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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Introducing non-pharmacologic strategies for pain reduction is a valid intervention for managing pain in a client with sickle cell anemia. However, in this scenario, the client's laughter on the phone call may not necessarily indicate that the pain level is accurately reflected by the numerical rating. It is essential to consider the client's overall well-being and pain management plan.
Choice B: Allowing adequate privacy and time for the client's phone call is a considerate and appropriate action. It acknowledges the client's need for communication and emotional support, which can be important in managing pain.
Choice C: Documenting the concern of incongruent pain rating and behavior is a necessary step for the nurse to record the observation. However, it should not be the only action taken in response to the situation.
Choice D: Administering pain medication should be based on a comprehensive assessment of the client's pain and the healthcare provider's orders. While pain medication may be indicated for this client, it should not be administered solely based on the numerical pain rating without further assessment and consideration of the client's overall condition.
Correct Answer is B
Explanation
Choice A: Sweaty palms may be related to various factors, including anxiety, physical activity, or environmental conditions. While it may warrant further assessment, it is not necessarily indicative of a nutritional issue in a professional dancer.
Choice B: Fatigue in a professional dancer can be a concerning issue and may indicate an underlying nutritional problem, such as inadequate calorie intake or nutrient deficiencies. Further assessment of the client's dietary habits and energy levels is warranted.
Choice C: Bunions are a foot deformity and are not directly related to nutritional assessment.
Choice D: Dry skin may be related to various factors, including environmental conditions and skin care practices. It may warrant assessment but is not necessarily indicative of a nutritional issue.
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