A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?

The correct answer is Choice A:

Collect fingerstick glucose levels.

Choice A rationale:

When a client is receiving total parenteral nutrition (TPN), it means they are receiving nutrients directly into the bloodstream, bypassing the digestive system. TPN often contains high levels of glucose, which can lead to hyperglycemia. Regular monitoring of blood glucose levels are crucial to detect and manage hyperglycemia effectively, especially in clients at risk for diabetes or those with impaired glucose metabolism.

Choice B rationale:

Implementing bleeding precautions (Choice B) is important for clients on anticoagulant therapy or with bleeding disorders. However, it is not the most important intervention for a client receiving TPN. Monitoring glucose levels takes precedence in this case.

Choice C rationale:

Obtaining daily weights is an important intervention to assess fluid balance and nutritional status in clients receiving TPN. However, it is not the most critical intervention compared to monitoring glucose levels to prevent complications of hyperglycemia.

Choice D rationale:

Checking urine for albumin is important in assessing kidney function and detecting proteinuria. While it is a valid nursing intervention, it is not the most important consideration for a client on TPN. Monitoring glucose levels is of higher priority.

Suction the trachea.

Choice A rationale:

The practical nurse (PN) should ensure the ready availability of equipment to perform tracheal suctioning for a client who requires seizure precautions. Seizures can sometimes cause excessive salivation or even vomiting, which may lead to the obstruction of the airway. Suctioning the trachea helps in quickly clearing any secretions or vomitus from the airway, preventing potential respiratory compromise and ensuring the client's airway remains patent.

Choice B rationale:

Inserting a nasogastric tube is not directly related to seizure precautions. Nasogastric tubes are used for various purposes, such as decompression of the stomach, feeding, or administering medications. While it might be necessary in specific situations, it is not a priority when caring for a client on seizure precautions.

Choice C rationale:

Inserting a urinary catheter is also not directly related to seizure precautions. It is typically done for clients who have difficulty urinating on their own or for precise monitoring of urine output. Seizure precautions focus on the client's airway and safety during a seizure episode.

Choice D rationale:

Applying soft restraints is generally not recommended for clients on seizure precautions. Restraints should only be used as a last resort for clients who pose a risk to themselves or others during a seizure. The primary goal is to provide a safe environment and prevent injuries without restraining the client unless absolutely necessary.