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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The nurse should plan to take the following actions:
A.Verify the prescription: Before administering any medication, the nurse must verify the prescription to ensure accuracy, appropriateness, and that it matches the provider's order.
Regarding option B, administering the medication at 1000, 1400, 1800, and 2200 may not be appropriate. The prescription states that ampicillin should be administered every 6 hours. The nurse should administer the medication at equally spaced intervals throughout the day. If the medication is prescribed every 6 hours, the appropriate administration times would be 0600, 1200, 1800, and 2400. However, the question does not provide sufficient information to determine the exact administration times, so option B cannot be definitively selected.
C. Assess the client for an allergy to penicillin: Since ampicillin is a penicillin-class antibiotic, it is essential for the nurse to assess the client for any history of allergies to penicillin or other beta-lactam antibiotics. A penicillin allergy could lead to a severe allergic reaction, so it is crucial to identify any potential allergies before administering the medication.
D. Document giving the medications: After administering the ampicillin, the nurse should document the administration in the client's medical record, including the time, dose, route, and any relevant observations or assessments.
E. Obtain a sputum for culture and sensitivity: The client's new prescription for ampicillin may be related to an infection. To ensure appropriate and effective treatment, obtaining a sputum specimen for culture and sensitivity is necessary. This will help identify the specific bacteria causing the respiratory infection and determine which antibiotics will be most effective in treating it.
Correct Answer is ["200"]
Explanation
To determine the infusion rate in mL/h, we need to divide the total volume (100 mL) by the total time (30 minutes) and then convert the result to hours.
100 mL / 30 min = 3.33 mL/min
To convert minutes to hours, we multiply by 60:
3.33 mL/min * 60 min/h = 199.8 mL/h
Rounding to the nearest whole number, the nurse should set the IV infusion pump to deliver 200 mL/h.
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