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." .

Answer and Explanation

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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Correct Answer is D

Explanation

The correct answer is choice d.

Choice A rationale:

Washing the penis from scrotum to tip using a spiral motion can trap bacteria under the foreskin and increase risk of infection.

Choice B rationale:

Soap helps remove dirt and bacteria, reducing infection risk. Soapy water is preferred over plain water for perineal care.

Choice C rationale:

While hand hygiene is crucial, sterile gloves are not typically required for routine perineal care in an SCI patient unless there's a break in the skin or a high risk of infection.

Choice D rationale:

Discarding the washcloth after cleansing the urethral meatus is essential to prevent transferring bacteria to other areas.

A. Choose a vein that is palpable and straight. B. Select a site on the client's dominant arm. C. Apply a tourniquet below the venipuncture site. D. Elevate the client's arm prior to insertion.

Correct Answer is A

Explanation

Choice A rationale:

Choosing a palpable and straight vein is essential for a successful IV insertion. A vein that is easily palpable and visible helps ensure that the catheter can be inserted smoothly, reducing the risk of complications such as infiltration or extravasation. Additionally, selecting a straight vein makes the insertion process easier and less painful for the client.

Choice B rationale:

Selecting a site on the client's dominant arm is not a requirement for IV insertion. The choice of arm depends on the individual client's condition, vein accessibility, and the healthcare provider's preference. Both arms can be used for IV insertion based on the client's specific needs.

Choice C rationale:

Applying a tourniquet below the venipuncture site helps distend the veins, making them more visible and accessible. This technique can aid in locating suitable veins for insertion. However, it is crucial to release the tourniquet once the vein is accessed to prevent complications such as thrombosis or hematoma.

Choice D rationale:

Elevating the client's arm prior to insertion can cause veins to collapse, making it more challenging to insert the IV catheter. Gravity can assist in distending the veins, so the arm should be positioned at or slightly below the level of the heart during IV insertion to maintain adequate blood flow.

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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?

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