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 C
Explanation
Choice A: Bread is generally considered a suitable food choice for individuals with cholelithiasis and is not typically associated with exacerbating symptoms or gallstone formation.
Choice B: Beef broth is a liquid and does not contain the same types of fats and cholesterol that can contribute to gallstone formation. It is not typically a concern for individuals with cholelithiasis.
Choice C: Ketchup is often high in sugar and can be made with vinegar, which may exacerbate symptoms in some individuals with cholelithiasis. It is advisable to omit or limit foods high in sugar and vinegar-based condiments.
Choice D: Ice cream, while high in fat, is generally tolerated by most individuals with cholelithiasis unless they experience specific dietary sensitivities. It is not typically recommended to omit ice cream from the diet unless advised by a healthcare provider.
Correct Answer is B
Explanation
Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.
Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.
Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.
Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.
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