# A severely malnourished client is started on TPN. Forty-eight hours later, the client develops dyspnea, confusion, weakness, and labs show low phosphate, magnesium, and potassium. Which is the priority interpretation and action?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391887&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A severely malnourished client is started on TPN. Forty-eight hours later, the client develops dyspnea, confusion, weakness, and labs show low phosphate, magnesium, and potassium. Which is the priority interpretation and action?

## Option

1. Refeeding syndrome — reduce caloric load, aggressively replace phosphate/magnesium/potassium, supplement thiamine before resuming, advance nutrition slowly under close monitoring **✔ Correct answer**
2. Discontinue all electrolyte monitoring
3. Expected normal response
4. Increase TPN rate for faster correction

**Correct answer: 1**

## Explanation

Correct (2): Refeeding syndrome — when carbohydrates are introduced after starvation, insulin surge drives phosphate, magnesium, potassium intracellularly → severe deficiencies with arrhythmia, respiratory failure, seizures, heart failure. Prevention: start TPN at 25-50% of goal, advance slowly over 4-7 days, give thiamine 100 mg before/during initial feeding, replete phosphate/Mg/K before progressing. (1,3,4) Dangerous.

## In-depth explanation

Memory Tip Refeeding = "Phosphate-Magnesium-Potassium DROP + Thiamine BEFORE carbs." Identify high risk: BMI 15%, no intake >10 days, low pre-feeding electrolytes.

## Clinical scenario

Scenario 65-year-old female with severe protein-calorie malnutrition started on TPN. 48 hr later: dyspnea, confusion, weakness, phosphate 1.2, Mg 1.3, K 3.0.

## Key concepts

- **Refeeding syndrome** — Insulin-driven electrolyte shifts (P/Mg/K) after refeeding malnourished client; fatal arrhythmia/respiratory failure.
- **Thiamine pre-feeding** — 100-300 mg thiamine before and during initial feeding to prevent Wernicke encephalopathy.
- **Slow nutrition advancement** — Start at 25-50% goal, advance over 4-7 days, monitor electrolytes daily.

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