A nurse on a medical surgical unit is caring for a client who has a small bowel obstruction and is receiving parenteral nutrition through a central venous catheter. Which of the following actions should the nurse plan to take? (Select all that apply)
Observe for dyspnea.
Infuse parenteral nutrition by gravity.
Administer parenteral nutrition solution within 30 min after removing from the refrigerator.
Change parenteral nutrition bag and infusion tubing every 72 hr.
Begin infusion of parenteral nutrition once central venous catheter position is confirmed by radiology.
Correct Answer : A,C,E
Choice A reason: Dyspnea is a sign of pulmonary edema, which can occur as a complication of parenteral nutrition due to fluid overload or allergic reaction¹². The nurse should monitor the client's respiratory status and oxygen saturation and report any signs of respiratory distress.
Choice B reason: Parenteral nutrition should not be infused by gravity, as this can cause fluctuations in the infusion rate and lead to hyperglycemia or hypoglycemia¹³. The nurse should use an infusion pump to deliver parenteral nutrition at a constant and controlled rate.
Choice C reason: Parenteral nutrition solution should be administered within 30 min after removing from the refrigerator, as prolonged exposure to room temperature can increase the risk of bacterial contamination and infection¹⁴. The nurse should check the expiration date and inspect the solution for any discoloration, cloudiness, or particulate matter before administration.
Choice D reason: Parenteral nutrition bag and infusion tubing should be changed every 24 hr, not every 72 hr, to prevent the growth of microorganisms and reduce the risk of infection¹⁵. The nurse should use aseptic technique when changing the bag and tubing and follow the facility's protocol for dressing changes and catheter care.
Choice E reason: Parenteral nutrition should be started only after the central venous catheter position is confirmed by radiology, as incorrect placement can cause serious complications such as pneumothorax, hemothorax, or cardiac tamponade¹⁶. The nurse should obtain a chest x-ray and wait for the provider's confirmation before initiating parenteral nutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elastic skin turgor is a sign of adequate hydration and fluid balance. Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled. When the skin is dehydrated, it loses its elasticity and becomes tented or wrinkled. The nurse should assess the skin turgor on the chest, abdomen, or forehead, and not on the hands or feet, which can be affected by aging or edema.
Choice B reason: Dry mucous membranes are a sign of fluid volume deficit, not fluid volume excess. Mucous membranes are the moist linings of the mouth, nose, eyes, and other body openings. When the body is dehydrated, the mucous membranes become dry, cracked, or sticky. The nurse should assess the mucous membranes for color, moisture, and capillary refill.
Choice C reason: Oliguria is a sign of fluid volume deficit, not fluid volume excess. Oliguria is the production of abnormally small amounts of urine, usually less than 400 mL per day or 30 mL per hour. Oliguria can indicate reduced kidney function, impaired blood flow to the kidneys, or inadequate fluid intake. The nurse should monitor the urine output, color, specific gravity, and presence of blood or protein.
Choice D reason: Tachycardia is a sign of fluid volume deficit, not fluid volume excess. Tachycardia is a rapid heart rate, usually more than 100 beats per minute. Tachycardia can occur when the body is dehydrated, as the heart tries to pump more blood to maintain the blood pressure and perfusion. The nurse should measure the pulse rate, rhythm, quality, and amplitude.
Correct Answer is B
Explanation
Choice B reason: Providing low-fat carbohydrates with meals can help reduce nausea and vomiting in clients who have equilibrium imbalance. Low-fat carbohydrates are easy to digest and can provide energy and prevent hypoglycemia. Examples of low-fat carbohydrates are crackers, toast, rice, and noodles.
Choice A reason: Serving hot foods at mealtime is not a good strategy for clients who have nausea from equilibrium imbalance. Hot foods can have strong odors and flavors that can trigger nausea and vomiting. Cold or room-temperature foods are more tolerable and less stimulating for the senses.
Choice C reason: Encouraging the client to eat even if nauseated is not a helpful strategy for clients who have nausea from equilibrium imbalance. Forcing the client to eat can worsen nausea and vomiting and cause discomfort and distress. The nurse should respect the client's preferences and appetite and offer small, frequent meals and snacks.
Choice D reason: Limiting fluid intake between meals is not a necessary strategy for clients who have nausea from equilibrium imbalance. Fluid intake is important to prevent dehydration and electrolyte imbalance, which can occur due to vomiting. The nurse should encourage the client to drink fluids between meals, but avoid drinking fluids with meals, as this can cause bloating and fullness.
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