The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client complains of blurred vision, dry mouth, and frequent urination. Which is the nurse's priority action?

Check the client's 24-hour fluid balance

Reducing the rate of the TPN infusion by half

Perform a finger-stick blood glucose check

Assessing the client's vital signs

Answer and Explanation

The Correct Answer is C

Rationale:
A. While reviewing fluid balance is important, it is not the priority in response to symptoms of hyperglycemia.
B. Reducing the TPN rate without verifying the cause of symptoms could lead to undernourishment or abrupt changes in glucose levels.
C. Blurred vision, dry mouth, and frequent urination are classic signs of hyperglycemia. Since TPN contains high levels of glucose, a finger-stick blood glucose check is the priority to confirm and address potential hyperglycemia.
D. Vital signs are important, but do not directly assess the suspected cause of the client's symptoms in this case.

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Correct Answer is A

Explanation

Rationale:
A. Frequent neurovascular assessments—checking circulation, movement, and sensation in the toes—are essential to detect early signs of complications such as compartment syndrome, impaired perfusion, or nerve damage. This is the priority nursing action.
B. Traction is not routinely applied with a long leg cast unless specifically ordered for a separate condition.
C. Heat and cold therapy should not be applied directly to a cast due to risk of skin injury and inability to accurately assess temperature through the cast material.
D. Complete bed rest is not necessary for most clients with a leg cast and can increase the risk of complications such as deep vein thrombosis and deconditioning.

A. I will put a heating pad on my ankle at bedtime tonight" B. I will rewrap my ankle starting from the knee down." C. I will bear weight on my ankle for 10 minutes every hour." D. 'I will apply ice to my ankle today and tomorrow."

Correct Answer is D

Explanation

Rationale:
A. Applying heat in the first 24–48 hours after a sprain can increase swelling and is not recommended. Cold therapy (ice) is preferred initially to reduce inflammation.
B. Wrapping should start from the toes and move upward toward the knee to promote venous return and proper compression, not from the knee down.
C. Bearing weight too soon can worsen the injury; rest and limited movement are advised initially.
D. Applying ice during the first 24–48 hours helps reduce swelling and pain, and is an appropriate self-care measure for a recent ankle sprain, indicating proper understanding of discharge instructions.

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The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client complains of blurred vision, dry mouth, and frequent urination. Which is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the most important nursing care aspect for a client with a new long leg cast?

Correct Answer is A

Explanation

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

Correct Answer is D

Explanation

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