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 C

Explanation

Choice A: A client receiving 30% oxygen via a non-rebreather face mask may be at risk for oxygen toxicity, but it does not necessarily indicate a higher risk of aspiration.

Choice B: A client with a nasogastric tube to low, intermittent suction may be at risk for aspiration if the tube is not functioning properly, but it does not represent the greatest risk compared to the other options.

Choice C: A client experiencing dysphagia who is prescribed a full liquid diet is at the greatest risk for aspiration. Dysphagia can lead to difficulty swallowing, increasing the risk of food or liquids entering the airway during swallowing.

Choice D: A client who has sensory aphasia and is receiving a clear liquid diet may have difficulty understanding or communicating about their dietary needs, but this does not necessarily indicate a higher risk of aspiration compared to a client with dysphagia.

A. Test the other reflexes later in the exam. B. Distract the client by instructing him to pull on his fingers. C. Instruct the client to see a neurologist as soon as possible. D. Record the patellar reflex as a zero.

Correct Answer is A

Explanation

Choice A: When a reflex response is not elicited, it is important to proceed with testing other reflexes later in the exam to assess the overall neurological status. A single absence of a reflex may not be indicative of a problem, so further assessment is needed.

Choice B: Distracting the client by instructing him to pull on his fingers is not an appropriate action when assessing reflexes.

Choice C: Instructing the client to see a neurologist as soon as possible based solely on the absence of one reflex would be premature. Further assessment is needed to determine the significance.

Choice D: Recording the patellar reflex as a zero without further assessment would not provide a comprehensive evaluation of the client's reflexes.

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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

Which client is at greatest risk for aspiration?

Correct Answer is C

Explanation

The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?

Correct Answer is A

Explanation

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