Fundamentals exam 3
A nurse is caring for a patient with chronic pain. Which statement by the nurse indicates an understanding of pain management? "I need to reassess the patient's pain 1 hour after giving an oral pain medication." "This patient says his pain is a 5 but he is not acting like it. I am not going to give any pain medication." "It wasn't time for the patient's pain medication, so when it was requested, I gave a placebo." "The patient was sleeping so I pushed the PCA button
"I need to reassess the patient's pain 1 hour after giving an oral pain medication."
A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? -I will allow him to be in the position where he is most comfortable during the feeding." -I will elevate the head of the bed 10 degrees during the feeding." -I will turn him on his left side during the feeding." -I will have him sit in his chair during the feeding."
"I will have him sit in his chair during the feeding." The client should be placed in a Fowler's position or in a sitting position in a chair, which is the normal position for eating. This is the position that will prevent aspiration of fluid into the lungs and promote a gravitational flow.
Hypertonic
-A fluid that is more concentrated than normal blood (fluid pull water from cell and cause it to shrink) -Used to increase vascular volume, use with caution due to fluid overload Ex: 3% normal saline
Hypotonic
-A fluid that is more dilute than blood (Fluid will shift from outside of the cell to inside the cell to even out) -Used to rehydrate the cells Ex: 0.45% NaCl, D5 0.45% NaCl
Which patient is at most risk for fluid volume overload? -Heart failure patient. -Renal failure patient. -Long-term corticosteroid therapy. -All of the above are correct.
-All of the above are correct.
Psychomotor Domain of Learning
-Demonstration -Return Demonstration -Games
Potassium (3.5-5)
-Largest intracellular electrolyte -Supports transmission of electrical impulses in the nerves and muscles (skeletal, cardiac, and smooth muscle contraction) -Regulates glucose use and storage -Kidneys eliminate approx 90% of K
Isotonic
-Most common -Fluid with the same concentration of normal blood -Used for volume replacement (ex. after prolonged vomiting) Ex. 0.9% sodium chloride, LR
A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) -Offer the client a back rub. -Remind the client to use incisional splinting. -Identify the client's pain level. -Assist the client to ambulate. -Change the client's position.
-Offer the client a back rub. -Remind the client to use incisional splinting. -Identify the client's pain level. -Change the client's position.
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.) -Poor skin turgor -Bradycardia -Hypotension -Pale yellow urine -Flat neck veins
-Poor skin turgor -Hypotension -Flat neck veins
A nurse is preparing a teaching plan for a client who speaks limited English and is scheduled for a surgical procedure. Which of the following guidelines should the nurse plan to use when selecting written educational materials for the client? (Select all that apply.) -Use culturally diverse materials. -Use pictures. -Use materials written at an eighth-grade level. -Use materials written in the client's spoken language. -Provide a variety of educational materials.
-Use culturally diverse materials -Use pictures -Use materials written in the client's spoken language -Provide a variety of educational materials
The nurse is caring for a patient to ease modifiable factors that contribute to pain. Which areas did the nurse focus on with this patient? -culture and ethnicity -age and gender -previous pain experiences and cognitive ability -anxiety and fear
-anxiety and fear
normal range for magnesium
1.2-2.0 mEq/L
Normal range for sodium
135-145 mEq/L
A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider? 25 mg/dL 13 mg/dL 10 mg/dL 18 mg/dL
25 mg/dL The expected reference range for BUN values is 10 to 20 mg/dL. If the BUN is above this range, the kidneys might be having difficulty excreting urea and nitrogen. Elevation can be seen in dehydration and might require the use of intravenous fluids.
A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process?1. Set mutual goals for knowledge of hypertension.2. Teach what the patient wants to know about hypertension.3. Assess what the patient already knows about hypertension.4. Evaluate the outcomes of patient education for hypertension. 2, 3, 1, 4 3, 1, 2, 4 3, 2, 1, 4 1, 3, 2, 4
3, 1, 2, 4 -Assess what the patient already knows about hypertension -Set mutual goals for knowledge of hypertension. -Teach what the patient wants to know about hypertension -Evaluate the outcomes of patient education for hypertension.
normal range for potassium
3.5-5.0 mEq/L
How many milligrams/day is the recommended amount for a patient on a low cholesterol diet?
300 mg/day
A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?
740 mL
normal range for calcium
8.5-10.5 mg/dL
A nurse is calculating a client's fluid output for a 12hr period. It includes Jackson-Pratt (JP) drainage 35mL, NG suction 120mL, and incontinence pads weighing 240g, 310g, and 270g. The dry weight of the incontinence pads is 90g. The nurse should record how many mL of output on the client's record?
890 mL
Which patient below would have a potassium level of 5.5? -A 76 year old who reports taking lasix four times a day -A patient with Addison's disease -A 55 year old woman who have been vomiting for 3 days consistently -A patient with liver failure
A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with Addison's disease.
Name 4 types of fat-soluble vitamins
A, D, E & K
A patient was just diagnosed with a DVT. What learning domain would assist the patient in learning positive coping mechanisms?
Affective
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? -Creatine kinase -Troponin -Total bilirubin -Albumin
Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.
A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing?
Basal metabolic rate (BMR)
These are 3 common symptoms of hypermagnesemia
Bradycardia and hypotension, Severe hypermagnesemia: cardiac arrest, Drowsy or lethargic, Coma, Deep tendon reflexes are reduced or absent, Skeletal muscle contractions become progressively weaker and finally stop
This electrolyte helps to maintain muscle tone and is necessary for nerve transmission.
Calcium
Hyperkalemia >5
Causes: -Failure to eliminate potassium (renal disease, potassium- sparing diuretics, ACE inhibitors) -Excess K intake -Excessive/ rapid parenteral administration -Shift of K out of the cells (acidosis, crushing injury, tissue catabolism fever, sepsis, burns) Symptoms: -Irritability -Abdominal cramping, diarrhea -Weakness of lower extremities -Irregular pulse -Cardiac arrest if hyperkalemia sudden or severe Treatment: -Eliminate K intake, both oral and IV -Kayexalate -Dialysis (if due to renal failure) -Diuretics (K wasting) -Insulin (pushes K into cell)
The nurse is preparing to check the gastric aspirate for pH. What types of equipment will the nurse obtain?
Clean gloves, cone-tipped syringe, pH strips
These are 3 common warning signs of dysphagia
Coughing/change in voice after swallowing Abnormal movements of mouth/tongue/lips Uncoordinated speech Abnormal gag Pocketing food Drooling
A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? -Lemon sherbet -Plain yogurt -Cranberry juice -Carrot juice
Cranberry juice Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.
A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available? -Lactated Ringer's -3% sodium chloride -Dextrose 10% in water -0.9% sodium chloride
Dextrose 10% in water Sudden withdrawal from TPN, which is a hypertonic solution that contains dextrose, vitamins, electrolytes and sometimes lipids, can result in a sudden drop in the client's blood glucose levels. Administering an infusion of 10% dextrose will prevent hypoglycemia.
Name 3 diet items that should be eliminated to have a gluten free diet order.
Eliminates wheat, oats, rye, barley, etc.
Formula and example 1 st 10 kg = 100 ml/kg 2nd 10 kg = 50 ml/kg Any other = 20 ml/kg
Example 25 kg 1st 10 kg = 100 (10 kg) = 1000 ml 2nd 10 kg = 50 (10 kg) = 500 ml other (5 kg ) = 20 (5 kg)= 100 ml Total = 1600 ml
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use?
Explore the client's feelings about dietary modifications. This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which position will the nurse have the patient take when feeding the patient?
Flex head with chin tuck.
Weight gain is an indicator of
Fluid retention and overload
In providing prenatal care to a pregnant patient, what is one item the nurse should teach the expectant mother to begin taking?
Folic Acid
Name three options from a high fiber diet order?
Fresh uncooked fruits, steamed vegetables, bran, oatmeal, dried fruits
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. 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
Potassium chloride (KCI) can never be
GIVEN IV PUSH since hyperkalemia can cause fatal cardiac dysrhythmias. Can be given IV in an infusion at a slow rate.
These are 3 common symptoms of hyponatremia (list any 3)
Headache, apathy, confusion Nausea, vomiting, anorexia, Lethargy, Weakness, Muscle spasms, seizures, coma, Diarrhea, Abdominal cramps, Weight gain↑ BP
This lab measures the amount of space (volume) RBCs take up in the blood.
Hematocrit
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
Hyperglycemia
What electrolyte has the signs and symptoms of bilateral muscle weakness in quadriceps, transient abdominal cramps, diarrhea, dysrhythmias, and potential cardiac arrest
Hyperkalemia
What signs and symptoms are the following associated with: weight loss, hypotension, thready pulse, dry mucous membranes, poor skin turgor, oliguria
Hypovolemia
Under no circumstances absolutely no potassium should be administered by this route?
IV PUSH22.
A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?
Indispensable amino acids
Magnesium (1.3-2.1)
Intracellular 50-60% stored in bones Regulation of nerve and muscle function Maintain BP, glucose Bone/ teeth health
These are 3 common symptoms of hyperkalemia (list any 3)
IrritabilityAbdominal cramping, diarrhea, Weakness of lower extremities, Irregular pulse, Cardiac arrest if hyperkalemia sudden or severe V. Fib
WHAT ELECTROLYTE IS PRIMARILY (90%) EXCRETED BY THE KIDNEYS?
K
These are 3 common symptoms of hypercalcemia
Lethargy, weakness, Depressed reflexes (DTR, )Decreased memory, Confusion, personality changes, psychosis, Anorexia, nausea, vomiting, constipation, Bone pain, fractures, Ventricular dysrhythmias, HTN
This electrolyte affects muscular irritability and contractions, as well as helps to maintain strong and healthy bones
Magnesium
The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding?
Obese
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? -Pain -Hearing loss -The client's culture -Motor impairment
Pain If the client reports pain, the nurse should address managing the client's pain and postpone the learning session until the client reports pain relief.
This electrolyte has a direct effect on the excitability of nerves and muscles (skeletal, cardiac, and smooth)
Potassium
What electrolyte is involved in the regulation of glucose use and storage?
Potassium
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary orders will the nurse add to the care plan?
Provide small, frequent nutrient-dense meals for maximizing kilocalories.
A patient needs to learn to use a walker. Which domain is required for learning this skill?
Psychomotor
What is the the amount of energy you need to consume over a 24 hour period for your body to maintain internal working activities while at rest?
Resting Energy Expenditure
These are 3 common symptoms of hypernatremia (list any 3)
Restlessness, agitation, twitching Seizures, Coma, Intense thirst, Flushed skin, Weight gain, Peripheral and pulmonary edema ↑ BP
What temperature do you administer an intermittent gastric tube feedingto the patient?
Room temperature
Hypernatremia >145
Too much sodium in the blood Causes: (Can occur if theres water loss or adding more sodium into system. Most causes is water loss) -Inadequate water intake -NPO status -Gastroenteritis/ vomiting/ watery diarrhea -NG suction -Severe burns -High fever -Excessive sweating Disease states Kidney disease/failure Uncontrolled diabetes mellitus Diabetes insipidus Symptoms: -Restlessness -Agitation -Confusion -Seizures -Thirst -Dry, swollen tongue -Hypotension -Flushed skin -Edema -Weight gain Treatment: -treat underlying symptoms -water replacement: oral, Na- free isotonic fluids to dilute serum Na, then 0.45%NS to prevent hyponatremia -Diuretics- promote excretion of Na -Dietary- Na may be restricted
A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? -Urine specific gravity 1.035 -Hematocrit 44% -BUN 19 mg/dL -Sodium 155 mEq/L
Urine specific gravity 1.035 A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030.
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? -Decreased heart rate -Dyspnea -Increased blood pressure -Weak pulse
Weak pulse A decreased volume of circulating blood and less pressure within the vessels results in weak peripheral pulses (rated as +1), which can be described as thready.
A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?
X-ray
A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use?
demonstration
A nurse is caring for a client receiving bolus enteral feedings several times daily. Which nursing intervention is most important to help prevent diarrhea? -Elevate the head of the bed 30 degrees continuously -Discard the refrigerated opened cans of formula after 24 hours -Flush the tube after every feeding -Check the residual before each feeding
-Discard the refrigerated opened cans of formula after 24 hours
Affective
-Discussion -Role Play
A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? -Refer to the client in the third person during the session. -Have short teaching sessions. -Use a passive voice to explain the information. -Emphasize four important points at each session.
Have short teaching sessions.
WHEN A NURSE IS TEACHING A PATIENT ABOUT HOW TO ADMINISTER AN EPINEPHRINE INJECTION IN CASE OF A SEVERE ALLERGIC REACTION, THE NURSE TELLS THE PATIENT TO HOLD THE INJECTION LIKE A DART. WHAT INSTRUCTIONAL METHOD DID THE NURSE USE?
analogy
A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take? label the tubing that leads to the epidural catheter ask the nursing assistant personal to check on the patient at least every 2 hours restrict fluid intake apply a guaze dressing to the epidural catheter insertion site
label the tubing that leads to the epidural catheter
A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? provide the learner with a case study about exercise equipment provide patient with pictures of exercise equipemnt let the patient listen to a video about exercise equipment let the patient touch and use the exercise equipment
let the patient touch and use the exercise equipment
Hypovolemia
low blood volume Causes: -Abnormal fluid loss -Diarrhea -Hemorrhage -Fever (High perspiration) -Inadequate intake -DKA Signs and Symptoms: -High HR (due to SNS) -Weak/ thready pulses -UO <500 ml/day or <30 ml per hr -Altered Mental Status -Restlessness -Lethargy Nursing Considerations: -Frequent skin care + changes in position. -Elevation of edematous extremities to promote venous return and fluid reabsorption
What is the closed-loop communication technique that assesses patient retention of the information imparted during a teaching session?
teach back
This patient was admitted with a severe headache and confusion after participating in a water drinking challenge on social media.
(Dilutional) Hyponatremia
A nurse is teaching the partner of a client who had a stroke about manifestations of dysphagia. Which of the following statements by the client's partner indicates the need for further teaching? -I will monitor my husband for coughing while he is eating." -I will monitor for a change in my husband's voice after he swallows." -I will monitor my husband for tilting his head forward when he swallows." -I will monitor my husband for pocketing food in his mouth."
"I will monitor my husband for tilting his head forward when he swallows." A client who tilts his head forward while eating reduces the risk for dysphagia.
The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? "Would you please rate your pain on a scale of 0 to 10 for me?" "When does your pain medications usually take affect on your pain?" "What activities, if any, has your pain prevented you from doing?" "Have you considered working with a physical therapist?"
"What activities, if any, has your pain prevented you from doing?"
A patient is admitted to the ER with the following findings: heart rate of 115 (thready upon palpation), 81/57 blood pressure, 25 ml/hr urinary output, and Sodium level of 162. What interventions do you expect the medical doctor to order for this patient? -Restrict fluid intake and monitor daily weights -Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output -Administer hypotonic IV fluid and administer sodium tablets. -No interventions are expected
-Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output The patient must be re-hyrdated and the sodium levels should be decreased at the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells. When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular compartment. After these fluids are infused the patient's NA level should decrease, BP increase, HR return to normal
Which of the following interventions help to prevent aspiration in patients with dysphagia? (Select all that apply). -Keep NPO through entire hospitalization -Allow plenty of time to eat meals -Offer thickened liquids as ordered -Coach the patient to use the chin-tuck technique when eating -Offer thin liquids/clear liquid diet only
-Allow plenty of time to eat meals -Offer thickened liquids as ordered -Coach the patient to use the chin-tuck technique when eating
A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? -Inspecting the site for reduced swelling -Monitoring the client's pulse rate -Asking the client to rate the pain -Having the client perform range-of-motion of the affected arm
-Asking the client to rate the pain Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness.
A patient is receiving TPN. What is the primary intervention the nurse should implement to prevent a central line infection? (Select all that apply) -Institute isolation precautions -Change the TPN tubing every 24 hours -Monitor glucose levels to watch and assess for glucose intolerance -Clean the central line port through which the TPN is infusing with an antiseptic -Infuse the TPN through a different port of the central line each day
-Change the TPN tubing every 24 hours -Clean the central line port through which the TPN is infusing with an antiseptic
A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? -Request a prescription for a medication to ease the client's anxiety. -Irrigate the NG tube with 100 mL of sterile water. -Check to see if the suction equipment is working. -Remove and reinsert the NG tube.
-Check to see if the suction equipment is working. The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.
The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply). -Cheese and eggs are good sources of protein -Limit fluids to decrease the risk of edema -Avoid grapefruit juice, which can impair drug absorption -Increase the amount of carbohydrates for energy -Take a multivitamin that includes vitamin D for bone health
-Cheese and eggs are good sources of protein -Avoid grapefruit juice, which can impair drug absorption -Take a multivitamin that includes vitamin D for bone health
The nurse would delegate which of the following to nursing assistive personnel? (Select all that apply). -Hanging a new bag of enteral feeding -Repositioning and re-taping the patient's NG tube -Administering enteral feeding bolus after tube placement is verified -Documenting PO intake on a patient who is on a calorie count -Performing glucose monitoring every 6 hours on a patient
-Documenting PO intake on a patient who is on a calorie count -Performing glucose monitoring every 6 hours on a patient
Calcium (9-10.5)
-Found in the blood and cells, but 99% stored in the bones and teeth -Needed for mineralization of bones, muscle contractions, nerve transmission, clotting hormone secretion, and cardiac function
A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment? -Flat neck and hand veins -Thready, weak pulse -Increased blood pressure and crackles throughout the lungs -Bradycardia and pitting edema in lower extremities
-Increased blood pressure and crackles throughout the lungs The correct answer is increased blood pressure and crackles throughout the lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but NOT bradycardia.
Cognitive
-Lecture -Question and Answer -Discussion
A nurse is reviewing the laboratory findings of a client to assess the client's nutritional status. Which laboratory result from among the following tests is an indicator of inadequate protein intake? -Low specific gravity -High hemoglobin -Low serum albumin -High blood urea nitrogen
-Low serum albumin
An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the client has no teeth and is having difficulty eating. Which diet should the nurse encourage the physician to order for this client? -Liquid supplements -Pureed -Mechanical soft -Soft
-Mechanical soft
In report from the emergency department, you receive information that your patient's Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to administer Magnesium Sulfate via IV. Which of the following interventions takes priority? -Set-up bedside suction -Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate -Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions -None of the above are correct
-Monitor the patient's for reduced deep tendon reflexes and initiate seizure precautions As the nurse administering Magnesium sulfate IV, you must monitor for reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In addition, seizure precautions should be initiated due to the patient's low magnesium level.
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? -Nausea and vomiting -Extreme thirst -Flushed skin -Fever
-Nausea and vomiting A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level.
After obtaining an EKG on a patient you notice peaked T waves are present along with a prolonged PR interval. What lab value would be the cause of this finding? -Magnesium level of 2.2 -Potassium level of 5.3 -Potassium level of 2.2 -Phosphorus level of 2.0
-Potassium level of 5.3 -Hyperkalemia (normal potassium levels are 3.5 to 5.1) will present with these type of EKG findings.
Sodium (ECF 136-145)
-Primary extracellular electrolyte -Helps maintain blood pressure by balancing the volume of the water in the body -works with other electrolytes to promote nerves, muscles, and other body tissues to work properly. (think fluid balance and neuro status)
A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect? -The client reports numbness at the site. -Purulent drainage is noted from the site. -The vein appears cordlike. -Skin over the site is sloughing
-Purulent drainage is noted from the site. Signs of infection include warmth, redness, swelling, and possible purulent drainage.
A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.) -Restlessness -Grimacing -Moaning -Clenching -Drowsiness
-Restlessness -Grimacing -Clenching
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? -Sodium 126 mEq/L -Potassium 3.6 mEq/L -Magnesium 1.9 mEq/L -Chloride 99 mEq/L
-Sodium 126 mEq/L Therapeutic sodium level is 136 to 145 mEq/L. Low sodium values can be seen with dehydration, use of diuretics, adrenal insufficiency, and water toxicity. Sodium is essential for maintaining acid-base balance and conduction of nerve and muscles tissue. Hyponatremia is a net gain of water or loss of sodium that results in a sodium level less than 136 mEq/L. Manifestations of hyponatremia include headache, confusion, lethargy, muscle weakness, fatigue, decreased deep-tendon reflexes, and seizures.
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms? -The kidneys retain bicarbonate. -The kidneys excrete bicarbonate. -The lungs will retain carbon dioxide. -The lungs will excrete carbon dioxide.
-The kidneys retain bicarbonate. Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Rationale 2: Excreting bicarbonate causes acidosis to develop. Rationale 3: Retaining carbon dioxide causes respiratory acidosis. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis
A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? -Use a 10-mL syringe to flush the catheter. -Flush the lumen with sterile water after each use. -Use clean technique when accessing the catheter. -Apply firm pressure to the syringe plunger when flushing the lumen.
-Use a 10-mL syringe to flush the catheter. During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.
A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them.
-cleanse with antiseptic swab -apply tourniquet/BP cuff -dilate vein -insert catheter -release tourniquet -flush catheter, secure it
A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior? -the primary health care provider did not prescribe the correct amount of medication -the patient's culture is possibly influencing the patient's perception of pain -the surgery successfully cured the patient's pain -the nurse is allowing personal beliefs about pain to influence pain management
-the patient's culture is possibly influencing the patient's perception of pain
To reduce the risk of aspiration how long should the nurse keep the bed up 30 to 45 degrees after eating?
1 hour
A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one?1. Elevate head of bed to at least 30 degrees.2. Check for gastric residual volume.3. Flush tubing with 30 mL of water.4. Verify tube placement.5. Initiate feeding.
1. Elevate head of bed to at least 30 degrees 4. Verify tube placement. 2. Check for gastric residual volume 3. Flush tubing with 30 mL of water. 5. Initiate feeding.
Which patient is at most risk for hypermagnesemia? -A 56 year old renal failure patient -A 59 year old with hyperthroidism -A patient reporting overuse of anatacids and laxatives -A 24 year old suffering from hypoglycemia
A 56 year old who is a renal failure patient. Patients who suffer from renal failure have a decreased secretion of magnesium they are at risk for higher magnesium levels.
A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration? -A client who has a chest tube following a fall from a ladder -A client receiving continuous enteral feeding through NG tube -A client who Crohn's disease and has an ileostomy -A client who had a hemi-colectomy and placement of a colostomy
A client receiving continuous enteral feeding through NG tube A client who is receiving continuous enteral feedings through an NG tube is at greatest risk for aspiration, because if the tube slips into the lungs the feeding can enter the lungs. The nurse should confirm placement of the NG tube after inserting and before initiating enteral feedings. The nurse should confirm initial placement with an x-ray and subsequently, check by aspirating stomach contents and measuring the pH of the fluid. The aspirate should have a pH of 1 to 4, or as high as 6 if receiving medication that controls gastric acid.
WHICH ELECTROLYTE IMBALANCE IS CAUSED BY DIABETES INSIPIDUS, OSMOTIC DIURETIC, LACK OF ACCESS TO WATER, OR TUBE FEEDINGS
HYPERNATREMIA
What is the best way to prevent hypoglycemia episodes when removing a patient from TPN?
Do not abruptly stop TPN - wean the patient.
What electrolyte is needed for nerve transmission, skeletal/cardiac muscle contraction, and is largely found in the bones?
Callcium
Recall the correct k/cal for carbohydrates, protein and fat
Carbs = 4k/cal Proteins = 4k/cal Fats = 9k/cal
Hypercalcemia >10.5
Causes: -Increased total calcium -Cancer -Hyperparathyroidism -Prolonged immobilization (u will get brittle bones since calcium leaves the bones and go into blood) -Thiazide diuretics -Renal failure Symptoms: -GI (first to occur): constipation, abdominal pain, N + V, anorexia -Lethargy, weakness -Depressed reflexes (DTR) -Confusion, personality changes, pychosis -Bone pain, fractures -Flank pain/ Renal Calculi -Ventricular dysrhythmias Treatment: -Phosphate -Calcitonin via IV to promote renal excretion of Ca -Stool softeners given for constipation (to relieve symptoms) -Administer IV fluids followed by loop diuretics -Dialysis for severe hypercalcemia -Management of kidney stones
Hypomagnesemia <8.4
Causes: Vitamin D deficiency Hypoparathyroidism Hormonal changes (menopause) Chronic renal failure Loop Diuretics Multiple blood transfusions Symptoms: Cardiac: chest pain, dyrhythmias, heart failure, syncope, Chvostek sign (tap facial nerve pt will get spams) Trousseau's sign (If u pump up BP cuff pt will have carpal spasms) Treatment: -Treat underlying cause -Ca supplementation
Hypermagnesemia >2.5
Causes: Renal failure -Pt who ingest large amounts of Mg- containing antacids such as Tums, Maalox, Mylanta Symptoms: -N + D, weakness, confusion - Bradycardia and hypotension - Severe hypermagnesemia: cardiac arrest -Lethargic -Coma -Deep tendon reflexes reduced -Skeletal muscle contractions become progressively weaker Treatment: -Treat underlying causes -IV diuretics
What type of diet has options of Clear broth, coffee, tea, carbonated drinks, clear fruit juice, jello, popsicles?
Clear liquid
Name 3 items from a mechanical soft diet order
Clear/full liquids, pureed foods, diced meats, flaked fish, cottage cheese, canned fruit, etc.
A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor? -Client is currently prescribed spironolactone. -Client has a history of alcohol abuse disorder. -Client reports drinking 3.5 to 4 L of water each day. -Client has an NG tube to gastric suction.
Client has an NG tube to gastric suction. The client who has an NG tube to gastric suction is at risk for developing hypokalemia due to the gastrointestinal loss of potassium.
Hyponatremia <135
Deficient sodium in the blood Causes: -Vomiting -Diarrhea -NG suctioning -Diuretic -Burns -Tap water enemas -Excessive weight gain Symptoms: -Nausea, vomiting, diarrhea -Lethargy -Confusion -Headache -Restlessness -Irritability -Tremors, seizures, coma -Weight gain - Increased BP Treatment: -Treat underlying cause -Potential fluid restriction
A patient's gastic risidual volume was 250 mL at 0800 and 350 mL at 0900. What is the appropriate nursing action? -Do not resinstill aspirate and hold the feeding until talking with the physician -Raise the HOB to at least 45 degrees -Assess bowel sounds -Position the patient on their right side to promote stomach emptying
Do not resinstill aspirate and hold the feeding until talking with the physician Do not administer feeding when a single gastric residual volume exceeds 500 mL or when two consecutive measurements (taken 1 hour apart) each exceed 250 mL because of the potential for aspiration.
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L Glucose 102 mg/dL Potassium 3.6 mEq/L BUN 18 mg/dL Chloride 105 mEq/L Creatinine 0.7 mg/dL -Renal failure -Low-protein diet -Dehydration -Syndrome of inappropriate antidiuretic hormone (SIADH)
Dehydration Hypernatremic (hypertonic) dehydration occurs with excessive fluid losses due to perspiration, respiration, and inadequate fluid intake. The nurse should note that the client's sodium is above the accepted reference range, while glucose, potassium, BUN, chloride, and creatinine are within the accepted reference ranges. The client's history, collapsing after activity on a hot day, and the sodium findings are consistent with dehydration due to water deficit.
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? -Reposition the client. -Administer the medication. -Determine the location of the pain. -Review the effects of the pain medication.
Determine the location of the pain. The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.
This patient was admitted with altered mental status. She is an 89 y.o. female who lives alone and has difficulty caring for herself d/t worsening dementia. On assessment she has dry mucous membranes, weakness, and lethargy. She is confused (a/o to person only). She has postural hypotension.
Hypernatremia
This type of fluid is more concentrated than normal blood and is used to increase vascular volume.
Hypertonic
A patient with this fluid balance issue would show these s/s: HTN, bounding pulses, polyuria, crackles, headache, edema
Hypervolemia
What condition has the sign and symptoms of jugular venous distention, edema, bounding pulses, crackles, pulmonary edema?
Hypervolemia
This patient was admitted with chronic renal failure. PMH includes ETOH abuse. On assessment you note hyperreflexia, muscle cramps, and a positive chvostek's sign.
Hypocalcemia
What EI has signs and symptoms of numbness and tingling, + Chvostek's sign, hyperactive reflexes, muscle twitching, carpal and pedal spasms, tetany, seizures, dysrhythmias
Hypocalcemia
The patient is on parenteral nutrition and is diaphoretic, shaky, and confused. Which problem does the nurse prepare to address?
Hypoglycemia
This patient was admitted with severe n/v. They are now NPO and have an NG tube to low, continuous wall suction (LCWS). On assessment they are fatigued, and have weak/irregular pulses. Home medications include Lasix for HTN.
Hypokalemia
This patient was admitted with c/o diarrhea after having a bowel resection 2 weeks ago. On exam they have tremors, numbness, and hyperactive deep tendon reflexes.
Hypomagnesemia
What electrolyte imbalance has related causes of chronic alcoholism, chronic diarrhea, laxative misuse, loop diuretics
Hypomagnesemia
What electrolyte imbalance is caused by excessive ADH, tap water enemas, polydipsia, excessive IV administration of D5W
Hyponatremia
A patient with this fluid balance issue would show the following s/s: Tachycardia, weak pulses, hypotension, increased RR, LOC changes, decreased UO, dry mucous membranes
Hypovolemia
The nurse evaluates which lab value to assess a patient's potential for wound healing? Fluid status Nitrogen balance Potassium Lipids
Nitrogen balance
A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? -Inject the solution more slowly while flushing the IV saline lock. -Apply a warm compress to the IV site. -Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. -Remove the IV saline lock.
Remove the IV saline lock. The nurse should remove and move the IV catheter to another location because evidence indicates that the lock is not functioning properly.
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take? -Remove the catheter and insert another into a different site. -Administer an analgesic PO. -Request a prescription for placement of a central venous access device. -Administer a local anesthetic
Remove the catheter and insert another into a different site. It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? -Vital signs -Self-report of pain -Severity of the condition -Nonverbal behavior
Self-report of pain According to evidence-based practice, the most reliable indicator of pain is the client's self-report of pain. A pain intensity scale is a reliable tool to identify the client's pain level.
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? -Excessive thirst and urination -Shakiness and diaphoresis -Fever and chills -Hypertension and crackles
Shakiness and diaphoresis When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.
The patient has just started on enteral feedings and is reporting abdominal cramping. Which action will the nurse take next?
Slow the rate of tube feeding
This electrolyte balances the volume of water in the body and promotes nerve and muscle function.
Sodium
The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? Turn her on her side Stop feeding her and place her on NPO Suction her mouth and throat Put on oxygen at 2L/min via nasal cannula
Stop feeding her and place her on NPO
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? -Warm the feeding solution to body temperature. -Place the client in low Fowler's position. -Discard any residual gastric contents. -Test the pH of gastric aspirate.
Test the pH of gastric aspirate. Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations.
Which patient is at more risk for an electrolyte imbalance? -A 5 month old with a fever of 102.4 'F and diarrhea -A 57 year old diabetic with nausea and vomiting -A 2 year old with RSV -A healthy 87 year old with intermittent episodes of gout
The 5 month old with a fever of 102.3 'F and diarrhea Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any other age group. This is because infants have the highest amount of total body fluid (80% of the body is made up of fluid) and if any type of illness especially GI effects the body this increases the chances of an electrolyte imbalance.
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? -The client who has a tracheostomy tube attached to humidified oxygen -The client who has an indwelling urinary catheter to gravity drainage -The client who has a chest tube to water seal -The client who has a nasogastric (NG) tube to suction
The client who has a nasogastric (NG) tube to suction Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.
What type of instructional methods requires rehearsing a desired behavior and allows patients to learn required skills and feel more confident in being able to perform them independently.
role play
A nurse is describing a patient's perceived ability to successfully complete a task. Which term should the nurse use to describe this attribute? active participation attentional set self-efficacy motivation
self-efficacy
Hypervolemia (fluid volume overload)
Too much volume/fluid in the blood Causes: -Excessive intake of fluids -Abnormal retention of fluids -Heart Failure -Renal Failure -Long- term corticosteroid therapy Signs and symptoms: -Pulses full and bounding -Distended neck veins -High BP -Moist crackles -Polyuria/nocturia -Edema possibly Nursing considerations: -Maintain O2 -Position Semi Fowlers to improve gas exchange -Fluid restriction: I & O -Monitor electrolytes to prevent tissue injury -Evaluate feet for edema -Observe suture line on surgical pt (potential for evisceration due to excess fluid retention) -Limit fluid intake
This is the minimum daily fluid requirement for a 45kg patient.
Total 2000 ml 1st 10: 1000mL 2nd 10: 500mL Last 25kg: 500mL
On morning assessment of your patient who has severe burns, you notice that fluid is starting to accumulate in his arms and legs. You note that his weight has not changed and his intake and output is equal. What do you suspect? -Third spacing -This is normal and expected after a burn and it is benign -Document this finding as non-pitting abdominal edema. -Intravascular compartment syndrome
You would suspect third spacing. Third-spacing is the accumulation of trapped extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output values.
A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. In which domain did learning take place?
cognitive
Hypokalemia <3.5
low potassium in the blood Causes: -Potassium Loss (GI losses- diarrhea, vomiting, fistulas, NG suction, NPO status) -Renal losses: diuretics -Skin losses: diaphoresis -Dialysis -Shift of potassium into cells (alkalosis) -Lack of K (starvation, low K diet, failure to include K in parental fluids if NPO/ TPN Symptoms: -Fatigue -Constipation -Muscle Weakness, leg cramps -N+V -Soft, flabby muscles -Dysrhythmias but not life threatening like with hyperkalemia Treatment: -Treat underlying cause -K supplementation ***Never give IV PUSH K)***
A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation method will the nurse use?
return demonstration
A nurse's goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? teaching a woman who had a recent hysterectomy about adoption teaching a family member to provide passive range of motion on a stroke patient teaching a teenager with a broken leg how to use crutches teaching expectant women about changes in child-bearing women
teaching a teenager with a broken leg how to use crutches
This is the single best indicator of fluid status.
weight
A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? develop a problem-solving scenario wrap a bandage around a stuffed animal's ear encourage independent learning use discussion throughout the teaching session
wrap a bandage around a stuffed animal's ear