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
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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Related Questions
Correct Answer is D
Explanation
A) Use clothing with buttons and zippers: This may create frustration for clients with dementia, who may struggle with complex clothing. Instead, simpler clothing options, like pull-on pants, may be more suitable.
B) Engage the client in activities that increase sensory stimulation: While some sensory stimulation can be beneficial, overwhelming sensory input may lead to confusion or agitation. It’s important to find a balance that suits the individual’s needs.
C) Discourage physical activity during the day: This is incorrect. Encouraging physical activity during the day can help improve mood, reduce restlessness, and promote better sleep at night.
D) Establish a toileting schedule for the client: This is the correct answer. A consistent toileting schedule can help manage incontinence and reduce anxiety related to bathroom needs, providing a sense of routine and security for clients with dementia.
Correct Answer is C
Explanation
A) Flushing: Flushing can occur as the body tries to regulate temperature, but it is not typically an adverse reaction to cooling measures.
B) Restlessness: While restlessness can indicate discomfort, it is not a specific sign of an adverse reaction to cooling therapy.
C) Shivering: This is the correct answer. Shivering is a direct response to cold exposure and indicates that the body is trying to generate heat in response to the cooling blanket. It can be an adverse reaction as it can increase metabolic demand and may counteract the intended effects of the cooling.
D) Tachycardia: Although an increase in heart rate can occur with fever or anxiety, it is not a definitive indicator of an adverse reaction to cooling. It can also be a normal physiological response.
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