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?
Uses the TPN IV tubing to administer the client's next dose of antibiotics
Plans for a check of the client's fingerstick glucose level every 6 hr
Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved
Schedules a bag and tubing change for 24 hr after the start of the infusion
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. "Alternate the shoes you wear each day.": Rotating shoes helps prevent pressure points and reduces the risk of skin breakdown or foot ulcers, which is important for clients with diabetes who have impaired circulation and sensation.
B. "Apply synthetic fabric socks.": Synthetic or moisture-wicking socks help keep feet dry and prevent fungal infections, a common concern in clients with diabetes. Cotton or synthetic blends are preferred over thick wool or socks that retain moisture.
C. "Wear open-toe shoes": Open-toe shoes increase the risk of injury, infection, and trauma, which can lead to serious complications in diabetic clients. Closed, well-fitting shoes provide protection and support.
D. "Wash your feet daily with warm water and soap": Daily washing and gentle drying of the feet helps maintain hygiene, prevents infection, and allows early detection of cuts, cracks, or sores. Warm, not hot, water prevents burns in clients with neuropathy.
E. "Soak your feet for 1 hour each day.": Prolonged soaking can cause skin maceration, increasing the risk of infection and breakdown. Soaking is generally discouraged for clients with diabetes.
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