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.
Prepare the client for a central venous line.
Obtain a random blood glucose daily.
Change the PN infusion bag every 48 hr.
The Correct Answer is B
Choice A rationale:
Administering the PN and fat emulsion separately is not necessary; they can be combined into one solution for administration.
Choice B rationale:
Preparing the client for a central venous line is appropriate when administering parenteral nutrition (PN) with a high dextrose concentration and fat emulsions. A central venous line is typically used for PN with higher osmolarity.
Choice C rationale:
Obtaining a random blood glucose daily is important for monitoring the client's response to PN but does not address the initial plan of care.
Choice D rationale:
Changing the PN infusion bag every 48 hours is not a standard practice. The frequency of bag changes should follow the facility's policy and the product manufacturer's guidelines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Determining areas of resonance across the abdomen can help evaluate for gas accumulation, but it is not as sensitive as visual inspection.
Choice B rationale:
Listening for bowel sounds can help assess for bowel function, but it is not reliable in detecting complications.
Choice C rationale:
The nurse should first expose the client's abdomen to look for changes in appearance. This is because sudden, severe abdominal pain after bowel resection could indicate a complication such as anastomotic leak, bowel perforation, or internal bleeding. These conditions can cause signs of peritonitis, such as abdominal distension, rigidity, or bruising. By visually inspecting the abdomen, the nurse can quickly assess for these signs and initiate appropriate interventions.
Choice D rationale:
Performing abdominal palpation can help identify areas of tenderness or masses, but it can also cause pain and discomfort to the client and increase the risk of infection.
Correct Answer is D
Explanation
A. The bottle should be held 5–10 cm (2–4 in) above the sterile field to prevent splashing, not 20 cm.
B. Sterile gloves are applied after the sterile field is set up; they are not required before opening the bottle.
C. The lid of the sterile solution bottle should be placed upside down on a clean surface, not on the sterile drape, to prevent contamination.
D. Holding the bottle with the label facing the palm protects the label from getting wet or contaminated while pouring the solution.
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