Author Question: The nurse is caring for a patient receiving PN. In planning the patient's care for the day, which ... (Read 105 times)

schs14 · **on:** Jul 24, 2018

The nurse is caring for a patient receiving PN. In planning the patient's care for the day, which nursing assessment is most essential?

a. Electrolyte levels
b. Weight
c. Temperature
d. Condition of insertion site

Question 2

The nurse receives orders on several patients for chest percussion, vibration, and shaking. The nurse is aware that chest physiotherapy maneuvers are indicated for which patient?

a. 18-year-old who sustained thoracic trauma from a motor vehicle accident
b. 75-year-old with osteoporosis who is underweight
c. 15-year-old with cystic fibrosis
d. 20-year-old with a fractured clavicle

Ddddd · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

A
Since the need for PN is usually associated with conditions that result in electrolyte instability, maintaining electrolyte balance during therapy is crucial. Monitor the patient's electrolyte levels (potassium, magnesium, and phosphorus) for low serum levels which may indicate a risk for arrhythmias and muscle weakness, Patient's at risk may require having electrolyte panels done several times a day. While it is necessary to monitor the patient's weight and temperature and be alert for signs of infection at the insertion site, the biggest risk to the patient is electrolyte instability.

Answer to Question 2

C
Chest physiotherapy (CPT) and coughing maneuvers assist with airway clearance of mucus in patients with retained tracheobronchial secretions. Secretions accumulate in the airways of patients with bronchitis, asthma, cystic fibrosis (CF), pneumonia, and bronchiectasis. Thoracic trauma, osteoporosis, and fracture of rib cage structures such as the clavicle contraindicate percussion, vibration, and shaking.