A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as an adverse effect of TPN
2+ deep tendons reflexes
Casual blood glucose 100 mg/dl
Potassium 4.8 mEq/L
2+ peripheral pitting Edema
The Correct Answer is D
TPN is a form of nutrition given intravenously to provide essential nutrients when a client is unable to consume an adequate oral diet. One of the potential adverse effects of TPN is fluid overload, which can manifest as peripheral edema. The presence of 2+ peripheral pitting edema indicates the accumulation of excess fluid in the tissues. It is important for the nurse to monitor the client's fluid balance closely and assess for signs of fluid overload, such as edema, to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should report to the provider that the client is taking ginkgo biloba. Ginkgo biloba is an herbal supplement that can interact with clopidogrel and other antiplatelet medications. It may increase the risk of bleeding when taken concurrently with clopidogrel, which is an antiplatelet medication used to prevent blood clots after coronary artery stenting.
Let's go through the other options:
A. The client is taking acetaminophen: Acetaminophen is not known to have significant interactions with clopidogrel. It is a commonly used pain reliever and fever reducer and does not usually affect the antiplatelet activity of clopidogrel.
B. The client is taking valerian: Valerian is an herbal supplement often used as a sleep aid or to reduce anxiety. While there is limited evidence of significant interactions with clopidogrel, it is generally recommended to use caution when combining valerian with antiplatelet medications. However, it is not as concerning as ginkgo biloba in terms of potential bleeding risk.
C. The client is taking vitamin B6: Vitamin B6 is a water-soluble vitamin and is not expected to have significant interactions with clopidogrel. It is generally considered safe to use vitamin B6 with antiplatelet medications like clopidogrel.
Correct Answer is A
Explanation
The nurse should include the statement that rifampin can cause the client's urine to turn orange. Rifampin is an antibiotic commonly used to treat tuberculosis and other bacterial infections. One of its common side effects is discoloration of bodily fluids, including urine, saliva, sweat, and tears. This discoloration is harmless and is not a cause for concern. Informing the client about this side effect helps prevent unnecessary worry or alarm.
"You should take this medication with food" (B) is not specifically related to rifampin. However, taking rifampin with food can help reduce gastrointestinal side effects such as stomach upset or nausea.
"This medication can cause insomnia" (C) is not a common side effect of rifampin. Insomnia is more commonly associated with certain other medications or medical conditions.
"You should take a stool softener with this medication" (D) is not necessary for rifampin. Stool softeners are typically used to alleviate constipation, but rifampin does not commonly cause constipation as a side effect.
Therefore, the nurse should primarily include the statement that rifampin can cause the client's urine to turn orange.
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