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.
Prepare the client for a central venous line.
Change the PN infusion bag every 48 hr.
Obtain a random blood glucose daily.
The Correct Answer is B
A. Administer the PN and fat emulsion separately:
Administering the PN and fat emulsion separately is not a typical practice. Usually, PN formulations are prepared to include both macronutrients (carbohydrates and fat) in a single bag to provide a balanced nutritional profile. Administering them separately might lead to inconsistencies in the client's nutritional intake.
B. Prepare the client for a central venous line:
This is the correct action. Parenteral nutrition (PN) with a high concentration of dextrose (20%) and fat emulsions can be hypertonic and irritating to peripheral veins. Therefore, a central venous line is often recommended for the administration of such solutions. Preparing the client for a central venous line helps ensure the safe and effective delivery of PN.
C. Change the PN infusion bag every 48 hr:
The frequency of changing the PN infusion bag is not solely determined by time but rather by factors such as the stability of the solution, risk of contamination, and compatibility of the components. The specific recommendation for changing the PN bag should be based on institutional policies and the characteristics of the PN solution being used.
D. Obtain a random blood glucose daily:
While monitoring blood glucose is important in clients receiving PN, obtaining a random blood glucose daily is not specific enough for managing the potential hyperglycemic effects of a 20% dextrose solution. Continuous glucose monitoring or more frequent and scheduled blood glucose checks may be necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Check that the client has a small gauge IV catheter in place:
While it is important to have an appropriate-sized IV catheter for blood transfusions, checking the compatibility of the blood product with the client's blood type is the primary concern before initiating the transfusion. The IV catheter size becomes relevant after confirming compatibility.
B. Check the blood product's compatibility with the client's blood type:
This is the first and most crucial step before administering any blood product. Ensuring compatibility between the packed red blood cells (PRBCs) and the client's blood type is vital to prevent a transfusion reaction. The nurse should carefully check the blood product against the client's
C. Prime the client's primary IV tubing with lactated Ringer's:
Priming the tubing with lactated Ringer's is not the first step. The initial focus should be on verifying the compatibility of the blood product with the client's blood type. After ensuring compatibility, the nurse can then prime the tubing with the appropriate blood product.
D. Confirm the identity of the client with the blood bank technician:
Confirming the identity of the client with the blood bank technician is important, but it is not the first step before the start of the infusion. The immediate priority is to check the compatibility of the blood product with the client's blood type. Confirming the client's identity becomes crucial during the administration process.
Correct Answer is C
Explanation
A. Four-point alternating gait:
This gait involves a more natural and stable walking pattern. However, it requires weight-bearing on both legs, which may not be suitable for a client who can only bear weight on one leg.
B. Swing-through gait:
The swing-through gait is typically used by clients with bilateral lower extremity weakness. It involves swinging both legs through while supporting weight on the crutches. This gait is not suitable for a client who can only bear weight on one leg.
C. Three-point gait:
This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client uses crutches and swings or hops the non-weight-bearing leg forward, landing on the good leg. This gait provides stability and reduces weight-bearing on the affected leg.
D. Two-point alternating gait:
In a two-point alternating gait, the client advances the crutch and the opposite foot simultaneously. This gait is more energy-efficient than the four-point gait but requires weight-bearing on both legs. It is not suitable for a client who can only bear weight on one leg.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today