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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Large soaking tub without a shower head: This poses a potential risk for injury. A large soaking tub can make it difficult for the client to safely enter and exit, increasing the risk of falls, especially after a total hip arthroplasty.
B. No stairs in the home: This is actually a positive finding, as having no stairs reduces the risk of falls and injury for the client during their recovery.
C. Elevated toilet seats: Elevated toilet seats are generally considered beneficial for clients recovering from hip surgery, as they make it easier to sit down and stand up, reducing strain on the hip.
D. Reclining chair with a straight back: This is also a positive finding. A reclining chair can provide comfort and support, and a straight back can promote proper posture during recovery.
Correct Answer is B
Explanation
A) "The client is exceptionally clingy to others.": While individuals with borderline personality disorder may have intense relationships, they are not typically described as "clingy" in the same way as those with dependent personality disorder. Instead, they may exhibit a fear of abandonment that leads to tumultuous relationships.
B) "The client exhibits impulsive behavior.": This statement accurately reflects a key characteristic of borderline personality disorder. Clients often engage in impulsive behaviors that can be self-destructive, such as spending sprees, substance abuse, or risky sexual activities. This impulsivity is a hallmark feature of the disorder.
C) "The client is overly concerned about minor details.": This behavior is more characteristic of obsessive-compulsive personality disorder rather than borderline personality disorder. Individuals with borderline personality disorder tend to struggle with emotional regulation and relationships rather than focusing on minor details.
D) "The client might act seductively.": While some individuals with borderline personality disorder may exhibit seductive behavior, it is not a defining characteristic of the disorder. This behavior can be a way to cope with feelings of emptiness or to seek validation, but it is not universally applicable to all clients with borderline personality disorder.
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