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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.

A.

Obtain client weight twice daily.

B.

Have 3 nurses verify the TPN solution prescription.

C.

Request a prescription for insulin.

D.

Request an antibiotic to be administered.

E.

Decrease the client's oxygen to 1.5 L/min oxygen via nasal cannula.

F.

Notify provider to increase TPN rate/hr.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

D. This sequence is important because regular insulin should not be contaminated with NPH insulin, and drawing up regular insulin first helps ensure accurate dosing and prevents mixing of the two insulins prematurely.

A Insulin injections are typically administered subcutaneously, which usually requires a 90-degree angle (perpendicular) for needle insertion, especially if the person has adequate subcutaneous tissue.

B. Prefilled insulin syringes should be stored with the needle pointing upward to prevent insulin leakage or air bubbles from affecting the accuracy of the dose.

C NPH (Neutral Protamine Hagedorn) insulin is a suspension and should not be vigorously shaken. Shaking could cause frothing or denaturation of the insulin, affecting its efficacy and consistency.

Correct Answer is C

Explanation

C. An increase in uric acid levels (hyperuricemia) is a hallmark finding in acute gout. Elevated uric acid levels predispose to the formation and deposition of urate crystals in joints, leading to the inflammatory response seen in gout attacks.

A While CK levels can increase in conditions affecting muscles (like rhabdomyolysis), it is not specifically associated with acute gout.

C Uric acid levels are typically elevated during acute gout attacks. This is because gout results from the deposition of urate crystals in the joints due to elevated serum uric acid levels. Therefore, during an acute gout attack, uric acid levels in the blood are often higher than normal.

D. Chloride is an electrolyte and its levels can vary based on hydration status, acid-base balance, and kidney function. It is not directly associated with acute gout, so its levels would not necessarily increase in this condition.

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