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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Metallic taste in mouth: This is not a commonly reported adverse effect of sertraline. While some medications may cause changes in taste, it is not characteristic of SSRIs like sertraline.
B. Increased urinary frequency: This is not a typical adverse effect associated with sertraline. While changes in urinary patterns can occur with some medications, it is not specifically noted for sertraline.
C. Excessive sweating: This is a recognized adverse effect of sertraline and other SSRIs. Patients may experience increased sweating, which can be uncomfortable and distressing.
D. Dry cough: This is not a common side effect of sertraline. While some medications may lead to respiratory side effects, it is not typical for SSRIs like sertraline to cause a dry cough.
Correct Answer is A
Explanation
A) Ensure that all area rugs are rubber-backed:Rubber-backed rugs help prevent slips and falls by keeping the rugs securely in place on the floor. This is particularly important for someone recovering from knee surgery to avoid additional injury and ensure a safe home environment.
B) Wear slippers with cloth soles:Slippers with cloth soles can be slippery and increase the risk of falls. It is safer to wear slippers with non-slip soles to provide better traction and stability.
C) Place a towel on the floor outside of the shower:Placing a towel on the floor can create a slipping hazard. Instead, using a non-slip bath mat outside the shower is recommended to prevent falls.
D) Place a handrail in the entryway of the house:While placing a handrail in the entryway can be beneficial, it is not as immediately critical as ensuring that area rugs are rubber-backed to prevent falls throughout the home. Handrails are more commonly recommended for stairs and bathrooms.
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