AH I Test 3: NCLEX: Lower GI Problems- ileostomy, Total Parenteral Nutrition

Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TPN administered through a central line? 1. Use a clean technique for all dressing changes. 2. Tape all connections of the system. 3. Encourage bed rest. 4. Cover the insertion site with a moisture-proof dressing.

2. Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system are taped. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.

The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution: 1. Provides essential fatty acids. 2. Provides extra carbohydrates. 3. Promotes effective metabolism of glucose. 4. Maintains a normal body weight.

1. The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.

TPN is ordered for a client with Crohn's disease. Which of the following indicate the TPN soloution is having an intended outcome? 1. There is increased cell nutrition. 2. The client does not have metabolic acidosis. 3. The client is hydrated. 4. The client is in a negative nitrogen balance.

1. The goal of TPN is to meet the client's nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen balance.

Using a sliding-scale schedule, the nurse is preparing to administer an evening dose of regular insulin to a client who is receiving total parenteral nutrition (TPN). Which action is most appropriate for the nurse to take to determine the amount of insulin to give? 1. Base the dosage on the glucometer reading of the client's glucose level obtained immediately before administering the insulin. 2. Base the dosage on the fasting blood glucose level obtained earlier in the day. 3. Calculate the amount of TPN fluid the client has received since the last dose of insulin and adjust the dosage accordingly. 4. Assess the client's dietary intake for the evening meal and snack and adjust the dosage accordingly.

1. When using a sliding-scale insulin schedule, the nurse obtains a glucometer reading of the client's blood glucose level immediately before giving the insulin and bases the dosage on those findings. The fasting blood glucose level obtained earlier in the day is not relevant to an evening sliding-scale insulin dosage. The nurse cannot calculate insulin dosage by assessing the amount of TPN intake or dietary intake.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: 1. An isotonic dextrose solution. 2. A hypertonic dextrose solution. 3. A hypotonic dextrose solution. 4. A colloidal dextrose solution.

2. The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.

The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which of the following would be the best response for the nurse? 1. "Many women with ileostomies decide to adopt. Why don't you consider that option?" 2. "Having an ileostomy does not necessarily mean that you can't bear children. Let's talk about your concerns." 3. "I can understand your reasons for being upset. Having children must be important to you." 4. "I'm sure you will adjust to this situation with time. Try not to be too upset."

2. The fact that the client has an ileostomy does not necessarily mean that she cannot get pregnant and bear children. It may be recommended, however, that the number of pregnancies be limited. Women of childbearing age should be encouraged to discuss their concerns with their physician. Discussing their concerns about sexual functioning and pregnancy will help decrease fears and anxiety. Empathizing or telling the woman that she can adopt does not address her concerns. Her current fears may be based on erroneous understanding. Telling the client that she will adjust to the situation ignores her concerns.

Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution? 1. Negative nitrogen balance. 2. Circulatory overload. 3. Hypoglycemia. 4. Hypokalemia.

2. Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last? 1. Change dressing per institutional policy. 2. Culture drainage at insertion site. 3. Notify physician. 4. Position rolled towel under client's back, parallel to the spine.

3, 4, 2, 1. A potential complication of receiving TPN is leakage or catheter puncture; notify the physician immediately and prepare for changing of the catheter. If pneumothorax is suspected, position a rolled towel under the client's back. If there is drainage at the insertion site, culture the drainage and change the dressing using sterile technique.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? 1. Have the client talk with a member of the clergy about these concerns. 2. Tell the client to worry about those concerns after surgery. 3. Arrange for a person with an ostomy to visit the client preoperatively. 4. Notify the surgeon of the client's question.

3. If the client agrees, having a visit by a person who has successfully adjusted to living with an ileostomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued postoperatively. Someone who has felt some of the same concerns can answer the client's questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client's concerns is not helpful. Although the physician should know about the client's concerns, this in itself will not reassure the client about life after an ileostomy.

The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately? 1. Passage of liquid stool from the stoma. 2. Occasional presence of undigested food in the effluent. 3. Absence of drainage from the ileostomy for 6 or more hours. 4. Temperature of 99.8 ° F (37.7 ° C).

3. Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the physician immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8 ° F is not necessarily abnormal or a cause for concern.

Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when: 1. There is no odor from the stoma. 2. The client is adequately hydrated. 3. There is no skin irritation around the stoma. 4. The client only changes the ostomy pouch once a day.

3. Because of high concentrations of digestive enzymes, ileostomy effluent is irritating to skin and can cause excoriation and ulceration. Some form of protection must be used to keep the effluent from contacting the skin. A skin barrier does not decrease odor formation; odor is controlled by diet. The barrier does not affect the client's hydration status, and the nurse can encourage the client to have an adequate daily intake of fluids. Pouches are usually worn for 4 to 7 days before being changed.

The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first? 1. Clean the insertion site and redress the area. 2. Document assessment findings in the client's chart. 3. Obtain a culture specimen of the drainage. 4. Notify the physician.

3. The nurse should first obtain a culture specimen. The presence of drainage is a potential indication of an infection and the catheter may need to be removed. A culture specimen should be obtained and sent for analysis so that treatment can be promptly initiated. Since removing the catheter will be required in the presence of an infection, the nurse would not clean and redress the area. After the culture report is obtained, the nurse should notify the physician and document all assessments and client care activities in the client's record.

The nurse evaluates the client's understanding of ileostomy care. Which of the following statements indicates that discharge teaching has been effective? 1. "I should be able to resume weight lifting in 2 weeks." 2. "I can return to work in 2 weeks." 3. "I need to drink at least 3,000 mL a day of fluid." 4. "I will need to avoid getting my stoma wet while bathing."

3. To maintain an adequate fluid balance, the client needs to drink at least 3,000 mL/ day. Heavy lifting should be avoided; the physician will indicate when the client can participate in sports again. The client will not resume working as soon as 2 weeks after surgery. Water does not harm the stoma, so the client does not have to worry about getting it wet.

Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy? 1. Glycosuria. 2. A 1- to 2-pound weight gain. 3. Decreased appetite. 4. Elevated temperature.

4. An elevated temperature can be an indication of an infection at the insertion site or in the catheter. Vital signs should be taken every 2 to 4 hours after initiation of TPN therapy to detect early signs of complications. Glycosuria is to be expected during the first few days of therapy until the pancreas adjusts by secreting more insulin. A gradual weight gain is to be expected as the client's nutritional status improves. Some clients experience a decreased appetite during TPN therapy.

A client is receiving Total Parenteral Nutrition (TPN) soulution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which of the following signs? 1. Tachycardia. 2. Hypertension. 3. Elevated blood urea nitrogen concentration. 4. Hyperglycemia.

4. During TPN administration, the client should be monitored regularly for hyperglycemia. The client may require small amounts of insulin to improve glucose metabolism. The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client's ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance.

A client with a well-managed ilesostomy calls the nurse to report the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. The nurse should: 1. Tell the client to take an antiemetic. 2. Encourage the client to increase fluid intake to 3 L/ day to replace fluid lost through vomiting. 3. Instruct the client to take 30 mL of milk of magnesia to stimulate a bowel movement. 4. Advise the client to notify the physcian.

4. Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the physician examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the physician has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.