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.)
Redness at intravenous site.
Generalized nonpitting edema.
Frequent productive cough.
Hypoactive bowel sounds in all 4 quadrants.
Urinary output greater than 30 mL per hour.
Correct Answer : A,B,C
Choice A: Redness at the intravenous site may indicate infection or phlebitis, which are complications of TPN.
Choice B: Generalized nonpitting edema may indicate fluid overload, which can occur due to the high osmolarity of TPN.
Choice C: Frequent productive cough may indicate pulmonary edema or aspiration, which are also potential complications of TPN.
Choice D: Hypoactive bowel sounds in all 4 quadrants are not necessarily abnormal, as TPN bypasses the gastrointestinal tract.
Choice E: Urinary output greater than 30 mL per hour is within the normal range and indicates adequate renal function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This response indicates an understanding of the need to avoid high- risk activities that could worsen the condition or cause injury to the affected leg, which is appropriate after acute osteomyelitis.
Choice B: While exercise is important, it should be done under medical guidance, especially after a significant illness like acute osteomyelitis.
Choice C: Resuming normal activities may not be appropriate immediately, and the level of activity should be determined by the healthcare provider.
Choice D: Keeping the leg immobile is not typically recommended as it can lead to muscle atrophy and other complications.
Correct Answer is A
Explanation
Choice A: The client's statement reflects an understanding of the DASH diet's emphasis on lean meats, nuts, and dried beans as protein sources, which aligns with the principles of the diet.
Choice B: The DASH diet encourages the consumption of more than 4 to 6 servings of fruits and vegetables daily.
Choice C: The DASH diet does not eliminate dairy-based products but recommends choosing low-fat or fat-free options.
Choice D: The DASH diet does not focus on gluten-free foods but rather on overall dietary patterns that promote heart-healthy eating.
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