After reviewing a client's intake and output record for the last eight hours, the nurse calculates the client's current fluid balance as how many mL? (Enter numeric value only).

0730-8 oz of orange juice, hard-boiled egg, and toast

0830-voided 200 mL

0900-a cup of water

1200-1 cup of soup, tuna sandwich, and 6 ounces of apple juice

1300 vomitus of 100 mL

1400-voided 250 ml

1430-12 ounce can have carbonated beverage.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

Generalized nonpitting edema.

Hypoactive bowel sounds in all 4 quadrants.

Redness at intravenous site.

Urinary output greater than 30 ml per hour.

Frequent productive cough.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A

Generalized nonpitting edema is correct. Nonpitting edema could indicate fluid retention, and it's important to assess for signs of fluid overload, electrolyte imbalances, or underlying cardiac issues.

Choice B

Hypoactive bowel sounds in all 4 quadrants is correct. Hypoactive bowel sounds could suggest gastrointestinal motility issues, which could be a sign of gastrointestinal complications related to TPN.

Choice C

Redness at intravenous site is correct. Redness at the intravenous site could be indicative of infection, infiltration, or irritation. It's important to assess for signs of infection and ensure proper IV site care.

Choice D

Urinary output greater than 30 ml per hour is incorrect. While increased urinary output could indicate adequate hydration, it's not typically a concerning finding unless there are other signs of fluid imbalance. Top of Form

Choice E

Frequent productive cough is correct. A frequent productive cough could indicate respiratory issues, including aspiration pneumonia, which can be a complication of TPN.

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Correct Answer is D

Explanation

Correct answer: D

Choice A

Urinary ketones are not most important. Monitoring urinary ketones can provide information about the utilization of glucose and fat as energy sources. However, it is not the primary lab value to monitor in TPN administration.

Choice B

Serum protein is not most important. Monitoring serum protein levels is important to assess nutritional status, but it might not be as immediate a concern as serum osmolarity.

Choice C

Serum osmolarity reflects the concentration of particles (such as electrolytes, glucose, and other solutes) in the blood. Monitoring serum osmolarity is importantto prevent complications related to fluid and electrolyte imbalances that can arise from the administration of TPN.Blood glucose levels (option D) are more critical because TPN can significantly impact glucose metabolism

Choice D

When caring for a client receiving total parenteral nutrition (TPN), the nurse’spriorityis tomonitor blood glucose levels. TPN can affect blood glucose, and observing for signs of hyperglycemia or hypoglycemia is crucial.Additionally, administering insulin as directed based on blood glucose levels is essential.

A. Observe for abdominal distention, B. Calculate 24-hour caloric intake. C. Measure the urinary output. D. Check for body weight changes.

Correct Answer is A

Explanation

Choice A

Observing for abdominal distention is recommended. Gastric residual volume (GRV) is the amount of formula or food remaining in the stomach after a feeding through a gastric tube. A GRV of 325 mL is relatively high, and it's important to assess the client for signs of potential complications before contacting the healthcare provider. Observe for signs of abdominal distention, which could indicate that the stomach is not adequately emptying or that the feeding is not being tolerated well.

Choice B

Calculating 24-hour caloric intake is not recommended: While monitoring caloric intake is important for overall nutritional assessment, it does not address the immediate concern of a high GRV and the potential need for adjustment of the feeding rate or management.

Choice C

Measuring urinary output is not recommended: Urinary output is important to monitor for fluid balance, but it may not be directly related to the elevated GRV.

Choice D

Checking for body weight changes is not recommended: Monitoring body weight is essential for assessing nutritional status, but it may not provide immediate insights into the impact of the elevated GRV.

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Naxlex Comprehensive Predictor Exams

While caring for a client receiving total parenteral nutrition (TPN), it is most important for the nurse to monitor which of the client's lab values?

Correct Answer is D

Explanation

A client is receiving a continuous gastric tube feeding at 80 mL/hour. The nurse records the client's gastric residual volume as 325 mL during each of two consecutive hourly measurements. What assessment should the nurse complete before contacting the healthcare provider?

Correct Answer is A

Explanation

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