A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications?
5% deficit in body weight compared to pre-illness weight and increased caloric need.
Significant risk of aspiration coupled with decreased level of consciousness.
Calorie deficit and muscle wasting combined with low electrolyte levels.
Inability to take in adequate oral food or fluids within 7 days.
The Correct Answer is D
Choice A rationale
A 5% deficit in body weight and increased caloric need alone do not warrant the initiation of parenteral nutrition (PN). PN is typically reserved for situations where oral or enteral feeding is not feasible or safe.
Choice B rationale
Significant risk of aspiration and decreased level of consciousness may necessitate alternative feeding methods, such as enteral feeding via a nasogastric or gastrostomy tube. PN is considered when enteral feeding is not possible.
Choice C rationale
Calorie deficit, muscle wasting, and low electrolyte levels indicate malnutrition, but PN is initiated when other feeding methods are inadequate or unsafe.
Choice D rationale
Inability to take in adequate oral food or fluids within 7 days is a clear indication for initiating PN. This ensures the patient receives essential nutrients and prevents further deterioration of their nutritional status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Keeping the dressing very wet at all times is not advisable with autolytic debriding agents. Excess moisture can cause maceration of the surrounding skin and increase the risk of infection. The dressing should maintain an optimal level of moisture to promote autolysis without causing harm.
Choice B rationale
Not using a dressing for 6 hours/day is incorrect advice. Continuous application of the dressing is essential for the autolytic process. Removing the dressing for extended periods disrupts the environment needed for autolysis, delaying wound healing.
Choice C rationale
Cleansing the wound with Dakin's solution is not recommended with autolytic debridement. Dakin's solution is a chemical debriding agent, and its use can interfere with the natural autolytic process. It is better to use saline or appropriate cleansers as directed.
Choice D rationale
The wound may have a foul odor due to the autolytic debridement process. As dead tissue is broken down, it can produce a distinct odor. Educating the client about this expected outcome helps them understand that it is a normal part of the healing process and not necessarily a sign of infection.
Correct Answer is D
Explanation
Choice A rationale
The occipital lobe is responsible for processing visual information and does not play a significant role in spatial relationships.
Choice B rationale
The frontal lobe is involved in higher cognitive functions, decision-making, and voluntary movements, but it is not primarily responsible for spatial relationships.
Choice C rationale
The temporal lobe is involved in auditory processing, language comprehension, and memory formation. It is not primarily responsible for spatial relationships.
Choice D rationale
The parietal lobe is responsible for processing sensory information and plays a crucial role in spatial relationships, helping to understand and navigate the environment.
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