A nurse on a medical surgical unit is caring for a client who has a small bowel obstruction and is receiving parenteral nutrition through a central venous catheter. Which of the following actions should the nurse plan to take? (Select all that apply)
Observe for dyspnea.
Infuse parenteral nutrition by gravity.
Administer parenteral nutrition solution within 30 min after removing from the refrigerator.
Change parenteral nutrition bag and infusion tubing every 72 hr.
Begin infusion of parenteral nutrition once central venous catheter position is confirmed by radiology.
Correct Answer : A,C,E
Choice A reason: Dyspnea is a sign of pulmonary edema, which can occur as a complication of parenteral nutrition due to fluid overload or allergic reaction¹². The nurse should monitor the client's respiratory status and oxygen saturation and report any signs of respiratory distress.
Choice B reason: Parenteral nutrition should not be infused by gravity, as this can cause fluctuations in the infusion rate and lead to hyperglycemia or hypoglycemia¹³. The nurse should use an infusion pump to deliver parenteral nutrition at a constant and controlled rate.
Choice C reason: Parenteral nutrition solution should be administered within 30 min after removing from the refrigerator, as prolonged exposure to room temperature can increase the risk of bacterial contamination and infection¹⁴. The nurse should check the expiration date and inspect the solution for any discoloration, cloudiness, or particulate matter before administration.
Choice D reason: Parenteral nutrition bag and infusion tubing should be changed every 24 hr, not every 72 hr, to prevent the growth of microorganisms and reduce the risk of infection¹⁵. The nurse should use aseptic technique when changing the bag and tubing and follow the facility's protocol for dressing changes and catheter care.
Choice E reason: Parenteral nutrition should be started only after the central venous catheter position is confirmed by radiology, as incorrect placement can cause serious complications such as pneumothorax, hemothorax, or cardiac tamponade¹⁶. The nurse should obtain a chest x-ray and wait for the provider's confirmation before initiating parenteral nutrition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Weight gain of 0.45 kg (1 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Choice B reason: Intake of 200 extra calories per day is within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice C reason: Intake of 100 extra calories per day is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended caloric intake for this client is 2200 to 2900 calories per day, which is about 340 to 450 calories more than the pre-pregnancy intake.
Choice D reason: Weight gain of 0.91 kg (2 lb) per week is not within the expected reference range for a client who is in the second trimester of pregnancy and has a normal BMI. The recommended weight gain for this client is 0.35 to 0.5 kg (0.8 to 1 lb) per week.
Correct Answer is B
Explanation
Choice D reason:A metallic taste in the mouth is not a recognized symptom of hyperglycemia. It may occur in other conditions, such as certain medication side effects, infections, or metabolic disorders, but it is not specific to diabetes or high blood glucose levels. Including this as a sign of hyperglycemia could lead to confusion or misinterpretation of symptoms.
Choice A reason: Anxiety is not a specific symptom of hyperglycemia, although it can be associated with stress or other psychological factors that can affect blood sugar levels. Anxiety can also be a symptom of hypoglycemia, or low blood sugar, which requires immediate treatment.
Choice B reason: Hyperventilation, characterized by deep and rapid breathing, is a critical manifestation of severe hyperglycemia, particularly in cases ofdiabetic ketoacidosis (DKA). When blood glucose levels are extremely high, the body may produce ketones, leading to metabolic acidosis. To compensate, the client may developKussmaul respirations, a type of hyperventilation aimed at expelling excess carbon dioxide. This is a medical emergency and requires immediate intervention. Teaching the client to recognize hyperventilation as a sign of severe hyperglycemia is essential for timely treatment and prevention of complications.
Choice C reason: Cool skin is not a symptom of hyperglycemia, but rather a sign of poor circulation, which can be a complication of diabetes. Diabetes can damage the blood vessels and nerves that supply blood and oxygen to the skin, especially in the feet and legs. This can lead to skin problems, infections, and ulcers.
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