# A nurse is caring for a severely malnourished 58-year-old client with a BMI of 14 and recent 20% weight loss who has just started total parenteral nutrition (TPN) through a tunneled central venous catheter. Which actions are essential during the first 72 hours? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368173&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A nurse is caring for a severely malnourished 58-year-old client with a BMI of 14 and recent 20% weight loss who has just started total parenteral nutrition (TPN) through a tunneled central venous catheter. Which actions are essential during the first 72 hours? Select all that apply.

1

Assess for fluid overload, including edema, crackles, and rapid weight gain, and weigh the client daily at the same time on the same scale

2

Check bedside blood glucose every 4 to 6 hours initially and administer insulin according to the prescribed protocol for hyperglycemia

3

Use strict aseptic central-line technique, disinfect the connector for the manufacturer-recommended contact time and allow it to dry, and dedicate a lumen to TPN when possible

4

If the next TPN bag is unavailable, replace it with D5W or normal saline at the same rate and continue that substitute until a new bag arrives because either fluid is equivalent to TPN

5

Give prescribed thiamine, monitor phosphorus, potassium, and magnesium about every 12 hours for the first 3 days in this high-risk client, replace deficits, and advance calories slowly

6

Advance the TPN infusion to the full calorie target during the first 24 hours because rapid correction of the calorie deficit takes priority over a gradual refeeding plan

## Explanation

This client is at very high risk for refeeding syndrome. Give thiamine as prescribed, begin calories conservatively, and monitor phosphorus, potassium, and magnesium about every 12 hours during the first 3 days, replacing deficits and slowing advancement if levels fall (Choice 5). Monitor glucose closely and treat hyperglycemia according to protocol (Choice 2). Use aseptic catheter care, allow antiseptic to dry, and dedicate a lumen to TPN when possible to reduce bloodstream infection risk (Choice 3). Daily weight and assessment for edema or crackles help detect fluid overload (Choice 1). Starting at the full goal rate can precipitate refeeding complications (Choice 6). D5W or normal saline is not an equivalent substitute for an interrupted high-dextrose TPN infusion; follow the facility's interruption protocol, commonly using prescribed 10% dextrose, and notify the provider or pharmacy (Choice 4).

## In-depth explanation

TPN — High-Risk Initiation
1. Refeeding syndrome risk: BMI <16, weight loss >10-15%, NPO >7-10 days, alcoholism, eating disorder
2. Slow advancement: ≤50% goal calories first 24 hr; full goal by day 3-5
3. Electrolytes: phosphorus, potassium, magnesium daily; replace before initiation if low
4. Glucose: q4-6h fingerstick early; insulin per sliding scale or drip
5. Fluid balance: daily weight, edema, crackles, I/O
6. CLABSI prevention: chlorhexidine hub scrub 15 sec, dedicated TPN lumen, no blood draws

If TPN Bag Delayed
Standard: hang 10% dextrose at the same rate (NOT D5W alone or saline) + notify provider; pharmacy compounds backup. Abrupt stop = rebound hypoglycemia.

Refeeding Pathophysiology
Carbohydrate load → insulin surge → intracellular shift of P, K, Mg → severe hypophosphatemia → cardiac/respiratory failure

Memory Tip
"Slow + Phos + Glu + Sterile + Weight"

## Clinical scenario

Scenario
58 yo, BMI 14, 20% weight loss, TPN initiated via newly placed tunneled central line. Severe refeeding risk.

First 72 Hours Priorities
1. Refeeding labs q24h: phosphorus, potassium, magnesium
2. Glucose q4-6h fingerstick + insulin titration
3. Aseptic line care: chlorhexidine scrub, dedicated lumen
4. Daily weight + edema/crackles assessment
5. Slow advance per refeeding protocol

Avoid
- Full goal rate from hour 1
- D5W or saline as TPN substitute
- Sharing TPN lumen with other infusions or blood draws

## Key concepts

- **Total Parenteral Nutrition (TPN)** — Intravenous administration of complete nutrition (dextrose 10-70%, amino acids, lipids, electrolytes, vitamins, trace elements) when GI tract cannot be used. Hyperosmolar — must be infused via central venous catheter. Major complications: refeeding syndrome (early), hyperglycemia, CLABSI, hepatic dysfunction (long-term), refeeding-related cardiac/respiratory failure.
- **Refeeding Syndrome** — Potentially fatal shift of fluids and electrolytes (especially phosphorus, potassium, magnesium) into cells when nutritional support is restarted in severely malnourished clients. Carbohydrate-driven insulin surge drives intracellular electrolyte uptake; severe hypophosphatemia causes cardiac arrhythmia, respiratory muscle failure, neurologic dysfunction. Risk factors: BMI <16, weight loss >10-15%, NPO >7-10 days, alcoholism. Prevention: slow advancement, daily P/K/Mg monitoring + replacement, thiamine pre-treatment.
- **CLABSI Prevention with TPN** — Central Line-Associated Bloodstream Infection. TPN-related risk is high due to dextrose-rich solution + indwelling central catheter. Bundle: hand hygiene, maximal sterile barriers at insertion, chlorhexidine skin antisepsis, daily necessity assessment, chlorhexidine hub scrub for 15 seconds before each access, dedicated TPN lumen (no blood draws or other infusions through that port), change tubing per protocol (typically every 24 hr for TPN with lipids).

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