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

Answer and Explanation

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.

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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.

A. Hct 42% B. WBC count 8.000/mm3 C. INR of 1.6 D. Platelets 95.000/mm

Correct Answer is C

Explanation

Choice A reason:

Hct 42% is not appropriate. This haematocrit value is within the normal range (usually around 36-46% for females and 38-50% for males).

Choice B reason:

WBC count 8,000/mm3 is not appropriate. This white blood cell count is within the normal range (typically around 4,500 to 11,000/mm3).

Choice C reason:

INR of 1.6 An INR (International Normalized Ratio) of 1.6 indicates that the client's blood clotting time is prolonged, which means that they might have a decreased ability to form blood clots. This could pose a significant risk during surgery, as proper blood clotting is important to prevent excessive bleeding. The surgeon needs to be aware of this result to determine if any adjustments to the surgical plan or preoperative medications are necessary to ensure the client's safety.

Choice D reason:

Platelets 95,000/mm3 is not appropriate This platelet count is slightly lower than the normal range (typically around 150,000 to 450,000/mm3), but it might not be low enough to be immediately concerning, especially if the client doesn't have a history of bleeding disorders. However, it's still important for the surgical team to be aware of this value.

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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?

Nursing Test Bank

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Explanation

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