Nu Process

Which of the following patients will have an increased metabolic rate and require nutritional interventions? A retired person living in a temperate climate An older, sedentary adult with painful joints A healthy young adult who works in an office A person with a serious infection and fever

A person with a serious infection and fever

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? FLACC Scale Braden Scale Morse Scale Glasgow Scale

Braden Scale

You receive an order to begin enteral tube feedings. The first step is to: A. Place the patient in a prone position. B. Irrigate the tube with normal saline. C. Check to see that the tube is properly placed. D. Flush the central line with normal saline.

C. Check to see that the tube is properly placed.

A nurse is feeding a patient. Which statement would help a person maintain dignity while being fed? A."I am going to feed you your cereal first, and then your eggs."B."I wish I had more time so I could feed you all of your meal."C."I know you don't like me to feed you, but you need to eat."D."What part of your dinner would you like to eat first?"

D) "What part of your dinner would you like to eat first?"Explanation: The loss of independence that comes with the inability to self-feed can be a severe blow to a person's self-esteem. Asking the person his or her preference regarding the order of items eaten can help maintain dignity while being fed.

A nurse is caring for a patient receiving enteral nutrition through a gastrostomy tube. The nurse is aware to monitor for which potential complications? Select all that apply. Diarrhea Epistaxis Hypercapnea Serum electrolyte imbalance Pulmonary aspiration

Diarrhea Serum electrolyte imbalance Pulmonary aspiration

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? Determine the extent of wound undermining. Measure length, width, and depth of the wound. Massage the healthy tissue surrounding the wound. Document the color, odor, amount, and type of wound drainage.

Document the color, odor, amount, and type of wound drainage.

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

From the tip of the nose to the earlobe to the xiphoid process

A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected? Skin pallor Eschar formation Blister formation Full-thickness skin loss Name what happens at each stage

Full-thickness skin loss Stage I Intact skin with localized area of ___________________________________ Stage 2 _________________-filled blister. Stage 3 Full-thickness skin loss. Adipose (fat) may be visible. May include rolled wound edges, slough, and/or eschar but nurse can visualize extent of tissue loss. May include undermining or tunneling. Stage 4 Full-thickness skin and tissue loss. Muscle, bone, tendon, ligament, cartilage exposed. May include rolled wound edges, slough, and/or eschar but nurse can visualize extent of tissue loss. Undermining and/or tunneling common. Deep-Tissue Injury Persistent nonblanchable deep red, maroon, or purple discoloration. Skin may be intact or nonintact. _______________ filled blister. Pain and temperature change precede color changes.

hypercapnia

Hypercapnia is the increase in partial pressure of carbon dioxide (PaCO2) above 45 mmHg. SX: Labored or shallow breathing. Wheezing. Altered consciousness or confusion. Fever. Flushed skin. Sweating profusely. Fatigue or sleepiness. Headache or nausea.

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. Which nursing intervention will the nurse implement to prevent skin breakdown? Implement a 2-hour repositioning schedule Perform passive range-of-motion exercises Frequently orient client to place and situation Massage skin surfaces daily, especially areas under pressure and bony prominences

Implement a 2-hour repositioning schedule

A nurse is collaborating with the interdisciplinary team to develop a nutritional plan for a patient with a nonfunctional GI tract due to a massive small bowel resection. Which of the following nutrition interventions would be most appropriate? Parenteral nutrition Enteral nutrition High fiber diet Regular diet

Parenteral nutrition

The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take first? Consult with the health care provider about prokinetic medication. Instill cold formula to "numb" the stomach. Slow the rate of tube feeding. Change the tube feeding to a high-fat formula.

Slow the rate of tube feeding.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? Adequate sleep and rest Thorough hand hygiene Proper intake of food and fluids Taking medications as prescribed

Thorough hand hygiene rationale: The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Proper intake of fluids and fiber as well as adequate sleep and rest are general guidelines to promote health. Taking medications especially antibiotics are important if an infection occurs.

ep·i·stax·is

bleeding from the nose.

The nurse observes a client with white skin for signs of stage I pressure injury development, which most likely will include which finding? visible subcutaneous fat exposed bone with eschar a shallow open injury nonblanchable redness

nonblanchable redness

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? lubricating the area with skin oil preventing the client from sliding in bed pulling the client up from under the arms improving the client's hydration

preventing the client from sliding in bed

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? removing excess drainage and wet tissue to prevent maceration of surrounding skin stimulating the wound bed to promote the growth of eschar tissue removing purulent drainage from the wound bed in order to accurately assess it removing dead or infected tissue to promote wound healing

removing dead or infected tissue to promote wound healing

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? clear, watery blood white blood cells, debris, bacteria mixture of serum and red blood cells large numbers of red blood cells

white blood cells, debris, bacteria