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 ["B","D","E"]
Explanation
. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L
The client's potassium level is slightly elevated at 5.5 mEq/L. Potassium replacement may be necessary if the level drops below 5.0 mEq/L, which is within the anticipated range for the nurse's actions.
D.0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr
This prescription addresses the need for fluid resuscitation to correct dehydration and electrolyte imbalances often seen in DKA. The client's initial blood pressure of 96/65 mm Hg suggests some degree of dehydration, further supporting the use of isotonic saline.
E.Regular insulin continuous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L
This prescription aligns with the client's presentation of severe hyperglycemia (468 mg/dL) and acidosis (pH 7.30), indicating diabetic ketoacidosis (DKA). Insulin infusion is crucial for lowering blood glucose levels and correcting acidosis.
Correct Answer is B
Explanation
B. Changes in the fluid level of the water-seal chamber correspond to the client's breathing pattern. During inhalation, the negative pressure in the chest cavity may cause the fluid level to rise slightly as air is drawn into the tube, and during exhalation, the fluid level may fall as air exits through the chest tube.
A Fluctuations in the fluid level can occur due to changes in suction pressure settings, but this is more relevant to the suction control chamber rather than the water-seal chamber.
C. If there is continuous bubbling in the water-seal chamber, it indicates an air leak, which disrupts the normal function of the water-seal mechanism.
D. The water-seal chamber's fluctuation does not directly indicate lung re-expansion. Lung re-expansion is assessed through clinical examination, chest X-ray, or other diagnostic tests rather than the water-seal chamber.
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