A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Confusion

Blurred vision

Diarrhea

Polyuria

Answer and Explanation

The Correct Answer is A

Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.

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Correct Answer is B

Explanation

A high calcium level (hypercalcemia) can indicate complications of TPN, such as bone demineralization, renal calculi, or metabolic alkalosis. The nurse should notify the provider of this finding and expect to adjust the TPN formula or administer fluids and diuretics to lower the calcium level. The other options are within normal or expected ranges for a client receiving TPN.

A. Check the IV site for redness. B. Ensure the tubing connections are secure. C. Reposition the client's left arm. D. Flush the IV catheter.

Correct Answer is C

Explanation

This is because the most common cause of infusion pump alarms is occlusion or obstruction of the IV line, which can be due to kinking, bending, or compression of the tubing or catheter by the client's arm or body position. By repositioning the client's arm, the nurse can relieve the occlusion and restore the flow of the IV fluid.

This action should be done before checking for other possible causes of alarm, such as redness at the IV site (which could indicate infection or inflammation), loose tubing connections (which could cause leakage or air embolism), or clogged IV catheter (which could require flushing with saline or heparin solution).

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A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been receiving total parenteral nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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