, including irritation and bleeding. Given the client’s history of peptic ulcers, using ibuprofen could lead to exacerbation of the condition and should be avoided in favor of safer alternatives for pain management.

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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?

Nursing Test Bank

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