[yoginurse2b]

Hi,

I need help on this question:

You have a pt who is receiving TPN and his V/S are:
Temp: 98.8
Pulse: 78
RR: 18
B/P: 130/86

Pt has complained about pain on his left leg.

What are you nursing intervention priorities when you are taking care of this pt?

a) assess right arm and neck for distention
b) get blood glucose result
c) assess central line for patency & central line dressing
d) assess Homan's sign
e) perform a body's systems physical assessment

[Jessy_RN]

I would check glucose levels.

[Daytonite]

Based on the information given and that the question is asking about the priority of nursing interventions, I would say "D" is the answer. His vital signs appear within normal limits. He is complaining about pain in his left leg and that would be something I would investigate as a priority. A body system physical assessment would be overkill, I think. I would want to assess the leg to get an idea of what this leg pain was about and checking for a Homan's sign would seem to be appropriate. He could have a blood clot or fat embolism in the leg.

[yoginurse2b]

Thanks for replying. But I think I asked the question wrongly. I need to know the sequence of the priorities, for example, 1) d, 2) c and etc.

This is what I would do:

1) d - pt might have DVT if Homan's sign is positive
2) a - assess for jugular vein distention, pt might have thrombosis from mechanical problem. That leads to...
3) c - check pt's central line to make sure that there's no infection or dislodgement.
4) b - get pt's blood glucose to make sure pt is not hyper/hypoglycemic.
5) e - perform a thorough physical assessment.

My rationale is, d and a are more life threatening than b.