A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home.
Which of the following instructions should the nurse include? (Select all that apply.)
Infuse 10 percent dextrose and water if the solution runs out.
Shake the TPN bag with fat emulsion if precipitate is present.
Maintain TPN infusion rate when behind schedule.
Keep the TPN refrigerated when not in use.
Correct Answer : A,D
Choice A rationale
Infusing 10 percent dextrose and water prevents hypoglycemia if TPN is temporarily unavailable. This is a crucial step in maintaining the patient's blood sugar levels.
Choice B rationale
Shaking the TPN bag with fat emulsion can cause the emulsion to break, leading to potential complications. Fat emulsions should be mixed gently.
Choice C rationale
Maintaining the TPN infusion rate when behind schedule is incorrect as it can lead to rapid infusion and complications such as hyperglycemia and fluid overload.
Choice D rationale
Keeping the TPN refrigerated when not in use helps to maintain its stability and prevent bacterial contamination. Proper storage is essential for patient safety. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale
Administering another nitroglycerin tablet is appropriate if the client's chest pain has not been fully relieved after the initial dose. Nitroglycerin helps to dilate blood vessels, improving blood flow to the heart and relieving angina. A second dose can be given if the pain persists, following the protocol for managing chest pain.
Choice A rationale
Obtaining an ECG is important for diagnosing and monitoring cardiac conditions; however, in this immediate context, further pain relief takes precedence. After ensuring pain relief, an ECG can be performed to assess the client's cardiac status.
Choice B rationale
Calling the Rapid Response Team is unnecessary if the client’s chest pain severity has already decreased. The priority should be to continue managing the chest pain with additional nitroglycerin if needed and monitoring the client's response.
Choice D rationale
Initiating a peripheral IV might be required for administering medications or fluids, but it is not the immediate action needed in this scenario. The priority is to provide additional pain relief with nitroglycerin.
Correct Answer is D
Explanation
Choice A rationale
A complete blood count (CBC) can provide general information about the body's response to an MI, such as white blood cell count, but it is not definitive for diagnosing an MI.
Choice B rationale
A lipid profile measures cholesterol levels and helps assess cardiovascular risk, but it is not useful for diagnosing an acute MI.
Choice C rationale
An electrocardiogram (ECG) is essential for diagnosing an MI as it shows the heart's electrical activity and can indicate ischemia or infarction.
Choice D rationale
Troponin levels are the most specific and sensitive markers for myocardial infarction. Elevated troponin levels confirm heart muscle damage due to an MI, making it the definitive test.
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