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This question focuses on identifying appropriate interventions for a client receiving total parenteral nutrition (TPN) who develops complications after restarting therapy. The client initially experienced interruption of TPN and then developed signs of fluid volume excess after TPN and maintenance fluids were resumed, including dyspnea, crackles, jugular venous distention, hypertension, tachycardia, hypoxia, and rapid weight gain. The client also developed hypokalemia, likely related to metabolic shifts associated with TPN administration and increased insulin activity. Nursing priorities include correcting electrolyte abnormalities, managing fluid overload, supporting oxygenation, and avoiding medications that may worsen the client’s condition.

Rationale:

• Calcium gluconate 1 gram IV bolus x 1 dose: Calcium gluconate is commonly used to stabilize cardiac membranes during severe hyperkalemia or to treat symptomatic hypocalcemia. This client’s calcium level is already within the normal range at 10.3 mg/dL, and there is no evidence of hypocalcemia requiring replacement. Unnecessary calcium administration may contribute to hypercalcemia and complications such as cardiac abnormalities or tissue calcification. Therefore, calcium gluconate is not appropriate for this client’s current electrolyte imbalance.

• Metformin 500 mg PO twice daily: Metformin is an oral antihyperglycemic medication that is not appropriate in this acute situation. The client’s blood glucose levels are within acceptable limits, and there is no indication of type 2 diabetes requiring treatment. Additionally, clients experiencing acute illness, hypoxia, or possible renal dysfunction are at increased risk for metformin-associated lactic acidosis. The client requires management of fluid overload and electrolyte abnormalities rather than initiation of glucose-lowering therapy.

Bumetanide 0.5 mg/hr IV infusion: Bumetanide is a loop diuretic used to treat fluid volume excess by promoting renal excretion of sodium and water. This client demonstrates multiple signs of fluid overload, including new bilateral 2+ pitting edema, crackles, jugular venous distention, increased blood pressure, increased weight, and decreased oxygen saturation. Removing excess fluid will reduce pulmonary congestion and improve respiratory status. IV administration provides a rapid therapeutic effect in acute fluid overload situations.

• Oxygen at 2 L/min via simple face mask: Oxygen therapy is appropriate because the client has developed respiratory compromise related to fluid accumulation in the lungs. The oxygen saturation has decreased from 99% to 92%, with tachypnea, dyspnea, and crackles indicating impaired gas exchange. Supplemental oxygen increases the amount of available oxygen for tissues and helps support breathing while the underlying fluid overload is treated. Continuous monitoring of oxygen saturation and respiratory status is necessary.

• Potassium 20 mEq intermittent IV bolus x 1 dose: Potassium replacement is indicated because the client’s potassium level has decreased to 2.8 mEq/L, which represents significant hypokalemia. Low potassium levels increase the risk of cardiac dysrhythmias, muscle weakness, and impaired cardiac conduction. TPN-related insulin shifts can drive potassium into cells, contributing to decreased serum potassium levels. IV potassium replacement should be administered carefully with monitoring because rapid infusion can cause dangerous cardiac effects.

• Labetalol 10 mg IV bolus x 1 dose: Labetalol is a combined alpha- and beta-adrenergic blocker used to reduce elevated blood pressure and decrease cardiac workload. The client’s blood pressure has increased to 160/98 mm Hg, accompanied by tachycardia at 124/min, likely related to fluid overload and increased sympathetic activity. Controlling hypertension reduces strain on the heart and helps prevent complications such as worsening heart failure. IV labetalol provides rapid blood pressure control in acute care settings.

• Midodrine 10 mg PO every 8 hrs: Midodrine is an alpha-adrenergic agonist used to treat hypotension by causing peripheral vasoconstriction and increasing blood pressure. This client already has hypertension with a blood pressure of 160/98 mm Hg and evidence of fluid overload. Administering midodrine could further increase vascular resistance and worsen hypertension. Therefore, it is inappropriate for a client requiring blood pressure reduction rather than elevation.

This question focuses on identifying medication-related adverse effects in a postoperative client receiving multiple medications. The client is recovering after a left knee replacement and is receiving hydrochlorothiazide, insulin glargine, and ketorolac. The client’s blood pressure has decreased from 121/80 mm Hg to 92/75 mm Hg after receiving medications, making hypotension a concern. Understanding the adverse effects and monitoring requirements of common medications allows the nurse to identify potential complications early and implement appropriate interventions.

Rationale for correct choices:

• Hypotension: The client is at risk for hypotension because hydrochlorothiazide, a thiazide diuretic, promotes sodium and water excretion through the kidneys. Excessive fluid loss can reduce circulating blood volume, resulting in decreased blood pressure, dizziness, and orthostatic hypotension. This client’s blood pressure has already decreased to 92/75 mm Hg compared with the previous reading of 121/80 mm Hg, suggesting possible volume depletion. Postoperative clients are particularly vulnerable to fluid shifts, making blood pressure monitoring essential.

• A thiazide diuretic: Hydrochlorothiazide is a thiazide diuretic commonly prescribed for hypertension and works by inhibiting sodium reabsorption in the distal convoluted tubules, increasing urinary excretion of sodium and water. This mechanism can cause adverse effects such as dehydration, hypotension, electrolyte disturbances, and dizziness. In this client, the medication may contribute to the reduced blood pressure observed after administration. The nurse should monitor blood pressure, fluid balance, and electrolyte levels while the client receives this medication.

Rationale for incorrect choices:

• Hypoglycemia: Although hypoglycemia is a possible adverse effect of insulin glargine administration, this client’s current glucose level is 118 mg/dL, which does not indicate low blood sugar. Insulin glargine provides long-acting glucose control and may cause hypoglycemia if the dose exceeds the client’s insulin requirements or if food intake is inadequate. However, the client is eating breakfast and has a normal glucose reading at this time. Therefore, hypoglycemia is not the priority medication-related risk identified in this scenario.

• Gastritis: Gastritis is a potential adverse effect of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac, because these medications inhibit prostaglandin production, reducing gastric mucosal protection. However, the client does not currently demonstrate signs of gastrointestinal irritation, such as abdominal pain, nausea, vomiting, or gastrointestinal bleeding. While the nurse should monitor for NSAID-related complications, the immediate concern based on the client’s decreased blood pressure is hypotension rather than gastritis.

• Insulin; Insulin glargine can cause hypoglycemia by increasing glucose uptake into cells and lowering blood glucose levels. However, the client’s glucose level is elevated at 118 mg/dL and there are no signs of hypoglycemia such as sweating, tremors, confusion, or weakness. The insulin dose was appropriately administered for diabetes management and is not the medication most associated with the current change in vital signs. Therefore, insulin is not the priority medication contributing to the client’s present risk.

• A nonsteroidal anti-inflammatory drug: Ketorolac is an NSAID used for short-term management of moderate to severe pain and can cause adverse effects including gastritis, gastrointestinal bleeding, renal impairment, and fluid retention. However, the client’s current assessment does not show evidence of these complications. Although ketorolac requires monitoring, the client’s decreased blood pressure is more closely associated with fluid loss from hydrochlorothiazide.

This question focuses on identifying potential adverse effects associated with bupropion therapy, a medication commonly prescribed for smoking cessation and depression management. Bupropion works by inhibiting the reuptake of norepinephrine and dopamine, reducing nicotine cravings and withdrawal symptoms. However, because of its effects on neurotransmitter activity and appetite regulation, it can cause neuropsychiatric effects and changes in weight. The client’s history of bipolar disorder and anorexia nervosa requires careful monitoring because bupropion may increase the risk of mood changes and appetite suppression.

Rationale for correct choices:

• Hallucinations: The client is at risk for hallucinations due to bupropion’s effects on the central nervous system and increased dopaminergic activity. Bupropion enhances norepinephrine and dopamine neurotransmission, which can rarely contribute to neuropsychiatric effects such as agitation, confusion, psychosis, or hallucinations. This risk is especially important in clients with a history of bipolar disorder because antidepressants can potentially trigger mood destabilization, including manic or psychotic symptoms. The nurse should monitor for changes in behavior, altered perception, severe mood changes, or signs of mania.

• Weight loss: The client is at risk for weight loss because bupropion can suppress appetite and is associated with decreased food intake in some individuals. This is particularly concerning because the client has a history of anorexia nervosa, a disorder characterized by restrictive eating patterns and unhealthy weight loss behaviors. The nurse should monitor the client’s weight, nutritional intake, and eating behaviors throughout treatment. Significant weight loss or recurrence of restrictive behaviors should be reported to the healthcare provider.

Rationale for incorrect choices:

• Sexual dysfunction: Sexual dysfunction is not a common adverse effect of bupropion. Unlike many selective serotonin reuptake inhibitors (SSRIs), which can cause decreased libido, delayed ejaculation, and difficulty achieving orgasm due to serotonin-related effects, bupropion generally has minimal sexual side effects and may improve sexual functioning in some clients. Therefore, sexual dysfunction is not an expected priority risk associated with this medication.

• Dependence: Bupropion does not cause physical dependence or addiction because it does not stimulate nicotine receptors or produce reinforcing effects similar to nicotine or controlled substances. Although the client previously experienced nicotine withdrawal after stopping smoking abruptly, this withdrawal is related to nicotine dependence rather than bupropion therapy. Bupropion is used specifically to reduce nicotine cravings and support smoking cessation without creating a substitute dependence.

• Somnolence: Somnolence is not a common adverse effect of bupropion because the medication is generally considered activating due to increased norepinephrine and dopamine activity. More commonly, clients experience insomnia, restlessness, anxiety, or agitation. Because of its stimulating effects, bupropion is usually prescribed in the morning and earlier in the day to reduce sleep disturbances. Therefore, excessive drowsiness is not an anticipated risk.

• Hypotension: Hypotension is not a typical adverse effect of bupropion. This medication may occasionally cause changes in blood pressure, including hypertension, especially in clients using nicotine replacement therapy concurrently. The client’s blood pressure readings are within an acceptable range, and there is no evidence of decreased blood pressure requiring concern. Therefore, hypotension is not an expected complication of bupropion therapy.