Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?
Collect fingerstick glucose levels
Implement bleeding precautions.
Obtain daily weights
Check urine for albumin
The Correct Answer is A
The correct answer is Choice A:
Collect fingerstick glucose levels.
Choice A rationale:
When a client is receiving total parenteral nutrition (TPN), it means they are receiving nutrients directly into the bloodstream, bypassing the digestive system. TPN often contains high levels of glucose, which can lead to hyperglycemia. Regular monitoring of blood glucose levels are crucial to detect and manage hyperglycemia effectively, especially in clients at risk for diabetes or those with impaired glucose metabolism.
Choice B rationale:
Implementing bleeding precautions (Choice B) is important for clients on anticoagulant therapy or with bleeding disorders. However, it is not the most important intervention for a client receiving TPN. Monitoring glucose levels takes precedence in this case.
Choice C rationale:
Obtaining daily weights is an important intervention to assess fluid balance and nutritional status in clients receiving TPN. However, it is not the most critical intervention compared to monitoring glucose levels to prevent complications of hyperglycemia.
Choice D rationale:
Checking urine for albumin is important in assessing kidney function and detecting proteinuria. While it is a valid nursing intervention, it is not the most important consideration for a client on TPN. Monitoring glucose levels is of higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B rationale:
The semi-Fowler's position involves elevating the head of the bed to 30-45 degrees, which is useful for clients with respiratory issues to promote lung expansion. However, for auscultation of the posterior lung fields in a client with left lower lobe pneumonia, the lateral, semi-prone position is more appropriate as it allows better access to the specific area of concern.
Choice C rationale:
Placing the client on the right side-lying position may not be as effective for auscultating the left lower lobe, as the target area is located on the opposite side. The lateral, semi-prone position offers better access to the left lower lobe for assessment.
Choice D rationale:
The forward orthopneic position is a sitting position with the arms supported on a table or over the bed. While this position can assist clients with breathing difficulties, it is not suitable for auscultation of the posterior lung fields. The lateral, semi-prone position is moreappropriate for this purpose.
Correct Answer is D
Explanation
The correct answer is choice D. Electrolytes.
Choice A rationale:
White blood cell count (WBC) is primarily used to detect infections, inflammation, and immune system disorders.While an abnormal WBC count can indicate various health issues, it is not directly related to numbness and tingling in the extremities.
Choice B rationale:
Hematocrit measures the proportion of red blood cells in the blood. It is useful for diagnosing anemia and other blood disorders.However, hematocrit levels are not typically associated with symptoms of numbness and tingling.
Choice C rationale:
Albumin and protein levels are important for assessing nutritional status and liver function.Low levels can indicate malnutrition or liver disease, but they are not directly linked to the sensation of numbness and tingling in the extremities.
Choice D rationale:
Electrolytes, such as sodium, potassium, calcium, and magnesium, play a crucial role in nerve function and muscle contraction. Imbalances in electrolyte levels can lead to symptoms like numbness, tingling, and muscle cramps.Therefore, reviewing the client’s electrolyte levels is essential when they report these symptoms.
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