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 C

Explanation

A) Insert a pillow under the client's knees: While placing a pillow under the knees may promote comfort, it can lead to increased pressure on the lower back and may not effectively address potential compression of the vena cava, which is crucial in maintaining optimal placental blood flow during surgery.

B) Assist the client into the lithotomy position: The lithotomy position can increase pressure on the abdominal vessels, potentially compromising blood flow to the placenta. This position should be used cautiously, especially in clients with concerns regarding blood flow.

C) Place a wedge under one of the client's hips: This action is appropriate as it helps to displace the uterus laterally, reducing pressure on the inferior vena cava. This maneuver improves venous return and maintains placental perfusion, which is critical during cesarean delivery.

D) Position the client in reverse Trendelenburg: Although this position elevates the upper body, it does not specifically address the potential for vena cava compression caused by the weight of the uterus. It is less effective than placing a wedge under the hips in terms of preserving placental blood flow.

A. Monitor the client's aPTT levels. B. Check the client for indications of bleeding C. Complete an incident report. D. Notify the risk manager.

Correct Answer is B

Explanation

A) Monitor the client's aPTT levels: While monitoring the activated partial thromboplastin time (aPTT) is important for managing heparin therapy, it is not the immediate priority after a significant medication error. The potential for bleeding due to the overdose is the most critical concern.

B) Check the client for indications of bleeding: This is the first and most crucial action. Assessing the client for signs of bleeding (such as bruising, hematuria, or bleeding gums) is essential to ensure their safety following an overdose of heparin, which can lead to life-threatening complications.

C) Complete an incident report: Documenting the medication error is important for institutional accountability and quality improvement. However, this action should occur after immediate patient safety is addressed.

D) Notify the risk manager: While this is an important step in the reporting process, it should be done after ensuring the client’s safety and taking appropriate actions to address any potential adverse effects of the medication error.

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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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