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. Negative clonus: Monitoring for a negative clonus is appropriate as it indicates effective control of neuromuscular excitability and seizure prevention in clients receiving magnesium sulfate for preeclampsia. A negative clonus response suggests that the magnesium sulfate is effectively managing the risk of seizures.

B. BP 150/92 mm Hg: While blood pressure management is important in preeclampsia, a blood pressure of 150/92 mm Hg indicates hypertension, which is not a desired therapeutic effect when managing preeclampsia with magnesium sulfate.

C. Pulse rate 100/min: A pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate and can indicate tachycardia, which might require further evaluation rather than being a target for monitoring.

D. Flushed face: A flushed face may occur as a side effect of magnesium sulfate infusion, but it is not a therapeutic effect. It does not indicate that the medication is working to control the symptoms of preeclampsia.

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. B. Open the outermost flap of the sterile kit toward the body. C. Place the cap from the solution sterile side up on a clean surface. D. Set up the sterile field 5 cm (2 in) below waist level.

Correct Answer is C

Explanation

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

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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 assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

Correct Answer is A

Explanation

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is C

Explanation

A nurse is creating a plan of care for a client who has cancer and is experiencing immunosuppression. Which of the following interventions should the nurse include in the plan of care?

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