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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Inquiring about how long the adolescent has seemed depressed is important for assessing the client's overall mental health history, but it may not provide immediate information about the seriousness of the suicide attempt.

Choice B: Asking about any previous suicide attempts is important for understanding the client's history and risk factors, but it does not directly assess the seriousness of the current attempt.

Choice C: Inquiring about any precipitating events is essential for understanding the context and triggers for the suicide attempt, but it may not be the most immediate question to assess seriousness.

Choice D: Asking "How did she attempt to kill herself?" is the most crucial question to assess the seriousness of the suicide attempt. It provides critical information about the method used, which can help determine the lethality of the attempt and guide immediate interventions and safety measures.

A. Offer water to the client hourly. B. Review the intake and output record. C. Increase daily sodium intake. D. Reduce dairy product intake.

Correct Answer is A

Explanation

Choice A: Offering water to the client hourly is an important intervention, especially for older clients who may be prone to dehydration. Confusion can sometimes be a symptom of dehydration, so ensuring adequate hydration is essential.

Choice B: Reviewing the intake and output record is important for assessing the client's fluid balance but may not directly address the client's current confusion.

Choice C: Increasing daily sodium intake would not be appropriate without a specific indication, and it may not address the client's confusion.

Choice D: Reducing dairy product intake is not a standard intervention for confusion and may not be appropriate unless there is a specific dietary restriction or allergy in place.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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