The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?- Nurselytic

Question 1 of 5

The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?

A. Blood glucose level of 200 mg/dL B. The client reports feeling weak and shaky C. The TPN bag is 5% dextrose D. The client reports feeling thirsty

Correct Answer: B

Rationale: Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed.

Question 2 of 5

A 48 year-old client with chronic alcoholism is admitted to the hospital. The nurse would anticipate that the client may be deficient in which vitamins?

A. Vitamin B and vitamin C B. Vitamin D and vitamin E C. Vitamin K and vitamin A D. Vitamin A and vitamin E

Correct Answer: A

Rationale: Chronic alcoholism commonly leads to deficiencies in B vitamins, particularly thiamine, and vitamin C.

Question 3 of 5

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?

A. Encourage the client to increase fluid intake B. Document the absence of reaction C. Notify the nurse if the client develops a fever D. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete

Correct Answer: D

Rationale: Monitoring vital signs throughout a transfusion is critical, as reactions can occur later in the process. The UAP should continue to check vital signs regularly to ensure that any delayed reaction is promptly detected.

Question 4 of 5

A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?

A. Administer a potassium supplement B. Encourage the client to eat potassium-rich foods C. Hold the next dose of furosemide D. Increase the client's fluid intake

Correct Answer: A

Rationale: A potassium level of 3.1 mEq/L is considered low. Administering a potassium supplement is the priority action to prevent complications such as cardiac arrhythmias, which can occur with hypokalemia.

Question 5 of 5

An older client with SIRS has a temperature of 101.8°F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?

A. Serum creatinine of 2.0 mg/dL B. Elevated WBC count C. Blood pressure of 100/60 mmHg D. Oxygen saturation of 95%

Correct Answer: A

Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage.

Nurselytic

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HESI RN

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