Module 1 Proctor U
A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk? A) Inspect the integrity of the client's oral mucosa B) Assess the client for nausea C) Assess the client's level of consciousness D) Inspect, auscultate and palpate the client's abdomen
C Decreased level of consciousness greatly increases a client's risk of aspirating; it is imperative that the nurse assess this prior to the client eating. It is appropriate for the nurse to assess the client's mouth and abdomen and assess for nausea, but none of these actions directly address the client's risk of aspiration.
A nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. The nurse knows that the client will likely receive which type of nutrition? A) Nasogastric feed B) Metabolizing nutrition C) Peripheral parenteral nutrition D) Total parenteral nutrition
C The client requires peripheral parenteral nutrition. Peripheral parenteral nutrition provides temporary nutritional support of approximately 2000 to 2500 calories daily. It can meet a client's metabolic needs when oral intake is interrupted for 7 to 10 days, or it can be used as a supplement during a transitional period as a client begins to resume eating. Total parenteral nutrition (TPN) is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. Metabolizing nutrition is a way to replenish and supply water to the body. A nasogastric feed is administered through narrow tubing that is inserted through the client's nose into the stomach.
A nurse calculates the BMI of a patient during a general survey as 26. Under which of the following categories would this patient fall? A) Normal B) Underweight C) Overweight D) Obesity Class I
C BMI values are: Underweight <18.5; normal 18.5 to 24.9; overweight 25.0 to 29.9; obesity class I 30.0 to 34.9; obesity class II 35.0 to 39.9; and extreme obesity 40.0+.
The nurse is providing care for an older adult client who is recovering from pneumonia on the hospital's medical unit. The nurse sets up the client's dinner tray on his overbed table. The client then states, "I won't be having any of this." What is the nurse's most appropriate response? A) "Nutrition will play a big part in how quickly you recover" B) "I'll set your tray aside and warm it up for you later this evening" C) Can you tell me why you don't want to have dinner tonight? D) Did the dietitian meet with you to discuss your nutritional needs?
C If a client does not want to eat, the nurse should begin by assessing the reasons behind the client's decision. This should precede any health education that may be needed. It is appropriate to set aside the tray for later, but assessment should take place first.
When completing an assessment, especially of the older adult, the nurse knows the importance of including spiritual development. Older adults have completed moral development and many experience self-transcendence, which may be defined as what? A) an ability to leave the past behind but still face the future without fear of the unknown B) a state of consciousness with lower levels of tension, anxiety, and increased tolerance of frustration C) capability to reach beyond prior limits with more awareness of other people's values and beliefs D) the ability to traverse life's difficulties with ease
C Self-transcendence in the older adult may be described as the characteristic that helps one expand beyond personal limits, and to reach out to others with greater awareness of other people's beliefs and values. Past and future are more integrated into the present without regret or fear. Transcendence is a source of strength for the older adult faced with inevitable change and loss. The state of consciousness described is transcendental meditation.
An occupational health nurse overhears an employee talking to his manager about a coworker 65 years of age. What would the nurse be concerned about when she hears the employee state "he should retire and make way for some new blood"? A) Intolerance B) Nonspecific prejudice C) Ageism D) Dependence
C) Ageism refers to prejudice against the aged. Intolerance is implied by the employee's statement, but the intolerance is aimed at the coworker's age, making this an incorrect answer. The employee's statement does not raise concern about dependence. The prejudice exhibited in the statement is very specific.
A nurse is performing a home assessment for a 90-year-old widower who lives in a third story apartment. As the nurse considers his home environment, the nurse knows that the greatest risk of injury-related death or disability for the client comes from: A) dementia B) myocardial infarction C) falls D) fire
C) As mobility impairment increases in persons over the age of 65, the risk of falls increases. Hip fractures are a particular risk factor for disability and death.
A nurse is making a home visit to an older adult with multiple chronic health problems. The client is alert and oriented and his cognition is intact. While talking with the client, he reveals that he thinks his son is stealing his social security checks to buy his beer and eat out all of the time. The nurse interprets this statement as possibly suggesting which type of elder abuse? A) Abandonment B) Emotional C) Exploitation D) Physical
C) Exploitation involves illegally taking or misusing the funds, property, or assets of a vulnerable older adult. Physical abuse involves the infliction of pain/injury on a vulnerable older adult, the threat of inflicting such pain or injury, or depriving them of basic needs. Emotional/psychological abuse involves verbal or nonverbal actions causing mental pain, anguish, or distress on the older adult. Abandonment involves desertion of a vulnerable adult by anyone who has assumed responsibility for his care.
A nurse is educating a group of middle adults about health promotion. What statement by one of the participants indicates the need for additional education? A) "I only have one glass of wine a day with dinner." B) "I will beging a smoking cessation program this week." C) "I should eat a diet high in fats but low in fiber." D) "I will make exercise a part of my daily activities"
C) Health promotion activities for the middle adult include a diet low in fat and cholesterol that includes fruits, vegetables, and fiber; regular daily exercise; drinking alcohol in moderation; and no smoking. The client who describes a diet high in fats needs additional instruction.
A client has a nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements. The client's expected outcome is: A) to consume 80% of diet tray for each meal B) to eat dessert after every meal C) to gain 5lb (2.25 kg) in 1 day D) to maintain a clear liquid diet
A Having the client consume 80% of the diet tray with each meal is a measurable and attainable goal for a client to gain weight. A weight gain of 5 lb (2.25 kg) is too much in 1 day. A clear liquid diet is a diet and not a measurable goal. Eating dessert after every meal is not a measurable outcome but an intervention.
A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: A) Fluid and electrolyte levels B) pain level during infusion C) nausea or vomiting D) ability to reposition
A Total parenteral nutrition (TPN) is nutrition administered through a central venous access and is high in nutrients and electrolytes. It is important to assess fluid and electrolyte levels with TPN infusions. Falls are a risk associated with ability to reposition and not TPN. There is no pain associated with TPN infusions as the medication is administered via a central venous access line. Nausea or vomiting are not adverse effects associated with TPN as the medication is administered via a central line and not by a feeding tube in the stomach.
The nurse is caring for a client who has recently had a gastrostomy placed. The nurse's assessment reveals a small amount of leakage from around the appliance. The nurse should choose interventions primarily based on which nursing diagnosis? A) Impaired skin integrity B) Risk for infection C) Risk for imbalance nutrition: less than body requirements D) Risk for acute pain
A Leakage from a gastrostomy site poses a significant threat to the client's skin integrity, due to the low pH of gastric contents. Pain and infection are possible, but the immediate threat to the client's skin integrity is the priority. The client's overall nutritional status will not be affected by a short-term leak.
Based on Havighurst's theory of human development, which nursing intervention would best facilitate the accomplishment of a developmental task of older adulthood? A) helping a client move independently using a walker B) helping a client accept a move to live with a daughter C) helping a client cope with living alone after the death of a spouse D) helping a client become established in the community
A According to Havighurst, the major tasks of old age are primarily concerned with the maintenance of social contacts and relationships. Successful aging depends on a person's ability to be flexible and adapt to new age-related roles. The person must find new and meaningful roles in old age while being reasonably comfortable with the social customs of the times. The only nursing intervention that addresses this theory would be helping a client move independently using a walker.
When completing an assessment of the middle-aged adult, the nurse makes note of the client's cognitive development. Then nurse would expect to find what? A) Increased motivation to learn B) Decreasing ability to focus and solve problems C) Memory processing is quickly reviewed D) Client wants to appear competent
A Cognitive changes such as intelligence change throughout life. The middle aged adult may begin to take a little longer to respond, related to more memories and information to process. They are often more motivated to learn, especially relevant and applicable information.
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching? A) "My husband and I are ordering a product that has megadoses of vitamins" B) "Cooking can change the vitamin contents in foods" C) "I drink orange juice fortified with added calcium" D) "My body does not make its own vitamins"
A Consuming megadoses (amounts exceeding those considered adequate for health) of vitamins and minerals can be dangerous. This statement requires further nursing teaching. The other statements do not require further teaching.
In planning to meet the nutritional needs of a critically ill patient in the intensive care unit, which factor will increase the patient's basal metabolic rate? A) Infection B) Advanced age C) Long periods of sleep D) Prolonged fasting
A 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 caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site? A) If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. B) If the gastrostomy tube is new, dip a cotton-tipped applicator into hydrogen peroxide and apply pressure to clean the site. C) If the gastrostomy tube is new and has crusts or drinage, do not disturb the site by cleaning it. D) Adjust or lift the external disk for the first few days after placement to keep crusts from forming.
A If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area.
A nutritionist helps to plan a diet for a patient with type 2 diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? A) Oatmeal B) Milk C) Nuts D) Eggs
A Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in diabetics. Milk, eggs, and nuts are proteins.
A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition? A) Total parenteral nutrition (TPN) B) Partial or peripheral parenteral nutrition (PPN) C) Percutaneous endoscopic jejunostomy tube (PEJ) D) Percutaneous endoscopic gastrostomy tube (PEG)
A TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein. PPN is nutritional therapy used for clients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. A PEG is a surgically placed gastrostomy tube. A PEJ is a surgically placed jejunostomy tube.
What independent nursing intervention can be implemented to stimulate appetite? A) Encourage or provide oral care B) Recommend dietary supplements C) Administer prescribed medications D) Assess manifestations of malnutrition
A 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. Administering medications and recommending dietary supplements are useful but are not independent nursing actions. The health care provider would need to prescribe the medications. Assessing manifestations of malnutrition occurs after malnutrition is recognized.
A middle adult client requests visits by the hospital chaplain and reads the Bible each day while hospitalized for treatment of heart problems. What is the individual illustrating? A) Trust in spiritual strength B) Support of the rights of others C) Fear for the future D) Midlife transition
A) The middle adult, according to Fowler's theory of spiritual development, is less rigid in his or her beliefs and has increased faith in a supreme being, as well as trust in spiritual strength. The client is not experiencing a fear of the future or supporting the rights of others. The client is experiencing a midlife transition but it is focusing on spiritual strength of Fowler's theory.
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. A) Cured ham B) Bacon C) Table salt D) Whole milk E) Whole wheat pasta F) Egg yolks
A, B, C Sodium is found in higher concentrations in table salt, bacon, and processed meats. The other choices do not have a high concentration of sodium.
A home health care nurse is educating a client and caregivers on how to administer an enteral feeding. Which teaching points are appropriate? Select all that apply. A) Check for leaking of gastric contents around the insertion site (e.g., is the guard too loose or balloon not filled adequately?) B) Clean around the gastric tube with soap and water, making sure it is adequately rinsed. C) Keep the head elevated while delivering a gastric feeding and for approximately 1 hour after the feeding. D) When checking residuals, routinely discard residuals to prevent an acid-base imbalance. E) Mark gastrostomy tubes with an indelible marker and check the mark to make sure it is at the level of the abdominal wall. F) When cleaning around a gastric tube insertion site, be careful not to rotate the guard after cleaning around it.
A, B, C, E The teaching points that the home health care nurse would include in an education plan would be: checking for leaking of gastric contents around the insertion site; cleaning around the gastric tube site with soap and water; keeping the head elevated while delivering a gastric feeding; and marking the tube with a marker, then checking that the mark is at the level of the abdominal wall.
A nurse working in a community clinic assists middle-age clients to follow guidelines for health-related screenings and immunizations. What preventive measures would the nurse recommend for this population? Select all that apply. A) Breast self-examination every month for women B) Pelvis examination and pap test at least every 3 years for women C) Clinical skin examination every 3 years D) Zoster vaccine live for adults 50 years and older E) Prostate-specific antigen (PSA) test every year for men F) A physical exam every year from age 40 on
A, B, D, E, F The nurse would recommend several different preventive measure that are listed. The nurse would recommend that the client have a physical exam every year from age 40 on; that the female client do a breast self-examination every month; a pelvic examination and Pap test at least every 3 years for women; a prostate-specific antigen (PSA) test every year for men; and a Zoster vaccine live vaccination for adults 50 years and older. The nurse would recommend a clinical skin examination every year.
The nurse is caring for older adult in an assisted care facility. What information about the older adult client should the nurse consider when caring for this population? Select all that apply. A) Observe for symptoms of depression since many clients go undiagnosed B) Some clients with dementia may experience sundowning syndrome and safety is a priority. C) Medication should be closely monitored for polypharmacy D) All older adults experience delirium when they are hospitalized E) Delirium experience by a client is a permanent state of confusion F) A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences.
A, B, F Several of the statements listed are true statements. Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark. Depression is a prolonged or extreme state of sadness occurring in many older adults. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. There were three statements that were not true. First, delirium is not a permanent state of confusion occurring in older adulthood. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. Polypharmacy does not look at the number of pharmacies used to obtain prescriptions but the amount of drugs prescribed by health care providers for a variety of medical conditions. Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Complicated regimens need careful review to minimize risks and complications and maximize benefits.
A home care nurse is visiting one of her elderly clients. Which of the following does the nurse do to screen from chronic illnesses common to the elderly? Select all that apply. A) Monitor blood pressure B) Assess visual acuity C) Assess joint mobility and presence of pain D) Perform blood glucose monitoring E) Assess skin turgor
A, C, D In the older adult, the most commonly encountered chronic disorders are hypertension (monitor blood pressure), arthritis (assess joint mobility and presence of pain), heart disease, cancer, diabetes (perform blood glucose monitoring), and sinusitis. Assessing skin turgor and visual acuity, which often decrease in the older adult, does not provide information about these chronic conditions.
A nurse is providing care to an older adult with moderate cognitive impairment. When interacting with the client, which actions would be most appropriate? A) call the client by name B) speak in a loud tone of voice C) ask the client "do you remember me?" when interacting D) Avoid identifying yourself each time E) Use short, simple words when conversing with the client
A, E When communicating with a client who is cognitively impaired, the nurse should identify himself with every interaction, call the client by name, use short, simple words and sentences and speak slowly, softly, and calmly. The nurse should also turn questions into answers; for example, rather than asking the client if he has to go to the bathroom, say, the bathroom is right here.
A client resides in a long-term care facility. Which nursing intervention would promote increased dietary intake? A) Discourage family from visiting during meals B) Encourage the client to eat in the dining room C) Allow the client to eat when they want to D) Feed the client their meal while in bed
B Encouraging the client to eat in the dining room will allow for socialization during meal time. This will have a positive effect on the amount of food consumed and provide enjoyment. Feeding the client in bed encourages isolation from other residents. Allowing the client to eat whenever they want does not support socialization. Discouraging the family is not recommended, as the family can provide support and be assistive to the client and their food needs.
Which of the following laboratory results indicates the presence of malnutrition? A) Hematocrit (Hct) 56% B) Serum albumin 2.8g/dL C) Creatine 1.9mg/dL D) Hemoglobin (Hgb) 11.3 g/dL
B Increased Hct indicates dehydration.
Erikson identified ego integrity vs. despair and disgust as the last stage of human development, which begins at about 60 years of age. Which intervention would best foster older clients' ego integrity? A) Promoting independent living B) Encouraging life review C) Distracting the client D) Praising the client
B The intervention that would best foster older clients' ego integrity would be encouraging life review. Older adults search for emotional integration and acceptance of the past and present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon, called life review or reminiscence, has been identified worldwide. In a sense, this is a way for an older adult to relive and restructure life experiences and is part of achieving ego integrity. Integrity vs. despair and disgust would not be fostered by distracting the client, praising the client, or promoting independent living.
Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor? A) "Semi-vegetarians exclude red meat from their diet and seek protein elsewhere." B) "According to research, vegetarians have a higher incidence of obesity than others" C) "Colorectal cancer is not as common in vegetarians compared to people who eat high fat diets" D) "Protein complementation is important to help the client get the needed amino acids"
B Vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Protein complementation helps a client get amino acids needed. Vegans rely solely on plant sources for protein; semi-vegetarians exclude only red meat from their diet.
Which of the following is a fat-soluble vitamin? A) Vitamin B6 B) Vitamin E C) Vitamin C D) Vitamin B12
B Vitamin E is a fat-soluble vitamin.
The nurse performs gastrostomy site care and notes drainage. What action does the nurse take? A) Clean the site with hydrogen peroxide B) Place a drain sponge under the external bumper C) Administer an antibiotic ointment to the site D) Notify the health care provider
B When the nurse notes drainage, a precut sponge or gauze is placed around the tube for comfort and to prevent irritation. Drainage is a normal finding. The health care provider is notified if the drainage has an odor, appears infected, or looks like the feeding solution being administered. Gastrostomy sites are no longer cleansed with hydrogen peroxide as this disrupts healing. Antibiotic ointments have not been found to be useful and are not used.
An elderly patient has come in to the clinic for her yearly physical. The patient tells the nurse that she is having difficulty with bowel movements. What intervention could the nurse suggest? A) Adequate privacy B) Increasing intake of water C) Increasing caloric intake D) Stress reduction
B) Age-related changes, as well as additional risk factors such as disease and the effects of medications, can result in a negative impact on function. Constipation is a common problem in aged people. The nurse should assess the patient for frequent laxative and antacid use, which is associated with constipation. The patient should eat high-fiber foods, drink eight to 10 glasses of water daily, and establish regular bowel habits. Interventions the nurse would not suggest are stress reduction, eating more, or insuring adequate privacy.
While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude? A) These are abnormal observations and must be reported B)These are normal physiologic changes of aging C)The observations are not typically found in older adults D)Extra education will be necessary to prevent complications
B) Dry wrinkled skin, gray hair, and needing glasses to read are all commonly occurring and normal physiologic changes of aging. They are not abnormal and no additional education is necessary as the changes observed do not lead to complications.
Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? A) Arranging for social services to assist with meals for a homebound client B) Encouraging a client to have regular checkups C) Providing entertainment for a client on bedrest D) Counseling a client who complains of being depressed
B) Gould viewed the middle years as a time when adults look inward (ages 35 to 43); accept their lifespan as having definite boundaries, and have a special interest in spouse, friends, and community (ages 43 to 50); and increase their feelings of self-satisfaction, value spouse as a companion, and become more concerned with health (ages 50 to 60). The nursing action that best facilitates this process would be encouraging a client to have regular checkups.
The home health nurse is making an initial home visit to a male widow age 76 years. During the assessment the nurse finds that the client is taking multiple medications. The client states that he has also been taking some herbal remedies. What should the nurse be sure to include in the client education? A) Herbal remedies are holistic B) Inform the physician and pharmacist about the herbal remedies C) Herbal remedies are often cheaper than prescribed medicine D) It is important to avoid herbal remedies
B) Herbal remedies combined with prescribed medications can lead to interactions that may be toxic. Clients should notify the physician and pharmacist of any herbal remedies they are using. Even though herbal remedies are considered holistic, this is not something that is necessary to include in the client education. Herbal remedies may be cheaper than prescribed medicine but this is also not necessary to include in the client education. For most individuals it is not necessary to avoid herbal remedies.
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which should the nurse educate the client about regarding TPN therapy? Select all that apply. A) TPN is an isotonic solution B) TPN has a high glucose concentration C) TPN has three primary components: proteins, carbohydrates, and fats D) Lipids are added to decrease caloric value E) TPN requires a PICC line or central venous access
B, C, E Total parenteral nutrition (TPN) has three primary components: proteins, carbohydrates, and fats; it also has a high glucose concentration. TPN does require a PICC line or central venous access. TPN is a hypertonic solution. Lipids or fats are added to add caloric value to meet energy requirements.
Which of the following are physical changes that occur in middle adulthood? Select all that apply. A) The skin is more elastic B) Muscle mass gradually decreases C) Body fat is redistributed D) Cardiac output begins to increase E) There is a loss of calcium from bones
B, C, E In middle adulthood, fatty tissue is redistributed; men tend to develop abdominal fat, women thicken through the middle, and the skin is drier. Also, cardiac output begins to decrease; muscle mass, strength, and agility gradually decrease; there is a loss of calcium from bones, especially in perimenopausal women; and hormone production decreases, resulting in menopause or andropause.
The middle adult is sometimes called the "sandwich generation". According to Erikson, the developmental task of the middle adult is what? A) Initiative versus guilt B) Ego-integrity versus dispair C) Generativity versus stagnation D) Goal attainment versus crisis
C) The developmental task of the middle adult is "generativity versus stagnation." They are in a stage of guiding the next generation, accepting their own changes and adjusting to need of aging parents, as well as evaluating their own goals and accomplishments. "Initiative versus guilt" is the developmental task for toddlers. "Ego integrity versus despair" is the developmental task for older adults. "Goal attainment versus crisis" is not a developmental task.
A nurse educates adults in preventive measures to avoid problems of middle adult years. Which of the following are the major health problems during the middle adult years? A) Upper respiratory infections, fractures B) Sexually transmitted infections, drug use C) Cardiovascular disease, cancer D) Communicable diseases, dementia
C) The major health problems of the middle adult years are cardiovascular and pulmonary diseases, cancer, rheumatoid arthritis, diabetes, obesity, alcoholism, and depression. The risk for these health problems often depends on a combination of lifestyle factors and aging. Any age group can have issues related to upper respiratory infections, fractures, sexually transmitted infections, and drug use. The pediatric population are at risk for communicable diseases (if not vaccinated). Dementia is a disease of the older adult.
The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate? A) administer a high-protein diet B) place the client on calorie restriction C) arrange for total parenteral nutrition (TPN) D) Increase the client's fluid intake
D Dehydration can cause increases in hematocrit, BUN, and creatinine. Calorie restriction, increased protein intake, and TPN are not indicated by these laboratory data.
The nurse is providing care for a client whose abdominal fistula has necessitated the use of total parenteral nutrition (TPN). What action should the nurse implement in the care of this client? A) add medications to the TPN solutions only after dissolving them in sterile water B) flush the client's central line with 30 to 60 mL of sterile water every 4 hours. C) Change the bag of TPN solution at least every 72 hours D) Use a pump to administer the client's TPN.
D TPN must always be administered with a pump. Central lines that are in use do not require flushing, and central lines in all circumstances are not normally flushed with sterile water. Medications may only be added by pharmacy prior to administration of the solution. TPN bags are changed a minimum of every 24 hours.
A client has a gastrostomy tube in place for intermittent tube feedings. What action should the nurse take prior to administering a tube feeding to ensure that the tube has not migrated? A) Inject water into the tube and assess if any comes out of the insertion site B) test the pH of the gastric aspirate C) Inject air and listen to see if sounds are heard for correct placement D) mark the length of tube and assess if it at the level of the abdomen
D The nurse would regularly make comparisons of the length of the tube to be sure it is still correctly in place. The nurse would not continue to regularly compare gastric fluid, pH, or air pressure.
A nurse is caring for a young adult female client who has a folic acid deficiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A) Impaired neuromuscular functioning B) Hemolysis of red blood cells C) Inadequate absorption of calcium and phosphorus D) Neural tube deficits in the fetus
D Folic acid deficiency in pregnant women can lead to neural tube deficits like spina bifida in the fetus. Because fetal neural development begins so early in pregnancy, women in their childbearing years must have adequate folic acid intake. Deficiency in vitamin D intake leads to inadequate absorption of calcium and phosphorus and a deficiency of mineralization in bones and teeth. Increased hemolysis of red blood cells, poor reflexes, impaired neuromuscular functioning, and anemias are signs of vitamin E deficiency, not folic acid deficiency.
The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? A) Offer nutritional supplements and explain the potential benefits of each B) Offer larger meals and encourage the client to eat as much as is comfortable C) Reduce the frequency of meals in order to allow the client to develop an appetite D) Try to ensure that the client's food is attractive and sufficiently warm
D Food in the health care setting can often be unattractive and cool. Ensuring that it is appealing to the eyes and presented at the correct temperature can stimulate the client's appetite. Meals should be small and more frequent, not less frequent and larger. Supplements may be nutritionally necessary, but these do not act to increase the client's appetite.
When assessing a client during the middle adult years, the nurse recognizes which of the following as a normal physical change? A) Increased oil levels in the skin B) Increased levels of energy C) Increased cardiac output D) Increased loss of calcium from the bones
D Some physical changes common during the middle adult years include increased fatigue, decreased cardiac output, increased loss of calcium from the bones, and decreased oil levels (resulting in dry skin).
Which situation would lead the client's family to suspect onset of dementia? A) The client has not attended church services in a month B) The client has experienced confusion with two new medications C) The client has increasingly experienced disorientation to familiar surroundings D) The client's air-conditioning is broken and he has not reported it
D) Dementia is a progressive cognitive disorder in older adults, characterized by increased forgetfulness, impaired judgment, progressive confusion, and disorientation. Other reasons may exist for the client not reporting a broken air-conditioner (e.g., financial) or not attending church (e.g., time or transportation). So these situations may not necessarily be related to dementia. Confusion, or delirium, can be an adverse effect of medications. This condition is temporary and can be resolved by stopping the use of the medication.
The nurse is evaluating a 42-year-old client who says that he is feeling stressed. Which of the following does the nurse know that could be a cause of stress for this age group? A) Retirement B) Losing driving privileges C) Social isolation D) Being caught in the sandwich generation
D) Middle-aged adults may be caught in a "generation sandwich," which includes involvement with children as well as aging parents and other family members. Retirement, the loss of driving privileges, and social isolation are often stressors for the older adult.
When the home care nurse visits a female client age 78 years who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. The nurse should assess the client for symptoms of: A) Drug overdoes B) Presbyopia C) Fatigue D) Depression
D) Symptoms of depression include poor cognitive performance, sleep problems, and lack of initiative.
Which nursing actions follow guidelines for preventing complications with enteral feedings? Select all that apply. A) give large, infrequent feedings B) check the residual before intermittent feedings and every 8 hours during continuous feedings C) change the delivery set every other day according to agency policy D) elevate the head of the bed at least 30 degrees during the feeding and for at least 1 hour afterward E) flush the tube before and after feeding F) clean and moisten the nares every 4 to 8 hours
D, E, F The head of the bed should be elevated at least 30 degrees during the feeding and for at least 1 hour afterward to prevent the potential of aspiration. The nurse would flush the tube before and after feeding to prevent the tube from potentially clotting. The nurse would clean and moisten the nares every 4 to 8 hours. The nurse would not give large, infrequent feedings, as the body cannot process the feedings with this type of schedule. The delivery set would be changed more often than every other day due to infection control issues. The nurse would check the residual before intermittent feedings, and every 4 to 6 hours during continuous feedings.
