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","B","C"]
Explanation
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.
Correct Answer is B
Explanation
Choice A: Comprehension of simple commands is an earlier developmental stage and not directly related to the infant's ability to search for a fallen toy.
Choice B: Exploration beyond caregiver presence is a key characteristic of the sensorimotor stage in Piaget's theory. During this stage, infants develop object permanence and begin to explore their environment independently.
Choice C: Visible or audible separation anxiety is common during the early stages of infancy and is not specific to the sensorimotor stage.
Choice D: The ability to place objects in a container is more related to later developmental stages when fine motor skills are more developed.
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