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 D
Explanation
Choice A reason:
WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.
Choice B reason:
Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.
Choice C reason:
Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.
Choice D reason:
Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.
Correct Answer is B
Explanation
Choice A Reason:
Placing the client in a protective environment is not necessary for C. difficile gastroenteritis. Standard precautions, including diligent hand hygiene and appropriate personal protective equipment, are sufficient.
Choice B Reason:
Obtain a stool specimen with gloves is necessary. Obtaining a stool specimen with gloves is an appropriate nursing action when caring for a client with Clostridium difficile (C. difficile) gastroenteritis. C. difficile is a bacterium that can cause diarrhea and other gastrointestinal symptoms. It's important to follow infection control practices to prevent the spread of the bacteria.
Choice C Reason:
Cleaning surfaces with chlorhexidine is not the preferred disinfectant for C. difficile. Sporicidal agents, such as bleach-based solutions, are recommended to effectively kill the spores of C. difficile.
Choice D Reason:
Washing hands with alcohol-based hand rub is not sufficient for C. difficile. C. difficile spores are resistant to alcohol-based hand sanitizers, so using soap and water for handwashing is recommended to ensure proper removal of the spores.
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