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
Explanation
Rationale:
A. "Can you tune out the voices by listening to music?": This question focuses on coping strategies, which is important, but it is not the immediate priority. The nurse must first assess the content of the hallucinations to determine potential risk.
B. "Are you also seeing unusual persons or things?": Assessing for visual hallucinations is useful, but the client is currently experiencing auditory command hallucinations. Immediate focus should be on the commands to ensure safety.
C. "What are the voices telling you to do?": Determining the content of the voices is the priority because command hallucinations may instruct the client to harm themselves or others. Assessing risk and ensuring safety comes before exploring coping or additional symptoms.
D. "Do the voices cause you to feel anxious?": Assessing emotional response is relevant, but it is secondary to understanding whether the hallucinations pose a safety risk to the client or others.
Correct Answer is B
Explanation
Rationale:
A. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: Severe pain is significant and requires timely management, but it is not immediately life-threatening compared to acute cardiac events. Pain control should follow stabilization of critical conditions.
B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG: ST-segment elevation indicates a possible acute myocardial infarction, which is a life-threatening emergency. Prompt assessment and intervention are crucial to prevent cardiac damage or death, making this the highest priority.
C. A client who has Clostridium difficile and a temperature of 38.5°C (101.5°F): Fever and infection require attention, but this client is currently stable compared with someone experiencing an acute myocardial infarction. Infection control and monitoring can follow stabilization of higher-priority emergencies.
D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: These findings indicate fluid imbalance and cardiovascular compromise, but they are not as immediately life-threatening as an acute STEMI. Monitoring and management should follow urgent cardiac care.
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