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
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.
Correct Answer is A
Explanation
Choice A reason: Giving the patient extra time to perform activities is an appropriate action by the nurse because it respects the patient's autonomy and dignity, and reduces frustration and anxiety. Bradykinesia is a condition of slow movement that affects people with Parkinson's disease due to decreased dopamine levels in the brain.
Choice B reason: Teaching the client to walk more quickly when ambulating is not an appropriate action by the nurse because it can increase the risk of falls and injuries, and worsen the patient's symptoms. Bradykinesia can impair the patient's balance, coordination, and gait, making it difficult to initiate and maintain movement.
Choice C reason: Placing the client on a low-protein, low-calorie diet is not an appropriate action by the nurse because it can lead to malnutrition, weight loss, and muscle wasting, which can further compromise the patient's health and function. Bradykinesia does not affect the patient's metabolism or nutritional needs.
Choice D reason: Completing passive range-of-motion exercises daily is not an appropriate action by the nurse because it does not address the underlying cause of bradykinesia, which is reduced dopamine production in the brain. Passive range-of-motion exercises are movements performed by another person without the patient's active participation, which can decrease the patient's motivation and self-efficacy.
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