Before administering a parenteral nutrition solution through a central vein, the nurse should confirm information from which sources? (Select all that apply)

Solution label.

Healthcare provider's prescription.

Medication administration record.

Measured residual volume.

Dietician's progress notes.

Client's identification band.

Answer and Explanation

Correct Answer : A,B,F

Choice A: Confirming information from the solution label is essential to ensure that the correct parenteral nutrition solution is being administered.

Choice B: Confirming the healthcare provider's prescription is critical to verify the type, rate, and duration of the parenteral nutrition therapy, as well as any specific additives or electrolyte requirements.

Choice C: The medication administration record (MAR) is not directly related to parenteral nutrition, so it is not a primary source of information for this specific procedure.

Choice D: Measured residual volume is relevant for enteral nutrition administration but is not applicable to parenteral nutrition.

Choice E: The dietitian's progress notes may provide valuable information about the client's overall nutrition plan but are not the primary source for confirming the immediate administration of a specific parenteral nutrition solution.

Choice F: Confirming the client's identification band is essential to ensure the correct client receives the parenteral nutrition and to prevent errors in administration.

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Correct Answer is A

Explanation

Choice A: Fluctuation with respiration in the water-seal chamber of the chest drainage system is a normal and expected finding for a client with a chest tube in place. It indicates that the system is functioning correctly and allows for the removal of air or fluid from the pleural space during inspiration and expiration.

Choice B: The condition of the dry gauze dressing over the insertion site is important for monitoring any potential signs of infection or bleeding but does not directly relate to the functioning of the chest tube.

Choice C: No bubbling in the suction chamber of the Pleur-Evac system may indicate that the suction pressure is not adequately transmitted to the chest tube or that there is an issue with the system's seal. This finding is not within normal limits and should be addressed.

Choice D: The presence of serous fluid in the drainage chamber of the Pleur- Evac system is expected and indicates that drainage from the pleural space is occurring. However, the key assessment for proper chest tube function is the fluctuation in the water-seal chamber with respiration.

A. Platelet count 135,000/mm3 or 135 x 10°/L B. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L C. Decreased deep tendon reflexes. D. Periodic nausea and vomiting.

Correct Answer is B

Explanation

Choice A: A platelet count of 135,000/mm3 is slightly below the lower end of the normal range, but it may not be considered critically low. It is not the highest priority finding among the choices provided.

Choice B: A blood urea nitrogen (BUN) level of 75 mg/dL is significantly elevated and outside the normal range. Elevated BUN can indicate kidney dysfunction or dehydration and should be reported promptly.

Choice C: Decreased deep tendon reflexes may be related to various factors, including medication effects, and may not be considered the highest priority finding unless it is associated with other concerning symptoms.

Choice D: Periodic nausea and vomiting can be common side effects of chemotherapy, but they may not be considered the highest priority finding unless they are severe, persistent, or associated with signs of dehydration or electrolyte imbalances.

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Before administering a parenteral nutrition solution through a central vein, the nurse should confirm information from which sources? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

Correct Answer is A

Explanation

The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse? Reference ranges: Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L] Platelets:

Correct Answer is B

Explanation

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