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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

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

These are the correct supplies for the PN to gather because they are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site and secure it with paper tape after removing the saline lock.

C. A three mL syringe is not needed to remove a saline lock and may cause confusion or harm if used incorrectly.

E. Sterile gloves are not needed to remove a saline lock and may be wasteful or unnecessary.

A. Catheterize the client for residual urine volume. B. Evaluate for normal involution, then massage the fundus. C. Measure the next voiding, then palpate the client's bladder. D. Obtain a specimen for urine culture and sensitivity.

Correct Answer is C

Explanation

Correct Answer: C. Measure the next voiding, then palpate the client's bladder.

Choice A rationale:

Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.

Choice B rationale:

Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.

Choice C rationale:

Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.

Choice D rationale:

Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.

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Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is C

Explanation

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