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,B,A,C
Explanation
Step D (Place the client in an upright sitting position): Elevating the client's head and upper body to an upright position helps to reduce blood pressure by promoting venous pooling in the lower extremities.
Step B (Confirm that the client's bladder is empty): Autonomic dysreflexia is often triggered by bladder distention or urinary retention. By confirming and addressing urinary issues promptly, the nurse can remove the triggering stimulus.
Step A (Administer an antihypertensive medication intravenously): In severe cases where blood pressure remains dangerously high despite other interventions, such as positioning and addressing bladder issues, antihypertensive medications may be necessary to lower blood pressure quickly and prevent complications.
Step C (Indicate the risk for autonomic dysreflexia in the client's medical record): Documentation of the occurrence of autonomic dysreflexia, its triggers, and interventions used is essential for continuity of care. It informs other healthcare providers about the client's condition and helps in implementing preventive strategies.
Correct Answer is D
Explanation
D. After inhaling the medication, holding the breath for about 10 seconds allows the medication to settle in the lungs and be absorbed effectively into the bloodstream. This improves the medication's effectiveness in controlling asthma symptoms.
A Waiting 30 seconds between puffs is not a standard instruction; instead, it is generally advised to wait about one minute between puffs if multiple doses are needed.
B. The whistling sound may indicate that the client is inhaling too quickly or forcefully, which can prevent the medication from reaching the lungs effectively.
C. Cleaning the spacer is also crucial, but it is typically recommended to use warm soapy water rather than cold water, and it should be left to air dry.
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