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:
"Describe your daily medication schedule” is not the correct statement. Understanding the medication schedule is important for adherence to antiretroviral therapy.
Choice B Reason:
"Tell me why it's important to have your CD4+ count checked." Is the correct statement, the priority information for the nurse to review with the client is why it's important to have their CD4+ count checked regularly? The CD4+ count is a crucial marker of immune system health and function in individuals with HIV. Monitoring CD4+ counts help guides treatment decisions, assess the effectiveness of antiretroviral therapy, and evaluate the progression of the disease. Understanding the significance of CD4+ counts is essential for the client's overall management of HIV.
Choice C Reason:
"List some ways you can cope with the stress of your illness" is not the correct statement - Coping strategies are important for the client's emotional well-being and overall health.
Choice D Reason:
"Name a few things you will change about your diet" is not the correct statement. Nutrition is important for overall health, including maintaining a strong immune system, but it may not be the most immediate priority compared to understanding the importance of CD4+ counts.
Correct Answer is A
Explanation
Choice A Reason:
A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.
Choice B Reason:
A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.
Choice CReason:
A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.
Choice DReason:
A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.
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