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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.

A. "Tell me more about your partner." B. "Have you thought about harming yourself?" C. "Why did you stop taking your medication? D. "You should discuss these feelings with your provider."

Correct Answer is B

Explanation

A. "Tell me more about your partner.":

While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.

B. "Have you thought about harming yourself?":

This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.

C. "Why did you stop taking your medication?":

While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.

D. "You should discuss these feelings with your provider.":

This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.

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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

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