The nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an Infusion pump. Which action would be appropriate?

Change the IV site dressing every 48-72 hours

Change the IV tubing every 24 hours

Weigh the client every other day on the same scale

Obtain the client's blood glucose every 12 hours

Answer and Explanation

The Correct Answer is B

B. Changing the IV tubing every 24 hours helps prevent the accumulation of bacteria and other contaminants within the tubing, reducing the risk of infection. This practice is particularly important for clients receiving TPN, as they are at higher risk of infection due to the direct infusion of nutrients into the bloodstream.
A. It is essential to maintain the integrity of the IV site to prevent infection and ensure proper TPN delivery. Changing the IV site dressing every 24 hours helps minimize the risk of contamination and infection at the insertion site.
C. Regular monitoring of the client's weight is not necessary.
D. While monitoring blood glucose levels is important for clients at risk of hyperglycemia or hypoglycemia, the frequency of monitoring should be individualized based on the client's clinical condition and risk factors.

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Correct Answer is C

Explanation

C. Thirst, polyuria, and abdominal pain are symptoms commonly associated with hyperglycemia. High blood glucose levels can lead to osmotic diuresis, causing increased urination and thirst. Abdominal pain may occur due to gastrointestinal symptoms related to hyperglycemia, such as bloating or discomfort.
A. Blurred vision, weakness, tingling of extremities are more indicative of hypoglycemia rather than hyperglycemia.
B. Hunger, shakiness, confusion are symptoms of hypoglycemia rather than hyperglycemia.
D. While tachycardia and anxiety can occur with various medical conditions, oliguria is not typically associated with hyperglycemia.

A. Urine specific gravity and antigen levels B. Urine characteristics and output C. Appearance of the surgical site D. Results of clean catch urine specimens

Correct Answer is B

Explanation

B. After ESWL for a urinary stone, it is essential to monitor the client's urine characteristics (such as color, clarity, and presence of blood) and output. The presence of hematuria is a common and expected finding after ESWL due to the disruption of tissue and blood vessels during the procedure. Monitoring urine output helps assess renal function and ensures adequate hydration, which is crucial for flushing out stone fragments.
A. While monitoring urine specific gravity can provide information about the concentration of urine, and assessing antigen levels may be relevant in certain contexts, these parameters are not typically the most important information to collect immediately after extracorporeal shock-wave lithotripsy (ESWL) for a urinary stone.
C. While it is important to monitor the surgical site for signs of infection or complications after any procedure, ESWL is a non-invasive procedure performed externally, typically without any incisions.
D. While obtaining clean catch urine specimens for urinalysis and culture may be relevant for assessing urinary tract infection or other urinary abnormalities, it is not typically the most important information to collect immediately after ESWL.

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The nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an Infusion pump. Which action would be appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What symptoms would indicate to the nurse that the client receiving TPN is experiencing hyperglycemia?

Correct Answer is C

Explanation

A client who has a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock- wave lithotripsy. What Information is most Important for the nurse to collect after lithotripsy?

Correct Answer is B

Explanation

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