A nurse is planning care for a client who has a new prescription to receive a continuous infusion of total parenteral nutrition (TPN) Which of the following interventions should the nurse implement?
Change the TPN infusion tubing once every 3 days
Check the client's blood glucose level regularly
Insert the peripheral IV catheter for administration
Monitor the client's weight every 3 days
The Correct Answer is B
When caring for a client receiving a continuous infusion of total parenteral nutrition (TPN), the nurse should implement the intervention of checking the client's blood glucose level regularly. TPN is a highly concentrated intravenous nutrition solution containing glucose, amino acids, lipids, vitamins, and minerals, and it is used to provide complete nutrition when the client cannot take oral nutrition.
Monitoring blood glucose levels regularly is essential because TPN is rich in glucose, which can significantly affect the client's blood sugar levels. Hyperglycemia (high blood sugar) is a potential complication of TPN infusion. Regular blood glucose monitoring allows the nurse to detect and address any changes in blood sugar levels promptly and to adjust the TPN infusion rate or administer insulin, if necessary, to maintain the client's blood sugar within the target range.
Let's go through the other options:
A. Change the TPN infusion tubing once every 3 days: While changing the TPN infusion tubing regularly is a good practice to maintain asepsis and prevent infection, it is not the priority intervention in this situation. Regularly checking the client's blood glucose level is more crucial to monitor the effects of TPN on blood sugar levels.
C. Insert the peripheral IV catheter for administration: Total parenteral nutrition is a hypertonic solution that can cause irritation and damage to peripheral veins. It is usually administered through a central venous catheter (CVC) placed in a large vein, such as the subclavian or jugular vein. Inserting a peripheral IV catheter for TPN administration is not recommended due to the risk of vein damage and thrombosis.
D. Monitor the client's weight every 3 days: Monitoring the client's weight is an important part of assessing their nutritional status and fluid balance. However, the priority intervention for a client receiving TPN is checking their blood glucose level regularly, as hyperglycemia is a common and significant concern in TPN administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When assessing a client receiving ciprofloxacin, the nurse should prioritize reporting tendon pain when walking to the provider. Ciprofloxacin is a fluoroquinolone antibiotic that can rarely cause tendonitis or tendon rupture, particularly in the Achilles tendon. Tendon pain, especially when associated with difficulty walking, can be indicative of a serious adverse effect and requires immediate attention and evaluation by the provider.
Nausea and vomiting (A) are common side effects of ciprofloxacin but are typically not considered urgent or life-threatening. They can often be managed with supportive care measures and may not require immediate intervention.
Daytime drowsiness (B) is not typically associated with ciprofloxacin and may be unrelated to the medication. It should be assessed and reported if it persists or is severe, but it is not a priority finding specifically related to ciprofloxacin administration.
Photosensitivity (D) is a known side effect of ciprofloxacin, but it is not typically considered a priority finding unless it is severe or causing significant discomfort. Adequate sun protection measures can help manage photosensitivity.
Correct Answer is A
Explanation
A client with a magnesium level of 3.2 mEq/L has a higher-than-normal magnesium level, indicating hypermagnesemia. The nurse should expect to administer calcium gluconate.
Calcium gluconate is the antidote for hypermagnesemia, as it works to antagonize the effects of magnesium on the body. By administering calcium gluconate, the nurse can help counteract the effects of excess magnesium and normalize the client's magnesium levels.
Let's go through the other options:
B. Calcitonin: Calcitonin is not used to treat hypermagnesemia. Calcitonin is a hormone that regulates calcium and phosphorus levels in the body. It is used in certain conditions, such as hypercalcemia (high calcium levels), but it is not indicated for hypermagnesemia.
C. Magnesium oxide: Magnesium oxide is a form of magnesium supplement, and it is not appropriate for a client with hypermagnesemia, as it would further increase the magnesium level, exacerbating the condition.
D. Magnesium sulphate: Magnesium sulfate is also not appropriate for a client with hypermagnesemia, as it would further elevate the magnesium levels in the body. Magnesium sulfate is often used to treat magnesium deficiency or as a tocolytic agent to prevent premature labor.
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