A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply)

Choice A reason: Palpate the client’s pedal pulses

Palpating the client’s pedal pulses assesses the blood flow to the lower extremities but does not provide information about the client’s muscle strength. This action is important for evaluating circulation but is not relevant for determining strength.

Choice B reason: Ask the client how strong she feels today

Asking the client how strong she feels today provides subjective information about the client’s perception of her strength. While this can be useful, it does not offer an objective measure of muscle strength. Objective assessments are more reliable for determining the client’s actual strength.

Choice C reason: Ask the client to touch her finger to her nose

Asking the client to touch her finger to her nose assesses coordination and fine motor skills rather than muscle strength. This test is often used to evaluate neurological function but does not provide information about the strength of the muscles needed for ambulation.

Choice D reason: Ask the client to push her feet against the nurse’s palms

Asking the client to push her feet against the nurse’s palms is an effective way to assess the strength of the lower extremities. This action provides an objective measure of the client’s muscle strength, which is crucial for determining her ability to ambulate safely. This test helps the nurse evaluate whether the client has sufficient strength to stand and walk.

Choice A reason: 0.9% sodium chloride, also known as normal saline, is not the best choice for interim fluid replacement when TPN is delayed. While it can maintain hydration and electrolyte balance, it does not provide the necessary calories that TPN supplies. TPN solutions are rich in dextrose, amino acids, and lipids, which are essential for patients who cannot receive nutrition through their gastrointestinal tract.

Choice B reason: Dextrose 5% in water (D5W) provides some calories but not enough to meet the nutritional needs of a patient who is dependent on TPN. D5W contains 5 grams of dextrose per 100 mL, providing 170 calories per liter. This is insufficient for patients who require high-calorie intake due to their inability to eat or absorb nutrients normally.

Choice C reason: Dextrose 10% in water (D10W) is the most appropriate choice for interim fluid replacement when TPN is delayed. D10W provides 10 grams of dextrose per 100 mL, offering 340 calories per liter. This higher concentration of dextrose helps to maintain the patient’s caloric intake and prevent hypoglycemia until the next TPN container is available.

Choice D reason: Lactated Ringer’s solution is primarily used for fluid and electrolyte replacement. It contains sodium, potassium, calcium, chloride, and lactate, but it does not provide the necessary calories that TPN supplies. Therefore, it is not suitable for maintaining the nutritional needs of a patient who is dependent on TPN.