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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take a hot shower every day: This is a beneficial nonpharmacological pain management technique for clients with osteoarthritis. Warm water can help relax muscles and soothe joint stiffness, providing relief from pain.
B. Limit dietary intake of phosphorus: This is not directly related to pain management in osteoarthritis. While managing overall nutrition is important, phosphorus specifically does not need to be limited unless there are other underlying health conditions.
C. Place a large pillow under the knees when sleeping: This instruction may not be optimal. While some support can be helpful, using a pillow under the knees can cause misalignment of the spine. A more neutral sleeping position is generally recommended.
D. Place an ice pack directly on the skin of the affected joints: Applying ice directly to the skin can cause frostbite or skin damage. It's better to use a cloth or towel as a barrier when applying an ice pack to avoid direct contact and protect the skin.
Correct Answer is D
Explanation
A) Educating clients about maintaining a low-cholesterol diet is a form of primary prevention aimed at reducing risk factors for chronic diseases, but it does not directly address individuals already diagnosed with Parkinson's disease. This intervention focuses more on general health rather than managing an existing condition.
B) Providing screenings for early manifestations of Parkinson's disease represents secondary prevention, as it aims to identify the disease at an early stage to allow for timely intervention. However, this option does not apply to clients who already have Parkinson's disease, thus it is not a tertiary prevention strategy.
C) Educating clients about techniques used to diagnose Parkinson's disease is informative but primarily falls under secondary prevention. It pertains to awareness rather than actively managing the condition in those already diagnosed.
D) Providing daily exercise classes to improve ambulation for clients who have Parkinson's disease is a tertiary prevention strategy. This intervention focuses on rehabilitation and improving the quality of life for individuals already diagnosed with the disease, aiming to manage symptoms and prevent further complications associated with Parkinson's disease.
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