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
a) Collect fingerstick glucose levels. Correct
Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or fluctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.
b) Implement bleeding precautions.
Implementing bleeding precautions is not the most important intervention for the PN to implement for a client who is receiving TPN. Bleeding precautions are measures to prevent or minimize bleeding in clients who have a high risk of hemorrhage due to conditions such as thrombocytopenia, coagulopathy, or anticoagulant therapy. TPN does not directly increase the risk of bleeding, although it may affect the liver function and clotting factors in some cases². Therefore, bleeding precautions are not a priority for a client who is receiving TPN.
c) Obtain daily weights.
Obtaining daily weights is not the most important intervention for the PN to implement for a client who is receiving TPN. Obtaining daily weights is a way to monitor the client's fluid balance, nutritional status, and response to therapy. TPN can cause fluid overload, dehydration, or electrolyte imbalances in some cases²⁵. Therefore, obtaining daily weights is important, but not as important as monitoring glucose levels.
d) Check urine for albumin.
Checking urine for albumin is not the most important intervention for the PN to implement for a client who is receiving TPN. Checking urine for albumin is a way to detect proteinuria, which is an indicator of kidney damage or disease. TPN does not directly cause kidney problems, although it may affect the renal function and urine output in some cases². Therefore, checking urine for albumin is not a priority for a client who is receiving TPN.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
- The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
- The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.
Option A is incorrect because the client’s comfort level may not reflect the optimal temperature for the
enema.
Option B is incorrect because the temperature of the enema does affect its effectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.
Correct Answer is B
Explanation
Choice A reason: Limiting fluid intake to prevent incontinence is not the highest priority intervention for this client because it can cause dehydration, urinary tract infections, or kidney stones, which can worsen the client's condition and quality of lifE. The client should be encouraged to drink adequate fluids and empty their bladder regularly.
Choice B reason: Providing regular perineal care to prevent skin breakdown is the highest priority intervention for this client because it can prevent infection, irritation, and ulceration of the skin around the genital and anal areas, which can cause pain, discomfort, and complications. The client should be kept clean and dry, and use barrier creams or pads as needeD.
Choice C reason: Administering hypotonic IV fluids is not an intervention for this client because it can cause fluid overload, hyponatremia, or cerebral edema, which can endanger the client's health and safety. The client does not need IV fluids unless they are dehydrated or have other indications.
Choice D reason: Teaching Kegel exercises to strengthen the pelvic floor is not an intervention for this client because it can be ineffective or harmful for clients with reflex incontinence, which is caused by loss of voluntary control over bladder contractions due to spinal cord injury. The client may benefit from other interventions such as bladder training, medication, or surgery.
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