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.
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Related Questions
Correct Answer is C
Explanation
This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.
A. Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.
B. Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.
D. Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.
Correct Answer is A,B,D,C
Explanation
= The correct sequence is: A. Perform standard hand washing, B. Put on disposable gown, D. Don a pair of procedure gloves, C. Remove gloves and gown in the room.
Choice A rationale:
Performing standard hand washing before donning personal protective equipment (PPE) is essential to ensure that the UAP's hands are clean before putting on gloves and gown.
Choice B rationale:
Putting on a disposable gown is the next step after hand washing to protect the UAP's clothing from potential contamination.
Choice D rationale:
Donning a pair of procedure gloves is the next step after putting on the gown to protect the UAP's hands from contact with potentially infectious material.
Choice C rationale:
Removing gloves and gown in the client's room is the last step in the sequence. This step ensures that any potential contaminants stay within the isolation room and do not spread to other areas of the facility.
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