Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

Collect fingerstick glucose levels

Implement bleeding precautions

Obtain daily weights

Check urine for albumin

Answer and Explanation

The Correct Answer is A

a) Collect fingerstick glucose levels. Correct

Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or ﬂuctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.

b) Implement bleeding precautions.

Implementing bleeding precautions is not the most important intervention for the PN to implement for a client who is receiving TPN. Bleeding precautions are measures to prevent or minimize bleeding in clients who have a high risk of hemorrhage due to conditions such as thrombocytopenia, coagulopathy, or anticoagulant therapy. TPN does not directly increase the risk of bleeding, although it may aﬀect the liver function and clotting factors in some cases². Therefore, bleeding precautions are not a priority for a client who is receiving TPN.

c) Obtain daily weights.

Obtaining daily weights is not the most important intervention for the PN to implement for a client who is receiving TPN. Obtaining daily weights is a way to monitor the client's ﬂuid balance, nutritional status, and response to therapy. TPN can cause ﬂuid overload, dehydration, or electrolyte imbalances in some cases²⁵. Therefore, obtaining daily weights is important, but not as important as monitoring glucose levels.

d) Check urine for albumin.

Checking urine for albumin is not the most important intervention for the PN to implement for a client who is receiving TPN. Checking urine for albumin is a way to detect proteinuria, which is an indicator of kidney damage or disease. TPN does not directly cause kidney problems, although it may aﬀect the renal function and urine output in some cases². Therefore, checking urine for albumin is not a priority for a client who is receiving TPN.

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Correct Answer is A

Explanation

Choice A reason: Monitoring vital signs and neurological status frequently is the priority intervention for the client because it can detect changes in the client's condition, such as increased intracranial pressure, bleeding, or infection, that require immediate action.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not the priority intervention for the client because it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumoniA. The client should be positioned with the head of the bed elevated at 30 degrees to reduce intracranial pressure and facilitate drainagE.

Choice C reason: Administering anticoagulant medications as prescribed is not the priority intervention for the client because it can worsen the bleeding and increase the risk of hemorrhagic transformation. Anticoagulants are contraindicated for clients who have hemorrhagic stroke, which is caused by rupture of a blood vessel in the brain.

Choice D reason: Assisting the client with active range of motion exercises is not the priority intervention for the client because it can cause fatigue, pain, or injury to the affected limbs. The client should be assisted with passive range of motion exercises to prevent contractures and maintain joint mobility.

A. Provide total assistance with all ADLs B. Order a low-residue diet C. Encourage client to void every hour D. Instruct the client on daily muscle stretching

Correct Answer is D

Explanation

Choice A reason: Providing total assistance with all ADLs is not an appropriate intervention for the client because it can decrease the client's independence and self-esteem, and increase the risk of complications such as pressure ulcers, contractures, and infections. The client should be encouraged to perform as much self-care as possible, with assistance as needeD.

Choice B reason: Ordering a low-residue diet is not an appropriate intervention for the client because it can cause constipation, which can worsen the client's bowel function and quality of lifE. The client should consume a balanced diet that includes adequate fiber, fluids, and nutrients.

Choice C reason: Encouraging the client to void every hour is not an appropriate intervention for the client because it can disrupt the client's normal bladder function and increase the risk of urinary tract infections. The client should follow a regular bladder training program that involves voiding at scheduled intervals, using pelvic floor exercises, and managing fluid intakE.

Choice D reason: Instructing the client on daily muscle stretching is an appropriate intervention for the client because it can improve the client's mobility, flexibility, and range of motion, as well as prevent muscle spasticity, stiffness, and pain. The client should perform gentle stretching exercises under the guidance of a physical therapist or nursE.

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