EAQ: Basic care and comfort

A client on hospice care is receiving palliative treatment. Which is the goal of palliative care for this client?

Palliative care is aimed at relieving discomfort without curing the problem

A client has a mean arterial blood pressure (MAP) of 97 mm Hg and an intracranial pressure (ICP) of 12 mm Hg. Calculate the cerebral perfusion pressure (CPP) for this client.

Rationale The CPP can be calculated by the following equation: CPP = MAP - ICP. If the MAP is 97 mm Hg and ICP is 12 mm Hg, the CPP is 85 mm Hg.

Which statement is applicable to Watson's theory of transpersonal caring?

Defines the outcome of nursing activity in relation to the humanistic aspects of life. Rationale Watson's theory of transpersonal caring defines the outcome of nursing activity in relation to the humanistic aspects of life. The Roy adaptation model views the client as an adaptive system. The Neuman systems model is based on stress and the client's reaction to the stressor. Leininger's theory focuses on cultural diversity; the goal of nursing care should be to provide the client with culturally specific nursing care.

During an 8-hour shift a client drinks two 6-oz (180-mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client's fluid balance during this 8-hour period?

Rationale 235 mL is the correct calculation. The client's intake was 360 mL (12 oz × 30 mL = 360 mL), and the loss was 125 mL of fluid; 360 mL - 125 mL = 235 mL.

B (niacin) 3 B (thiamine) 1 B (riboflavin) 2 B (pyridoxine)

What is vitamin B3 best for? It helps keep your nervous system, digestive system, and skin healthy. Niacin (vitamin B-3) is often part of a daily multivitamin, but most people get enough niacin from the food they eat. Foods rich in niacin include yeast, milk, meat, tortillas, and cereal grains. Vitamin B1, or thiamin, helps prevent complications in the nervous system, brain, muscles, heart, stomach, and intestines. It is also involved in the flow of electrolytes into and out of muscle and nerve cells. Vitamin B2 and Health Riboflavin works to reduce oxidative stress and inflammation of nerves, which are contributors to migraine headaches. The vitamin is also needed for normal mitochondrial activities; migraines are sometimes caused by mitochondrial abnormalities in the brain. Vitamin B-6 (pyridoxine) is important for normal brain development and for keeping the nervous system and immune systems healthy. Food sources of vitamin B-6 include poultry, fish, potatoes, chickpeas, bananas, and fortified cereals.

In which parts of the kidney are glucose and amino acids reabsorbed?

Rationale Glucose, amino acids, electrolytes, and bicarbonate are reabsorbed in the proximal tubule. In distal tubules, water and bicarbonate are reabsorbed, but not glucose and amino acids. Sodium and chloride are reabsorbed in the ascending limb, and water in the descending loop, of the Loop of Henle. Water is reabsorbed in the presence of antidiuretic hormone in the collecting duct.

A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns require about 73 mL of fluid per pound (454 g) of body weight each day. In light of this information, approximately how much formula would the infant receive at each feeding?

Rationale Infants require about 73 mL of fluid per pound (454 g) and 60 calories a day per pound (454 g) for growth. The infant's weight of 6 lb × 73 mL of fluid = 438 mL (2722 g/454 g × 73 mL = 438 mL). If fed every 4 hours the infant will have six feedings: 438 ÷ 6 = 73 mL; 73 ÷ 30 (30 mL/oz) = 2.4 oz (73 mL per feeding).

Which functional level of trauma center is involved in providing a full continuum of trauma services?

Rationale Level I trauma centers provide a full continuum of trauma services for all clients. Level II trauma centers provide care for most injured clients. Level III centers are able to stabilize clients with major injuries, but must transport clients if needs exceed resource capabilities. Level IV trauma centers are usually involved in providing basic trauma client stabilization and advanced life support within the resource capabilities. They are also responsible for the transfer of clients if need exceeds the resource competencies.

The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. How would the edema be documented?

A grade of 4+ indicates an 8-mm depression. A grade of 1+ indicates a 2-mm depression. A grade of 2+ indicates a 4-mm depression. A grade of 3+ indicates a 6-mm depression.

The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m ?

Rationale A BMI between 25 and 29.9 kg/m places the client in the overweight category. A BMI of 30 kg/m is considered obese. A normal BMI is between 18.5 kg/m and 24.9 kg/m . A BMI below 18.5 kg/m is considered underweight.

In which location would the Doppler ultrasound transducer be placed to best auscultate fetal heart tones when the fetus is in the right occiput posterior (ROP) position?

Rationale Fetal heart tones are best auscultated through the fetal back. In this case the presenting part is in the ROP position; the back is below the umbilicus and on the right side. Above the umbilicus in the midline is the placement that should be used when the fetus is lying in the midline in a breech position. Placement above the umbilicus on the left side is appropriate when the fetus is in the left sacrum anterior position. Placement below the umbilicus near the left groin is appropriate when the fetus is in the left occiput anterior or left occiput posterior position.

The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water was administered initially and then repeated × 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output?

Rationale Intake: Gastric tube: 250 × 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL. I &O difference: 1100 - 605 = 495 mL

Which nursing interventions indicate client care that supports physical functioning?

Rationale Providing interventions to maintain the client's nutritional status and providing interventions to maintain the client's regular bowel patterns are interventions that support physical functioning.

Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client's skin?

Rationale A nodule is an elevated solid lesion greater than 0.5 cm in diameter. A papule is an elevated solid lesion less than 0.5 cm in diameter. A vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.

When the nurse arrives at 8:00 AM, a client has a 1000-mL bag of D W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 AM the health care provider changed the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 PM to the end of the 12-hour shift at 8:00 PM, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters would the nurse document as the client's total fluid intake for the 12-hour shift?

Rationale Between 8:00 AM and 11:00 AM, 100 mL per hour were infused. Between 11:00 AM and 8:00 PM, 75 mL per hour were infused. A half cup is 4 oz, and each ounce is equivalent to 30 mL, so the juice, tea, and gelatin each provided 120 mL. Water intake was 180 mL. The 450 mL infused during the prior shift would not be included. The secret is from 11a - 8p (75 mL x 9 )

A client with cor pulmonale?

Rationale Cor pulmonale is right-sided heart failure caused by pulmonary hypertension secondary to chronic obstructive pulmonary disease. The client will have clinical manifestations of right-sided heart failure such as neck vein distension, peripheral edema, hepatomegaly with right upper quadrant tenderness and elevated BNP due to atrial enlargement. Weight gain would be expected because of fluid retention. Chronic hypoxemia in cor pulmonale leads to polycythemia with increases in hemoglobin and hematocrit and increased blood viscosity.

Which hormone would the nurse identify as inhibiting insulin and glucagon secretion? Amylin Somatostatin Triiodothyronine (T ) 3 Pancreatic polypeptide

Rationale Somatostatin is a hormone that inhibits insulin and glucagon secretion, as well as growth hormone, thyroid stimulating hormone, and cholecystokinin. Amylin decreases glucagon secretion, but not insulin; it also decreases gastric motility and endogenous glucose release from the liver. Triiodothyronine (T ) regulates the metabolic rate of all cells and processes of cell growth and tissue differentiation; it does not influence insulin and glucagon secretion. Pancreatic polypeptide affects the regulation of pancreatic exocrine function and metabolism of absorbed nutrients.

The nurse working the 7 AM to 3 PM shift is caring for an adolescent for whom intake and output are being monitored. The primary health care provider prescribes an intravenous infusion to be administered at a rate of 50 mL/hr. The adolescent had 4 oz (120 mL) of milk and a muffin for breakfast at 8:30 AM. At 9 AM the adolescent vomited 200 mL. At 10 AM the adolescent had 60 mL of water with medications. At 11 AM the adolescent voided 550 mL of urine. For lunch, at 12:30 PM, the adolescent ate 3 oz (90 mL) of soup and 4 oz (120 mL) of ice cream. The adolescent voided 450 mL at 2 PM. Calculate the adolescent's total intake for the 7 AM to 3 PM shift.

Rationale The client had 120 mL of milk (1 oz = 30 mL) at 8:30 AM, 60 mL of water with medications at 10 AM, 90 mL of soup at 12:30 PM, 120 mL of ice cream at 12:30 PM (counted as a liquid—it melts at room temperature), and 400 mL of IV fluid (50 mL × 8 hours = 400) for a total intake of 790 mL. Do not include the client's emesis or urine in the intake.

A client is prescribed a 1500-calorie diet. For breakfast, the client consumes 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat), ¾ cup cornflakes (15 grams of carbohydrate, 2 grams of protein), and half an orange (5 grams of carbohydrate). How many calories will the nurse document that the client has ingested?

Rationale The client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram. The total carbohydrate calories are 32 × 4 = 128. The total protein calories are 10 × 4 = 40. The total fat calories are 10 × 9 = 90; 128 + 40 + 90 = 258 calories

At the beginning of the shift at 7:00 AM, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 AM the health care provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution would the client have received by the end of the 8-hour shift?

Rationale The client will have absorbed 313 mL of solution before the health care provider changes the prescription (2.5 hours × 125 mL/hour = 312.5, rounded up to 313); for the remaining 5.5 hours of the shift, the client will have received 550 mL (5.5 hours × 100 mL/hour), for a total of 863 mL.

As a component of a client's routine physical examination, the nurse calculates the client' s body mass index (BMI). The client' s weight is 65 kg, and the height is 1.7 meters. What is the client' s BMI?

Rationale The formula for BMI is weight in kg ÷ (height in meters) . The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9.

What is the body mass index (BMI) of a child who weighs 16.36 kg and is 42 inches tall?

Rationale To calculate BMI, first convert the child's height to meters. One inch equals 2.54 cm, so the child would be 106.68 cm ( move decimal to the left 2 places) for 1.07 m tall. To find the child's BMI, divide the weight in kg by the height squared in meters. 16.36 / (1.07) squared 16.36 / 1.14 14.35

A school-aged child with acute glomerulonephritis has fluid intake restricted to the previous day's output plus 40 mL. The child's output over the past 24 hours was 140 mL. From 3:00 PM to 11:00 PM the child is to receive one-third of the total daily fluid permitted. How much fluid would the nurse provide for the evening intake?

60 mL Rationale The child should receive 60 mL from 3:00 PM to 11:00 PM. 40 mL + 140 mL = 180 mL per day. There are three 8-hour segments in a day; 180 divided by 3 equals 60 mL for the 8-hour segment from 3:00 PM to 11:00 PM. The amounts of 70, 80, and 90 mL are all more than the amount of fluid the child may safely receive.

A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1 kg). How many milliliters of fluid has the client retained?

One liter of fluid equals 1000 mL; each liter of fluid is equal to 1 kg of weight. 82.1 kg - 79.4 kg = 2.7 kg = 2700 mL.