What should the nurse assess the patient for after discontinuing the TPN?

Hypoglycemia.

Hyperthermia.

Flatulence.

Tachycardia.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Abrupt cessation of total parenteral nutrition (TPN) can lead to a rapid decrease in blood glucose levels. While receiving TPN, the body is continuously supplied with glucose. When this external glucose source is suddenly removed, the pancreas may continue to secrete insulin at a rate higher than needed, resulting in hypoglycemia. Signs and symptoms of hypoglycemia include sweating, tremors, confusion, and dizziness.

Choice B rationale

Hyperthermia, or elevated body temperature above the normal range of approximately 36.5°C to 37.5°C (97.7°F to 99.5°F), is not a typical complication following the discontinuation of TPN. Fever is usually associated with infection or inflammation, neither of which are a direct consequence of stopping TPN.

Choice C rationale

Flatulence, or the accumulation of gas in the digestive tract leading to bloating and the passage of gas, is related to dietary intake and digestive processes. Discontinuing TPN, which bypasses the digestive system, would not directly cause an increase in flatulence. In fact, digestive issues might improve once oral or enteral feeding resumes.

Choice D rationale

Tachycardia, an abnormally rapid heart rate (typically defined as above 100 beats per minute in adults), is not a direct physiological consequence of discontinuing TPN. While changes in fluid balance or electrolyte levels (which can occur with TPN but are monitored closely) could indirectly affect heart rate, hypoglycemia is a more immediate and direct risk upon TPN cessation.

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Correct Answer is C

Explanation

Choice A rationale

Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.

Choice B rationale

Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.

Choice C rationale

Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.

Choice D rationale

Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.

A. Verify tube placement. B. Check the residual feeding contents. C. Administer the feeding. D. Evaluate tolerance to the feeding.

Correct Answer is A,B,C,D

Explanation

Choice A rationale

Verifying tube placement is the initial critical step to ensure the feeding is delivered into the gastrointestinal tract and not the respiratory system, thereby preventing aspiration. Methods for verification include pH testing of aspirate (target pH ≤ 5.5), and radiographic confirmation is the gold standard, especially after initial placement.

Choice B rationale

Checking the residual feeding contents before administering a new feeding is essential to assess the client's tolerance to the previous feeding and prevent overfeeding, which can lead to complications like abdominal distension, nausea, vomiting, and aspiration. A high residual volume may indicate delayed gastric emptying.

Choice C rationale

Administering the feeding follows confirmation of tube placement and assessment of residual volume. The feeding should be administered at the prescribed rate and volume, ensuring the client receives adequate nutrition and hydration. The client should be positioned with the head of the bed elevated at least 30-45 degrees during and for at least 30-60 minutes after feeding to minimize aspiration risk.

Choice D rationale

Evaluating the client's tolerance to the feeding is an ongoing process that involves monitoring for signs and symptoms such as abdominal distension, pain, nausea, vomiting, diarrhea, or aspiration. This evaluation helps determine if the feeding regimen needs adjustment in terms of rate, volume, or formula.

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What should the nurse assess the patient for after discontinuing the TPN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen.Before reporting this finding as silent bowel sounds, the nurse should listen for at least:

Correct Answer is C

Explanation

A nurse is preparing to administer an enteral feeding via an established NG tube. Identify the sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

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