A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will change your IV tubing once every 48 hours."

"Abdominal distention is an expected effect of this therapy."

"I will need to check your gastric residual before administering feedings."

"I will need to measure your weight daily."

Answer and Explanation

The Correct Answer is D

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- A is incorrect because IV tubing for total parenteral nutrition should be changed every 24 hours to prevent infection.

- B is incorrect because abdominal distention is not an expected effect of total parenteral nutrition. It could indicate a complication such as fluid overload or bowel obstruction.

- C is incorrect because gastric residual is not relevant for total parenteral nutrition, which bypasses the gastrointestinal tract.

- D is correct because weight measurement is an important indicator of fluid balance and nutritional status for clients receiving total parenteral nutrition.

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Correct Answer is C

Explanation

- A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP. -

B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.

- C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.

- D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.

A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here is so controlling C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting

Correct Answer is D

Explanation

The client is pacing around the chair in which their partner is sitting.

Rationale:

A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

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A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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