health alterations exam 3 prepus

A nurse is teaching an older adult client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? "I need to drink 2 to 3 liters of fluids every day." "I should exercise four times per week." "I should eat a fiber-rich diet with raw, leafy vegetables, unpeeled fruit, and whole grain bread." "I need to use laxatives regularly to prevent constipation."

"I need to use laxatives regularly to prevent constipation." Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.

Nurse Russell is preparing to give a total parenteral nutrition using a central line. Place the following steps for administration in the correct order? 1. Connect the tubing to the central line. 2. Regulate the electric infusion pump at the ordered rate. 3. Maintain aseptic technique when handling the injection cap. 4. Check the solution for cloudiness, particles, or a change in color. 5. Prime the IV tubing through an infusion pump. 6. Select and flush the correct tubing and filter. A. 4, 3, 5, 6, 1, and 2. B. 6, 4, 5, 1, 3, and 2. C. 4, 6, 5, 3, 1, and 2. D. 3, 4, 6, 1, 5, and 2.

4, 6, 5, 3, 1, and 2

A nurse observes the client receiving fat emulsions is having hives. A nurse reviews the client's history and note in which of the following may cause about by the complaint of the client? A. Allergy to an egg. B. Allergy to peanut. C. Allergy to shellfish. D. Allergy to corn

A. Allergy to an egg Fat emulsions (lipids) contain egg yolk phospholipids and should not be given to clients with egg allergies.

A nurse is preparing to hang a fat emulsion (lipids) and observes some visible fat globules at the top of the solution. The nurse ensure to do which of the following actions? A. Take another bottle of solution. B. Runs the bottle solution under a warm water. C. Rolls the bottle solution gently. D. Shake the bottle solution vigorously.

A. Take another bottle of solution Fat emulsions are used as dietary supplements for patients who are unable to get enough fat in their diet, usually because of certain illnesses or recent surgery. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or the accumulation of froth. The nurse should not hang a fat emulsion if any of these observed and should return the solution to the pharmacy.

A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation? Obtain medical and allergy history. Obtain complete food history. Assist client to increase dietary fiber. Provide adequate quantity of food.

Assist client to increase dietary fiber. Explanation: The nurse should assist the client to increase the dietary fiber in food because it helps reduce constipation. Providing an adequate quantity of food is necessary in maintaining sufficient nutrition and in sustaining normal body weight. Obtaining medical, allergy, and food history would provide valuable information, however, it would not help reduce constipation.

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse? Stops the admixture while the fat emulsion infuses Attaches the fat emulsion tubing to a Y connector close to the infusion site Connects the tubing for the fat emulsion above the 1.5 micron filter Starts a peripheral IV site to administer the fat emulsion

Attaches the fat emulsion tubing to a Y connector close to the infusion site Explanation: An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Putting slippers on the client's feet Crossing the client's ankles every 2 hours Attaching braces or splints to each foot and leg Placing hand rolls on the balls of each foot

Attaching braces or splints to each foot and leg Explanation: Attaching braces or splints to each foot and leg prevents foot drop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent foot drop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment.

A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? Chronic constipation with sporadic bouts of diarrhea Blood and mucus in the stool Client is awakened from sleep due to abdominal pain. Weight loss due to malabsorption

Chronic constipation with sporadic bouts of diarrhea Explanation: Most clients with irritable bowel syndrome (IBS) describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.

Which term refers to a state of microorganisms being present within a host without causing host interference or interaction? Immune Infection Colonization Susceptible

Colonization Explanation: Understanding the principle of colonization facilitates interpretation of microbiologic reports. A susceptible host is one that does not possess immunity to a particular pathogen. An immune host is one that is not susceptible to a particular pathogen. Infection refers to host interaction with an organism.

A client is receiving nutrition via parenteral nutrition (PN). A nurse assess the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia? A. High-grade fever, chills, and decreased urination. B. Fatigue, increased sweating, and heat intolerance. C. Coarse dry hair, weakness, and fatigue. D. Thirst, blurred vision, and diuresis.

D. Thirst, blurred vision, diuresis Signs of hyperglycemia include excessive thirst, fatigue, restlessness, blurred vision, confusion, weakness, Kussmaul's respirations, diuresis, and coma when hyperglycemia is severe. Option A are signs of infection. Option B are signs of hyperthyroidism. Option C are signs of hypothyroidism.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. Daily weights Strict bedrest Calorie counts for oral nutrients Daily transparent dressing changes Intake and output monitoring

Daily weights Intake and output monitoring Calorie counts for oral nutrients Explanation: For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.

The following appears on the medical record of a male patient receiving parenteral nutrition:WBC: 6500/cu mmPotassium 4.3 mEq/LMagnesium 2.0 mg/dLCalcium 8.8 mg/dLGlucose 190 mg/dLWhich finding would alert the nurse to a problem? Potassium level Glucose level Magnesium level White blood cell count

Glucose level Explanation: Of the values listed, only the glucose level is above normal, indicating hyperglycemia, a potential complication of parenteral nutrition.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? Hang a solution of dextrose 10% and water until the new solution is available. Begin an infusion of normal saline in another site to maintain hydration. Have someone go to the pharmacy to obtain the new solution. Slow the current infusion rate so that it will last until the new solution arrives.

Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency.

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next? Obtain a transfer board to ease the change. Have the patient lie back down. Encourage the patient to take deep breaths. Have the patient stand up immediately.

Have the patient lie back down. Explanation: The patient is exhibiting signs of orthostatic hypotension and cerebral insufficiency from the change in position. The best action would be have the patient lie back down because he or she is not tolerating the change in position. Taking deep breaths would be ineffective in raising the patient's blood pressure or increasing the blood supply to the brain. Having the patient stand up immediately would worsen the patient's symptoms. Using a transfer board would have no effect on the patient's symptoms, which are from the change in position.

The nurse prepares to assess a patient with fatigue.When completing the health history, the nurse should focus on which data?

current medications

After teaching a group of students about irritable bowel syndrome (IBS) and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an antidiarrheal agent commonly administered for IBS? Loperamide Dicyclomine Lubiprostone Peppermint oil

Loperamide Explanation: Loperamide is an opiate-related antidiarrheal agent. Lubiprostone is used to treat constipation; it activates chloride channels in the gastrointestinal tract to increase gastrointestinal transit. Dicyclomine, a smooth muscle antispasmodic agent, is used to treat pain accompanying IBS. Peppermint oil may also be taken to ease discomfort.

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address? Moisture Skin color Tissue perfusion Drainage

Moisture Explanation: Although skin color, tissue perfusion, and drainage are important assessment areas to address, the Braden scale uses the following categories to predict pressure ulcer risk: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide? Extend the legs with a firm support under the popliteal area. Position the trunk so that hip flexion is minimized. Place the uppermost hip slightly forward in a position of slight abduction. Align the lower extremities in a neutral position.

Place the uppermost hip slightly forward in a position of slight abduction. Explanation: Supporting the patient in a 30-degree side-lying position avoids pressure on the trochanter. In older adult patients, frequent small shifts of body weight may be effective. Placing a small rolled towel or sheepskin under a shoulder or hip allows a return of blood flow to the skin in the area on which the patient is sitting or lying. The towel or sheepskin is moved around the patient's pressure points in a clockwise fashion. A turning schedule can help the family keep track of the patient's turns.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pneumonia Panic attack Congestive heart failure Pulmonary edema

Pulmonary edema Explanation: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers? Lifting rather than sliding the patient when repositioning her Repositioning the patient about once a shift Using a static support device on the patient's bed Lubricating the skin with a non-irritating lotion

Repositioning the patient about once a shift Explanation: Turning should occur every 1 to 2 hours — not once a shift — for patients who are in bed for prolonged periods. The nurse should apply a non-irritating lotion, use static support devices to relieve pressure, and lift rather than slide the patient when repositioning to reduce shearing forces.

She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? Stage I pressure ulcer Stage IV pressure ulcer Stage III pressure ulcer Stage II pressure ulcer

Stage II pressure ulcer Explanation: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

The primary source of microorganisms for catheter-related infections are the skin and the IV tubing. catheter hub. IV fluid bag. catheter tubing.

catheter hub. Explanation: The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first? 1. Check for a fecal impaction 2. Encourage the client to drink fluids 3. Check the chart for sodium and potassium levels 4. Apply a protective barrier cream to the perianal area

check for fecal impaction

The nurse plans care for a patient experiencing fatigue.Which outcome should the nurse identify as a priority?The patient will experience increased motivation.The patient will verbalize an understanding of good sleep hygiene.The patient will indicate an increased ability to perform activities of daily living (ADLs).The patient will participate in a mild exercise program.

The patient will indicate an increased ability to perform activities of daily living (ADLs).

A client informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about taking a stimulant laxative? As long as the client is drinking 8 glasses of water per day, he can continue to take them. The laxative is safe to take with other medication the client is taking. The client should take a fiber supplement along with the stimulant laxative. They can be habit forming and will require increasing doses to be effective.

They can be habit forming and will require increasing doses to be effective. Explanation: The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication, every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer oil retention enemas. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

administer oil retention enemas

An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: A. Harsh crackles B. Wheezing on inspiration C. Diminished breath sounds D. Bronchovesicular whooshing

diminished breath sounds

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to: document the condition of the client's skin. contact the client's family. give the client a donut ring to reduce pressure on the affected area. do nothing; the client's skin is intact.

document the condition of the client's skin. Explanation: The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy.

Rebound hypoglycemia is a complication of parenteral nutrition caused by a cap missing from the port. feedings stopped too abruptly. fluid infusing rapidly. glucose intolerance.

feedings stopped too abruptly. Explanation: Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port.

Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes: spicy foods. high-fiber diet. caffeinated products. fluids with meals.

high-fiber diet. Explanation: A high-fiber diet is prescribed to help control constipation. Individuals experiencing diarrhea may be advised to eat a low-fiber diet. Foods that are possible irritants, such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, and alcohol, should be avoided. Fluids should not be taken with meals because they cause abdominal distention.

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is elevated blood pressure. decreased pulse rate. loose, watery stools. increased urination.

loose, watery stools. Explanation: When the client indicates that loose, watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the client understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, changes in mental activity, diarrhea, nausea, skin changes, and decreased urine output.

Which musculoskeletal assessment finding should the nurse anticipate for a patient complaining of fatigue?

muscle weakness

A nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse ask the client to take which essential action during the tube change? A. Turn the head to the right. B. Inhale deeply, hold it, and bear down. C. Breathe normally. D. Exhale slowly and evenly

B. Inhale deeply, hold it, and bear down The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tube changes. The nurse asks the client to take a deep breath, hold it, and bear down. Option A is incorrect because if the intravenous line is on the right, the client turns his or head to the left. This position increases intrathoracic pressure. Options C and D can cause the potential for an air embolism during the tube change.

A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 2 hours delay. The nurse should do which of the following actions? A. Adjust the infusion rate to catch up over the next hour. B. Make sure the infusion rate is infusing at the ordered rate. C. Increase the infusion rate to catch up over the next few hours. D. Adjust the infusion rate to full blast until the solution is back on time.

B. make sure infusion rate is infusing at ordered rate The nurse should maintain the prescribed rate of a fat emulsion even if the infusion's time consume is behind. Options A, C, and D are incorrect since increasing the rate will potentially cause a fluid overload.

A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? A. Time of last dressing change. B. Tightness of the tuning connections. C. Client's temperature. D. Expiration date on bag

C. Temperature Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess.

An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? two bowel movements daily one bowel movement every other day one bowel movement daily stool consistency and client comfort

stool consistency and client comfort Explanation: Normal bowel patterns range from three bowel movements per day to three bowel movements per week. In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination.

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding? Eschar Ischemia Hyperemia Anoxia

Hyperemia Explanation: The initial sign of pressure is erythema (redness of the skin) caused by reactive hyperemia, which normally resolves in less than 1 hour. Unrelieved pressure results in tissue ischemia or anoxia. Eschar is a dry scab that forms over a healing ulcer.

An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to? Hypokalemia Hyponatremia Hypernatremia Hyperkalemia

Hypokalemia Explanation: The older client taking digitalis must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the client to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.

Which nutritional deficiency may delay wound healing? Lack of calcium Lack of vitamin C Lack of vitamin E Lack of vitamin D

Lack of vitamin C Explanation: Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown? Place an indwelling catheter in the patient. Apply powder. Administer vitamin B12 to the patient. Practice meticulous hygiene measures.

Practice meticulous hygiene measures. Explanation: Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly. The soiled skin should be washed immediately with mild soap and water and blotted dry with a soft towel. The skin may be lubricated with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Topical barrier ointments (e.g., petroleum jelly) may be helpful in protecting the skin of patients who are incontinent. Placing an indwelling catheter and administering vitamin B12 would not be effective measures in preventing continuous moisture.

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? Stage III Stage IV Stage II Stage I

Stage III Explanation: Clinically, in a stage III pressure ulcer, a deep crater with or without undermining of adjacent tissues is noted. A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. A stage II ulcer exhibits a break in the skin through the epidermis or dermis. A stage I pressure ulcer is an area of non-blanchable erythema, tissue swelling, and congestion, and the client complains of discomfort.

To prevent foot drop, what is the best way for the nurse to position the client? To keep the feet at right angles to the leg In a semi-sitting position in bed In a side-lying position In a sitting position with legs hanging off the side of the bed

To keep the feet at right angles to the leg Explanation: When the client is supine in bed, padded splints or protective boots are used. Semi-Fowler's positioning is used to decrease the pressure of abdominal contents on the diaphragm. To prevent foot drop, the feet must be supported at right angles to the leg. Side-lying positions do not provide support to prevent foot drop.

The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation? Usual pattern of elimination Alcohol consumption Activity levels Current medications

Usual pattern of elimination Explanation: Constipation has many possible causes and assessing the client's usual pattern of elimination is the first step in identifying the cause. The nurse should obtain a description of the bowel elimination pattern, asking about the frequency, overall appearance and consistency of stool, blood in the stool, pain, and effort necessary to pass stool. It is also essential for the nurse to review the client's current medications, diet, and activity levels.

A longitudinal tear or ulceration in the lining of the anal canal is termed a(n): anal fissure. anal fistula. hemorrhoid. anorectal abscess.

anal fissure. Explanation: Fissures are usually caused by the trauma of passing a large, firm stool or from persistent tightening of the anal canal secondary to stress or anxiety (leading to constipation). An anorectal abscess is an infection in the pararectal spaces. An anal fistula is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus. A hemorrhoid is a dilated portion of vein in the anal canal.

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? lack of exercise lack of solid food increased fiber lack of free water intake

lack of free water intake Explanation: A client who cannot swallow food cannot drink enough water to meet daily needs. Inadequate fluid intake is a common cause of constipation

The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 139 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.0 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semi-liquid stools totaling 300 mL.

serum sodium of 139 mEq/L in a client with obstipation

A client has been experiencing lower GI difficulties that have increased in severity, and the gastroenterologist is concerned that the client's bowel is not functioning properly. What function of the lower GI tract is most likely to be affected by the client's disorder? water and electrolyte absorption protein digestion All options are correct. fat digestion

water and electrolyte absorption Explanation: Disorders of the lower GI tract usually affect movement of feces toward the anus, absorption of water and electrolytes, and elimination of dietary wastes.

A client is receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to identify the presence of which of the following? A. Hypotension. B. Crackles upon auscultation of the lungs. C. Thirst. D. Polyuria

B. Crackles upon auscultation of the lungs Normally, the weight gain of a client receiving PN is about 1-2 pound a week. A weight gain of 5 pounds over a week indicates a client is experiencing fluid retention that can result to hypervolemia. Signs of hypervolemia includes weight gain more than desired, headache, jugular vein distention, bounding pulse, and crackles on lung auscultation. Option A: Hypertension, not hypotension is expected. Options C and D are associated with hyperglycemia.

A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular distension, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? A. Air embolism. B. Hypervolemia. C. Hyperglycemia. D. Sepsis.

B. Hypervolemia Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at risk. The client's symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles.