A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Administer the PN and fat emulsion separately.

Change the PN infusion bag every 48 hr.

Obtain a random blood glucose daily.

Prepare the client for a central venous line

Answer and Explanation

The Correct Answer is D

. PN with 20% dextrose requires a central venous line for administration. Peripheral veins cannot handle the high osmolarity of such solutions, which can cause phlebitis and vein damage. A central venous line is necessary to deliver the solution safely into a larger vein with a higher blood flow.
A. Fat emulsions (lipids) are often administered separately from the PN solution, but they can also be infused concurrently through a Y-connector to minimize the risk of contamination. However, it is crucial to follow the specific guidelines of the healthcare facility and the manufacturer’s recommendations. The decision to administer separately or concurrently depends on the prescribed protocol.
B. PN solutions are typically changed every 24 hours to reduce the risk of infection. The high glucose content in PN solutions provides a rich medium for bacterial growth, making it essential to adhere to strict aseptic techniques and timely changes of the infusion bag.
C. Blood glucose monitoring is crucial for clients receiving PN due to the high dextrose content, which can significantly impact blood glucose levels. However, more frequent monitoring, such as every 4-6 hours initially, is often required rather than just a random daily check. This helps in promptly identifying and managing hyperglycemia or hypoglycemia.

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Correct Answer is B

Explanation

B. When the client believes that learning how to self-administer daily low-dose heparin injections will meet their needs, such as improving their health, managing their condition effectively, or promoting independence, they are more likely to be motivated to engage in the learning process.
A. Understanding the importance of education is crucial, but it may not directly impact the client's motivation unless it is coupled with other factors.
C. While seeking family approval may be a motivating factor for some clients, it may not necessarily be the most significant factor in increasing motivation to learn.
D. Empathy from the nurse can create a positive learning environment and foster trust between the nurse and client, which can indirectly contribute to the client's motivation. However, the client's motivation is primarily influenced by their own beliefs, needs, and perceived benefits of education.

A. A sudden decrease in heart rate B. A sharp decrease in blood pressure C. A feeling of swelling in the feet D. Pain at the injection

Correct Answer is B

Explanation

B. This is a hallmark sign of anaphylaxis. During an anaphylactic reaction, blood vessels dilate, and fluid can leak out of the bloodstream into surrounding tissues, leading to a sudden drop in blood pressure (hypotension). This is a key indicator of anaphylaxis and requires immediate attention.
A. Anaphylactic reactions typically cause an increase in heart rate (tachycardia) rather than a decrease (bradycardia). The body reacts to the perceived threat by releasing a flood of chemicals, such as histamine, which can cause the heart to pump faster. Therefore, a sudden decrease in heart rate is not characteristic of anaphylaxis.
C. Swelling can occur in various parts of the body during an allergic reaction, but it is more common in areas such as the face, lips, tongue, and throat, which can compromise the airway. Swelling in the feet

alone is less likely to be associated with anaphylaxis and more indicative of localized or less severe reactions.
D. Pain at the injection site is a common local reaction to an IM injection and is not specific to anaphylaxis. While it can be uncomfortable, it is not indicative of a systemic allergic reaction.

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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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