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 B

Explanation

A. Turning the client onto their side helps prevent aspiration and ensures a clear airway but since the client is seated on a chair, they run the risk of getting a fall hence lying them down is the priority.
B. If a client has a seizure when seated, it is best to ensure their safety by lying them on the floor and moving any objects that can cuase injury.
C. Loosening clothing is important but not the priority over ensuring a clear airway.
D. Moving items away from the client is important to prevent injury, but ensuring airway safety comes first.

A. Wear clean gloves while cleaning the inner cannula. B. Cut a 4 inch x 4 inch (10 cm x 10 cm) gauze pad to place under the flanges of the tracheostomy tube. C. Cleanse the skin around the stoma with full-strength hydrogen peroxide. D. Secure the tracheostomy in place with a collar that has hook-and-loop fasteners.

Correct Answer is D

Explanation

A. Sterile gloves, not clean gloves, should be worn when cleaning the inner cannula to reduce the risk of introducing infection into the tracheostomy site, which is a direct pathway to the airway.

B. Placing gauze pads under the flanges of the tracheostomy tube isn't a standard practice for tracheostomy care.
C. Cleansing the skin around the stoma with full-strength hydrogen peroxide can be too harsh and irritating to the skin.
D. Using a tracheostomy collar with hook-and-loop fasteners is a safe and effective way to secure the tracheostomy tube, ensuring it remains in place while minimizing the risk of skin breakdown and irritation. This method also allows for easier adjustment and replacement of the collar.

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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 enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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