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 B

Explanation

A) Premature ventricular contraction: A premature ventricular contraction (PVC) typically presents as an early heartbeat originating from the ventricles, often accompanied by a wide QRS complex. The heart rate in this case is regular at 69/min, and there is no indication of early beats, making this option unlikely.

B) First-degree AV block: A first-degree AV block is characterized by a prolonged PR interval greater than 0.20 seconds, which is noted at 0.24 seconds in this scenario. This indicates a delay in conduction through the AV node. While the heart rate is normal, the prolonged PR interval clearly suggests a first-degree AV block.

C) Atrial fibrillation: Atrial fibrillation typically presents with an irregularly irregular rhythm and variable heart rates. The client’s heart rate of 69/min is regular, and there is no mention of an irregular pulse or varying R-R intervals, making atrial fibrillation an unlikely diagnosis in this case.

D) Sinus bradycardia: Sinus bradycardia is defined as a heart rate of less than 60 beats per minute and is characterized by a normal PR interval. In this situation, the heart rate is 69/min, which does not meet the criteria for bradycardia, thus ruling out this option.

A. "This type of seizure lasts 30 to 60 seconds." B. "The child usually has an aura prior to onset." C. "This type of seizure has a gradual onset." D. "This type of seizure can be mistaken for daydreaming."

Correct Answer is D

Explanation

A) "This type of seizure lasts 30 to 60 seconds.": While absence seizures typically last about 10 to 20 seconds, they can occasionally last longer, but they usually do not extend to 30 to 60 seconds. This statement may lead to misunderstanding of the duration.

B) "The child usually has an aura prior to onset.": Absence seizures generally do not have a warning or aura, which is more common in other types of seizures, such as focal seizures. Including this information could provide incorrect expectations.

C) "This type of seizure has a gradual onset.": Absence seizures have a sudden onset and are characterized by a brief loss of awareness rather than a gradual beginning. This statement does not accurately describe the nature of the seizures.

D) "This type of seizure can be mistaken for daydreaming.": This is correct. Absence seizures often result in a brief loss of consciousness that can be misinterpreted as the child simply daydreaming or zoning out, making this information essential for parents to understand.

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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?

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Explanation

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