A nurse is providing discharge teaching to a client who will receive total parenteral nutrition (TPN) at home. Which of the following information should the nurse include?
Instruct the client that their central line dressing must be changed every 24 hr.
Instruct the client to weigh themselves daily and record their weight.
Instruct the client that one container of TPN may infuse for up to 72 hr.
Instruct the client to speed up the rate of their TPN infusion if it falls behind schedule.
The Correct Answer is B
A) Instruct the ’lient that their central line dressing must be changed every 24 hr: While it's essential to maintain proper hygiene a’d care for a central line to prevent infection, changing the dressing every 24 hours may not be necessary. The frequency of dressing changes depends on institutional policies and the client's condition. Providing accurate informat’on about dressing changes based on specific guidelines is important for the client's safety and the prevention of central l’ne-related infections.
B) Instruct the client to weigh themselves daily and record their weight: This is the correct instruction. Monitoring daily weight allows for the assessment of fluid status and the effectiveness of TPN therapy. Weight gain or loss can indicate fluid retention or depletion, respectively, which may necessitate adjustments to the TPN prescription. Recording daily weights provides valuable data for healthcare providers to evaluate the client's response to TPN and make appropriate m’difications to the treatment plan.
C) Instruct the client that one container of TPN may infuse for up to 72 hr: The duration of TPN administration varies depending on factors such as the client's nutritional needs, medical condition, ’nd the stability of the TPN solution. While some TPN solutions may be stable for up to 24-48 hours, infusing for 72 hours could increase the risk of contamination and compromise the integrity of the solution, leading to adverse effects. Providing accurate information about the duration of TPN infusion based on the specific prescription ensures the client's safety and the efficacy of therapy.
D’ Instruct the client to speed up the rate of their TPN infusion if it falls behind schedule: Altering the rate of TPN infusion without healthcare provider guidance can lead to complications such as hyperglycemia, electrolyte imbalances, or fluid overload. TPN infusion rates are carefully prescribed based on the client's nutritional needs and metabolic status’ If the infusion falls behind schedule, it's essential for the client to contact th’ir healthcare provider for guidance on adjusting the infusion rate or managing any potential issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) PTT (Partial Thromboplastin Time): While the PTT is a laboratory test used to assess the intrinsic pathway of the coagulation cascade and monitor the effectiveness of heparin therapy, it is not routinely used to monitor warfarin therapy. Therefore, reviewing the PTT prior to administering warfarin is not necessary.
B) PT (Prothrombin Time): Prothrombin time measures the extrinsic pathway of the coagulation cascade and is commonly used to monitor warfarin therapy. Since warfarin works by inhibiting vitamin K-dependent clotting factors, such as factors II, VII, IX, and X, monitoring the PT allows for the assessment of the anticoagulant effect of warfarin and helps guide dosing adjustments. Therefore, reviewing the PT prior to administering warfarin is essential to ensure appropriate anticoagulation therapy.
C) WBC (White Blood Cell Count): The white blood cell count is not directly related to warfarin therapy monitoring. While an elevated white blood cell count may indicate infection, it is not specific to warfarin therapy and does not influence the administration of the medication.
D) Total iron-binding capacity: Total iron-binding capacity is a laboratory test used to assess iron status and is not relevant to monitoring warfarin therapy. It measures the body's ability to bind and transport iron in the blood, and its results are not indicative of warfarin's anticoagulant effect or dosage adjustments.
Correct Answer is C
Explanation
A) A client vomits after receiving an oral medication: While vomiting after medication administration should be documented in the client's medical record as it could indicate a ’otential adverse reaction or medication intolerance, it does not necessarily require an incident report unless there are unusual circumstances surrounding the event.
B) A client receives their meal tray 20 minutes before time: This situation does not require an incident report. It may be considered a minor deviation from the usual mealtime schedule, and no harm or adverse outcome is implied.
C) A client receives their insulin before scheduled time: This is the correct answer. Administering insulin before the scheduled time can pose significant risks to the client, potentially leading to hypoglycemia or other adverse effects. Such deviations from the prescribed administration time should be documented in an incident report to ensure appropriate investigation and prevention of recurrence.
D) A client experiences a seizure: While a client experiencing a seizure is a critical event that requires immediate nursing intervention and documentation, it does not typically warrant an incident report unless it occurs in unusual circumstances or if there are concerns about the client's safety or well-being during the seizur’.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
