a client is receiving total parenteral nutrition tpn which of these interventions should the nurse perform to reduce the risk of infection
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HESI RN

HESI Nutrition Practice Exam

1. A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?

Correct answer: A

Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.

2. A client is receiving treatment for hypothyroidism. Which of these assessments would be most concerning to the nurse?

Correct answer: B

Rationale: A blood pressure of 110/70 mm Hg would be most concerning to the nurse because changes in blood pressure can indicate worsening hypothyroidism, potentially leading to complications such as myxedema coma. A heart rate of 70 beats per minute, a respiratory rate of 16 breaths per minute, and a temperature of 98.6 degrees Fahrenheit are within normal ranges and not typically directly associated with hypothyroidism complications.

3. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

Correct answer: C

Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.

4. A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client?

Correct answer: B

Rationale: Prompt reporting of peptic ulcers is crucial in managing Zollinger-Ellison syndrome to prevent complications and guide treatment. While choices A, C, and D provide relevant information about the condition and its treatment, the most important aspect in the client's care is the prompt reporting of peptic ulcers. This is because untreated peptic ulcers in Zollinger-Ellison syndrome can lead to serious complications such as gastrointestinal bleeding or perforation. Therefore, ensuring timely communication with the healthcare provider is essential for effective management of the condition.

5. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

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