The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

Redness at intravenous site.

Generalized nonpitting edema.

Frequent productive cough.

Hypoactive bowel sounds in all 4 quadrants.

Urinary output greater than 30 mL per hour.

Answer and Explanation

Correct Answer : A,B,C

Choice A: Redness at the intravenous site may indicate infection or phlebitis, which are complications of TPN.

Choice B: Generalized nonpitting edema may indicate fluid overload, which can occur due to the high osmolarity of TPN.

Choice C: Frequent productive cough may indicate pulmonary edema or aspiration, which are also potential complications of TPN.

Choice D: Hypoactive bowel sounds in all 4 quadrants are not necessarily abnormal, as TPN bypasses the gastrointestinal tract.

Choice E: Urinary output greater than 30 mL per hour is within the normal range and indicates adequate renal function.

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Correct Answer is D

Explanation

Choice A: Nasogastric tube insertion may be indicated in the management of a client with peptic ulcer disease (PUD) to assess bleeding, relieve gastric distention, or administer medications. However, in this scenario, the client's presentation with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia suggests a potentially life-threatening condition that requires immediate intervention beyond nasogastric tube insertion.

Choice B: Iced saline lavage is not a standard procedure for managing peptic ulcer disease (PUD) or its complications. It is not the immediate intervention required for the client's presentation.

Choice C: Administration of pantoprazole (Protonix) IV, a proton pump inhibitor, is a relevant intervention for managing peptic ulcer disease (PUD), but it may not be the most immediate action needed for a client with sudden severe abdominal pain, hypotension, and tachycardia. More urgent interventions are required.

Choice D: Emergency abdominal surgery is the most appropriate and immediate intervention for a client with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia. These signs and symptoms may indicate a perforated peptic ulcer, which is a surgical emergency requiring prompt exploration and repair of the perforation to prevent peritonitis and sepsis.

A. Determine pH value of specimen. B. Withdraw the NGT and reinsert. C. Connect the NGT to wall suction. D. Send fluid specimen to the lab.

Correct Answer is A

Explanation

Choice A: The nurse should determine the pH value of the aspirated fluid to confirm the placement of the NGT. Gastric aspirate typically has an acidic pH (usually below 5), which indicates that the tube is correctly placed in the stomach.

Choice B: Withdrawing the NGT and reinserting it is not necessary if the pH of the aspirate confirms gastric placement.

Choice C: Connecting the NGT to wall suction is not appropriate until placement has been confirmed with a pH test.

Choice D: Sending the fluid specimen to the lab is not the first step in verifying NGT placement. Checking the pH is a more immediate and reliable method.

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The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse Implement?

Correct Answer is A

Explanation

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