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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?

A.

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

B.

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

C.

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

D.

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

Answer and Explanation

The Correct Answer is A

Rationale:

A. Uses the TPN IV tubing to administer the client's next dose of antibiotics: TPN lines should never be used for administering other medications or fluids because this increases the risk of contamination, infection, and incompatibility reactions. TPN requires dedicated IV access to maintain sterility and prevent complications such as sepsis.

B. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose regularly is essential during TPN administration because high dextrose concentrations can cause hyperglycemia. Checking every 4–6 hours aligns with safe monitoring practices and does not require intervention.

C. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Slowly titrating the TPN rate helps the client adjust to the high glucose content and reduces the risk of hyperglycemia or fluid overload. This demonstrates safe and appropriate administration practice.

D. Schedules a bag and tubing change for 24 hr after the start of the infusion: Changing the TPN solution and tubing every 24 hours is consistent with infection control guidelines. This action maintains sterility and prevents microbial growth, reflecting proper technique.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

  • Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
  • High parity: Multiparity increases the risk of uterine atony due to repeated stretching and decreased tone of the uterine muscles. This predisposes the postpartum client to poor uterine contraction and increased risk of hemorrhage.
  • Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
  • Prolonged rupture of membranes: Extended rupture of membranes (>18 hours) significantly increases the risk of intrauterine or postpartum infection, including endometritis, due to ascending bacteria from the vaginal canal. This can lead to fever, leukocytosis, and foul-smelling lochia.

Correct Answer is A

Explanation

Rationale:

A. "I will change my baby's diaper at least every 4 hours.": Frequent diaper changes help keep the circumcision site clean and dry, reducing the risk of infection and irritation from urine or stool. Keeping the area free from moisture allows proper healing and minimizes discomfort for the newborn. This reflects correct home care following a circumcision.

B. "I will wash the penis with soap and warm water until the circumcision has healed.": Using soap on the circumcision site can cause irritation and delay healing. The area should be gently cleansed with warm water only, allowing the natural healing process to occur without additional chemical irritation from soaps or wipes containing alcohol or fragrances.

C. "I will apply topical lidocaine following each diaper change.": Topical anesthetics such as lidocaine are not recommended for routine circumcision care because they may cause toxicity or be absorbed unpredictably in newborns. Pain is managed through comfort measures such as swaddling, breastfeeding, or using petroleum jelly, not through anesthetic application.

D. "I will apply an ice pack to my baby's penis twice daily to decrease swelling.": Applying ice to a newborn’s circumcision site is unsafe and can cause tissue injury due to extreme temperature sensitivity. Mild swelling is expected and resolves naturally; the recommended care involves gentle cleansing and protecting the site with petroleum jelly not cold therapy.

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