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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Increasing abdominal pain, tachycardia, and a low-grade fever in a postoperative bariatric surgery client may indicate a serious complication such as an anastomotic leak. This requires immediate communication with the healthcare provider.
B. Dumping syndrome typically causes symptoms like dizziness, diarrhea, and sweating after eating—not increasing pain and fever.
C. Nasogastric tube insertion is usually contraindicated after bariatric surgery unless specifically ordered, as it may disrupt surgical sites.
D. These are not mild findings that warrant passive monitoring; prompt intervention is necessary to prevent worsening of a potentially life-threatening complication.
Correct Answer is B
Explanation
Rationale:
A. While keeping a toothbrush clean is important, running it in the dishwasher monthly is not an effective or necessary method of infection prevention. A soft-bristled toothbrush should be rinsed and replaced regularly.
B. Excessive menstrual bleeding can indicate thrombocytopenia, a serious side effect of chemotherapy, and should be reported immediately. This statement shows appropriate understanding.
C. Clients with neutropenia should avoid crowds to protect themselves from infection, not to prevent spreading it to others.
D. Antiemetics are most effective when taken before chemotherapy begins, not after the infusion is complete.
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