Exam (elaborations)

Saunders NCLEX Critical Care

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Saunders NCLEX Critical Care

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Saunders NCLEX Critical Care

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1. Discontinue the PN. 2. D...

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Saunders NCLEX Critical Care

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today.
The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription
regarding the PN solution will accompany the diet prescription?

1.

Discontinue the PN.

2.

Decrease PN rate to 50 mL/hour.

3.

Start 0.9% normal saline at 25 mL/hour.

4.

Continue current infusion rate prescriptions for PN. - Decrease PN rate to 50 mL/hour.

When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually.
PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being
without food for some time, and the digestive tract also is not used to producing the digestive enzymes
that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately
nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even
before clients are started on a solid diet, they are given clear liquids followed by full liquids to further
ease the transition. A solution of normal saline does not provide the glucose needed during the
transition of discontinuing the PN and could cause the client to experience hypoglycemia.

The nurse is preparing to change the parenteral nutrition (PN) 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
essential action during the tubing change?

1.

Breathe normally.

,2.

Turn the head to the right.

3.

Exhale slowly and evenly.

4.

Take a deep breath, hold it, and bear down. - Take a deep breath, hold it, and bear down.

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 intravenous line is on the right, the client turns his or her head to the left. This position
increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate
and could enhance the potential for an air embolism during the tubing change.

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line
catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately
place the client in which position?

1.

On the left side, with the head lower than the feet

2.

On the left side, with the head higher than the feet

3.

On the right side, with the head lower than the feet

4.

On the right side, with the head higher than the feet - On the left side, with the head lower than the
feet

Air embolism occurs when air enters the catheter system, such as when the system is opened for
intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if
it is suspected, the client should be placed in a left side-lying position. The head should be lower than
the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by

,trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air
embolism is suspected.

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids)
to infuse at 50 mL/hour?

1.

Ensure that the client does not have diabetes.

2.

Determine whether the client has an allergy to eggs.

3.

Add regular insulin to the fat emulsion, using aseptic technique.

4.

Contact the health care provider (HCP) to have a central line inserted for fat emulsion infusion. -
Determine whether the client has an allergy to eggs.

The client beginning infusions of fat emulsions must be first assessed for known allergies to eggs to
prevent anaphylaxis. Egg yolk is a component of the solution and provides emulsification. The remaining
options are unnecessary and are not related specifically to the administration of fat emulsion.

The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and
should assess the client for which manifestations of hyperglycemia?

1.

Fever, weak pulse, and thirst

2.

Nausea, vomiting, and oliguria

3.

Sweating, chills, and abdominal pain

4.

, Weakness, thirst, and increased urine output - Weakness, thirst, and increased urine output

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

The 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 should next assess which item?

1.

Client's temperature

2.

Expiration date on the bag

3.

Time of last dressing change

4.

Tightness of tubing connections - Client's temperature

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.

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of
the solution. The nurse should take which action?

1.

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