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
A. Double room with a 4-month-old who has RSV: This is the best option. RSV is highly contagious but children with the same infection may be cohorted (roomed together) to minimize transmission to other clients and conserve private rooms for uninfected or immunocompromised children.
B. Private room with negative air pressure: Negative pressure rooms are reserved for airborne infections like tuberculosis, not RSV, which is spread through contact and droplets.
C. Private room furthest from the nurses station: While a private room is acceptable, location relative to the nurses station is not a priority. Cohorting with another RSV-positive child is equally effective.
D. Double room with a 6-month-old on droplet precautions: Unless the other child also has confirmed RSV, placing them together risks spreading the virus if their infections differ. Droplet precautions alone do not confirm the same diagnosis.
Correct Answer is B
Explanation
Choice A: Fats are an important component of the diet, but they do not typically require specific counting for meal planning in the same way that carbohydrates do for clients with type 1 diabetes mellitus.
Choice B: Carbohydrates are essential for the client to count for each meal and snack. Monitoring carbohydrate intake is a key aspect of managing blood glucose levels in clients with diabetes, especially for those using short-acting insulin to cover meals.
Choice C: Dairy products, while they contain carbohydrates, are not the primary nutrient that requires counting for meal planning in diabetes management.
Choice D: Protein is an important nutrient in the diet, but it does not require the same level of counting and monitoring as carbohydrates for clients with type 1 diabetes mellitus.
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