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 D
Explanation
Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.
Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.
Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.
Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.
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.
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