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 B

Explanation

Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.

Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.

Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.

Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.

A. Thready pulse volume. B. Missing pulse. C. Pulse skips beats. D. Light pressure applied to pulse.

Correct Answer is A

Explanation

Choice A: A thready pulse is one that is weak and can be easily obliterated by light pressure.

Choice B: A missing pulse is one that cannot be felt at all.

Choice C: "Pulse skips beats" is a different phenomenon and not an accurate description of the pulse disappearing with light pressure. It is irregular and may indicate a cardiac arrhythmia.

Choice D: Documenting "light pressure applied to pulse" does not convey the specific finding that the pulse disappears with pressure, which is more clinically relevant. It is not a finding, but a method of assessing the pulse.

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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

Correct Answer is B

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is A

Explanation

Which pathology of autonomic cardiac regulation is mediated by sympathetic innervation?

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