a nurse is caring for a client who is receiving total parenteral nutrition tpn which of the following findings should the nurse identify as a possible

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?

A. Pitting edema of bilateral lower extremities
B. Hypoactive bowel sounds in all four quadrants
C. Weight is the same as the day before
D. Bilateral posterior lung sounds are diminished

Correct answer: A

Rationale: The correct answer is A: Pitting edema of bilateral lower extremities. Pitting edema can indicate fluid overload, which is a potential complication of TPN administration. Choice B, hypoactive bowel sounds, is more indicative of a gastrointestinal issue rather than a complication of TPN. Choice C, weight remaining the same, is expected to remain stable with proper TPN administration. Choice D, diminished lung sounds, is not directly related to TPN administration and is more suggestive of a respiratory issue.

2. What is a typical symptom of a hemorrhagic stroke in a patient?

A. Sudden, severe headache
B. Gradual onset of numbness
C. Loss of consciousness
D. Loss of speech ability

Correct answer: A

Rationale: A sudden, severe headache is a common symptom of a hemorrhagic stroke due to brain bleeding. This headache is often described as the worst headache of one's life. Gradual onset of numbness (choice B) is more characteristic of an ischemic stroke, where a blood clot blocks an artery in the brain. Loss of consciousness (choice C) can occur in severe cases of stroke but is not specific to hemorrhagic strokes. Loss of speech ability (choice D) is more associated with ischemic strokes affecting language centers of the brain.

3. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?

A. Urine specific gravity 1.020
B. Sodium 119 mEq/L
C. BUN 8 mg/dL
D. Calcium 8.7 mg/dL

Correct answer: A

Rationale: A urine specific gravity of 1.020 is within the expected reference range and indicates that the kidneys are appropriately concentrating urine, which is a sign that the syndrome of inappropriate antidiuretic hormone (SIADH) is resolving. A low sodium level (choice B) is associated with SIADH, so a sodium level of 119 mEq/L is not indicative of resolution. BUN (choice C) and calcium levels (choice D) are typically not directly related to SIADH resolution.

4. What ECG changes are seen in hypokalemia?

A. Flattened T waves on the ECG
B. Elevated ST segments on the ECG
C. Widened QRS complex
D. Prominent U waves on the ECG

Correct answer: A

Rationale: The correct answer is A: Flattened T waves on the ECG. Flattened T waves are an early indicator of hypokalemia on an ECG. Choice B, Elevated ST segments, is not typically seen in hypokalemia but can be a sign of myocardial infarction. Choice C, Widened QRS complex, is more commonly associated with hyperkalemia. Choice D, Prominent U waves, is typically associated with hypokalemia, but flattened T waves are considered a more specific and early sign.

5. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

A. Tighten the connections of the chest tube system
B. Replace the chest tube system
C. Clamp the chest tube
D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.