NCLEX-PN

Category - Pharmacological Therapies

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A nurse is monitoring a client who has been receiving total parental nutrition for the past 24 hours. Which of the following assessment findings best indicates that the client is developing an infection associated with TPN administration?

Temperature = 101^OF
Heart rate = 110 beats per minute
Blood glucose = 201 mg/dL
Cold and clammy skin

Explanation

Answer: A - Fever during the first 24 to 48 hours of TPN strongly suggests infection. Heart rate usually occurs with fever, but it is not the best indication of fever. Hyperglycemia suggests increased infusion of glucose, whereas cold and clammy skin indicates hypoglycemia.

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