Difficulty: Medium
Average Score: 93%
Simulated
A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse?
Correct answer
D
Rationale
The correct answer is D. A weight increase of 2 kg in 24 hours could indicate fluid overload, putting the client at risk for heart failure or pulmonary edema. Immediate intervention is needed to assess the client's fluid balance and adjust the total parenteral nutrition accordingly. Choice A is within the normal range for blood glucose levels. Choice B is a normal serum sodium level. Choice C is a slightly elevated temperature but not a critical finding.