A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?

Low-grade fever

Fatigue

Anorexia

Hypoactive bowel sounds

Answer and Explanation

The Correct Answer is A

A. Low-grade fever: A low-grade fever could indicate an infection or other complications related to TPN or bowel surgery, and it is crucial to report this to the healthcare provider.
B. Fatigue: While fatigue is a common symptom, it is less urgent compared to a potential infection.
C. Anorexia: Anorexia is a concern but is not as immediate as a fever.
D. Hypoactive bowel sounds: This is expected after extensive bowel surgery and may not be as urgent as signs of infection.

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Correct Answer is C

Explanation

A. Furosemide (Lasix): This is a diuretic used to treat fluid retention and does not address the symptoms related to calcium imbalances.
B. Diazepam (Valium): This is an anxiolytic and does not address the symptoms associated with hypocalcemia following a thyroidectomy.
C. Calcium gluconate: This is the appropriate medication for treating hypocalcemia, which can occur after a thyroidectomy due to potential damage to or removal of parathyroid glands, leading to symptoms such as abdominal cramping and irregular heart rate.
D. Calcitonin: While this hormone helps regulate calcium levels, it is more commonly used to treat hypercalcemia, not hypocalcemia.

A. Teach the client a relaxation technique to use until the next dose is due. B. Obtain an order for an immediate-release opioid for breakthrough pain. C. Explain to the client that the medication being administered lasts for 12 hours. D. Assess the client's vital signs and administer the next dose of opioids early.

Correct Answer is B

Explanation

A. Teach the client a relaxation technique to use until the next dose is due: While relaxation techniques can be helpful in managing pain, they are not sufficient for severe pain rated 9/10. The client requires more immediate pharmacological intervention.
B. Obtain an order for an immediate-release opioid for breakthrough pain: This is the most appropriate action. Immediate-release opioids are specifically used to manage breakthrough pain in clients on sustained-release opioid therapy. It addresses the client's severe pain effectively and promptly.
C. Explain to the client that the medication being administered lasts for 12 hours: Simply explaining the duration of the medication does not address the client's current severe pain. Effective pain management requires action, not just education.
D. Assess the client's vital signs and administer the next dose of opioids early: Administering the next dose early can lead to inappropriate dosing schedules and potential overdose. It is important to follow the prescribed dosing regimen and manage breakthrough pain appropriately.

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A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

Correct Answer is B

Explanation

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