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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Providing pin care when the client is 4 hours postoperative is not appropriate. The client has just undergone skeletal traction placement, and pin care is usually initiated after 24 hours to allow for initial wound healing.
Choice B rationale:
Removing the weights from the traction while repositioning the client in bed is unsafe and not recommended. The weights should remain in place to provide continuous traction and alignment for the fractured hip.
Choice C rationale:
Assessing the client's circulation every 4 hours is essential to monitor for any signs of impaired circulation, such as swelling, pallor, or decreased pulses. Early detection of circulatory compromise is critical to prevent complications like compartment syndrome.
Choice D rationale:
Requesting the client to perform ankle exercises on the affected extremity is not appropriate after skeletal traction placement. Ankle exercises could disrupt traction and hinder the healing process of the fractured hip.
Correct Answer is D
Explanation
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
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