A nurse is reviewing the laboratory values of a patient receiving total parenteral nutrition (TPN). The glucose is 72 mg/dL, chloride is 100 mEq/L, sodium is 138 mEq/L, and potassium is 3.0 mEq/L. What action should the nurse plan to take?

Administer glucagon IM.

Discontinue the TPN infusion.

Request a potassium replacement.

Check the patient for a positive Chvostek’s sign.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Step 1 is to interpret the laboratory values. The glucose level is within the normal range (7099 mg/dL). The chloride level is within the normal range (97-107 mEq/L). The sodium level is within the normal range (135-145 mEq/L). However, the potassium level is low (normal range is 3.5-5.0 mEq/L)89101112.

Step 2 is to plan the action based on the interpretation. Given the low potassium level, the nurse should plan to request a potassium replacement

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Correct Answer is A

Explanation

Choice A rationale

Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.

Choice B rationale

Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.

Choice C rationale

Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.

Choice D rationale

Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.

A. Auscultate stomach sounds B. Warm the formula to body temperature C. Assist the client to sit in an upright position D. Discard residual gastric contents

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.

Choice B rationale

Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.

Choice C rationale

Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.

Choice D rationale

Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.

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A nurse is reviewing the laboratory values of a patient receiving total parenteral nutrition (TPN). The glucose is 72 mg/dL, chloride is 100 mEq/L, sodium is 138 mEq/L, and potassium is 3.0 mEq/L. What action should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of assistive personnel (AP) about infection control measures on the unit. Which of the following is the most effective way to prevent the spread of pathogens during patient care?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a patient in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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