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?

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

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

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

Answer and Explanation

The Correct Answer is D

A: Changing the TPN bag and tubing every 24 hours is standard practice to prevent infection, so this action is appropriate.
B: Checking glucose levels every 6 hours is necessary because TPN can significantly affect blood glucose levels.
C: Gradually increasing the TPN rate is a standard procedure to monitor tolerance to the infusion.
D: This indicates a need for intervention. TPN lines should not be used for any other infusions to prevent contamination and interactions between the nutrition formula and medications.

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Correct Answer is ["A","B","C"]

Explanation

The presence of more frequent headaches and difficulty sleeping, coupled with a significant increase in blood pressure (BP 169/91 mm Hg), could suggest potential adverse effects of the medication phenelzine, which is known to cause headaches and hypertensive reactions. It is crucial for the nurse to monitor these symptoms closely, as they may require medical attention and could indicate the need for an adjustment in the client's treatment plan. The client's vital signs should be regularly monitored, and any new or worsening symptoms should be reported to the healthcare provider promptly to ensure the client's safety and well-being.

A. Apply lotion to skin every 4 hr. B. Supplement feeding with sterile water. C. Brestfeed every 2 to 3 hr. D. Cover newborn's eyes with a shield. E. Dress in only a diaper.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

A. Applying lotion to the skin is contraindicated during phototherapy because it can interfere with the effectiveness of the therapy by blocking the light from reaching the skin. B. Supplementing feeding with sterile water is contraindicated because it can decrease the newborn's intake of breast milk or formula, which is essential for hydration and nutrition, especially during phototherapy. C. Breastfeeding is indicated and encouraged every 2 to 3 hours because it helps to maintain hydration and promotes bilirubin excretion, which can help in reducing jaundice levels. D. Covering the newborn's eyes with a shield is indicated during phototherapy to protect the eyes from the bright lights used in the treatment, which can potentially damage the retina and cause eye problems. E. Dressing the newborn in only a diaper is indicated during phototherapy to maximize the exposure of the skin to the light, which enhances the effectiveness of the treatment in reducing bilirubin levels.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a 36-hr old infant. Exhibits For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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