A nurse is preparing to administer total parenteral nutrition (TPN) to a client. The nurse should notify the provider of which of the following findings?
Blood glucose 100 mg/dL.
Client's temperature 37.6°C (99.7°F).
Potassium 5.7 mEq/L.
Weight loss of 0.8 kg/day (1.8 lb/day).
The Correct Answer is C
Choice A rationale:
A blood glucose level of 100 mg/dL is within the normal range, so there is no need to notify the provider of this finding.
Choice B rationale:
A client's temperature of 37.6°C (99.7°F) is slightly elevated but not considered a critical finding. It may be indicative of an infection or other mild inflammation, but it does not warrant immediate provider notification.
Choice C rationale:
A potassium level of 5.7 mEq/L is above the normal range (3.5-5.0 mEq/L). Hyperkalemia can lead to serious cardiac complications, such as arrhythmias, and requires immediate attention from the provider.
Choice D rationale:
Weight loss of 0.8 kg/day (1.8 lb/day) should be evaluated and monitored, but it is not an immediate concern that warrants urgent provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Administering phenytoin IV no faster than 100 mg/min is crucial to prevent adverse effects such as cardiovascular collapse or severe hypotension. Rapid administration of phenytoin can cause cardiac arrhythmias and should be avoided.
Choice B rationale:
Monitoring plasma phenytoin levels to establish the therapeutic range is a necessary action in managing the client's seizure disorder, but it does not pertain to the specific administration of phenytoin via intermittent bolus.
Choice C rationale:
Adding the medication to the existing IV solution is not appropriate for phenytoin administration. Phenytoin should be administered separately and not mixed with other IV solutions to maintain its stability and prevent interactions.
Choice D rationale:
Monitoring the client for hypertension is not directly related to the administration of phenytoin via intermittent bolus. Hypertension is not a common adverse effect of this medication. However, blood pressure should be monitored as part of routine care for any client on antiepileptic therapy.
Correct Answer is B
Explanation
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
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