Nurs 215 Test 3
ANS: C The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.
. The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding should the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation
ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.
ANS:D During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take to prepare the patient for this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Administer prescribed sedatives. d. Assist the patient to a flat position.
ANS: C Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Are you taking any oral contraceptives?" b. "Have you been prescribed antiseizure drugs?" c. "Do you take medication containing salicylates?" d. "How long have you taken antihypertensive drugs?"
ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Tender, bleeding gums d. Numbness of extremities
ANS: C The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patient's electrolyte disturbances, but it does not suggest imminent life-threatening complications.
A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? a. The patient uses laxatives daily. b. The patient's knuckles are macerated. c. The patient's serum potassium level is 2.9 mEq/L. d. The patient has a history of extreme weight fluctuations.
ANS: A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.
A 58-yr-old patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth
ANS: D The patient's statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake. The other interventions may also help improve the patient's intake, but the most effective action will be to offer the patient more appealing foods.
A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Ask family members to bring favorite foods.
ANS: C Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.
A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2and a low serum albumin level is being admitted. Which assessment finding will the nurse expect? a. Restlessness b. Hypertension c. Pitting edema d. Food allergies
ANS: A The recommended daily protein intake is 0.8 to 1 g/kg of body weight. Therefore, the minimum for this patient is 66 kg 0.8 g = 52.8 or 53 g/day
A healthy adult woman who weighs 145 lb (66 kg) asks the clinic nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? a. 53 b. 66 c. 79 d. 98
ANS: B All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase patient risk for infection. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.
A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action should the nurse take? a. Add a new container of PN using the current tubing and filter. b. Hang a new container of PN and change the IV tubing and filter. c. Infuse the remaining 50 mL and then hang a new container of PN. d. Ask the health care provider to clarify the written PN prescription.
ANS: D Because the total white blood cell (WBC) count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised, and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
A nurse reviews the laboratory data for an older adult. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell count of 2800/µL
ANS: B The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.
A patient has a body mass index (BMI) of 31 kg/m2 , a normal C-reactive protein level, and low serum transferrin and albumin levels. What should the nurse encourage the patient to increase in the diet? a. Iron b. Protein c. Calories d. Carbohydrate
ANS: C A temperature elevation may indicate that an acute perforation has occurred. The other assessment data are normal immediately after the procedure.
A patient has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.4° F. d. The apical pulse is 100 beats/min.
ANS: D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.
A patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.
ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.
A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a. Check often for swollen lymph nodes. b. Watch for excess bleeding or bruising. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.
ANS: A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure
ANS: B The feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.
A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Ask the health care provider to reschedule the scan. b. Shut the feeding off 30 to 60 minutes before the scan. c. Connect the feeding tube to continuous suction before and during the scan. d. Send a suction catheter with the patient in case of aspiration during the scan
ANS:C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. Bleeding does not affect the white blood cell count.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell count
ANS: A Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea
A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6 liquid stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the feeding. b. Check gastric residual volumes more often. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.
ANS: A A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent
A patient with pancytopenia of unknown origin is scheduled for diagnostic tests. The nurse will ensure a consent form was signed before which test? a. Bone marrow biopsy b. Abdominal ultrasound c. Complete blood count (CBC) d. Activated partial thromboplastin time (aPTT)
ANS: C To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head
A patient with pancytopenia will have a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Use a -in sterile gauze to pack the wound. c. Have the patient lie on the left side for 1 hour. d. Apply a sterile 2-in gauze dressing to the site.
ANS: C Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, infusion rate changes are not needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. What is the appropriate action by the nurse? a. Obtain a venous blood glucose specimen. b. Slow the infusion rate of the PN infusion. c. Recheck the capillary blood glucose level in 4 to 6 hours. d. Contact the health care provider for infusion rate changes.
ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.
A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meat and protein?"
ANS: B The tube is flushed every 4 hours during continuous feedings to avoid tube obstruction. The patient should be positioned with the head of the bed elevated. Crushed medications mixed in with the formula are likely to clog the tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed
A young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned lying on the left side. b. Flush the tube with 30 mL of water every 4 hours. c. Crush and mix medications in with the feeding formula. d. Obtain a daily abdominal radiograph to verify tube placement.
ANS: C Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.
After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.
ANS: B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and abdominal tympany are within normal findings for an adult of normal weight.
An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding should the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area
ANS: B The gastrocolic reflex is most active after the first daily meal. Awakening, the anticipation of eating, and mid-afternoon timing do not stimulate these reflexes.
An older patient reports chronic constipation. To promote bowel evacuation, when should the nurse suggest that the patient attempt defecation? a. In the mid-afternoon b. After eating breakfast c. Right after awakening in the morning d. Immediately before the daily meal.
ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in a known area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
The nurse examines the lymph nodes of a patient during a physical assessment. Which finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot
ANS: B This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.
The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most appropriate initial question? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"
ANS: C, A, D, B The assessment data indicate that aspiration may have occurred. The nurse's first action should be to turn off the enteral feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action? (Put a comma and a space between each answer choice [A, B, C, D].) a. Check the patient's oxygen saturation. b. Notify the patient's health care provider. c. Stop administering the continuous feeding. d. Measure the gastric residual volume per agency policy
ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.
The nurse is caring for a patient with an obstructed common bile duct. What condition should the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level
ANS: B The aPTT level is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production
The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a.aspirin b. Heparin c. Warfarin d. Erythropoietin
ANS: C Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. Hemoglobin level d. White blood cell count
ANS: A If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure would be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.
The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination.
ANS: D The elevation in white blood cells indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cell count 15,500/µL
ANS: B After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site
What action should the nurse take after assisting with a needle biopsy of the liver at a patient's bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient's postbiopsy coagulation studies. d. Position a sandbag over the liver to provide pressure
ANS: B Elevate the head of the bed to decrease the risk of aspiration. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes but flushing after medication administration is important to avoid clogging. Do not mix medications with formula, as the combination can clog the tube
What action should the nurse take when caring for a patient with a soft, silicone nasogastric tube in place for enteral nutrition? a. Avoid giving medications through the feeding tube. b. Keep head of bed elevated to 30- to 45-degree angle. c. Replace the tube every 3 days to avoid mucosal damage. d. Administer medications mixed with enteral feeding formula
ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.
What condition should the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency
ANS: B LPN/VN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require registered nurse (RN)-level education and scope of practice.
Which action for a patient receiving enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/VN)? a. Assessing the patient's nutritional status weekly b. Providing skin care to the area around the tube site c. Teaching the patient how to administer the feedings d. Determining the need for adding water to the feedings
ANS: B (LUQ) The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen.
Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. 1 (RUQ) b. 2 (LUQ) c. 3 (RLQ) d. 4(LLQ)
ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.
Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds
ANS: A Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as paresthesias, peripheral neuropathy, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet.
Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation? a. Paresthesias b. Ecchymoses c. Dry, scaly skin d. Gingival swelling
ANS: C Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.
Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing food
ANS: B The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.
Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Assessment Complete Blood Count Patient History • BP 110/68 • Pulse 98 beats/min • Brisk capillary refill • Multiple ecchymoses on arms • Hgb 10.6 g/dL • Hct 30% • WBC 5100/µL • Platelets 19,500/µL • Occasional aspirin use • Abdominal pain x 1 week • Large, dark stool this morning a. Heart rate b. Platelet count c. Abdominal pain d. White blood cell count
ANS: B The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.
Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.
ANS: D Foods that are high in calories include fried foods and those covered with sauces. High-protein foods include meat and dairy products. The other choices are lower in calories and protein.
Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose high-calorie, high-protein foods? a. Baked fish with applesauce b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Fried chicken with potatoes and gravy
ANS: B, C, D Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.
Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment? (Select all that apply.) a. A 35-yr-old patient who reports intermittent nausea for the past 2 days b. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily c. A 23-yr-old patient who has a history of fluctuating weight gains and losses d. A 64-yr-old patient who is admitted for debridement of an infected surgical wound e. A 52-yr-old patient admitted with chest pain and possible myocardial infarction (MI)
ANS: D Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education.
Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I take an antacid for indigestion several times a week" d. "I use acetaminophen (Tylenol) every 4 hours for pain."
ANS: C FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.
While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). What area of patient knowledge should the nurse plan to assess? a. Preventing noninfectious hepatitis b. Treating inflammatory bowel disease c. Risk for developing colorectal cancer d. Using antacids and proton pump inhibitors
