Elsiver NCLEX Critical Care Latest 301Questions and
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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. - CORRECT ANSWERS
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.
,Elsiver NCLEX Critical Care Latest 301Questions and
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3.
Exhale slowly and evenly.
4.
Take a deep breath, hold it, and bear down. - CORRECT ANSWERS 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 - CORRECT ANSWERS
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.
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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. - CORRECT ANSWERS 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.
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Weakness, thirst, and increased urine output - CORRECT ANSWERS
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 - CORRECT ANSWERS 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?
