A nurse finds that the infusion pump for a patient’s total parenteral nutrition (TPN) solution is not working. What condition should the nurse monitor the patient for?
Excessive thirst and urination.
Shakiness and diaphoresis.
Fever and chills.
Hypertension and crackles.
The Correct Answer is B
Choice A rationale
Excessive thirst and urination are symptoms of hyperglycemia, not hypoglycemia. Hyperglycemia could occur if the TPN solution was infusing too quickly, but it would not be a result of the infusion pump not working.
Choice B rationale
Shakiness and diaphoresis are manifestations of hypoglycemia. When a sudden interruption in the infusion of TPN occurs, the patient is at risk for hypoglycemia.
Choice C rationale
Fever and chills are symptoms of infection, not a direct result of the TPN infusion stopping.
Choice D rationale
Hypertension and crackles in the lungs are signs of fluid overload, not hypoglycemia. These symptoms would not be expected if the TPN infusion stopped.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale
A specific gravity of 1.036 is higher than the normal range of 1.005 to 1.030345. This could indicate dehydration or other conditions that cause the urine to be more concentrated. This finding should prompt the nurse to follow up.
Choice B rationale
A pH of 6.4 is within the normal range for urine, which is typically between 4.6 and 8.03. Therefore, this finding would not necessarily require follow-up.
Choice C rationale
The presence of proteinuria (protein in the urine) is abnormal and could indicate kidney disease or other serious health conditions. This finding should prompt the nurse to follow up.
Choice D rationale
The presence of hematuria (blood in the urine) can be a sign of several conditions, including urinary tract infections, kidney stones, or bladder infections. However, without more information, it’s not clear whether this finding alone should prompt the nurse to follow up.
Correct Answer is B
Explanation
Choice A rationale
Emptying the drainage bag when half full is a correct action by the AP4. It is important to empty the drainage bag regularly to prevent infection and maintain accurate intake and output records.
Choice B rationale
Placing the drainage bag on the side rail of the patient’s bed is an incorrect action by the AP4. The drainage bag should be placed below the level of the bladder to prevent backflow of urine, which can lead to infection.
Choice C rationale
Kinking the catheter tubing to obtain a urine specimen is an incorrect action by the AP4. This can cause discomfort to the patient and potentially damage the catheter.
Choice D rationale
Securing the catheter tubing to the patient’s thigh is a correct action by the AP4. This helps to prevent pulling on the catheter, which can cause discomfort and potential damage to the urethra.
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