A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Administer the PN and fat emulsion separately.

Change the PN infusion bag every 48 hr.

Obtain a random blood glucose daily.

Prepare the client for a central venous line

Answer and Explanation

The Correct Answer is D

. PN with 20% dextrose requires a central venous line for administration. Peripheral veins cannot handle the high osmolarity of such solutions, which can cause phlebitis and vein damage. A central venous line is necessary to deliver the solution safely into a larger vein with a higher blood flow.
A. Fat emulsions (lipids) are often administered separately from the PN solution, but they can also be infused concurrently through a Y-connector to minimize the risk of contamination. However, it is crucial to follow the specific guidelines of the healthcare facility and the manufacturer’s recommendations. The decision to administer separately or concurrently depends on the prescribed protocol.
B. PN solutions are typically changed every 24 hours to reduce the risk of infection. The high glucose content in PN solutions provides a rich medium for bacterial growth, making it essential to adhere to strict aseptic techniques and timely changes of the infusion bag.
C. Blood glucose monitoring is crucial for clients receiving PN due to the high dextrose content, which can significantly impact blood glucose levels. However, more frequent monitoring, such as every 4-6 hours initially, is often required rather than just a random daily check. This helps in promptly identifying and managing hyperglycemia or hypoglycemia.

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Correct Answer is D

Explanation

D. It is the most appropriate action to ensure accuracy and reliability of the blood pressure reading. Discrepancies in blood pressure readings between arms may indicate arterial abnormalities or differences in blood pressure measurement technique. Rechecking the client's blood pressure in her other arm allows the nurse to verify the consistency of the reading and identify any potential discrepancies.
A. Requesting that another nurse check the client's blood pressure in 30 minutes, is not appropriate as the next course of action. If there is a concern about the accuracy of the blood pressure reading, it's best to first verify the reading using another method, such as rechecking in the other arm, before determining the need for further monitoring.
B. Ensuring that the width of the blood pressure cuff is 50% of the client's upper arm circumference, is a standard recommendation for obtaining accurate blood pressure measurements. However, in this scenario, the priority is to verify the accuracy of the initial reading by rechecking in the other arm.
C. Repositioning the client supine and rechecking her blood pressure, may not be necessary at this point unless there are specific indications or concerns about orthostatic hypotension or positional effects on blood pressure. The immediate priority is to verify the accuracy of the initial reading by rechecking in the other arm.

A. The client's blood pressure is 142/94 mm Hg. B. The client is consuming 25% of their meals. C. The client coughs frequently while eating. D. The client leans to the left side while sitting

Correct Answer is C

Explanation

C. This finding suggests a swallowing difficulty (dysphagia), which is a significant concern for clients with left-sided weakness following a stroke. Dysphagia increases the risk of aspiration, choking, and pneumonia. Immediate intervention is necessary to prevent complications and ensure safe oral intake.
A. While elevated blood pressure may be a concern for a client with a history of stroke, it is not the priority finding in this scenario unless it is significantly high or symptomatic. The immediate priority is addressing issues related to the client's physical function and safety.
B. Malnutrition and dehydration are common risks for clients with left-sided weakness following a stroke. Ensuring adequate nutrition and hydration is essential for promoting recovery and preventing complications such as pressure ulcers and infections.
D. While leaning to one side may indicate asymmetrical weakness or impaired balance, it is not the priority finding compared to issues related to nutrition, swallowing safety, and blood pressure control.

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A nurse is caring for a client

Exhibits

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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

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A nurse is caring for a client Exhibits

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