NCLEX Review - Fundamentals of Nursing 7th edition (46-50)

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46. A client is receiving nutrition by means of parenteral nutrition (PN). A nurse monitors the client for complications of  the therapy and assesses the client for which of the following signs of hyperglycemia?

a) fever, weak pulse, and thirst
b) nausea, vomiting, and oliguria
c) sweating, chills, and abdominal pain
d) weakness, thirst, and increased urine output


47. At 8 am, a nurse checks the amount of solution left in a parenteral nutrition (PN) infusion bag for an assigned client. It is a 3000 ml bag with 1000 ml remaining. The solution is running at a rate of 100 ml/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at:

a) noon
b) 2 pm
c) 4 pm
d) 8 pm

48. A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items?

a) client's temperature
b) expiration date on the bag
c) time of last dressing change
d) tightness of tubing connections

49. A nurse is preparing to hang fat emulsion (lipids) and notes that the fat globules are visible at the top of the solution. The nurse takes which of the following actions?

a) rolls the bottle of solution gently
b) obtains a different bottle of solution
c) shakes the bottle of solution vigorously
d) runs the bottle of solution under warm water

50. A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which most essential action during the tubing change?

a) breathe normally
b) turn the head to the right
c) exhale slowly and evenly
d) take a deep breath, hold it, and bear down





Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

46) D

- The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul’s respirations, diuresis, and coma, when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately. Options A, B, and C do not identify signs specific to hyperglycemia.

47) A

- Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend changing tubing every 48 to 72 hours. The nurse always should adhere to specific agency policies. Options B, C, and D identify insufficient time frames and present the risk for infection.

48) A

- Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.

49) B

The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Options A, C, and D are inappropriate actions.

50) D

- The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client turns his or her head to the left. This position will increase intrathoracic pressure. Options A and C are inappropriate and could cause the potential for an air embolism during the tubing change.



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Fundamentals of Nursing 7th edition (1-5)

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Fundamentals of Nursing 7th edition (51-55)