A nurse is caring for a patient who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition.
The nurse should actively monitor the patient for which of the following?
Intermittent abdominal pain
Increased serum glucose levels
Absent bowel sounds
Decreased calcium levels
The Correct Answer is B
Choice A rationale
Intermittent abdominal pain is not typically associated with total parenteral nutrition (TPN) or burn injuries.
Choice B rationale
Increased serum glucose levels can occur with TPN due to the high glucose content of the solution. This should be monitored closely, especially in patients with burns, who may have altered glucose metabolism.
Choice C rationale
Absent bowel sounds are not typically associated with TPN or burn injuries.
Choice D rationale
Decreased calcium levels are not typically associated with TPN or burn injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Bulging skin around the stoma can be a sign of a hernia, but it’s not uncommon in the early postoperative period. It should be monitored, but it’s not typically a cause for immediate concern.
Choice B rationale
A stoma that protrudes 2 cm (0.8 in) above the abdominal wall is considered normal. The stoma should protrude above the skin to prevent stool from coming into contact with the skin, which can cause irritation and breakdown.
Choice C rationale
A stoma that is moist and beefy red is a sign of a healthy stoma. This indicates that the stoma has a good blood supply and is not ischemic or necrotic.
Choice D rationale
No fecal output from the stoma 24 hours after surgery could indicate a blockage or other complication and should be reported to the provider immediately.
Correct Answer is B
Explanation
Choice A rationale
Intermittent abdominal pain is not typically associated with total parenteral nutrition (TPN) or burn injuries.
Choice B rationale
Increased serum glucose levels can occur with TPN due to the high glucose content of the solution. This should be monitored closely, especially in patients with burns, who may have altered glucose metabolism.
Choice C rationale
Absent bowel sounds are not typically associated with TPN or burn injuries.
Choice D rationale
Decreased calcium levels are not typically associated with TPN or burn injuries.
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