A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?

Change the IV tubing for TPN solution every 72 hr.

Discard the remaining TPN solution that is still infusing after 24 hr.

Change the dressing around the IV site weekly.

Remove TPN from the refrigerator 5 min before infusing it.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
Changing the IV tubing for TPN solution every 72 hr is not necessary unless there is a complication or a specific reason to do so. TPN tubing should be changed based on the facility's protocol and the patient's condition, not on a fixed time frame.
Choice B rationale:
This choice is the correct answer. TPN solutions are susceptible to bacterial growth due to their nutrient-rich composition. Discarding any remaining TPN solution after 24 hr helps minimize the risk of bacterial contamination and subsequent infection in the patient.
Choice C rationale:
Changing the dressing around the IV site weekly is a common practice for peripheral IV sites, but TPN administration usually requires a more frequent dressing change due to the higher risk of infection associated with central venous access.
Choice D rationale:
Removing TPN from the refrigerator 5 min before infusing it is unnecessary. TPN solutions are typically stored in a refrigerator and should be brought to room temperature gradually before administration. However, 5 minutes is not sufficient time for the solution to reach an appropriate temperature.

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Correct Answer is B

Explanation

Choice A rationale:
A temperature of 37.2°C (99°F) is within the normal range (approximately 36.5°C to 37.5°C or 97.7°F to 99.5°F) and does not specifically indicate fluid volume deficit. It's important to consider this value along with other findings.
Choice B rationale:
(Correct Choice) A pulse rate of 118/min is indicative of tachycardia, which can be a sign of fluid volume deficit. When the body is experiencing a decrease in fluid volume, the heart rate often increases as a compensatory mechanism to maintain adequate circulation. Tachycardia helps to pump a reduced blood volume more rapidly to vital organs.
Choice C rationale:
A blood pressure of 152/90 mm Hg is elevated but does not solely indicate a fluid volume deficit. While low blood pressure can be a sign of dehydration, high blood pressure does not necessarily correlate directly with fluid volume status.
Choice D rationale:
Central venous pressure (CVP) of 25 mm Hg is elevated. CVP reflects the pressure in the vena cava and right atrium, indicating the amount of blood returning to the heart. An elevated CVP might be seen in fluid volume excess or right-sided heart failure, not fluid volume deficit.

A. Obtain the client's electrolyte levels every 4 hr. B. Measure the client's gastric residual every 12 hr. C. Keep the client's head elevated at 15 during feedings. D. Flush the client's tube with 30 mL of water every 4 hr.

Correct Answer is B

Explanation

Choice A rationale:
Obtaining the client's electrolyte levels every 4 hours is not standard practice when initiating continuous enteral feedings via a gastrostomy tube. While monitoring electrolytes is important, it's not done at such a high frequency unless there's a specific indication or concern.
Choice B rationale:
Measuring the client's gastric residual every 12 hours is a crucial action when initiating continuous enteral feedings. Gastric residual volume helps to assess the client's tolerance to the feeding, the rate of digestion and absorption, and the risk of aspiration. If the residual volume is too high, it could indicate feeding intolerance or delayed gastric emptying.

Choice Crationale:
Keeping the client's head elevated at 15 degrees during feedings is not standard practice for continuous enteral feedings. This angle could potentially promote reflux and increase the risk of aspiration. Instead, the head of the bed is usually elevated at least 30 degrees to help prevent reflux and aspiration.

Choice Drationale:
Flushing the client's tube with 30 mL of water every 4 hours is not a standard practice for continuous enteral feedings. Flushing the tube helps maintain its patency, but it's usually done before and after medication administration or as needed to prevent clogs, not on such a frequent schedule.

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