A nurse is preparing to administer total parenteral nutrition (TPN) to a client. The nurse should notify the provider of which of the following findings?
Blood glucose 100 mg/dL.
Client's temperature 37.6°C (99.7°F).
Potassium 5.7 mEq/L.
Weight loss of 0.8 kg/day (1.8 lb/day).
The Correct Answer is C
Choice A rationale:
A blood glucose level of 100 mg/dL is within the normal range, so there is no need to notify the provider of this finding.
Choice B rationale:
A client's temperature of 37.6°C (99.7°F) is slightly elevated but not considered a critical finding. It may be indicative of an infection or other mild inflammation, but it does not warrant immediate provider notification.
Choice C rationale:
A potassium level of 5.7 mEq/L is above the normal range (3.5-5.0 mEq/L). Hyperkalemia can lead to serious cardiac complications, such as arrhythmias, and requires immediate attention from the provider.
Choice D rationale:
Weight loss of 0.8 kg/day (1.8 lb/day) should be evaluated and monitored, but it is not an immediate concern that warrants urgent provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not instruct the older adult client with osteoporosis to increase high-impact activities. Osteoporosis is a condition characterized by decreased bone density and strength, making high-impact activities potentially harmful as they could increase the risk of fractures.
Choice B rationale:
The nurse should not advise the client to consume a low-protein diet. Adequate protein intake is essential for maintaining muscle mass and overall musculoskeletal health, especially in older adults who may be at risk of muscle wasting.
Choice C rationale:
The nurse should not encourage the client to maintain a BMI of 30 to 35. A BMI within this range is considered obese and can put additional stress on the musculoskeletal system, increasing the risk of joint problems and other health issues.
Choice D rationale:
Including fiber in the diet is a correct instruction for promoting musculoskeletal health. Fiber-rich foods can help maintain bowel regularity and prevent constipation, which is important for overall comfort and mobility in older adults with osteoporosis.
Correct Answer is A
Explanation
Choice A rationale:
Tender, bleeding gums could be a sign of phenytoin-induced gingival hyperplasia, a serious adverse effect of phenytoin. This condition requires immediate medical attention to prevent further complications.
Choice B rationale:
Increased facial hair is not a common adverse effect of phenytoin and may not require immediate medical attention. It could be due to other factors or conditions.
Choice C rationale:
Constipation is a common side effect of many medications, including phenytoin. While it should be monitored, it does not require immediate reporting to the provider unless severe or persistent.
Choice D rationale:
A skin rash can be an adverse effect of phenytoin, but it does not necessarily require immediate reporting unless it is severe, accompanied by other symptoms, or indicative of a serious allergic reaction.
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