NCLEX-PN

dimensions. B focuses on Biochemical Data, examining laboratory test results such as serum albumin, hemoglobin, urinary creatinine, and serum transferrin levels to gain insights into the individual's biochemical status. C involves Clinical Data, where healthcare professionals observe the client's physical condition, skin health, activity level, and mucous membrane status for signs of nutritional deficiencies or imbalances. Finally, D stands for Dietary Data, where clients provide information about their food and fluid intake over the last 24 hours, dietary preferences, and typical dietary choices. The incorrect options include additional elements that are not traditionally part of a nutritional assessment, highlighting the importance of understanding and applying the A, B, C, and D components for a thorough nutritional evaluation. (See Assessing the Client's Eating Ability and Nutritional Status ) 22. Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their “chest hurts.” You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?

A.​ Your client may be experiencing a fluid overload B.​ Your client may be experiencing an embolus C.​ Your client may be hyperglycemic D.​ Your client may have an inadvertent pneumothorax Correct Response: B

Explanation : The correct answer is (B) . If a client receiving total parenteral nutrition for bowel rest reports chest pain and experiences dyspnea, the most likely occurrence is an embolus, as explained in (B). This complication can arise when air enters the closed system during tubing changes or when connecting a new container of hyperalimentation. Symptoms associated with an embolus, including chest pain, difficulty breathing (dyspnea), shortness of breath, coughing, and respiratory distress, are indicative of a potential issue in the circulatory system. Prevention measures, such as instructing clients to perform the Valsalva maneuver during tubing changes and ensuring rapid changes in tubings and solutions to minimize air exposure, are essential to mitigate this risk. While fluid overload (A) and hyperglycemia (C) are potential complications of total parenteral nutrition, they typically present with different symptoms. Additionally, an inadvertent pneumothorax (D) , involving air trapped in the chest cavity, may occur during catheter insertion and is more likely to manifest immediately rather than after four days of TPN administration. In summary, recognizing the signs of an embolus and understanding preventive measures are crucial components of care for clients receiving total parenteral nutrition. (See Evaluating the Client's Response to Intermittent Parenteral Fluid Therapy ) 23. Which of the following are included in the Rights of Medication Administration? Select all that apply.

A. right dose ​ B. right time ​

C. right explanation ​ D. right client ​ E. right route

A.​ B, C, D, E B.​ B, C, E C.​ A, B, D D.​ A, B, D, E

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