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 A
Explanation
Choice A Reason:
"I can drink vegetable juice with a meal."
Limiting sodium intake is a crucial part of managing heart failure, as excess sodium can lead to fluid retention and exacerbation of symptoms. Among the options provided, drinking vegetable juice with a meal is the one that suggests the client understands the need to limit sodium intake. Fresh vegetable juice typically has lower sodium content compared to other options, and incorporating it into meals can help the client manage their sodium intake.
Choice B Reason:
"I can have mayonnaise on my sandwiches." - Mayonnaise is often high in sodium and is not typically recommended in a low-sodium diet.
Choice C Reason:
"I can season my foods with garlic and onion salts." - Garlic and onion salts are often high in sodium. It's better to use fresh herbs and spices for seasoning.
Choice D Reason:
"I can have a frozen fruit juice bar for dessert." - Frozen fruit juice bars might contain added sugars or high sodium content. It's important to check the nutrition label for sodium content before consuming such items.
Correct Answer is C
Explanation
Choice A reason:
Loose tracheal secretions are incorrect. While this could lead to airway issues if not managed, it's not as urgent as stridor.
Choice B reason:
Hypoactive bowel sounds are incorrect. Bowel sounds can be affected by anaesthesia and the surgical procedure, but they are not as immediately critical as airway issues.
Choice C reason:
High-pitched sound on inspiration. A high-pitched sound on inspiration, also known as stridor, can indicate a potential issue with the airway or breathing. Stridor can occur due to narrowing or obstruction of the upper airway, which can be particularly concerning after a thyroidectomy. It could suggest edema, bleeding, or damage to the laryngeal nerves, which are critical for vocal cord function and airway control. Stridor could potentially lead to airway compromise, making it a priority to report to the provider for immediate evaluation and intervention.
Choice D reason:
Client report of pain at the incision is incorrect. Pain management is important, but it's not an immediate threat to the client's airway or overall condition.
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