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
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart attack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
B. The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
C. The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
D. The lab results do not indicate risk factors for transient ischemic attack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Correct Answer is A
Explanation
This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about the fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will affect the client's elimination and body image.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today