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

A. A minimally furnished room may be beneficial for safety, but it is not the primary consideration for room assignment.
B. A room with multiple roommates may increase stimulation, which can worsen manic symptoms.
C. A quiet room away from the nurse's station helps reduce environmental stimuli, which can help manage the client's elated state.
D. A bright-colored room near the recreation area may increase sensory stimulation, potentially worsening manic symptoms.

A. Comprehension of simple commands. B. Exploration beyond caregiver presence. C. Visible or audible separation anxiety. D. Ability to place objects in a container.

Correct Answer is B

Explanation

Choice A: Comprehension of simple commands is an earlier developmental stage and not directly related to the infant's ability to search for a fallen toy.

Choice B: Exploration beyond caregiver presence is a key characteristic of the sensorimotor stage in Piaget's theory. During this stage, infants develop object permanence and begin to explore their environment independently.

Choice C: Visible or audible separation anxiety is common during the early stages of infancy and is not specific to the sensorimotor stage.

Choice D: The ability to place objects in a container is more related to later developmental stages when fine motor skills are more developed.

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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

An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. What is the best room assignment the nurse can make for this client?

Correct Answer is C

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Correct Answer is B

Explanation

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