A nurse is assessing a client who has acute pancreatitis and has been receiving total parenteral nutrition for the past 72 hr. Which of the following findings requires the nurse to intervene?
Capillary blood glucose level 164 mg/dl.
Crackles in bilateral lower lobes
WBC count 13.000/mm
Right upper quadrant pa
The Correct Answer is A
Choice A Reason:
Capillary blood glucose level 164 mg/dl is appropriate. A capillary blood glucose level of 164 mg/dl is above the target range for blood glucose control. In a client receiving total parenteral nutrition (TPN), it's essential to monitor blood glucose levels closely, as hyperglycaemia can lead to complications. The nurse should intervene by notifying the healthcare provider and following the prescribed protocols for managing elevated blood glucose levels in a client with acute pancreatitis receiving TPN.
Choice B Reason:
Crackles in bilateral lower lobes is inappropriate. Crackles in the lungs could be indicative of fluid accumulation or inflammation, which can occur in various conditions. While it should be monitored, it may not require immediate intervention related to the TPN.
Choice C Reason:
WBC count 13,000/mm is inappropriate-. An elevated white blood cell count could be related to the acute pancreatitis itself or other factors. It might require further assessment and monitoring but may not be directly related to the TPN.
Choice D Reason:
Right upper quadrant pain is inappropriate- The client's right upper quadrant pain might be related to the acute pancreatitis or another cause, but it does not specifically indicate a need to intervene with the TPN at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Taking an antacid 30 minutes before taking ciprofloxacin is not necessary. Ciprofloxacin should generally be taken on an empty stomach, either 1-2 hours before or 2 hours after meals, but antacids containing aluminium, magnesium, or calcium can interfere with its absorption.
Choice B Reason:
Drinking 2 to 3 L of fluids daily is correct. For a client with chronic urinary tract infections who is taking ciprofloxacin, the nurse should instruct the client to increase fluid intake to maintain good urine flow and help flush out bacteria from the urinary system. Adequate hydration can contribute to preventing and managing urinary tract infections.
Choice C Reason:
Taking a laxative to prevent constipation is not directly related to ciprofloxacin use. While constipation can be a side effect of some medications, it is not a primary concern with ciprofloxacin.
Choice D Reason:
Monitoring heart rate is not a typical instruction related to ciprofloxacin use. While ciprofloxacin can have potential effects on heart rhythm (especially in high doses), this is not a common aspect of its use and does not typically require daily monitoring of heart rate.
Correct Answer is A
Explanation
Choice A reason:
Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.
Choice B reason:
Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.
Choice C reason:
Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.
Choice D reason:
Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.
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