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 D

Explanation

A. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
B. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
C. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
D. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)

A. Circulatory overload B. Extravasation C. Phlebitis D. Infiltration

Correct Answer is C

Explanation

A. Circulatory overload is characterized by symptoms such as dyspnea, crackles, and increased blood pressure, rather than localized redness and warmth.
B. Extravasation refers to the leakage of IV fluid into surrounding tissue, causing swelling and pain.
C. Redness and warmth around the peripheral catheter insertion site are indicative of phlebitis, which is inflammation of the vein. It's essential to document this finding accurately to monitor for worsening or complications.
D. Infiltration occurs when IV fluid leaks into the surrounding tissue, but it typically presents with swelling, pallor, and coolness at the site rather than redness and warmth.

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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

A nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is D

Explanation

A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

Correct Answer is C

Explanation

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