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","C","D","E"]

Explanation

A. The presence of wheezing indicates potential airway compromise, which is a significant concern in the context of an allergic reaction. Wheezing suggests bronchoconstriction and difficulty breathing, requiring immediate assessment and intervention to ensure adequate oxygenation.
B. significant drop in blood pressure (hypotension) is a red flag for anaphylaxis, a severe and potentially life-threatening allergic reaction. Hypotension can lead to inadequate tissue perfusion and organ dysfunction, requiring immediate intervention with fluids and medications to stabilize blood pressure.
C. rapid heart rate (tachycardia) can be a sign of an allergic reaction, particularly if accompanied by other symptoms such as hypotension or respiratory distress. Tachycardia may indicate the body's response to hypotension or increased sympathetic activity, and it warrants immediate follow-up to assess for shock or other complications.
D. Swelling of the tongue (angioedema) can compromise the airway and lead to respiratory distress or obstruction. It is a concerning sign that requires immediate intervention to ensure the client's airway remains patent and adequate ventilation is maintained.
E. A While an elevated temperature can indicate an inflammatory response, it is not typically the most concerning finding in an allergic reaction. In this case, the temperature elevation is mild and may be secondary to the allergic reaction, but it is not a critical priority for immediate follow-up compared to other findings.
F .Urticaria (hives) is a common manifestation of an allergic reaction and can be uncomfortable for the client. While it is important to address, it is typically not as immediately life-threatening as other symptoms such as wheezing or angioedema.

A. Deliver a series of high-pitched sounds at random intervals. B. Whisper a series of words softly into one ear. C. Place an activated tuning fork in the middle of the client's forehead. D. Hold an activated tuning fork against the client's mastoid process.

Correct Answer is C

Explanation

C. This procedure helps assess the conduction of sound through bone to both ears, which can indicate whether hearing loss is conductive or sensorineural. The sound should be heard equally in both ears if hearing is normal. If there is unilateral hearing loss, the sound will be heard better in one ear.

A. Not part of the weber’s test

B. Not part of the weber’s test D. Described the Rinne’s test

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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 caring for a client. Exhibits Select the 4 findings that require immediate follow-up.

Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is C

Explanation

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