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
The nurse should monitor the client receiving long-term treatment with oral doses of prednisone for the development of osteoporosis. Prednisone is a corticosteroid medication that can lead to decreased bone density and increase the risk of fractures. Prolonged use of prednisone can interfere with calcium absorption and increase bone resorption, leading to osteoporosis.
Hypoglycemia (A) is not a common adverse effect of prednisone. In fact, prednisone can cause hyperglycemia and increase the risk of developing diabetes.
Hyperreflexia (B) is not typically associated with prednisone use. Hyperreflexia is an exaggerated reflex response and is not a common adverse effect of corticosteroid therapy.
Inflammatory bowel disease (D) is not an adverse effect of prednisone. In fact, prednisone is often used as a treatment for inflammatory bowel disease to reduce inflammation and symptoms.
Therefore, the nurse should primarily monitor the client for the development of osteoporosis when receiving long-term treatment with oral doses of prednisone.
Correct Answer is A
Explanation
Neonatal abstinence syndrome (NAS) is a group of withdrawal symptoms that occur in newborns who were exposed to drugs, including heroin, in utero. Hyporeflexia, which refers to reduced or diminished reflexes, is one of the key findings in neonates experiencing NAS.
During pregnancy, when the mother uses opioids like heroin, the baby becomes dependent on the drug. After birth, when the drug is no longer available, the baby experiences withdrawal symptoms as the body adjusts to the absence of the drug. Hyporeflexia is a common manifestation of NAS and is observed due to the central nervous system's response to the withdrawal.
Let's go through the other options:
B. Frequent yawning: While yawning can be seen in neonates with NAS, it is not as specific to the condition as hyporeflexia. Yawning can occur for various reasons and may not always be indicative of NAS.
C. Respiratory depression: Respiratory depression can be a severe complication of opioid exposure in utero and can result in life-threatening situations for the neonate. However, it is not specific to NAS. Respiratory depression is more closely associated with opioid overdose in the newborn, which can be a separate concern from NAS.
D. Constipation: Constipation is a possible symptom in neonates experiencing NAS, but it is not as specific as hyporeflexia. Constipation can occur due to various factors and is not unique to NAS.
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