A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?

Plans for a check of the client's fingerstick glucose level every 6 hr

Schedules a bag and tubing change for 24 hr after the start of the infusion

Uses the TPN IV tubing to administer the client's next dose of antibiotics

Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved

Answer and Explanation

The Correct Answer is C

A. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose levels is essential for clients receiving TPN due to the risk of hyperglycemia. Checking glucose every 6 hours is a standard practice that helps ensure appropriate glycemic control, so this action is appropriate.

B. Schedules a bag and tubing change for 24 hr after the start of the infusion: It is standard practice to change the TPN bag and tubing every 24 hours to reduce the risk of infection and maintain sterility. This timing aligns with best practices for TPN administration, indicating no need for intervention.

C. Uses the TPN IV tubing to administer the client's next dose of antibiotics: Using the TPN line for additional medications, such as antibiotics, can lead to complications like incompatible drug interactions or infection. TPN should ideally be delivered through a dedicated line to prevent these risks, which necessitates intervention from the supervising nurse.

D. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Gradual escalation of the TPN infusion rate is important to prevent complications such as hyperglycemia. This action is appropriate, as it allows the body to adapt to the increased caloric intake safely.

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Correct Answer is D

Explanation

A) Noting changes in the treatment plan in the client's medical record: While this is important for continuity of care, it may not directly facilitate communication among staff in real-time or promote a collaborative approach.

B) Recording the client's progress in the nurses' notes: Documenting progress is essential, but it serves more as a record of care rather than an active communication tool among the team members.

C) Posting swallowing precautions at the head of the client's bed: This helps ensure that all staff are aware of the precautions, but it does not promote a broader dialogue about the client's overall care and communication needs.

D) Having interdisciplinary team meetings for the client on a regular basis: This is the correct answer. Regular interdisciplinary meetings encourage collaborative communication, allowing various healthcare professionals to discuss the client’s needs, share observations, and develop a cohesive care plan, which is especially important for clients with communication barriers like expressive aphasia.

A. "That can't be true. The only voices in this room are yours and mine." B. "Do you recognize the voices as belonging to anyone you know?" C. "I understand the voices are frightening you, but I do not hear any voices." D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself."

Correct Answer is C

Explanation

A. "That can't be true. The only voices in this room are yours and mine.": This response dismisses the client’s experience and can invalidate their feelings, which is not therapeutic or supportive.

B. "Do you recognize the voices as belonging to anyone you know?": While this question could gather more information, it might divert the focus from the client’s immediate feelings of fear and distress.

C. "I understand the voices are frightening you, but I do not hear any voices.": This response validates the client's experience of fear and acknowledges their distress while also gently indicating that the nurse does not perceive the voices. It encourages open communication about the client’s feelings.

D. "You shouldn't be afraid when you think the voices are telling you to hurt yourself.": This response is inappropriate as it minimizes the client’s feelings and does not address the seriousness of their statements about self-harm. It’s crucial to acknowledge their fear rather than dismissing it.

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A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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