Unit 1 NUR 104

Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply.

"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

An older adult client who is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply.

"It may take you longer to heal than someone younger." "Eat nourishing foods after surgery to promote healing." "Wound healing can take longer if you have been exposed often to the sun." "Monitor your moods after surgery. Depression after surgery is not normal."

The nursing instructor is having a discussion related to the gastrointestinal (GI) system. Which statements by the students would indicate that the discussion was effective? Select all that apply.

"Movement of the colon is stimulated by the parasympathetic nervous system." "The last part of the large intestine is the rectum, not the anus." "The stool becomes hard if it remains in the large intestine too long."

The nurse is performing a health history for a client who presents to the clinic with abdominal discomfort. Which statements made by the client indicate that the client is at risk for the development of constipation? Select all that apply

"Sometimes I don't have the opportunity to defecate when I need to while I am at work." "I drink about 16 ounces of fluids a day." "I don't like to exercise because I am tired all of the time."

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?

"That is necrotic tissue, which must be removed to promote healing."

Water makes up how much intracellular fluid?

2/3

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32%

Water makes up how much of the body?

50-60% of adult body weight

A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. Upon inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next?

Apply gentle pressure to the tube while pressing the external bumper closer to the skin.

The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's priority action?

Assess the client for signs and symptoms of hypoglycemia.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

Vitamins that make up Vitamin B Complex

B6 B9 B12

What is the most important assessment in understanding cognition?

Baseline level of function

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites.

If deficient in this mineral, it can case tetany (muscle twitching) and osteoporosis

Calcium

Mineral found in dairy products, leafy greens, salmon and tuna

Calcium

Mineral that helps with bone (teeth formation, muscle contraction, clot formation and nerve conduction)

Calcium

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

Corticosteroids

Who would be a part of a patients healthcare team for a nutrition plan?

Dietician Physician Speech Therapist

Who writes the order for the patients diet?

Dietician or Physician

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation.

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding.

Which of the following feeding assitance techniques would you use when assisting a patient who has dysphagia? Select all that apply

Encourage pt to take a 1/2 tsp of food with each bite Encourage pt to swallow twice before eating the next spoonful Encourage the pt is sitting upright with their head slightly tilted forward

A client is reporting increased flatulence which is causing great embarrassment. When creating a plan of care for this client, what interventions will be most helpful to the client to control the excess flatulence. Select all that apply.

Encourage the client to limit the intake of carbonated beverages. Provide smoking cessation education and literature Encourage the client to avoid the use of straws when drinking liquid Inform the client that eating slowly and chewing food well can reduce the incidence of flatulence

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?

Ensure that the client fasts 6 to 12 hours before the test as per policy.

The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order.

Inspection Auscultation Percussion Palpation

If deficient in this mineral, it can cause, anemia, weakness & fatigue

Iron

Mineral found in organ meats, beef, poultry, shellfish, beans and leafy-greens

Iron

Mineral that has oxygen carrying protein

Iron

What are minerals?

Iron Sodium Calcium Potassium

A patient most likely has a ______ deficiency based on _______ and _______ assessment

Iron weakness low hemoglobin

What vitamins are micronutrients?

Iron, Sodium, Calcium, Potassium and water

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

A nurse is assessing middle-age adults living in a retirement community. What behavior would the nurse typically see in the middle-age adult?

Looks inward, accepts life span as having definite boundaries, and has special interest in spouse, friends, and community

A speech-language pathologist ordered a thickened liquid diet for a client diagnosed with dysphagia. Which food items would you find on the client's tray? Select all that apply

Oatmeal Yogurt Hummus

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

If deficient in this mineral, it can cause ECG changes, muscle cramps and weakness

Potassium

Mineral that helps with cardiac muscle contraction, acid-base balance and nerve conduction?

Potassium

What mineral is found in potatoes, veggies, avocados, bananas and oranges?

Potassium

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

Provide oxygen for consistent hypoxia

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Quickly and carefully remove tube while the client breathes out.

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube?

Radiographic confirmation of position

What nursing actions will you do to safely manage her a patients tube feeding?

Raise head of bed 30-45 degrees Confirm placement Check/Measure Gastric Residual Volume Flush tube with water Document

You need to assist a pt who is 2 months post CVA with left-sided weakness and dysphagia. Which side of the pt's mouth should you place the food?

Right side because the muscles of the left side of the mouth are weaker, so placing food on this side increases their risk of aspiration and choking.

If deficient in this mineral, it can cause dizziness, tachycardia and confusion?

Sodium

Mineral found in salt and processed foods

Sodium

Mineral that maintains fluid balance

Sodium

A client receiving a sitz bath starts complaining of light-headedness to the nurse. What is the nurse's most appropriate action?

Stop the sitz bath and call for help

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor(s) will prevent the nurse from administering this type of enema? Select all that apply.

The client has a history of chronic kidney injury The client has an elevated phosphorus level The client has a history of left-sided heart failure

Which of the following assessment findings of a male client age 77 years should signal the nurse to a potentially pathologic finding, rather than a normal age-related change?

The client is oriented to person and place but is unsure of the month

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

What vitamins are fat soluble?

Vit A Vit D Vit K

What vitamins are water soluble?

Vit B6 Vit B9 Vit B12 Vit C

What vitamins are macronutrients?

Vit B6 Vit B9 Vit B12 Vit C Vit A Vit D Vit K

Vitamin found in liver, carrots and fortified milk

Vitamin A

Vitamin that can cause night blindness and rough/dry skin if deficient?

Vitamin A

Which vitamin promotes visual acuity, immune function, cell growth in skin and mucous membranes?

Vitamin A

Vitamin found in salmon, tuna, liver, eggs and animal products

Vitamin B 12 (Cobalamin)

What vitamin causes a deficiency in pernicious anemia

Vitamin B 12 (Cobalamin)

What vitamin is found only in animal foods?

Vitamin B12

Vitamin that promotes RBC formation and neurological function

Vitamin B12 (Cobalamin)

Helps metabolize macronutrients and promotes brain health/immune function

Vitamin B6

Vitamin found in salmon, organ meat, poultry, bananas and broccoli

Vitamin B6

What vitamins can cause microcytic anemia, confusion and lowered immunity

Vitamin B9 & Vitamin B6

Vitamin found in seafood, liver, leafy greens and nuts/seeds

Vitamin B9 (Folic Acid)

Vitamin that promotes red & white blood cell production, DNA/RNA formation and protein metabolism

Vitamin B9 (Folic Acid)

Vitamin found in citrus, strawberries, broccoli and brussel sprouts

Vitamin C

Vitamins that promote wound healing, immune function and iron absorption

Vitamin C

What vitamin can cause delayed wound healing and bleeding if deficient?

Vitamin C

This vitamin if deficient in can cause tetany-hypocalcemia and poor dental/bone health

Vitamin D

Vitamin found in organ meats, fortified milk products, egg yolks and salmon?

Vitamin D

What vitamin that can promote phosphorous & calcium metabolism/calcium absorption?

Vitamin D

If deficient in delayed clotting and bleeding, what vitamin could cause this?

Vitamin K

Vitamin that promotes prothrombin production?

Vitamin K

What vitamin can be found in dark leafy veggies, brussel sprouts and soybean oil?

Vitamin K

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water.

What micronutrient regulates temperature and acts as a lubricant?

Water

The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?

a client who has a fever

The nurse would anticipate a patient with Vitamin D deficiency having a low ________ level because Vitamin D helps _________ ________

calcium absorb calcium

In order to promote wound healing the nurse would recommend eating _________ because it is rich in ___________

chicken protein

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure.

The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply.

cured ham table salt bacon

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

When a client provides a return demonstration of appropriate food selections for carbohydrates, which food does the nurse acknowledge as rich in carbohydrates? Select all that apply.

milk oatmeal bread

A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

niacin

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.

pursed-lip breathing diaphragmatic breathing

What do speech therapists determine?

the consistency of foods the patient can eat

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate?

vegetable plate for a client who practice Hinduism