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 C
Explanation
Choice A reason: A negative-pressure isolation room is not appropriate for this client because it is used for clients who have airborne infections that can spread through small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. Scabies is a skin infection that is spread by direct contact with infested skin or clothinG.
Choice B reason: A positive-pressure isolation room is not appropriate for this client because it is used for clients who have compromised immune systems and need protection from environmental contaminants, such as bone marrow transplant recipients, burn victims, or organ transplant recipients. Scabies is not caused by environmental contaminants, but by parasitic mites that burrow under the skin.
Choice C reason: A private room is appropriate for this client because it prevents contact transmission of scabies to other clients or stafF. The client should also have dedicated equipment and linens, and wear gloves and gown when leaving the room. The room should be thoroughly cleaned and disinfected after the client's dischargE.
Choice D reason: A semi-private room with a client who has pediculosis capitis is not appropriate for this client because it increases the risk of cross-contamination between the two clients. Pediculosis capitis is a head lice infestation that can also be spread by direct contact with infested hair or personal items.
Correct Answer is C
Explanation
c) Bilateral lung sounds.
Explanation:
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admited with complications of left-sided heart failure.
The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.
Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of fluid in the lungs.
Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.
Option d) Mood and affect: Assessing the client's mood and affect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.
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