EXAM 3 29,35,36

A client who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return?

"That is called phantom pain, and it is not unusual." Feedback:The pain that is often referred to an amputated leg where receptors and nerves are clearly absent is a real experience for the client. This type of pain is called phantom pain.

A client is discussing weight loss with a nurse. The client says, "I will not eat for 2 weeks, then I will lose at least 10 lb (4.5 kg)." What would the nurse state to the client?

"That will decrease your metabolic rate and make weight loss more difficult." Feedback:Most nutritionists agree that fasting or following a very low-calorie diet defeats a weight-loss plan because the body interprets this eating pattern as starvation, and compensates by slowing down the basal metabolic rate, making it even more difficult to lose weight. The nurse should have a thorough knowledge of this and make statements that reflect the correct information. Most people do not find that fasting or following a very low-calorie diet is successful.

What would a nurse instruct a client to do after administration of a sublingual medication?

"Try not to swallow while the pill dissolves." Feedback:Sublingual and buccal medications should not be swallowed, but rather held in place so that complete absorption takes place.

A nurse is feeding a client. Which statement would help a person maintain dignity while being fed?

"What part of your dinner would you like to eat first?" Feedback: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 their preference regarding the order of items eaten can help maintain dignity while being fed. Telling the client that they do not like the nurse to feed them is assuming that the client does not like the nurse. The nurse should be prepared to spend as much time with the client to assist with the entire meal to provide self worth to the client. Telling a client what the nurse will do does not promote self-esteem but identifies the nurse wanting to control the feeding.

A nurse is conducting a health history interview for an older adult. Which question or statement should the nurse prioritize for nutritional assessment?

"Which prescribed and over-the-counter medicines do you take?" Feedback:When collecting dietary data for an older adult, it is important to gather information about prescribed and over-the-counter medications to assess for food drug interactions and adverse effects of medications.

For which of the following clients should the nurse anticipate the need for a pureed diet?

A man whose stroke has resulted in difficulty swallowing Feedback:Pureed diets are indicated for clients who have significant problems chewing and/or swallowing. Surgery and confusion are not indications for this change in the texture and consistency of food. An obese women after bariatric surgery would need a liquid diet.

The nurse is preparing to administer an intermittent feeding to a client who has a nasogastric feeding tube. Arrange the following steps in the correct order.A. Position client with head of bed elevated to 30 to 45 degrees.B. Aspirate some gastric contents, and check the pH of the fluid.C. Visualize aspirated contents, checking for color and consistency.D. Verify residual volume of the gastric contents is less than 250 mL.E. Flush the nasogastric tube with 30 mL water.F. Administer the gastric feeding.

A, B, C, D, E, F When the nurse prepares to administer an intermittent tube feeding, the nurse would elevate the client's head of the bed to 30 to 45 degrees. Elevating the head of the bed minimizes the possibility of aspiration of contents into the trachea or lungs. After placing on gloves, the nurse verifies the tube is in the correct position by several methods. The nurse aspirates some gastric contents to check the pH of the fluid. The pH of gastric contents is less than 5.5 If the client is taking an acid-inhibiting medication, the pH may be 4.0 to 6.0. The pH of respiratory fluid is 6.0 or higher. The nurse visualizes aspirated contents, checking for color and consistency. Gastric fluid may be green with particles, off-white, or brown if old blood is present. A small amount of blood-tinged fluid may be present if the NG tube was recently inserted. The nurse then aspirates all contents to verify the residual volume is less than 200 to 250 mL. The nurse flushes the NG tube with 30 mL of water to prevent occlusion of the tube. The nurse administers the tube feeding.

A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty do immediately upon detection of the medication error?

Check the client's condition. Feedback:On detection of the medication error, the nurse should immediately check the client's condition. When medication errors occur, nurses have an ethical and legal responsibility to report them to maintain the client's safety. As soon as the nurse recognizes an error, he or she should check the client's condition and report the mistake to the prescriber and supervising nurse immediately. Health care agencies have a form for reporting medication errors called an incident sheet or accident sheet.

A student nurse is administering medications through a nasogastric tube connected to continuous suction. How will the student do this accurately?

Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30 minutes. Feedback:To administer medications to clients with a nasogastric tube connected to continuous suction, disconnect the tubing from the suction, administer the medications one at a time, and then clamp the tubing for 20 to 30 minutes after administration to allow absorption.

A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle?

Do not recap the needle; place it in a puncture-resistant container. Feedback:After use, needles and syringes are placed in a puncture-resistant container without being recapped. This prevents needlestick injuries, because most occur during recapping.

The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake?

Encourage his daughter to prepare food at home and bring it to the client. Feedback:The nurse should solicit food preferences and encourage favorite foods from home, when possible. Be sure the foods look attractive and the eating area is free of odors, clutter, and distractions during mealtime. Provide small, frequent meals to avoid overwhelming the client with large amounts of food.

What independent nursing intervention can be implemented to stimulate appetite?

Encourage or provide oral care. Feedback:There are many methods of stimulating appetite in a client to prevent malnutrition. One independent nursing intervention that is useful is to encourage or provide oral care.

A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain?

Endorphins Feedback:Endorphins, which are opioid neuromodulators, are produced at neural synapses at various points in the CNS pathway. They have prolonged analgesic effects and produce euphoria. It is suggested that they may be released when measures such as skin stimulation and relaxation techniques are used. A delta fibers stimulate pain receptors (known as nociceptors), which helps rapidly communicate initial information about pain to the body. These signals are sent to the brain and spinal cord and are usually perceived as acute, sharp pain. Sedatives are a group of drugs taken for its calming or sleep-inducing effect. A narcotic is a drug that relieves pain and induces drowsiness, stupor, or insensibility.

The nurse is preparing to administer a medication via a nasogastric tube. Which guideline is appropriate for the nurse to follow when administering a drug via this route?

Flush the tube with water between each drug administered. Feedback:Guidelines to consider when administering a drug via nasogastric tube include positioning the client with the head of the bed elevated, administering the medication at room temperature for the client's comfort, flushing the tube with water between each drug administered, and avoiding the use of suction for 20 to 30 minutes after the drug is administered.

A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this intervention?

Gate control theory Feedback:The gate control theory of pain describes the transmission of painful stimuli. Nursing interventions, such as massage or a warm compress to a painful lower back, stimulate large nerve fibers to close the gate, thus blocking nerve impulses from that area.

Which factors increase basal metabolic rate (BMR)? Select 3 that apply.

Growth Correct! Infections Correct! Fever Feedback:Factors that increase BMR include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones, especially epinephrine and thyroid hormones. Aging, prolonged fasting, and sleep all decrease BMR.

Most nutritionists recommend having a proper amount of fiber in the diet. In addition to other benefits, how does fiber affect cholesterol?

Increases fecal excretion of cholesterol Feedback:To help lower serum cholesterol levels, researchers recommend limiting cholesterol intake, eating less total fat, eating more unsaturated fat, and increasing fiber intake. Fiber increases fecal excretion of cholesterol.

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate?

Infection Feedback:Factors that increase a person's basal metabolic rate (BMR) include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones (epinephrine and thyroid hormones). Aging, prolonged fasting, and sleep all decrease BMR.

A nurse is administering a medication to a client for acute pain. Of the various routes for drug administration, which would be chosen because it is absorbed most rapidly?

Injected medications Feedback:Injected medications are usually absorbed more rapidly than oral or topical medications.

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse, and the morphine doesn't help anymore." The nurse determines the client's pain is which of the following?

Intractable Feedback:Chronic malignant pain is acute pain episodes, persistent chronic pain, or both, associated with a progressive malignant-type process.

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 10 breaths per minute. The client is somnolent, with minimal response to physical stimulation. The nurse should prepare to administer which medication?

Intravenous naloxone Feedback:Albuterol is a bronchodilator and not appropriate for this clinical situation.

Why is acute pain said to be protective in nature?

It warns an individual of tissue damage or disease. Feedback:Pain is a subjective experience. Acute pain, lasting from a few minutes to less than 6 months, warns an individual of tissue damage or organic disease. After its underlying cause is resolved, acute pain disappears.

A client has been prescribed a clear liquid diet. What food or fluids will be served?

Jell-O, carbonated beverages, apple juice Feedback:Clear liquid diets contain only foods that are clear liquids at room or body temperature such as are gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. A full liquid diet includes all fluids and foods that become liquid at room temperature. This would include ice cream, chocolate milk, and liquid dietary supplements. Solid food examples are desserts, egg substitutes, and hot cereals. High calorie, high protein supplements are considered full liquids.

A nurse has documented that a client has anorexia. What does this term mean?

Lack of appetite Feedback:Anorexia is lack of appetite. It may be related to multiple factors, including diseases, psychosocial causes, impaired ability to chew and taste, or inadequate income. Anorexia is eating less than the recommended amount. Anorexia can have more of caloric deficit rather than a fluid deficit as the client is eating less food than fluids. In developed countries, vitamin C deficiency can occur as part of general undernutrition.

A nutritionist helps to plan a diet for a client with diabetes. Which food is a carbohydrate that should be included to help improve glucose tolerance?

Oatmeal

A nutritionist helps to plan a diet for a client with diabetes. Which food is a carbohydrate that should be included to help improve glucose tolerance?

Oatmeal Feedback:Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in diabetics. Milk, eggs, and nuts are proteins.

What must a nurse do each time medications are administered to ensure that medication errors do not occur?

Observe the three checks and five rights. Feedback:Safety is of the utmost when preparing and administering drugs. The nurse observes the three checks and five rights each time medications are administered.

Eight hours after spinal surgery a client has not voided. The client is restless and reports abdominal pain. What action would the nurse perform before administering pain medications?

Palpate abdomen for distended bladder. Feedback:Nurses can provide interventions to alter or relieve pain. A client has not voided for 8 hours after surgery. The client is restless and reports having abdominal pain. The nurse would assess for a distended bladder by palpating the lower abdomen. The client most likely has a distended bladder and needs to be catherized to obtain relief. The client probably does not have peristalsis following surgery. A bowel movement is not expected this soon after surgery. A physical assessment would be performed before checking the database for the last bowel movement. The dressing is on the spine and not where the pain is located which is the abdomen.

The nurse is administering an oral opioid medication to a client who reported pain. The client dropped the medication on the floor. What actions would the nurse take now? Select 3 that apply.

Search for the pill on the floor until the pill is found. Correct! Discard the pill in an appropriate container with a witnessing nurse present. Correct! Obtain another dose of the medication for the client. Feedback:If an oral medication falls to the floor, the nurse searches for the pill until the pill is found. This is particularly important for an opioid medication, which the nurse must account for according to federal law. The pill is to be discarded in an appropriate container with a witness, also according to federal law. The nurse obtains another dose of the medication to administer to the client. The nurse does not wipe the pill and try to administer the pill to the client. This is to prevent contamination and transmission of microorganisms. Only if the client drops multiple dosages of opioid medications on the floor would the nurse ask for a liquid form of the medication.

Which laboratory result indicates the presence of malnutrition?

Serum albumin 2.8 g/dL Feedback:Increased Hct indicates dehydration.

A client who has been taking no medications has just been diagnosed as having diabetes. The client is prescribed an injectable medication once a day and an oral medication twice a day for blood glucose control. What would the nurse teach the client about taking these medications? Select 4 that apply.

Take the medications at the same time each day. Correct! Do not abruptly stop the medication or alter the dosage. Correct! The intended effects and adverse effects of the medications The appropriate timing of the medications in relation to food Feedback:The nurse, when teaching a client about medications, would include in the instructions to take the medications at the same time each day, to not abruptly stop the medications or alter the dosage of the medications, and would teach about the intended/adverse effects of each medication. For diabetic medications, it is important for the nurse to teach the client when to take these medications in relation to ingestion of food. These medications would make the client's blood glucose drop to critically low levels if food is not also ingested. Medications should not be exposed to light. Medications should be kept in a cool, dry place. Light, temperature, and humidity can inactivate the medications.

A client who has breast cancer is said to be in remission. What does this term signify?

The disease is present but the client is not experiencing symptoms. Feedback:Commonly, people with chronic pain experience periods of remission (when the disease is present but the person does not experience symptoms) or exacerbation (the symptoms reappear). During the end stages of cancer or final stages of cancer, problems may occur in several parts of the body and pain is present.

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect? Peak level

Therapeutic range Feedback:A drug's therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. The peak level, or highest plasma concentration, of the drug should be measured when absorption is complete. The peak level may be affected by factors that affect drug absorption as well as the route of administration. The trough level is the point when the drug is at its lowest concentration, and this specimen is usually drawn in the 30-minute interval before the next dose. A drug's half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

The nurse has just completed programming of a patient-controlled analgesia (PCA) pump using prescribed parameters. Which action should the nurse take next?

Verify the settings with another nurse. Feedback:This action should be performed before programming is initiated.

A client has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain will predominate?

Visceral pain Feedback:Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen. The pain occurs as organs stretch abnormally and become distended, ischemic, or inflamed.

The medical chart of a newly admitted client notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the client's wound culture and sensitivity. How should the nurse respond to this situation?

Withhold the medication until the potential drug allergy has been addressed by the care team. Feedback:Client safety is paramount, and the nurse has a responsibility to ensure that a potential threat of harm is identified and dealt with promptly. It is beyond the nurse's scope of practice to independently substitute another drug, and it would be unsafe to administer the drug in light of this revelation. The nurse would not administer the drug even if the client stated that his allergy is mild.

Which client would be classified as having chronic pain?

a client with rheumatoid arthritis Feedback:Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Acute pain is generally rapid in onset and varies in intensity from mild to severe. After its underlying cause is resolved, acute pain disappears. It should end once healing occurs. A client with rheumatoid arthritis has chronic pain derived by the inflammatory process in the joints. Pneumonia is an acute problem that generally does not have pain associated with it. Controlled hypertension does not have any pain associated with it. Flu, in the beginning stages, can have acute pain and not chronic pain associated with it.

Which client will have an increased metabolic rate and require nutritional interventions?

a person with a serious infection and fever Feedback:Factors that increase metabolic rate include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of some hormones. Aging, prolonged fasting, and sleep decrease metabolic rate.

A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of:

allergic reaction. Feedback:In a client with urticaria, the symptoms of severe allergic reaction are hives, wheezing, and dyspnea, which is due to an anaphylactic reaction. Minor adverse effects are called side effects. Many side effects are essentially harmless and can be ignored. Toxicity results from overdosage or buildup of medication in the blood due to impaired metabolism and excretion. Antagonism is a drug interaction by which drug effects decrease.

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy?

carbohydrates, protein, and lipids Feedback:Of the six classes of nutrients, three supply energy (carbohydrates, protein, and lipids), and three are needed to regulate body processes (vitamins, minerals, and water).

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

cutaneous stimulation Feedback:Acupressure, a modern-day Western descendant of acupuncture, involves the use of the fingertips to create gentle but firm pressure to usual acupuncture sites. This technique of holding and releasing various pressure points has a calming effect, most likely related to the body's release of endorphins and enkephalins. Acupressure is easily taught to patients and families. Because patients can perform acupressure on themselves, it gives them a feeling of control in their care.

A nurse is preparing to administer a medication by intravenous piggyback. Where will the piggyback container be placed?

higher than the primary solution container Feedback:The intravenous piggyback delivery system requires the intermittent or additive solution to be placed higher than the primary solution container. The primary solution container is placed on an extension hook to lower it when the piggyback container is hung.

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which technique varies for an adult and child client?

manipulation of the client's ear to straighten the auditory canal Feedback:The nurse should be aware that the method of manipulation of the client's ear to straighten the auditory canal varies between an adult and child. In a young client, the nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The medication is not diluted; the number of medication drops instilled is as per the physician's prescription, and does not depend on the client's age. The position in which the client remains until the medication reaches the eardrum, and the amount of time before instilling medication in the client's opposite ear, does not differ with the age of the client.

What type of order would a physician most likely write to treat a client whose pain levels vary widely throughout the day?

p.r.n. Feedback:The prescriber may write a p.r.n. order ("as needed") for medication. The client receives medication when it is requested or required. These orders are commonly written for treatment of symptoms. For example, medications used for pain relief, to relieve nausea, and for sleep aids are often written as a p.r.n. order.

A hospitalized client has been n.p.o. with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?

poor wound healing, apathy, edema Feedback:The stress of illness, surgery, or prolonged periods of time on simple intravenous therapy without oral intake places hospitalized clients at risk for developing protein-calorie malnutrition. This can result in weakness, poor wound healing, mental apathy, and edema.

A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain?

referred Feedback:Referred pain is pain that is perceived in an area distant from the point of origin. Pain associated with a myocardial infarction is frequently referred to the neck, shoulder, or arm.

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as:

somatic pain. Feedback:Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.

Of the following individuals, who can best determine the experience of pain?

the person who has the pain Feedback:According to Margo McCaffery, a nursing expert on pain, "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The only one who can be a real authority on whether and how a person experiences pain is that individual. The physician and nurse can assess and document the client's pain in the health record. The immediate family does not have the best understanding of the pain that the client is experiencing.

A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?

to prevent gastric irritation Feedback:Enteric-coated tablets are covered with a hard surface to impede absorption until the tablet has left the stomach. Enteric-coated tablets should not be chewed or crushed because the active ingredient of the drug is irritating to the gastric mucosa.

A nurse is conducting an interview for a health history. In addition to asking the client about medications being taken, what else should be asked to assess the risk for drug interactions?

use of herbal supplements Feedback:Herbal remedies can interact with prescribed medications. When asking a client if he is taking any medications, the nurse should specifically ask if herbal supplements are also being used.

A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain?

whenever the vital signs are measured and documented Feedback:The nurse should assess the client's pain whenever the nurse measures and documents vital signs. When administering a prescribed analgesic, the nurse should assess pain before implementing a pain-management intervention, and again 30 minutes later. The nurse should assess the client's pain when the client is admitted to, not discharged from, the health care facility. Similarly, the nurse should assess pain once per shift when pain is an actual or potential problem.