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 A

Explanation

Rationale:

A. Speak in a neutral tone when addressing the client: Clients with paranoid personality disorder are often suspicious of others’ motives and may perceive hostility or manipulation. Using a neutral, calm, and nonjudgmental tone helps build trust and reduces anxiety, increasing the likelihood of cooperation with care, including medication administration.

B. Rotate staff members caring for the client: Frequently changing caregivers can increase mistrust and paranoia in these clients, as consistency and predictability are important for establishing a therapeutic relationship. Continuity of care helps the client feel more secure and supported.

C. Mix the medication with the client's food items: Covertly administering medication can further damage trust and may be considered unethical. Clients with paranoid personality disorder require transparency and respect for autonomy to maintain a therapeutic relationship.

D. Limit the client's opportunities to socialize with others: Social isolation is not an appropriate intervention and may worsen symptoms of paranoia and distrust. Encouraging safe, structured social interactions can support the client’s overall functioning without compromising boundaries or autonomy.

A. Administer the medication into the vastus lateralis muscle. B. Administer the medication with a 20-gauge needle. C. Administer the medication into the deltoid muscle. D. Administer the medication over 2 min.

Correct Answer is A

Explanation

Rationale:

A. Administer the medication into the vastus lateralis muscle: The vastus lateralis is the preferred site for intramuscular injections in infants because it is well-developed and free of major nerves and blood vessels. This site allows for safe and effective absorption of the medication.

B. Administer the medication with a 20-gauge needle: A 20-gauge needle is too large for infants and can cause unnecessary tissue trauma. A smaller gauge, typically 22–25, is appropriate for IM injections in infants to minimize pain and tissue damage.

C. Administer the medication into the deltoid muscle: The deltoid muscle is underdeveloped in infants, making it unsuitable for IM injections due to limited muscle mass and risk of injury to underlying structures. It is generally used only in older children or adults.

D. Administer the medication over 2 min: IM injections are typically administered at a moderate pace, but a 2-minute administration is unnecessarily slow for infants. Proper technique involves steady, controlled injection without causing excessive discomfort.

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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?

Nursing Test Bank

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