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. Offering to play music in the client's room can provide a distraction and promote relaxation, which may help alleviate the client's perception of pain. Music therapy has been shown to have analgesic effects and can contribute to a more comfortable and calming environment for the client.
A. Massaging the client's sacrum may not be appropriate for acute pain resulting from a pressure injury. Direct pressure or manipulation of the affected area could potentially exacerbate pain or cause further tissue damage. It's essential to avoid activities that may aggravate the pressure injury or compromise healing.
B. Providing bright lights in the client's room is not typically indicated for pain management in clients with pressure injuries. In fact, excessive light exposure may be disruptive to sleep and rest, which are important for the healing process. Maintaining a comfortable and soothing environment is more conducive to pain relief and overall well-being.
C. Loosening bed linens can help reduce friction and pressure, but it does not directly address the client's acute pain.

A. "I will hold my breath when rising from a sitting position." B. "I will have my partner help me change positions every 4 hours." C. "I will remove my antiembolic stockings while I am in bed." D. "I will perform ankle and knee exercises every hour."

Correct Answer is D

Explanation

D. This statement shows a good understanding of measures to reduce the adverse effects of immobility. Regularly performing ankle and knee exercises helps promote circulation, prevent muscle atrophy, and reduce the risk of DVT and joint stiffness. Hourly exercises are an excellent practice to mitigate the negative effects of immobility.
A. This statement indicates a misunderstanding. Holding the breath while changing positions can lead to a Valsalva maneuver, which can cause a sudden drop in blood pressure and increase the risk of dizziness or fainting, especially in immobile clients. Instead, clients should be encouraged to breathe normally and rise slowly to avoid orthostatic hypotension.
B. This frequency of position changes is inadequate for preventing pressure ulcers. It is generally recommended to change positions at least every 2 hours to prevent pressure on any one area of the body for too long. Therefore, this statement indicates a partial understanding but needs adjustment to more frequent position changes.
C. Antiembolic stockings (TED hose) are designed to promote venous return and reduce the risk of DVT. They are typically worn continuously, except during hygiene routines or as directed by a healthcare

provider. Removing them while in bed could increase the risk of thrombus formation. This statement indicates a misunderstanding of their purpose and usage.

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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?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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