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?

Obtain a random blood glucose daily.

Change the PN infusion bag every 48 hr.

Prepare the client for a central venous line.

Administer the PN and fat emulsion separately.

Answer and Explanation

The Correct Answer is C

A.   Obtaining a random blood glucose daily is important for monitoring glucose levels but might not be specifically related to the introduction of PN in this context.
B.   Changing the PN infusion bag every 48 hours might not be universally applicable; the frequency of changing PN bags depends on institutional policies and the stability of the solution being administered.
C.   PN with high concentrations of dextrose and fat emulsions typically requires a central venous line for administration to prevent peripheral vein irritation or damage.
D.   Administering PN and fat emulsion separately might not be practical as PN usually includes all necessary components in a single infusion.

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Correct Answer is ["A","B","C"]

Explanation

A. Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B. Administering oxygen helps address hypoxia and supports adequate oxygenation.
C. Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D. Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E. Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.

A. Roll the client as one unit in a smooth, continuous motion. B. Flex the client's knees. C. Place the client's arms at their sides. D. Place the client on the side of the bed nearest the direction they will be turned.

Correct Answer is A

Explanation

- Rationale for A: Rolling the client as one unit helps maintain spinal alignment and prevents further injury. It ensures that no additional strain is placed on the injured area, which could exacerbate pain or cause further damage. This method distributes the client's weight evenly and avoids twisting movements that could be harmful.

- Rationale for B: While flexing the client's knees may be part of the process to prepare for repositioning, it is not the most critical action to take. Flexing the knees alone does not ensure the safety of the client's lower back and could potentially lead to discomfort or injury if not done in conjunction with other measures.

- Rationale for C: Placing the client's arms at their sides is not advisable as it does not provide any support or stability during the repositioning process. Arms should be positioned in a way that they do not bear weight or interfere with the movement, ensuring the client's comfort and safety.

- Rationale for D: While placing the client on the side of the bed nearest the direction they will be turned may seem practical, it is not the primary action to ensure the client's safety. This position does not address the need for maintaining proper spinal alignment or the smooth, controlled movement required to protect the lower back injury.

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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 assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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