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?
Schedules a bag and tubing change for 24 hr after the start of the infusion
Plans for a check of the client's fingerstick glucose level every 6 hr
Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved
Uses the TPN IV tubing to administer the client's next dose of antibiotics
The Correct Answer is D
A: Changing the TPN bag and tubing every 24 hours is standard practice to prevent infection, so this action is appropriate.
B: Checking glucose levels every 6 hours is necessary because TPN can significantly affect blood glucose levels.
C: Gradually increasing the TPN rate is a standard procedure to monitor tolerance to the infusion.
D: This indicates a need for intervention. TPN lines should not be used for any other infusions to prevent contamination and interactions between the nutrition formula and medications.
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Related Questions
Correct Answer is D
Explanation
A. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
B. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
C. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
D. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
Correct Answer is C
Explanation
A. While rest and a quiet environment can be beneficial, encouraging the client to address the hallucinations directly is more appropriate.
B. Avoiding eye contact may be perceived as dismissive or unhelpful.
C. Engaging the client in open communication about their hallucinations can help build trust and rapport, as well as provide valuable information for treatment planning.
D. Validating hallucinations as real can reinforce delusional thinking and may not be therapeutically beneficial.
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