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

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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Correct Answer is C

Explanation

Rationale:

A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.

B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.

C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.

D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.

A. Shoulders B. Palms of the hands C. Area of trauma D. Sacrum

Correct Answer is B

Explanation

Rationale:

A. Shoulders: The shoulders are usually covered with clothing and have more pigmentation and subcutaneous tissue, making color changes less apparent. Cyanosis may be difficult to detect in these areas, especially in clients with dark skin.

B. Palms of the hands: The palms, along with the soles of the feet, nail beds, and mucous membranes, have less melanin and are more reliable sites to observe for cyanosis in clients with dark skin. These areas can show a bluish or grayish discoloration more accurately when oxygenation is low.

C. Area of trauma: Trauma sites may exhibit bruising, erythema, or inflammation, which can mask the presence of cyanosis. Assessing these areas may lead to inaccurate conclusions regarding oxygenation status.

D. Sacrum: While the sacrum may be assessed for pressure injuries, it is not a reliable site for detecting cyanosis because of pigmentation, limited blood flow, and potential masking by subcutaneous tissue. The nurse should focus on areas with minimal pigmentation for accurate assessment.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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

A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

Correct Answer is B

Explanation

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