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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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: "I may experience urinary incontinencE." This statement does not indicate the need for additional teaching because it is truE. Urinary incontinence is a common symptom of MS due to nerve damage affecting the bladder control.
Choice B reason: "I should not exercise because this may trigger an exacerbation." This statement indicates the need for additional teaching because it is falsE. Exercise is beneficial for people with MS as it can improve strength, balance, mobility, fatigue, mood, and quality of lifE. Exercise does not cause or worsen MS relapses.
Choice C reason: "I should alternate the eye patch every other day to help with the double vision." This statement indicates the need for additional teaching because it is not recommendeD. Eye patching is not an effective treatment for double vision caused by MS, as it can impair depth perception, increase eye fatigue, and delay recovery. Eye patching should only be used temporarily and under medical supervision.
Choice D reason: "I may experience visual disturbances." This statement does not indicate the need for additional teaching because it is truE. Visual disturbances are common in MS due to inflammation or damage of the optic nerve or other parts of the visual pathway. Visual disturbances can include blurred vision, reduced color vision, pain in the eye, and loss of vision.
Choice E reason: "I need to check the water temperature before I take a batH." This statement does not indicate the need for additional teaching because it is truE. People with MS may have impaired sensation and temperature regulation, which can increase the risk of burns or hypothermia when exposed to hot or cold water. Checking the water temperature before bathing can prevent injury and discomfort.
Correct Answer is B
Explanation
Choice A reason: A black tag is not an appropriate priority tag for this client because it indicates that the client is dead or has injuries that are incompatible with life and survival is unlikely even with treatment.
Choice B reason: A red tag is an appropriate priority tag for this client because it indicates that the client has life-threatening injuries that require immediate attention and treatment to survivE.
Choice C reason: A green tag is not an appropriate priority tag for this client because it indicates that the client has minor injuries that do not require immediate attention and treatment and can wait until the more urgent cases are handleD.
Choice D reason: A yellow tag is not an appropriate priority tag for this client because it indicates that the client has serious injuries that require attention and treatment within a short time, but can wait until the more critical cases are handleD.
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