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 A rationale
Encouraging the client to ambulate within 30 minutes following the procedure is not recommended as it could lead to complications such as bleeding or hematoma at the insertion site.
Choice B rationale
Keeping the client NPO for at least 2 hours following the procedure is not typically necessary and does not relate directly to the care required after a cardiac catheterization.
Choice C rationale
Assessing pulses in the client's affected arm is crucial to ensure that there is adequate blood flow and no compromise in circulation following the procedure.
Choice D rationale
Applying light pressure to the insertion site may help in preventing bleeding initially, but it is more critical to monitor for signs of bleeding or hematoma formation over time. .
Correct Answer is A
Explanation
Choice A rationale
The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygenation of central tissues. When there is a lack of oxygen in the bloodstream, the lips and mucous membranes, such as the oral mucosa, appear blue or cyanotic. This is a clear sign that the central tissues are not receiving adequate oxygenation.
Choice B rationale
The sclera of the eye is not a reliable indicator of central cyanosis. The sclera is white and does not change color due to oxygen levels. Instead, it may become yellow in jaundice or red in inflammation but does not reflect central cyanosis.
Choice C rationale
The ear lobes are peripheral areas and do not reliably indicate central cyanosis. Peripheral cyanosis can occur due to local blood flow issues, and ear lobes can appear blue in cold conditions even when central oxygenation is normal.
Choice D rationale
The soles of the feet, similar to the ear lobes, are peripheral areas and not reliable indicators of central cyanosis. Cyanosis in the feet can result from poor peripheral circulation rather than central hypoxia.
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