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.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}
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 ["A","D","E"]
Explanation
A A perforated eardrum can lead to conductive hearing loss, where sound waves cannot efficiently travel through the middle ear to the inner ear.
D. Chronic infections of the middle ear (otitis media) can cause damage to the delicate structures of the middle ear, including the ossicles (bones) and the eardrum, leading to conductive hearing loss or, if severe and untreated, sensorineural hearing loss.
E. Loop diuretics such as furosemide can sometimes cause ototoxicity, which means they can damage the inner ear and lead to hearing loss. This is an important consideration for individuals who are prescribed loop diuretics for medical conditions.
B. High birth weight is not typically considered a significant risk factor for hearing loss unless it was associated with other complications that affected the ears during infancy or childhood.
C. Frequent exposure to low-volume noise is not typically associated with an increased risk of hearing loss
Correct Answer is C
Explanation
C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.
A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.
B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.
D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.
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