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 D
Explanation
A. Bradypnea: This refers to a slower than normal respiratory rate, which is not a typical manifestation of pulmonary congestion. In fact, pulmonary congestion often leads to tachypnea (increased respiratory rate).
B. Jugular vein distention: This is more indicative of right-sided heart failure or fluid overload rather than left-sided heart failure, where the primary issue is related to pulmonary congestion.
C. Weight gain: While weight gain can occur due to fluid retention in heart failure, it is not specific to pulmonary congestion and can be seen in both left-sided and right-sided heart failure.
D. Frothy, pink sputum: This is a classic manifestation of pulmonary congestion and indicates the presence of fluid in the lungs, often seen in left-sided heart failure. The pink color is due to the presence of blood, which may leak into the alveoli due to increased pressure. This finding is critical and should be closely monitored.
Correct Answer is A
Explanation
A) Initiate droplet precautions: This is the correct answer. Epiglottitis can be caused by infections such as Haemophilus influenzae type b (Hib), which can spread through respiratory droplets. Implementing droplet precautions helps prevent the transmission of the infection to others.
B) Carefully suction the child's oropharynx to remove secretions: This intervention is risky in cases of epiglottitis because it may cause further airway obstruction or distress. It is generally avoided unless there is a clear indication that it is safe to do so.
C) Offer a high-calorie, high-protein diet: While nutrition is important, the immediate priority in a child with epiglottitis is to ensure airway patency and manage the infection, not dietary considerations.
D) Administer pancreatic enzymes with meals: This intervention is not relevant to epiglottitis, as pancreatic enzymes are typically indicated for conditions affecting digestion, such as cystic fibrosis or pancreatic insufficiency, rather than for an upper airway infection.
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