1 :

Hint : 🧴 TPN tubing q24 hr

Correct Answers:

  • "l will hang a new bag of TPN and IV tubing every 24 hours."

Rationale :

🔷 TPN requires strict aseptic technique because the high-glucose solution supports bacterial growth.

🔷 A new TPN bag and IV tubing should be hung every 24 hours to reduce infection risk.

🔷 Blood glucose is usually monitored more frequently than every 8 hours, often every 4 to 6 hours, especially when starting therapy.

🔷 The client’s weight should be monitored daily, not every other day, to assess fluid and nutritional status.

🔷 The infusion rate should never be increased to catch up, because rapid infusion can cause hyperglycemia and fluid imbalance.

Incorrect Options

❌ “I will monitor the client’s blood glucose level every 8 hours.” This is not frequent enough for many clients receiving TPN. TPN can cause significant hyperglycemia, so glucose monitoring is commonly done every 4 to 6 hours.

❌ “I will obtain the client’s weight every other day.” Weight should be obtained daily to monitor nutrition response and fluid balance. Sudden weight changes can indicate fluid overload or dehydration.

❌ “I will increase the rate of the TPN infusion to ensure the correct amount is given.” The TPN rate should not be increased to catch up missed volume. Rapid infusion can cause hyperglycemia, electrolyte shifts, and fluid overload.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

2 :

Hint : 🩺 Explore options first

Correct Answers:

  • "Let's discuss other treatment options available."

Rationale :

🔶 The nurse should respond therapeutically by exploring the client’s concerns and discussing available treatment options.

🔶 A competent client has the right to refuse or discontinue treatment, including hemodialysis, but the nurse should first assess understanding, decision-making capacity, and whether the statement reflects hopelessness or suicidal thinking.

🔶 Discussing options allows the client to consider alternatives such as palliative care, symptom management, counseling, social support, or modified treatment goals.

🔶 This response keeps communication open and supports informed decision-making.

🔶 It also helps the nurse identify whether further interdisciplinary support is needed.

Incorrect Options

❌ “I will document your wishes in your medical record.” Documentation is necessary, but this response is too passive and does not assess the client’s meaning, understanding, or emotional state. The nurse should first explore the client’s concerns.

❌ “It’s too late to discontinue treatment now.” This is false and violates client autonomy. A client with decision-making capacity can refuse or stop treatment.

❌ “I can see you’re upset. Let’s talk about this later.” This delays addressing a serious statement about wanting to die. The nurse should respond immediately and continue assessment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

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