Exhibits
Which of the following actions should the nurse take?
For each potential nursing intervention, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.
Obtain client weight twice daily.
Have 3 nurses verify the TPN solution prescription.
Request a prescription for insulin.
Request an antibiotic to be administered.
Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.
Notify provider to increase TPN rate/hr.
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Obtain client weight twice daily
Anticipated: This intervention is anticipated. Monitoring the client's weight is crucial when they are receiving Total Parenteral Nutrition (TPN) to assess for fluid status, nutritional adequacy, and response to therapy. It helps in adjusting TPN rates and managing fluid balance.
Have 3 nurses verify the TPN solution prescription
Anticipated: Verifying TPN solution prescription by multiple nurses is a critical safety measure to prevent errors in TPN administration, which can have serious consequences. This ensures that the TPN solution matches the prescribed order in terms of content, concentration, and rate.
Request a prescription for insulin
Anticipated: Given the client's hyperglycemia (fasting blood glucose of 140 mg/dL) and potential exacerbation by TPN administration (which can be rich in glucose), requesting insulin is appropriate. Insulin helps manage blood glucose levels and prevent hyperglycemia, especially important in clients with diabetes or those on TPN.
Request an antibiotic to be administered
Anticipated: The client presents with signs of infection (fever, productive cough, yellow sputum) and crackles auscultated in the lungs, indicating a possible respiratory infection. Requesting antibiotics is essential to treat the infection promptly and prevent further complications.
Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula
Nonessential: The client is currently receiving 2 L/min oxygen via nasal cannula with an oxygen saturation of 90%. Decreasing the oxygen flow may compromise oxygenation further, especially given the crackles and productive cough. It is more appropriate to maintain or potentially increase oxygen support based on the client's oxygen saturation.
Notify provider to increase TPN rate/hr
Contraindicated: The client has diarrhea (3 episodes in the past 4 hours) and an abdominal distension, which may indicate gastrointestinal intolerance to TPN. Increasing the TPN rate could exacerbate diarrhea and worsen fluid and electrolyte imbalances. It is important to address the underlying cause of diarrhea and abdominal symptoms before considering any increase in TPN rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A Breathing exercises can help improve lung function and oxygenation. However, the specific type of breathing exercise is crucial. Emphysema typically involves air trapping due to loss of elasticity in the lungs, so teaching a breathing exercise with a longer exhalation phase (to facilitate complete exhalation and prevent air trapping) would be more beneficial than emphasizing a longer inhalation phase.
B. Fluid restriction is not typically indicated for clients with emphysema. It is more relevant for conditions where fluid overload can exacerbate symptoms (like congestive heart failure). In emphysema, maintaining adequate hydration is important to keep secretions thin and more manageable for clearing.
C.Incentive spirometry is used to help promote deep breathing and prevent atelectasis (lung collapse) by encouraging the client to take slow, deep breaths. However, incentive spirometry is typically more useful for clients recovering from surgery or immobilized clients rather than for those with emphysema.
D. The use of oxygen therapy at 2 L/min is a standard intervention for clients with emphysema who have low oxygen levels, as it helps maintain proper oxygenation. It is crucial to manage oxygen levels carefully to prevent complications such as hypoxia or pulmonary hypertension while avoiding excessive oxygen, which may reduce the patient's drive to breathe.
Correct Answer is D
Explanation
D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.
A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.
B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.
C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.
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