A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
"I will monitor the client's blood glucose level every 8 hours."
"I will hang a new bag of TPN and IV tubing every 24 hours."
"I will increase the rate of the TPN infusion to ensure the correct amount is given."
"I will obtain the client's weight every other day." .
The Correct Answer is B
The correct answer is choice b. “I will hang a new bag of TPN and IV tubing every 24 hours.”
Choice A rationale:
Monitoring the client’s blood glucose level every 8 hours is important, but it is not the best indicator of understanding the TPN procedure. Blood glucose levels should be monitored regularly, but the frequency can vary based on the client’s condition and physician’s orders.
Choice B rationale:
Hanging a new bag of TPN and IV tubing every 24 hours is correct. This practice helps prevent infection and ensures the client receives the correct formulation of nutrients.
Choice C rationale:
Increasing the rate of the TPN infusion to ensure the correct amount is given is incorrect. The rate of TPN infusion should be strictly controlled and adjusted only by a physician’s order to prevent complications such as hyperglycemia or fluid overload.
Choice D rationale:
Obtaining the client’s weight every other day is important for monitoring nutritional status, but it does not directly indicate an understanding of the TPN procedure. Daily weights are often recommended to closely monitor the client’s response to TPN.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Wearing clothing with zippers instead of buttons does not address the safety concerns related to Alzheimer's disease. This choice does not ensure the client's safety or prevent wandering, which are common issues in Alzheimer's patients.
Choice B rationale:
Placing locks at the tops of exterior doors is essential for the safety of clients with Alzheimer's disease. Alzheimer's patients often have a tendency to wander and may become disoriented, putting them at risk of getting lost or injured outside the home. Proper locks can prevent them from leaving the house unsupervised.
Choice C rationale:
Replacing the carpet with hardwood floors may reduce the risk of falls but does not specifically address the safety concerns related to Alzheimer's disease. It is important to focus on measures that prevent wandering and ensure the client's safety in various situations.
Choice D rationale:
Encouraging physical activity prior to bedtime is a good practice for promoting sleep in older adults but does not directly address the safety concerns of Alzheimer's patients. Safety measures, such as securing doors, supervising the client, and preventing wandering, are more crucial in this context.
Correct Answer is B
Explanation
The correct answer is Choice B: Assign the child to a negative air pressure room.
Choice A rationale: Assessing the child for Koplik spots is not appropriate in this situation because Koplik spots are associated with measles, not varicella. Koplik spots are small, white, irregular lesions that appear on the buccal mucosa during the prodromal phase of measles. They do not present in cases of varicella, which is characterized by a pruritic, vesicular rash.
Choice B rationale: Assigning the child to a negative air pressure room is the most suitable action because varicella is highly contagious and can be transmitted through airborne particles. A negative air pressure room helps to contain these particles and minimize the risk of infection transmission to other patients, healthcare workers, and visitors. Airborne precautions are the recommended infection control measures for managing varicella cases in healthcare settings.
Choice C rationale: Utilizing droplet precautions alone is insufficient for managing varicella because the virus can also be spread through airborne particles. While droplet precautions may be a component of the overall infection control strategy, they are inadequate without the additional implementation of airborne precautions, such as a negative air pressure room.
Choice D rationale: Administering aspirin to a child with a viral illness is generally contraindicated due to the potential risk of Reye's syndrome, a rare but severe condition characterized by liver failure and encephalopathy. It is essential to follow appropriate guidelines for managing fever and discomfort in pediatric patients with varicella, which typically involve using acetaminophen or ibuprofen instead of aspirin.
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