Chapter 14: Parenteral Nutrition Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition

Multiple Choice

1. The nursing assistive personnel (NAP) reports that a patient receiving parenteral nutrition via a central line is coughing and short of breath. Which action by the nurse is the priority?

a. Clamp the IV tubing.

b. Call for a chest x-ray.

c. Notify the provider.

d. Check a bedside glucose.

ANS: A

This patient has manifestations of an air embolus. The nurse would first clamp the IV tubing to prevent more air from entering the tube. The nurse will notify the provider and perhaps call for a chest x-ray, but the priority is to stop the problem. A bedside glucose is not warranted.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “Your copper and zinc levels may change rapidly.” b. “We will check your protein levels about weekly.” c. “The staff will check your blood glucose frequently at first.” d. “Your white blood cell count can help us assess for infection.”

2. A nursing student is teaching a patient about lab testing that will be done frequently while the patient is on parenteral nutrition. Which statement by the student requires the registered nurse to intervene?

ANS: A

Trace elements such as copper and zinc are usually tested monthly or biannually because they do not fluctuate rapidly. The nurse would intervene to correct the student. The other statements are accurate.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Holding the lipid infusion b. Ensuring osmolality is less than 900 mOsm c. Doubling the insulin concentration d. Cutting the total fluid volume to 1500 mL

3. A patient has been receiving parenteral nutrition (PN) via a central line that has now occluded. The patient also has a midline catheter. What modification of the PN does the nurse ensure prior to switching the PN to the midline catheter?

ANS: B

PN formulations with an osmolality of greater than 900 mOsm should not be infused through midline, peripheral, or midclavicular lines due to the increased risk of phlebitis. Lipids can run through a midline catheter. There is no reason to double the insulin. Peripheral PN is usually delivered in a higher fluid volume than TPN, of about 2000–3000 mL.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Performs fingerstick blood glucose monitoring and records results. b. Reports shortness of breath or headaches right away. c. Turns the alarming IV pump off and calls for the nurse. d. Informs the nurse promptly of any changes in vital signs.

4. The nurse delegates some care activities to nursing assistive personnel (NAP). What action by the NAP requires immediate intervention by the registered nurse?

ANS: C

Adjusting the IV pump in any way is beyond the scope of practice for a NAP, so the nurse would intervene immediately if this happened. The other actions are appropriate.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Weight has increased by 5 pounds (2.26 kg). b. Patient describes correct care of system. c. Exit site is free of redness, tenderness, or drainage. d. Fingerstick glucose readings are out of range only 20% of the time.

5. The nurse is evaluating goals for a patient who has been on home parenteral nutrition for a month. What finding indicates that a priority goal has been met?

ANS: C

Patients on long-term PN are at risk for infections and sepsis. The site being free of signs of infection is a met outcome for a priority goal. The patient describing correct care is also a good outcome but not the priority. Weight should increase by 0.5–1.5 kg or 1–3 pounds each week, so this gain is below standards. Glucose readings ideally stay within range.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Verify patient using two unique identifiers. b. Label each line of the tubing carefully. c. Wipe the end port of the tubing with alcohol. d. Check solution for particulates or discoloration.

6. A patient is receiving parenteral nutrition through a multi-lumen central venous catheter. What intervention is most important related to this patient’s situation?

ANS: B

The line used for PN should not be used for any other purpose. Clearly labeling each line of the tubing helps prevent errors. The other actions are appropriate for any patient on PN.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Notify the provider and request sliding scale insulin. b. Inform the patient’s nurse about the need for an insulin drip. c. Asks the pharmacy to dilute the glucose concentration. d. Determine if the nurse drawing the blood follow protocol.

7. The lab calls the charge nurse and reports a blood glucose reading of 220 mg/dL for a patient on parenteral nutrition via a central line. What action does the charge nurse take first?

ANS: D

If the blood was drawn while the PN was infusing, or if the nurse who drew the blood did not follow the proper procedure (such as discarding the first syringe of blood), glucose readings can be artificially high. The charge nurse would first verify the process the nurse used before contacting the provider. The patient does not need an insulin drip for a glucose of 220. The charge nurse does not ask the pharmacy to dilute the glucose concentration; rather he or she anticipates sliding scale insulin being ordered. However, before requesting the insulin, the charge nurse ensures the reading is accurate.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. 80-year-old on dialysis b. 18-year-old with anorexia nervosa c. 75-year-old with a bowel obstruction d. 35-year-old undergoing chemotherapy

8. A provider has listed orders for Peripheral Parenteral Nutrition with lipids for four patients. Which patient will the nurse clarify the orders about?

ANS: A

PPN is delivered in high fluid volumes, so patients with cardiac or renal problems may not be able to tolerate it. The nurse should verify the orders for the older patient on dialysis. The other patients are appropriate candidates.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Checks the bag label with the medication record at the bedside. b. Reviews the chart to determine if the order has been entered in the system. c. Verifies that the bag of TPN is the same that is on the medication record. d. Reviews information on bag of TPN with pharmacist when delivered.

9. A faculty member is evaluating the student’s performance when hanging a bag of Total Parenteral Nutrition. Which step indicates the student has completed the third check for accuracy?

ANS: A

The third and final check for medication accuracy includes checking the bag label with the medication record and identifying the patient at the bedside.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Refer the patient to a home nutrition therapy team. b. Order three months’ worth of supplies for the patient. c. Assess the patient’s psychological response to the therapy. d. Determine if any family members are willing to help.

10. A nurse is preparing to discharge a patient who is going home on Total Peripheral Nutrition (TPN). What action by the nurse is most helpful in ensuring positive outcomes for the patient?

ANS: A

Patients on home TPN benefit greatly from the services provided by a home nutrition therapy team. Three months’ worth of supplies may be too much and might end up being wasteful. Assessing the patient’s psychological response to therapy is important, but not as important as ensuring the patient has a nutrition team for support. Family members may or may not be willing to help, but the patient may not need their assistance.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

Multiple Response

1. The faculty member describes conditions that indicate a need for parenteral nutrition to nursing students. Which conditions does the faculty member include? (Select all that apply.)

a. Abdominal trauma b. Severe pancreatitis c. Short-term bowel rest d. Poor appetite with malnutrition e. Serious malabsorption

ANS: A, B, E

Some indications for parenteral nutrition (PN) include abdominal trauma, severe pancreatitis, and severe malabsorption. Parenteral nutrition is not used for short-term support (less than 14 days). Nurses should collaborate with the patient, family, and interdisciplinary team to promote the patient’s appetite and eating before turning to PN.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Integrated Process: Teaching-Learning