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?

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

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

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

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

Answer and Explanation

The Correct Answer is C

A. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose levels is essential for clients receiving TPN due to the risk of hyperglycemia. Checking glucose every 6 hours is a standard practice that helps ensure appropriate glycemic control, so this action is appropriate.

B. Schedules a bag and tubing change for 24 hr after the start of the infusion: It is standard practice to change the TPN bag and tubing every 24 hours to reduce the risk of infection and maintain sterility. This timing aligns with best practices for TPN administration, indicating no need for intervention.

C. Uses the TPN IV tubing to administer the client's next dose of antibiotics: Using the TPN line for additional medications, such as antibiotics, can lead to complications like incompatible drug interactions or infection. TPN should ideally be delivered through a dedicated line to prevent these risks, which necessitates intervention from the supervising nurse.

D. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Gradual escalation of the TPN infusion rate is important to prevent complications such as hyperglycemia. This action is appropriate, as it allows the body to adapt to the increased caloric intake safely.

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Correct Answer is A

Explanation

A) Monitoring the child's cardiac status is crucial in the acute phase of Kawasaki disease, as the disease can lead to complications such as myocarditis and coronary artery aneurysms. Regular assessment of heart rate, blood pressure, and any signs of heart failure is essential for early detection and intervention.

B) Antibiotics are not routinely administered for Kawasaki disease unless there is a concurrent bacterial infection. The primary treatment includes high-dose aspirin and intravenous immunoglobulin (IVIG) to reduce inflammation and prevent cardiac complications.

C) While acetaminophen can be used to manage fever and discomfort, giving it every hour is not appropriate. Scheduled doses should follow dosing guidelines to avoid toxicity and manage the child's symptoms effectively.

D) During the acute phase, children with Kawasaki disease may experience irritability and require rest. Providing stimulation with peers in the playroom may be inappropriate due to the need for reduced activity and rest, making this intervention less suitable.

A. Take pancrelipase. B. Complete oral hygiene. C. Eat a meal. D. Use an albuterol inhaler.

Correct Answer is D

Explanation

A) Taking pancrelipase is important for digestion in clients with cystic fibrosis, but it is not directly related to postural drainage. This medication is taken with meals to help with nutrient absorption rather than respiratory care.

B) Completing oral hygiene is generally good practice for overall health but does not specifically prepare the client for postural drainage. It does not impact the effectiveness of the drainage technique.

C) Eating a meal right before postural drainage is not advisable, as it may cause discomfort during the procedure. It's often recommended to wait after eating to allow for better clearance of mucus.

D) Using an albuterol inhaler prior to postural drainage is beneficial because it helps to open the airways, making it easier to clear mucus during the procedure. This action optimizes the effectiveness of postural drainage and is a standard practice in managing cystic fibrosis.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Correct Answer is D

Explanation

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