Module 3 Tests

screening for malnutrition in older adults

-"DETERMINE" -Disease -Eating poorly (history) -Tooth loss (chew+swallow problem) -Economic hardship -Reduced social contact -Multiple medications (poly pharmacy—drug interaction) -Involuntary weight loss -Needs assistance in self-care (self-care deficit) -Elderly above age 80 years

Signs and symptoms of infection

-Localized signs & symptoms: Redness, pain, warmth, swelling, pus/drainage, lack of feeling/numbness or tingling, tenderness -Systemic signs & symptoms: Fever, tachycardia (⬆️HR), malaise, lethargy, ⬆️RR, anorexia, chills, HA Lymph node tenderness or enlargement

Types of Medication Orders

-Standing order (routine order): carried out until cancelled by another order -PRN order: as needed and only given when pt requires the med -Single or one-time order: given only once at a specified time -Stat order: carried out immediately -Now order: needed quickly but not immediately

The nurse provides care for an older patient who uses a wheelchair for mobility. The nurse identifies that the patient is at risk for which bowel condition? 1 Fecal impaction 2 Colonic perforation 3 Clostridium difficile infection 4 Short bowel syndrome (SBS)

1 Fecal impaction Fecal impaction is a common problem in older adults with limited mobility. Fecal impaction is a collection of hardened feces in the rectum or sigmoid colon that a person cannot expel. In the presence of obstipation (absolute constipation with no passage of gas or stool) or fecal impaction secondary to constipation, colonic perforation may occur. Patients receiving broad-spectrum antibiotics (e.g., carbapenems, cephalosporins, piperacillin/tazobactam) are susceptible to pathogenic strains of C. difficile. Causes of short bowel syndrome (SBS) include diseases that damage the intestinal mucosa, surgical removal of too much small intestine (e.g., with Crohn's disease, cancer), and congenital defects.

Which intervention would the nurse recommend first when providing care for a 31-year-old patient experiencing occasional urinary incontinence when sneezing or laughing eight months after delivery of her first child? 1 Kegel exercises 2 Use of adult incontinence pads 3 Intermittent self-catheterization 4 Dietary changes including fluid restriction

1 Kegel exercises Patients who experience stress incontinence frequently benefit from Kegel exercises (pelvic floor muscle exercises). The use of incontinence pads does not resolve the problem, and intermittent self-catheterization would be a premature recommendation. Dietary changes are not likely to influence the patient's urinary continence.

When teaching a patient about techniques to manage urinary incontinence, which instructions would the nurse to include? Select all that apply. 1 Practice timed voiding. 2 Drink a cup of coffee. 3 Perform pelvic floor muscle training. 4 Perform intermittent catheterization. 5 Use incontinence protective pads

1, 3, 5 Practicing timed voiding, ideally every two to three hours during waking hours, can help to empty the bladder, thereby reducing the chances of incontinence. Pelvic floor muscle training is important to strengthen the pelvic floor muscles that control the relaxation of the urinary sphincters, and improved muscle control can reduce the complaints of incontinence. Incontinence protective pads are urine-containing assistive devices that can help in cases of mild to moderate urine incontinence. Coffee is a bladder irritant and will increase the urge to urinate, thus increasing the likelihood of incontinence. Advise intermittent catheterization in cases of urinary retention, not in urinary incontinence.

The nurse provides discharge education for a patient who has been treated for severe constipation. Which information does the nurse include? Select all that apply. 1 Establish a regular time to defecate. 2 Defecate on commode with knees higher than hips. 3 Perform sit-ups and straight-leg exercises. 4 Consume a high-fiber diet. 5 Consume a clear-liquid diet one day per week.

1,2,3,4 Establishing a regular time to defecate is an important part of bowel training. Defecation is easier when the knees are higher than the hips. Sit-ups and straight-leg exercises can help improve abdominal muscle tone. A high-fiber diet helps to prevent constipation. A clear-liquid diet is not helpful to avoid constipation.

In which order would the nurse perform the actions to measure a patient's BP? 1. Place the appropriate-size cuff on the upper arm. 2. Inflate the cuff to 20 to 30 mm Hg above the estimated SBP. 3. Lower the cuff pressure and auscultate the artery. 4. Note the tapping sound as the systolic BP (SBP). 5. Note the diastolic pressure when the sound disappears.

1,2,3,4,5 The nurse would first place the appropriate size of cuff on the upper arm. This is because the brachial artery is the recommended site for measuring the BP, and the wrong cuff size can give an inaccurate reading. The cuff is then inflated to a pressure 20 to 30 mm Hg above the most recently recorded SBP. This causes the blood flow in the artery to cease. The nurse would then lower the pressure in the cuff while auscultating the artery and also note the first phase of the Korotkoff sound. It is a tapping sound caused by the spurt of blood into the constricted artery. This is the SBP. Finally, when the sound disappears, the nurse notes the diastolic pressure.

Which patient statements indicate understanding of instructions provided about pelvic floor muscle exercises to treat stress incontinence? Select all that apply. 1 "I can do this exercise in a sitting or lying position." 2 "I can do quick two-second squeezes periodically." 3 "I am doing it right when I release the muscle to urinate." 4 "I can tighten the muscle for 10 seconds, relax, and repeat." 5 "I will see less leakage and urgency because of my efforts within three weeks."

1,2,4

When teaching a patient about ways to prevent constipation, which instructions does the nurse include? Select all that apply. 1 Eat a high-fiber diet. 2 Use laxatives regularly. 3 Exercise occasionally. 4 Increase fluid intake. 5 Do not suppress the urge to defecate.

1,4,5 To prevent constipation, it is important to have a high-fiber diet, increase fluid intake, and not suppress the urge to defecate. Dietary fibers are bulking agents and help in easy defecation. Adequate fluid intake prevents the stool from hardening and prevents constipation. The urge to defecate should not be suppressed because this can lead to the absorption of water from the digestive tract, resulting in hardened stools. Laxatives should not be used regularly because they can cause the patient to become reliant on them. Exercising regularly aids in peristalsis and helps to prevent constipation.

Which amount of time in seconds is considered normal for capillary refill? 1. 1 2. 4 3. 6 4. 8

1. 1 The capillary refill test assesses arterial flow to the extremities. The fingernail is pressed, and the time required for the refilling of blood is noted. This refill is appreciated by the change in the color of the nail bed. This should occur in less than two seconds with normal tissue perfusion and cardiac output. Capillary refill times of four seconds, six seconds, and eight seconds indicate an underlying defect in circulation.

Which criteria would the nurse use to assess the mental status of a patient? Select all that apply. 1. Alert and oriented 2. Intact sense of smell 3. Pupils reactive to light 4. Midline protrusion of tongue 5. Appropriate mood and affect

1. Alert and oriented 5. Appropriate mood and affect The patient's alertness and orientation, along with appropriate mood and affect, help the nurse to assess the mental status of the patient. An intact sense of smell, reaction of pupils to light, and a midline protrusion of the tongue suggest normal functioning of associated cranial nerves.

Which techniques will the nurse use when planning effective teaching for a hospitalized patient who has had a stroke? Select all that apply. 1. Develop clear and measurable learning goals. 2. Ask about the patient's preferred learning style. 3. Offer detailed explanations of health information. 4. Involve the patient and health caregiver in the process. 5. Emphasize relevancy of the information to the patient's lifestyle.

1. Develop clear and measurable learning goals. 2. Ask about the patient's preferred learning style. 4. Involve the patient and health caregiver in the process. 5. Emphasize relevancy of the information to the patient's lifestyle. Clear learning goals, use of a patient's preferred learning style, inclusion of the caregiver in teaching, and emphasizing the relevancy of health information are all recommended actions for effective teaching and changes in health behavior. Detailed explanations may overwhelm the patient who is recovering from a stroke; usually it is best to begin with simple information and then add more detail later.

Which patient factors will the nurse consider when determining a patient's learning needs? Select all that apply. 1. Expectations 2. Cultural values 3. Socioeconomic factors 4. Knowledge and past experience 5. Staffing needs on the nursing unit

1. Expectations 2. Cultural values 3. Socioeconomic factors 4. Knowledge and past experience Patient expectations for teaching may be different from what the nurse thinks are priorities, but these expectations need to be considered in order to have patient compliance with any teaching. Spiritual needs are considered because spiritual beliefs may impact on health practices. Socioeconomic factors such as living conditions may impact on what is taught, since factors such as not having electricity may impact on discharge instructions. The patient's knowledge and experience of health issues are considered because the nurse will include different content when teaching someone with previous knowledge about a topic. In addition, adult learners are more motivated to learn when they already have some experience with a topic, and previous learning helps build patient confidence. Although staffing needs on the unit may impact the amount of time that is available for teaching or how teaching is implemented, staffing issues are not a consideration when determining patient learning needs

Which sequence does the nurse follow when examining a patient's abdomen? 1. Inspection first, then auscultation, percussion, and palpation 2. Percussion first, then auscultation, palpation, and inspection 3. Auscultation first, then palpation, percussion, and inspection 4. Inspection first, then palpation, auscultation, and percussion

1. Inspection first, then auscultation, percussion, and palpation The correct order for an assessment of the abdomen is inspection, auscultation, percussion, and palpation. This sequence is used because it ensures that there is no disturbance to the abdomen before auscultation. Percussing first, then auscultating, palpating, and inspecting; auscultating, then palpating, percussing, and inspecting; or inspecting, then palpating, auscultating, and percussing would cause false bowel sounds because the nurse would be touching or pressing on the abdomen during percussion and palpation before auscultation.

Which musculoskeletal assessment findings are normal? Select all that apply. 1. Muscle strength 5/5 2. No spinal curvature 3. No muscle atrophy or asymmetry 4. No joint swelling, deformity, or crepitation 5. Full range of motion of all joints without pain or laxity 6. No tenderness on palpation of spine, joints, or muscles

1. Muscle strength 5/5 3. No muscle atrophy or asymmetry 4. No joint swelling, deformity, or crepitation 5. Full range of motion of all joints without pain or laxity 6. No tenderness on palpation of spine, joints, or muscles The components of a normal musculoskeletal system include muscle strength of 5/5; no muscle atrophy or asymmetry; no joint swelling, deformity, or crepitation; a full range of motion of all joints without pain or laxity; and no tenderness on palpation of spine, joints, or muscles. The spine should have ordinary spinal curvatures, not an absence of curvature.

Which assessment techniques would the nurse use to assess the musculoskeletal system? Select all that apply. 1. Palpation 2. Inspection 3. Percussion 4. Auscultation 5. Comprehensive

1. Palpation 2. Inspection For assessing the musculoskeletal system, just inspecting the diseased area and palpation are sufficient. Inspection involves direct observation of the affected area. Palpation involves using light or deep touch to assess a body part. Percussion involves hearing the resonance of the sounds produced by certain body parts. It is not required for assessing the musculoskeletal system. Comprehensive assessment is a very general assessment of the whole body and is not specifically targeted for assessing the musculoskeletal system. Auscultation involves listening to body sounds using a stethoscope. It is not required for musculoskeletal system assessment.

Which assessment techniques would the nurse perform to obtain objective data from a patient? Select all that apply. 1. Palpation 2. Inspection 3. Interrogation 4. Diagnostic tests 5. Direct questioning

1. Palpation 2. Inspection 4.Diagnostic tests Objective data are the data that can be observed or measured through inspection, palpation, percussion, and auscultation. The objective data about the patient can also be obtained through diagnostic testing. Subjective data are obtained through interviews that include direct questioning and interrogation.

Which cardiovascular assessment findings are considered normal for an adult patient? Select all that apply. 1. Pulses 2+ 2. Point of maximal impulse (PMI) not visible 3. Heart rate 64, regular 4. Capillary refill 3 seconds 5. Blood pressure right arm: 124/80 mm Hg; left arm: 110/62 mm Hg

1. Pulses 2+ 2. Point of maximal impulse (PMI) not visible 3. Heart rate 64, regular 5. Blood pressure right arm: 124/80 mm Hg; left arm: 110/62 mm Hg Pulses of 2+, a nonvisible point of maximal impulse, a heart rate between 60 and 100, and a blood pressure difference between arms of 5 to 15 mm Hg are all considered normal. Color should return to the nail bed in less than 2 seconds with normal tissue perfusion and cardiac output.

Normal BMI

18.5-24.9

A patient tells the nurse, "I have been constipated and have to strain to have a bowel movement. When cleaning after defecation, I notice blood on the toilet tissue." Which does the nurse suspect as the source of bleeding? 1 Anal fissure 2 Hemorrhoids 3 Anorectal abscess 4 Anal fistula

2 Hemorrhoids Hemorrhoids are the most common reason for bleeding with defecation. Although bleeding can be associated with an anal fissure and anal fistula, it is not the most common cause of bleeding with defecation. An anorectal abscess is less commonly associated with bleeding upon defecation.

How does psyllium in the diet benefit the patient with fecal incontinence? 1 It slows the intestinal transit. 2 It promotes firm consistency. 3 It improves awareness of rectal sensation. 4 It increases the strength of external sphincter contraction.

2 It promotes firm consistency. Dietary fiber supplements or bulk-forming laxatives, like psyllium (e.g., Metamucil), increase stool bulk and firm consistency, and promote the sensation of rectal filling. Loperamide helps to slow intestinal transit time. Biofeedback therapy helps to improve awareness of rectal sensation and increase the strength of external sphincter contraction.

A patient reports a new onset of diarrhea. To identify a potential cause of the condition, the nurse asks the patient about the consumption of which item? 1 Fish oil 2 Spicy foods 3 Coenzyme Q10 4 Chondroitin sulfate

2 Spicy foods When assessing the nutritional-metabolic component of the patient's functional health patterns, the nurse should ask about the ingestion of fatty and spicy foods. These types of foods are known to cause diarrhea. Fish oil, coenzyme Q10, and chondroitin sulfate are not associated with diarrhea. Fish oil is rich in omega-3 fatty acids, which are beneficial in preventing or treating hypertension. Coenzyme Q10 is used in the treatment of hypertension. Chondroitin sulfate is given to a patient with osteoarthritis.

How will the nurse document a weakly palpable pulse? 1. 0 2. 1+ 3. 2+ 4. 3+

2. 1+ A weak pulse in a patient with cardiovascular disease is indicated by 1+. The absence of a pulse is indicated by 0. A normal pulse rate is indicated by 2+, and 3+ indicates an increased, full, bounding pulse.

Which patient data would the nurse classify as objective data? Select all that apply. 1. Nausea 2. Presence of crepitus 3. A report of a headache 4. A lump in the abdomen 5. Blood sugar levels of 280 mg/dL

2. Presence of crepitus 4. A lump in the abdomen 5. Blood sugar levels of 280 mg/dL Objective data are obtained by physically examining the patient. Blood sugar levels can be tested and verified. A lump in the abdomen can be assessed through palpation. The presence of crepitus can be auscultated. The headache and the nausea cannot be measured through exam. This information can be obtained by directly questioning the patient.

When the nurse is caring for a patient following a myocardial infarction, which patient finding might adversely affect patient teaching? 1. Presence of patient's caregiver 2. Report of fatigue and weakness 3. Increase in patient's self-efficacy 4. Previous myocardial infarction history

2. Report of fatigue and weakness Fatigue and weakness could affect patient teaching because the patient is less likely to focus. The presence of a caregiver will positively affect teaching, since the caregiver and patient will both have the same information. Patients with increased self-efficacy are better able to make changes. Previous experience with myocardial infarction will enhance the patient's motivation and self-confidence. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

A patient's son visits her and ask the nurse what could have contributed to his mother getting an infection. The nurse bases her answer on knowing that the patient has a higher risk for developing an infection. Which factors make the patient more susceptible to infection? (Select all that apply) 1. Gender 2. age 3. poor nutrition 4. low blood sugar 5. stress

2. age 3. poor nutrition

Overweight BMI

25-29.9

What will the nurse take first in order to individualize teaching for a patient who has newly diagnosed diabetes? 1. Use Internet learning materials about diabetes management. 2. Only teach the high priority, "need-to-know" diabetes topics. 3. Ask the patient to choose priorities from a list of diabetes topics. 4. Have the patient view a video followed by one-on one discussion.

3. Ask the patient to choose priorities from a list of diabetes topics. By allowing a patient to prioritize his or her own learning needs, the nurse can begin with the patient's highest concerns and perceived greatest teaching needs. While using Internet learning materials can help individualize teaching, the nurse should determine what the patient considers priority information before choosing web-based information. Teaching only high priority information may lead to leaving out some topics that the patient considers important and may not consider the patient's perceived priority information. One-on-one discussion after watching a video helps individualize teaching, but the nurse should determine which topics the patient considers as priorities before choosing the video.

After demonstrating use of a home blood glucose meter to a patient, how can the nurse best evaluate the effectiveness of the teaching? 1. Arranging for follow-up with a home care nurse 2. Having the patient take a brief quiz about glucose meter use 3. Asking the patient to re-demonstrate how to use the blood glucose meter 4. Questioning the patient about what was helpful about the teaching experience

3. Asking the patient to re-demonstrate how to use the blood glucose meter A return demonstration ("show back") can evaluate a patient's ability to perform skills such as using a glucometer or giving an injection. Arranging for follow-up with a home care nurse would lead to an unnecessary delay in evaluation of teaching effectiveness. For skills teaching, re-demonstration of the skill is a better way to evaluate teaching effectiveness than a quiz. Questioning the patient about helpful strategies helps the nurse self-evaluate, but does not assure that the patient can successfully perform the taught skill.

Which PPE worn by the nurse with every patient interaction shows protection against the spread of infection? 1. Mask 2. Gown 3. Gloves 4. Shoe covers

3. Gloves

The nurse recalls that which minimum body mass index (BMI) value is classified as obese? Record the answer using a whole number. Fill in the blank. _______ kg/m?

30

Obese BMI

30 or greater

The nurse recalls that one gram of protein yields how many calories? Record the answer using a whole number. ______ cals

4

While assessing a patient with constipation, the nurse finds that the patient chronically uses bisacodyl. The nurse identifies that the patient is at risk for which complication? 1 Obstipation 2 Toxic megacolon 3 Idiopathic constipation 4 Cathartic colon syndrome

4 Cathartic colon syndrome Bisacodyl is a laxative and is used to treat constipation. Cathartic colon syndrome occurs because of laxative abuse; the nerves of the colon are damaged, causing dilation of the colon, making it atonic. Obstipation is a severe form of constipation in which no gas or stool is expelled; it does not occur due to chronic use of bisacodyl. Toxic megacolon is colonic dilation greater than 5 cm. It is seen in patients with irritable bowel syndrome who are on antidiarrheal therapy. Idiopathic constipation is the presence of chronic constipation symptoms, which does not occur due to use of bisacodyl.

A nurse notes a patient has wheezes in the apex of one lung upon assessment. Which technique of physical assessment did the nurse use to make this determination? 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

4. Auscultation Auscultation is a technique in which a stethoscope is used to hear the sounds produced in the body. Wheezes produced at the apex of the lung can be heard by auscultation. Inspection involves visual examination of a part or an area to determine any abnormalities. Palpation involves examination of the body using touch. Percussion involves producing sound and vibration to obtain information about an underlying area of the body.

A nurse would use which technique to assess the bowel sounds of a patient? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

4. Auscultation Auscultation is used to listen to sounds produced in the body using a stethoscope. This technique can be used to assess bowel sounds. Inspection may or may not show the presence of fluid in the abdomen. Palpation can be used to assess masses, vibrations, swelling, and tenderness. Percussion is a technique that produces a specific sound and vibration to obtain information about underlying area.

A nurse is reviewing the history reports of a patient. One report reads, "Crackles in the apex of the left lung." Which technique of physical assessment would yield this result? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

4. Auscultation Crepitation in the apex of the left lung can be heard by using a stethoscope. This technique of hearing sounds produced in the body using a stethoscope is called auscultation. Palpation can be used to assess masses, vibrations, swelling, and tenderness. Inspection involves visual examination of the body part to determine abnormalities. Percussion is a technique that produces a specific sound and vibration to obtain information about the underlying area.

Which action would the nurse take when a patient with cognitive dysfunction due to stroke is unable to learn the self-care techniques taught by the nurse? 1.Provide teaching materials such as books. 2. Encourage the use of adaptive equipment for self-care. 3. Provide hearing aids to help the patient understand the teaching. 4. Encourage the caregiver to be more involved in patient care activities

4. Encourage the caregiver to be more involved in patient care activities. The patient may not be able to provide self-care due to cognitive dysfunction. Therefore, the nurse should involve the caregiver when teaching patient care. Providing hearing aids and teaching materials would help patients with sensory dysfunction learn better, but they may not be helpful to patients with cognitive dysfunction. Adaptive equipment is helpful only if there are problems in performing manual procedures.

Which is an example of an objective finding the nurse would record after completing a health history and physical examination on a patient? 1. The patient has no known allergies. 2. The patient states: "I feel weak and fatigued." 3. The patient is currently taking labetalol 200 mg twice a day. 4. The patient's pulse is 98 beats per minute, and the heart rate is regular.

4. The patient's pulse is 98 beats per minute, and the heart rate is regular. Objective data are data that the nurse has directly observed or inspected on physical examination, such as vital signs. A pulse of 98 beats per minute and a heart rate that is regular are examples of objective data. Subjective data are data that the nurse has received directly from the patient, such as a list of current prescriptions or any allergies. The patient's statement of, "I feel weak and fatigued," is an example of subjective data.

Teaching is

A change that may occur when a person acquired knowledge,skills, or attitudes Pt determines if change occurs

Learning is

A complex process that facilitates learning through instruction, coaching, counseling, and/or behavior modification Encourage pt to have motivation and confidence for a new attitude

The nurse encourages which dietary habits for a patient who desires a healthy lifestyle? Select all that apply. A. A well balanced diet B. Adequate intake of water C. Consumption of whole milk D. Intake of whole grains E. Consumption of preserved foods

A. A well balanced diet B. Adequate intake of water D. Intake of whole grains

The nurse provides care for a patient who is diagnosed with malnutrition and expects which assessment findings? Select all that apply. A. Anemia B. Infection C. Hyperglycemia D. Delayed wound healing E. Wasted and flabby muscle

A. Anemia B. Infection D. Delayed wound healing E. Wasted and flabby muscle

The nurse advises a patient to include complex carbohydrates in the diet and lists which examples? Select all that apply. A. Cereals B. Potatoes C. Legumes D. Milk E. Table sugar

A. Cereals B. Potatoes C. Legumes

The nurse reviews a patient's history and recognizes that which conditions increase the risk for malnutrition? Select all that apply. A. Corticosteroid use B. Excessive dieting C. Swallowing disorder D. Fracture of a bone E. Chronic alcohol use

A. Corticosteroid use B. Excessive dieting C. Swallowing disorder E. Chronic alcohol use

The nurse is helping a patient select food for a healthy lifestyle. Which instructions does the nurse give to the patient? Select all that apply

A. Eat more whole grains B. Avoid oversized portions E. Add fruit to meals as part of main or side dishes

The nurse recognizes that which food items are complete proteins? Select all that apply. A. Eggs B. Corn C. Peanuts D. Milk products E. Sesame seeds

A. Eggs D. Milk products

Which component of nutritional assessment includes determining a patient's body mass index, height, weight, and amount of weight loss?

A. Health history B. Functional status C. Physical examination D. Anthropometric measurements

The nurse recalls that which socioeconomic factors contribute to the development of malnutrition? Select all that apply. A. Older adults on a fixed income B. Alcoholism C. Hospitalization D. Food insecurity E. Food-drug interactions

A. Older adults on a fixed income D. Food insecurity E. Food-drug interactions

The nurse is reviewing diagnostic study results for a patient with suspected malnutrition. When compared to other lab studies, which diagnostic test is considered the best indicator of current nutritional status? A. Pre albumin B. Transferrin C. Serum albumin D. Hemoglobin

A. Pre albumin

The nurse identifies that patients with which conditions are at increased risk for malnutrition? Select all that apply. A. Trauma B. Dementia C. Depression D. HTN E. Chronic alcohol abuse

A. Trauma B. Dementia C. Depression E. Chronic alcohol abuse

he nurse provides care for a patient with suspected malnutrition. Which assessment data are used for diagnosing malnutrition? Select all that apply. A. Vital signs B. Diet history C. X-rays D. Capnography E. BMI

A. Vital signs B. Diet history E. BMI

A patient is admitted to the ER after taking high doses of vitamin B and D. The nurse is more concerned about the vitamin D because A. Vitamin D is a fat soluble B. Vitamin d is a water- soluble C. Vitamin d in high doses causes bleeding D. Vitamin d in low doses results in scurvy

A. Vitamin D is a fat soluble The body can store toxic amounts of vitamin d

To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. the presence of food stimulates peristalsis. B. mass colonic peristalsis occurs at this time. C. irregularity helps to develop a habitual pattern. D. neglecting the urge to defecate can cause diarrhea.

A. the presence of food stimulates peristalsis

Which following factor should be considered first when developing a teaching plan? a. The patient's priorities b. The patient's stability c. The patient's insurance coverage d. The patient's economic resources

ANS: A Assisting the patient to identify his/her priorities in learning will help guide the teaching plan and keep the patient motivated and interested. The patient's stability may be relevant in some instances but would be more related to timing of the teaching or environment rather than establishing the teaching plan. While the patient's insurance coverage and economic resources may affect the interventions or number of teaching sessions, they would not direct the development of the plan.

The nurse is inserting an indwelling catheter into a male patient. While initially passing the catheter through the urethra, resistance is met. What action would the nurse take next? a. Withdraw the catheter and obtain a coude catheter. b. Straighten the penis and attempt to progress the catheter again. c. Remove the catheter and insert one with a smaller lumen. d. Inflate the balloon and wait for urine passage.

ANS: A Coudé catheters are a special type of double-lumen, indwelling catheters that are slightly stiff and bent at the end, allowing the catheter to pass more easily through a partially constricted urethra. They are used mostly in men experiencing prostate enlargement or BPH. The nurse would not continue trying to advance the catheter, try one with a smaller lumen, or inflate the balloon before the catheter was properly inserted.

The nurse is providing discharge teaching to a who had a gallbladder removal yesterday. The nurse should consider further health literacy-related assessment when the patient states: a. "Can you read that to me? My spouse took my glasses home." b. "I don't understand what you are saying about what I can eat." c. "Do I have to take the pain medicine even if I don't feel I need it?" d. "Do I still need to use that breathing exerciser when I get home?"

ANS: A Individuals with health literacy limitations may be embarrassed to admit they have difficulty or are unable to read. They may state that they didn't bring glasses or the spouse took them home. All the other options are related to specific items the nurse has reviewed with the patient and he is seeking clarification.

Nursing interventions for the patient who suffers from stress incontinence include: a. Kegel exercises. b. surgical interventions. c. bowel retraining. d. intermittent catheterization.

ANS: A Kegel exercises also are known as pelvic floor exercises. They improve muscle tone in the pelvic floor, which helps to prevent stress incontinence.

The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? a. Patients receiving tube feedings often experience constipation. b. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. c. Patients with impaired mobility may experience constipation. d. Medications commonly taken by elders often contribute to constipation

ANS: A Patients on tube feedings often experience diarrhea, not constipation.

A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? a. Weighing the patient daily b. Encouraging a diet high in fiber c. Decreasing the patient's fluid intake d. Instructing the patient to increase protein in the diet

ANS: A The patient with diarrhea is susceptible to dehydration. Checking the patient's weight daily will monitor fluid status. Fiber will help firm up the stools but is not the priority. The patient should increase fluid intake. Increasing protein will not help the diarrhea

Which organism is responsible for the majority of urinary tract infections in female patients? a. Escherichia coli b. Neisseria gonorrhoeae c. Candida albicans d. Haemophilus influenza

ANS: A Urinary tract infections (UTIs) are the result of bacteria in the urine. Infection occurs when bacteria from the digestive tract, usually E. coli, invade the urethra and multiply. N. gonorrhoeae causes gonorrhea. C. albicans causes yeast infections. H. influenza causes influenza

The nurse sees information from a VARK assessment and asks the mentor what the acronym stands for. What response from the mentor is best? a. Verbal, aural, read/write, and kinesthetic. b. Verbal, aural, readiness, and kinesthetic. c. Verbal, auditory, readiness, and kinesthetic. d. Verbal, auditory, read/write, and kinesthesia.

ANS: A VARK is an assessment tool to assist in determining health literacy; it explores the way individuals learn. The acronym stands for verbal, aural, read/write, and kinesthetic

A nurse is determining the health literacy of a patient who is preparing to go home from the hospital. Which of the following attributes or abilities contribute to health literacy? (Select all that apply) a. Able to schedule appointments. b. Identifies credible health information. c. Advocates for appropriate care. d. Owns a source of technology to access information. e. Asks appropriate questions of providers.

ANS: A, B, C, E According to Healthy People 2020, defining characteristics of good health literacy include: being able to schedule appointments, able to identify credible health information, advocate for appropriate care, ask appropriate questions of providers, understand numbers as they apply to one's own case, fill out forms, gather records, navigate complex insurance systems, and use technology to access information. This does not require owning the technology.

Prior to discharge, the nurse teaches the patient the proper techniques for applying an ostomy pouch. When evaluating the teaching, the nurse observes the patient apply a new ostomy pouch without cleansing the skin underneath. What actions would the nurse implement following this patient's return demonstration? (Select all that apply.) a. Repeat the demonstration to show the patient how to clean the ostomy site. b. Document that the patient performed the initial return demonstration accurately and safely. c. Offer positive reinforcement regarding the need to cleanse the site to prevent skin breakdown below the appliance. d. Discharge the patient with written instructions and illustrations that demonstrate the correct procedure. e. Notify the health care provider that a repeat demonstration of the ostomy appliance procedure is needed.

ANS: A, C, D The initial return demonstration was not performed accurately, and since it is the nurse's responsibility to complete the needed teaching, the health care provider does not need to be notified. Discomfort and damage to the skin can result from not washing the site; therefore, the nurse would repeat the demonstration, emphasizing the importance of cleansing. Positive reinforcement and the provision of written instructions are valuable teaching strategies

The nursing student has assessed a patient's health literacy prior to teaching. What consideration would indicate the student needs to review this information? a. Age and role b. Gender and IQ score c. Cultural diversity components d. Economic resources

ANS: B Neither a patient's gender nor his/her IQ directly correlate to his/her health literacy whereby the other answers are relevant factors.

Average urine pH is: a. 4. b. 6. c. 7. d. 9.

ANS: B Urine normally is slightly acidic, with an average pH of 6.

To best determine the patient's competency in changing an ostomy appliance, what does the nurse ask the patient to do? a. Verbalize the procedure. b. Identify the supplies needed. c. Perform the procedure. d. List the steps in the procedure

ANS: C Repeat performance is the best way to ensure competency. The other actions demonstrate knowledge in limited specifics of the procedure

Which discharge instruction does the nurse provide to the patient following a colonoscopy? a. Some discomfort and bleeding are normal postprocedure. b. Return to the emergency room if you experience abdominal cramping. c. Do not drive or operate heavy machinery for 12 hours postprocedure. d. Return to your normal bowel pattern immediately postprocedure.

ANS: C Since sedation is given for the procedure, the patient should not drive or operate heavy machinery. Cramping and bloating can be seen in the first hour afterward. The patient's normal pattern for bowel elimination will not return immediately.

The domain of learning directly related to a patient's motivation to learn is: a. cognitive. b. psychomotor. c. affective. d. dependent on their reading level.

ANS: C The affective domain of learning considers feelings, values, motivation, and attitudes of the learner. Cognitive and psychomotor are not directly affected by the patient's motivation. The patient's reading level is not a domain of learning.

What would be included in teaching for a patient who will be discharged with a prescription for a laxative? a. Calling the health care provider if nausea, vomiting, or abdominal pain occurs b. Continuing use of laxatives to encourage bowel evacuation c. Adding regular exercise, sufficient fluids, and regular defecation habits to his/her routine d. Knowing the difference between laxatives and cathartics

ANS: C The patient who is discharged on laxatives should still be instructed on the nonpharmacologic methods to decrease constipation and promote normal bowel patterns. Laxatives are contraindicated in patients with nausea, vomiting, or undiagnosed abdominal pain. Ongoing use of laxatives is associated with harmful side effects, such as an increase in constipation and impaction, predisposition to colorectal cancer, dependency, and electrolyte imbalance and should not be encouraged. Knowing the difference between laxatives and cathartics will not help the patient in this case.

The unique ability of the patient to understand and integrate health-related knowledge is known as: a. basic literacy. b. medical literacy. c. health literacy. d. consumer literacy.

ANS: C The patient's health literacy is individual and unique to each person. Basic literacy describes an individual who has very rudimentary skills allowing him/her to read short, simple printed and written materials. Medical literacy is specifically that addressed in a health care setting. Consumer literacy is not a term addressed in this content

The student describes the "3 A's of health information" identified by the National Action Plan to Improve Health Literacy. Which "A" demonstrates a need to review the information? a. Accessible b. Accurate c. Actionable d. Appropriate

ANS: D Accessible, accurate and actionable are the 3 A's of health information as identified by the National Action Plan to Improve Health Literacy.

The patient is ordered an ultrasound of the kidneys. The nurse knows that prior to the test the patient will: a. be required to have a bowel cleansing enema. b. be checked for any allergies to shellfish. c. be required to drink a large amount of fluids before the test. d. have no pretest requirements.

ANS: D An ultrasound scan may be performed to assess the size, shape, and location of the kidneys. Ultrasound studies may be safely conducted in patients who have allergies to contrast media, because no radiation or contrast dyes are used. No patient preparation such as fasting or sedation is required.

A patient with a history of kidney stones is experiencing difficulty urinating and laboratory findings indicate the patient is in acute renal failure. What is the probable cause of this condition? a. Hypovolemia b. Cardiogenic shock c. Nephrotoxic substances d. Urethral obstruction

ANS: D Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, resulting in acute or chronic renal failure. With a history of kidney stones, it is most probably that one is moving down the urinary tract and got lodged, leading the patient to have difficulty urinating.

Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: a. the patient will return to previous elimination pattern. b. the patient will increase intake of grains, rice, and cereals. c. the patient will discontinue antibiotic use. d. the patient will increase fluid intake.

ANS: D The highest priority goal is for the patient to increase fluid intake since diarrhea can lead to dehydration

A patient is scheduled for an upper GI series. Which information is most important for the nurse to obtain before the procedure? a. Allergy to shellfish b. Last bowel movement c. Time the enema was administered d. Any difficulty swallowing

ANS: D The patient will need to drink barium for this x-ray; therefore, swallowing ability should be assessed prior to the start of the procedure. The test does not use contrast dye, so the allergy to shellfish is not related. Time of the last bowel movement and enema administration is also not related since the test is not of the lower GI tract.

Which following environmental situation would be the most beneficial in which to hold a patient teaching session? a. Waiting room of the provider's office b. The nurse's station c. The patient's room d. The family visiting room

ANS: D The patient's room provides the most privacy and the least potential for interruptions. If the patient has a roommate, teaching would be done when the roommate is out of the room

Physical assessment

Ability to consume fluids and food (Swallow ability, chewing ability) Anthropology metric measurements Height Weight BMI Trifold thickeness General observations- skin, admin, hair, nails Hydration status Mouth inspection (dentition)

eLiteracy

Accessing medical info on the internet Tailor info to meet the literacy needs of the person **Help pts/caregivers sift through info to decide if it's valid, reliable, usable, and from reputable sites** Telehealth- remote communication using technology for consultation, monitoring, and education Online support groups and chronic illness support groups

Factors affecting urination

Age Physiologic characteristics (mobility,etc) Meds Nutrition (food, fluid intake)

Adverse reactions for anti-microbial's

Allergic reactions Mild: rash, pruritus, hives Severe: anaphylactic shock Potential for CDI (C. Diff infection) diarrhea

A 15-year-old female gymnast is hospitalized with the diagnosis of bulimia nervosa. Which data would the nurse anticipate finding in the patient's admission history and physical assessment? a. Excessive intake of food, self-induced vomiting, and use of laxatives b. Refusal to eat, body image disturbance, constipation, and amenorrhea c. Excessive exercise, refusal to eat, poor muscle tone, and social isolation d. Hair loss, BMI of 27, occasional use of diuretics, calorie intake 2200/day

Answer: a Bulimia involves the obsession with binging (the intake of excessive amounts of food), with consumption of as much as 2000 to 3000 calories at one time, followed by purging (vomiting). In an effort not to gain weight from the excessive amount of food eaten, the affected person may use self-induced vomiting or excessive exercise. It also may involve the abuse of laxatives or diuretics. A refusal to eat, excessive exercise, body image disturbance, poor muscle tone, hair loss, amenorrhea, social isolation are relevant to anorexia nervosa. Intake of 2200 calories/day and BMI of 27 are indications of excessive dietary intake and borderline obesity in a 15-year-old female.

Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Ready to Learn b. Lack of Knowledge c. Effective Information Processing d. Health-Seeking Behaviors

Answer: a A patient's expression of an interest in learning would indicate correct use of the nursing diagnosis, Ready to Learn. Lack of Knowledge would indicate the patient has a deficiency of knowledge on a particular subject. Effective Information Processing is the patient's ability to acquire useful information. Health-Seeking Behaviors is active seeking by a person of ways to alter habits to enhance health

The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient? A. Private room staph B. Private, negative-airflow room C. Mask worn by the staff when entering the room D. Mask worn by the staff and the patient when leaving the patient's room

Answer: a A private room decreases the chance of another patient contracting the infection. The other precautions (i.e., private room with negative airflow, mask worn by staff when entering the room, and mask worn by staff and patient when leaving the patient's room) are airborne precautions, which are not necessary in managing this patient.

The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal

Answer: a Diarrhea is associated with high risk for dehydration, so the patient should increase the fluid intake. The patient may need increased sodium and potassium intake owing to loss of these electrolytes in the frequent stools. Fiber will add bulk and help form the stools so should be increased. Whole-grain products contain fiber

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger gauge catheter. d. Notify the primary care provider.

Answer: a Checking the position and patency of the catheter first will determine whether the problem is mechanical or physiologic. At times, the end of the catheter may become lodged up against the side of the bladder, preventing the flow of urine into the tubing. Telling the patient that is impossible to void while catheterized is erroneous. Catheterizing the patient with a larger-gauge catheter is unnecessary at this point, as is contacting the primary care provider

Teaching a patient to use an incentive spirometer by demonstration, with a return demonstration by the patient is an example of teaching based on which domain of learning? a. Psychomotor b. Affective c. Psychosocial d. Cognitive

Answer: a Demonstration along with a return demonstration by the patient is an example of psychomotor domain learning. Affective domain learning integrates new knowledge by recognizing an emotional component. Psychosocial is not one of the domains of learning. Cognitive domain learning is based on knowledge and material that is remembered, memorized, and recalled

A patient recovering from major abdominal surgery is to be progressed from a clear liquid diet to the next diet level. Which statement by the nurse would be most appropriate in this circumstance? a. "You will progress from a clear liquid diet to a mechanical soft diet." b. "If you can tolerate the clear liquid diet, your next meal will be a full liquid." c. "You will receive a regular diet tray with anything you want at the next meal." d. "It is important that you eat a pureed diet after you are able to tolerate the clear liquids."

Answer: b A full liquid diet is used as a transition diet to avoid overdistending the abdomen after abdominal surgery. A mechanical soft diet incorporates modified food consistency such as ground meat or soft cooked foods. It also is used for people who have difficulty chewing effectively. The regular diet has no restrictions, which could cause damage to the abdomen if the wrong food were selected. A pureed diet is given to persons who cannot tolerate the texture of some foods, which have to be blended so the patient can chew them. There is no indication that this patient has difficulty chewing food.

A Jewish patient who adheres to a kosher diet is diagnosed with type 1 diabetes. What would be the best response of the nurse when the patient refuses to take insulin, stating, "Insulin contains pork and I do not eat pork"? a. "There is only a tiny amount of pork by-product in insulin. b. "All of the insulin used today is made synthetically." c. "I will notify your physician to change the insulin order." d. "You really do not have the option of not taking insulin."

Answer: b All insulin manufactured today is biosynthetic. It is no longer derived from pork or cattle pancreas. There is no need to contact the physician to change the order. Patients always have the right to refuse medication. In this case, educating the patient about the source of the insulin should allay any fears of the insulin coming from pigs

Of the following hospitalized patients, who is most at risk for acquiring a health care-associated infection? a. A 60-year-old who smokes two packs of cigarettes per day b. A 40-year-old who has an indwelling urinary catheter in place c. A 65-year-old who is a vegetarian and slightly underweight d. A 60-year-old who has a white blood cell count of 6000

Answer: b Hospital-acquired infections are associated with indwelling urinary catheters. A normal white blood cell count, smoking cigarettes, or being a vegetarian has not been associated with hospital-acquired infections.

Which is true about patient teaching sessions? a. Present all of the information so the patient can learn all that is needed. b. Present the patient with one idea at a time. c. Ensure the presence of a family member at each session. d. End with a written quiz to ensure understanding of the information.

Answer: b Presenting patients with one idea, task, or concept at a time allows them to focus on that item without becoming overwhelmed. For this reason, presenting all of the information is incorrect. Although it may be beneficial to have a family member or friend present in a teaching session, this is sometimes not feasible or appropriate. Providing a written quiz at the end of the session may evoke anxiety if the patient knows he or she is going to be tested on the content.

The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? a. Virus b. Bacterium c. Fungus d. Spore

Answer: b The cause of an infection in the surgical wound in a hospitalized patient who has had abdominal surgery is most likely bacteria because it is present on the skin as normal flora. Fungi and spores are the focus of removal during the surgical preparation. Viruses are target specific and do not usually live on the skin.

The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those--I'll read them at home.!" What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required.

Answer: b The patient's mother may have limited reading skills or health literacy and should be further assessed. Contacting the physician in this situation would not be appropriate because ensuring that the patient and family understand discharge instructions is the responsibility of the nurse. Assuming that the mother has taken care of casts in the past may be inaccurate. Stating that reading the instructions with the nurse is a requirement does not ensure that the patient or mother comprehends the instructions.

A 58-year-old man is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. Which action(s) should the nurse do before placing the NG tube? a. Take two additional staff members into the room when placing the tube so the patient can be restrained if needed. b. Request an interpreter per facility protocol. c. Do not place the NG tube because the physician would not want to frighten the patient. d. Document the inability to place the NG tube due to lack of ability to communicate.

Answer: b An interpreter employed by the hospital would be the best choice so that someone in the room can communicate and provide comfort for the patient. Taking additional staff into the room may increase the patient's anxiety, thereby decreasing his ability to comprehend the instructions. Although the physician would not want to frighten the patient, he or she ordered the nasogastric (NG) tube for the benefit of the patient; therefore it needs to be carried out. Documenting the inability to place the NG tube due to lack of means of communication is not acceptable and does not ensure the patient gets what is needed

A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Impaired Skin Integrity b. Fluid Imbalance c. Acute Pain d. Self-Care Deficit (i.e., toileting)

Answer: b Diarrhea can cause dehydration with loss of fluids and electrolytes. There is no statement of problems with the skin, although this patient may be at risk for skin breakdown if the diarrhea continues. In addition, no self-care deficit is stated for this patient. Although the patient has experienced cramping and the pain needs to be addressed, the main consideration would be correction of any fluid and electrolyte problems, followed by determination of the cause of the diarrhea

A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Home care nurse b. Wound ostomy continence nurse c. Registered dietitian d. Primary care provider

Answer: b The wound ostomy continence nurse (WOCN) is the most important person to contact to schedule teaching sessions and follow-up care. This nurse specialist is certified in the treatment of patients who have a bowel or bladder diversion. Although team input is important, the contribution of the WOCN is paramount to help the patient achieve competence and comfort with self-care before discharge

The nurse is placing an indwelling catheter in a female patient. The nurse accidentally inserts the catheter into the vagina. What is the next action for the nurse to implement? a. Collect a urine specimen and notify the primary care provider (PCP). b. Leave the catheter in place and insert a new catheter into the urethra. c. Remove the catheter from the vagina and place it into the urethra. d. Ask another nurse to attempt the catheterization of the patient.

Answer: b By leaving the first catheter in place in the vagina, the nurse can more accurately identify the urethra for insertion of the new catheter. This prevents misplacing the new catheter into the vagina during the second catheterization attempt. The catheter that was placed in the vagina is no longer sterile, so it should not be reused and should be discarded after the new catheter is properly placed into the bladder. It is impossible to get a urine sample from the catheter placed in the vagina. Only after having trouble with proper placement of the new catheter may the nurse wish to ask for assistance from another nurse

A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis negative for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination

Answer: b Contraindications for intravenous pyelogram (IVP) include an allergy to iodine, which is similar to the contrast material injected during the IVP. Knowing this information would be critical to providing safe patient care. Frequency of urination may be an indication to perform an IVP; however, this is not critical to know before performing an IVP. The results of a urinalysis and history of a recent thyroid scan would not affect a scheduled IVP

An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure

Answer: b It is most important to maintain strict aseptic technique while inserting an indwelling catheter, to try to prevent a urinary tract infection. It is not necessary to medicate patients before urinary catheterization. Although comfortable positioning and deep breathing may help relax the patient, this is not the primary concern

The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider. b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.

Answer: b The next action by the nurse should be to check the patency of the catheter tubing. At this point there is no need to aspirate any urine or call the primary care provider. The catheter should not be changed unless absolutely necessary, owing to the possibility of causing an infection

Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop mid-stream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container.

Answer: b Urine specimens for culture and sensitivity testing must be collected in sterile containers using the clean-catch, midstream method whenever possible. All voided urine specimens should be collected directly into the specimen container, not transferred to another, potentially contaminated receptacle. Discarding the entire first void and saving urine in a chilled, opaque container are both procedures for conducting a 24-hour urine collection

A young adult female is considering becoming pregnant and is not taking any multivitamins. Which nursing action would best help reduce the potential for development of neural tube defects in the fetus? a. Discuss taking selenium supplements with meals. b. Stress the importance of prenatal exercise. c. Recommend folic acid dietary supplements. d. Inquire about the patient's diet and birth control method.

Answer: c Folic acid is necessary to prevent the formation of neural tube defects (such as spina bifida). Selenium is unrelated to the prevention of neural tube defects. Exercise, diet, and birth control methods do not specifically relate to neural tube defect prevention.

The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation C. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury

Answer: c A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection.

A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions C. Contact precautions d. Protective isolation

Answer: c Contact precautions are used with C. difficile because transmission of a contagious disease is possible through contact with the patient or with the equipment or items in the patient's room. Airborne precautions are used when a contagious disease is spread by small droplets that remain suspended in the air for a long period of time. Droplet precautions are used when a disease is spread by large droplets in the air. Protective isolation is used for patients who are immunosuppressed.

What is the proper order of removal of soiled personal protective equipment when the nurse leaves the patient's room? A. Gown, goggles, mask, gloves, and exit the room b. Gloves, wash hands, remove gown, mask, and wash hands C. Gloves, goggles, gown, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands

Answer: c Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Protective eyewear or goggles are removed next by grasping them by the earpieces. Gowns are removed by untying the waist and then the neck and grasping inside the neck. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the equipment has been removed and before leaving the room.

A patient tells the nurse that he needs to increase his intake of potassium because he has been taking large doses of diuretics. To minimize complications from hypokalemia, the nurse should instruct the patient to include which of the following foods as a part of his diet? a. Cheese and crackers b. Peanut butter and jelly sandwich c. Tomatoes and spinach d. Apples and grapes

Answer: c Tomatoes and spinach are good sources of potassium. Cheese and crackers are sources of calcium and fiber. Peanut butter is a good source of protein; jelly is mostly sugar and does not provide necessary nutrients. Apples and grapes are fruit and are sources of fiber.

Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise

Answer: c Fiber is encouraged in patients with diarrhea to add bulk to the stools. Fluid intake and exercise should be encouraged. Cathartics would not be used because they are strong laxatives used to soften the stool and evacuate the bowels

A female Muslim patient is admitted to the hospital and informs the nurse that it is the month of Ramadan. Which action should be taken by the nurse to address possible dietary concerns while caring for this patient? a. Provide a vegetarian diet for the patient on Friday throughout her hospitalization. b. Ask the dietitian to visit the patient to ensure that fruit and cheese are not combined. c. Check on the potential effect fasting until sundown will have on the patient's condition. d. Document that milk and milk products cannot be prepared with meat or meat products.

Answer: c Some persons of the Islamic faith fast until sundown during the month of Ramadan so, the nurse needs to check on the potential effect of having the patient fast until sundown. Fruit is not restricted in the patient's culture or religion. No meat on Fridays is commonly followed in the Catholic faith. Kosher diets restrict the preparation of meat and milk products together

A patient is scheduled for a colonoscopy. After pre-procedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."

Answer: c The patient will be on a clear liquid diet for 1 to 3 days before the procedure. The patient should not eat or drink anything immediately before the procedure. Drinks with red or purple dye are contraindicated because they could interfere with the examination findings. Patients are given medications during the procedure that alter the sensorium and therefore need to have someone else drive them home

The nurse is providing home care to a 62-year-old woman who was recently diagnosed with insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented.

Answer: c Although the remaining options may be true, the primary reason for specific documentation of a patient's progress in a teaching plan is to ensure that other nurses or members of other disciplines can pick up the teaching plan and know precisely what the patient has accomplished and where to begin additional sessions

Written instructions showing pictures of the steps necessary to test blood glucose, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive

Answer: c Psychomotor learning involves physical movement and the use of motor skills such as demonstration and return demonstration. The affective domain involves emotion, and the cognitive domain is memorization and recall. VARK (verbal, aural, read/write, kinesthetic) refers to a method of assessing learning style

What self-care measure is most important for the nurse to include in the teaching plan for a patient who will be discharged with a urostomy? a. Change the appliance before going to bed. b. Cut the wafer 1 inch larger than the stoma. c. Cleanse the peristomal skin with mild soap and water. d. Use firm pressure to attach the wafer to the skin.

Answer: c The peristomal area should be washed by the patient using warm water and mild soap as needed and routinely at bath time. The collection device typically has a face plate to ensure a good fit and prevent leakage of urine. These appliances are changed less frequently than before bed each night, and neither a widely cut wafer nor firm pressure is needed for their application

What snack choice would be the best suggestion by the nurse for a patient on a renal diet? a. Peanut butter b. Bananas c. Diet cola d. Carrot sticks

Answer: d Carrot sticks are the best snack food to suggest for a patient on a renal diet. Renal diets restrict potassium, sodium, protein, and phosphorus intake, making peanut butter, bananas, and diet cola poor choices.

The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching? a. Do it right before the patient's next intravenous pain medication. b. Wait until tomorrow morning because he is in too much pain today. c. Leave written materials on his over-the-bed tray that he can read at his convenience. d. Wait until 10 to 15 minutes after his next intravenous pain medication

Answer: d Patients in pain are unable to focus on learning. Waiting 10 to 15 minutes after the administration of intravenous pain medication allows it to provide relief, but the patient is not sedated or resting soundly. Waiting until the following day is inappropriate because early intervention and prevention are necessary to avoid the development of deep vein thrombosis. Leaving important information where it can be easily covered up, set aside, or overlooked is not an effective method of patient education. The nurse should remember the concepts of health literacy and consider the potential effects of visual impairments, reading ability, and pain level in ensuring patient comprehension.

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, from the stoma that is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy

Answer: d An ascending colostomy meets the description of fecal output of liquid consistency and with a pungent odor, as well as location of the stoma in the upper right quadrant of the abdomen. Descending colostomies produce increasingly formed stool. An ileostomy will produce liquid stool but with less odor because enzyme activity is not present. Ureterostomies drain urine, not stool

The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing

Answer: d Green leafy vegetables are high in fiber. None of the other options are high in fiber but could be modified by using or adding whole-grain products

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum

Answer: d The most important item in preadministration assessment data is a history of surgery to the anus or rectum, which may contraindicate enema administration. The nurse needs to know the proper patient position for an enema and must observe for signs of intolerance to the procedure, but these are done during the procedure. Vital signs are not routinely obtained before an enema

Which action should the nurse take first when caring for a patient receiving a continuous enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube if the feeding tube becomes occluded? a. Use 15 mL of cranberry juice in a 20-mL syringe to clear the tubing. b. Ask to have the PEG tube replaced to prevent rupture of the gastrostomy. c. Flush the PEG tube with 60 mL of cold tap water, using gravity. d. Try using enzyme solution if a 30-mL warm-water flush is ineffective.

Answer: d Using enzyme solution to try to flush the tube if flushing with warm water does not work would be the best option. Using cranberry juice in a small, 20-mL syringe is not a recommended solution and using a 20 mL syringe may cause excessive force on the tube, resulting in rupture. Replacing the tube would increase the patient's discomfort and should be a last-resort action. Cold tap water and gravity should not be used because this measure is unlikely to be effective owing to the lack of even, gentle force needed to clear the occlusion, and because cold water may cause abdominal cramping if it reaches the stomach

Which nursing intervention would be the highest priority when caring for a patient complaining of voiding small amounts of urine in relation to his fluid intake? a. Placing a disposable waterproof pad on the patient's bed before he goes to sleep. b. Documenting in the patient's electronic health record that he is complaining of anuria. c. Notifying the patient's primary care provider (PCP) of the need for intermittent catherization. d. Palpating the patient's bladder for distention before scanning for possible retention.

Answer: d The highest priority nursing intervention for a patient experiencing oliguria (reduced urine volume) is to check the patient for bladder distention and retention. Placing a waterproof pad on the patient's bed at bedtime would be more appropriate if the patient was incontinent or experiencing nocturia (excessive urination at night). Documentation of anuria (excretion of 50-100 mL or less of urine each day) would be erroneous since the patient is complaining of repeatedly passing small amounts of urine. Notifying the primary care provider may be necessary, but only after the patient is assessed for distention and retention that is not resolved by other less invasive methods of relief

A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. "I will use only organic bath bombs when bathing." c. "I will wait to wear my tight jeans until after my urine is clear." d. "I will wipe from the front to back after voiding."

Answer: d Wiping the female perineal area from front to back after voiding is crucial in the prevention of microorganisms, which lead to infection, being transferred from the rectum or vagina to the urethral meatus. Limiting fluid intake, using any type of bath bombs, and wearing tight-fitting clothing all may contribute to the promotion of urinary tract infections rather than their prevention

When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine b. A diet that includes a large number of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake

Answers: a, b, c, d Urine may appear orange when a patient is taking phenazopyridine. Urine can appear red or pink with a diet including beets or blackberries and if blood is present in the urine, which may be secondary to an enlarged prostate or kidney stones. Urine often has a brownish appearance when liver disease such as hepatitis or cirrhosis is present. Carbohydrate intake does not typically cause urine to be discolored

in which situations does the nurse wear clean gloves as part of standard precautions? (Select all that apply) A. in the care of a patient diagnosed with an inctious process b. When the patient is diaphoretic C. During perineal care of each individual under treatment in the facility D. In the presence of urine or stool E. When taking the patient's blood pressure

Answers: a, c, d The nurse uses standard precautions for situations in which an infectious disease is known or when there is a possibility of contact with blood or body fluids (except perspiration). Gloves are not necessary when taking the blood pressure of a patient who is not in isolation and who does not have any other risk factors.

To prevent constipation in an inactive patient, which early interventions should the nurse implement Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

Answers: a, c, d, e Administering stool softeners, increasing the fiber and fluids in the diet, and increasing physical activity are all early interventions to prevent constipation. Although used to treat constipation, an enema would not be an early intervention for prevention

The nurse is caring for an elderly patient who has weakness on the right side as the result of a cerebrovascular accident (CVA). The nurse is correct in reporting dysphagia when the patient exhibits which symptoms? (Select all that apply.) a. Incomplete lip closure b. Presence of a normal gag reflex c. A change in voice quality after eating d. Difficulty speaking, with a slow, weak voice e. Abnormal movements of the mouth, tongue, and lips

Answers: a, c, e Persons with weakness of the throat and mouth after a stroke have poor muscle tone in the mouth and throat, lack of tongue action, and loss of the ability to chew and swallow effectively. Normal gag reflex is not an adverse symptom. Difficulty speaking is dysphasia

When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to a left side-lying (Sims) position. b. Add room-temperature solution to enema bag. c. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. d. Raise container, release clamps, and allow solution to fill tubing before administration. e. Clamp tubing after solution is instilled

Answers: a, d, e The patient should be assisted to the left side-lying (Sims) position. The container release clamps must be released and the solution allowed to flow to fill the tubing. After the solution is instilled, the tubing should be clamped. Solution should be warmed to slightly warmer than body temperature (or 100° to 105° F) to prevent cramping. The tip of the rectal tube should be lubricated 6 to 8 cm (3 to 4 inches)

A 61-year-old man is undergoing an emergency cardiac catheterization when the nurse gives his wife a packet of registration paperwork and asks her to complete the forms. Which observed actions may indicate a health literacy issue? (Select all that apply.) a. Putting on glasses before beginning the paperwork. b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses--these just don't work." c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms. d. Setting the clipboard aside and staring tearfully out the window. e. Returning the forms only partially filled out, with missing or inaccurate information.

Answers: b, c, e Asking someone else to read the form, waiting for help with the forms, and partially or inaccurately filling out forms are behaviors indicative of potential health literacy issues. Needing glasses does not correlate directly with health literacy. A tearful spouse requires additional assessment to see whether health literacy is a problem. The wife may be overwhelmed and feel unable to complete the forms, or she may need to collect her thoughts in the midst of a stressful time.

Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Moral Distress b. Ready to Learn c. Difficulty Coping d. Literacy Problem e. Anxiety

Answers: b, d Ready to Learn and Literacy Problem are appropriate nursing diagnoses for use in developing a patient teaching plan. Moral Distress is a nursing diagnosis for those facing ethical decisions. Difficulty Coping is not a nursing diagnosis used in developing a teaching plan, but if a patient is not coping effectively, it may affect the ability to learn. A nursing diagnosis of Anxiety may affect the patient's ability to learn but is not directly related to developing a teaching plan.

The greatest risk to a patient with a swallowing problem

Aspiration

Effects of medications on stool

Aspirin, anticoagulants: pink to red to black stool (Black=GI bleed indication) Iron salts: black stool (sticky and tar) Antacids: white discoloration or speckling in stool Antibiotics: green-gray color

Guidelines to consider with external feeding

Assess bowel sounds Hold feeding if absent (PT is not digesting; no peristalsis) Notify provider Assess tube placement Aspirate gastric contents and measure pH (5.0 or lower); If the pH is higher than 5.0 the tube may not be in the stomach Follow HCP orders and agency policy regarding residual amounts Warm the feedings to room temperature to prevent diarrhea and cramps May be administered continuously or bolus method

Considerations with nutritional care

Assess pt ability to assist with feeding (you want pt to do as much as they can independently) Limited mobility of hands/arms; pt may be able to feed themselves or use assistive feeding devices Poor tolerance of activity; becoming easily fatigued Poor cognitive or physical state; will pt remember to eat? Are they depressed/disinterested? Age-related GI changes; metabolism slows, taste changes, swallow ability, dentition Chronic illness Effects of meds; nausea, vomiting, taste change Financial; poor nutrition (malnutrition)

Promoting normal urination

Assess urinary pattern Use alternative methods to help the pt relax and stimulate urination Provide proper position (elevate head of bed) Provide privacy and time for urination and complete emptying of bladder Provide sensory stimuli (turn on water) Maintain a toileting schedule If putting pt on a bedpan, only allow a max of 10 minutes (risk for skin breakdown)

Using the Mini Nutritional Assessment (MNA), the nurse identifies an elderly patient as a nutritional risk. Which action does the nurse take? A. Use the minimum data set (MDS) to obtain further information B. Perform a full nutritional assessment C. Notify the HCP D. Use the outcome and assessment information set (OASIS) to obtain further information

B. Perform a full nutritional assessment

A patient who is diagnosed with malnutrition experiences edema of the face and legs. The nurse identifies that which event most likely caused the edema to occur? A. Infection B. Protein depletion C. Increase in oncotic pressure D. Reduction in blood volume

B. Protein depletion

water soluble vitamins

B3 B6 C Folic acid

Nursing intervention with laxative therapy

Before doing... Assess abdomen for distention, listen to bowel sounds, monitor I&O Monitor frequency, volume, and consistency of stools Assess for esophageal obstruction, intestinal obstruction, fecal impaction, undiagnosed abdominal pain If severe diarrhea occurs, discontinue laxative use Minimize risk of dehydration and electrolyte balance (increase fluid intake)

The nurse performs a dietary assessment on a patient. The nurse recalls that the Dietary Reference Intake (DRI) recommends that which percentage of total calories should come from carbohydrates? A. 10% to 15% B. 30% to 45% C. 45% to 65% D. 70% to 80%

C. 45% to 65%

The nurse is caring for a pt who has a urinary catheter. To accurately assess the urine color, it is important for the nurse to: A. Look at the urine and the amount of urine in the drainage bag B. Draw 1 to 2 mL of urine from the catheter part C. Look at the color of the urine in the drainage tube D. Review the color of the urine documented by the previous shift

C. Look at the color of the urine in the drainage tube (B is for when sending a urine sample)

The body mass index (BMI) of a patient is 26 kg/m?. How does the nurse interpret the assessment finding? A. The pt is obese B. The pt is normal C. The pt is overweight D. The pt is underweight

C. The pt is overweight

Which patient is most likely to need a complete nutritional assessment? A. A 38 year old diabetic who is undergoing laser eye surgery B. a 55 year old with a history of alcoholism who is hospitalized after surgery for a fractured femur C. a 44 year old who is on corticosteroid therapy for one week to three and asthma exacerbation D. A 35-year-old hospitalized with nausea and abdominal pain who has had no oral intake and only IV fluids of D51/2NS for one day

C. a 44 year old who is on corticosteroid therapy for one week to three and asthma exacerbation ** Count up the wrist factors to get correct answer**

After educating a patient with a respiratory etiquette, The nurse would be concerned if the patient exhibited which action! A. Stood 3 feet away from others B. washed hands right after coughing C. used the same tissue after repeatedly sneezing D. wore a mask when leaving the room to go to radiology

C. used the same tissue after repeatedly sneezing "Concerned" = the patient is in doing something right

Laboratory and diagnostic tests for infection

CBC Differential WBC count (increased= infection) Culture and sensitivity testing Determines which microorganism is cause Presence of pathogens in a specimen is a positive result and needs sensitivity test done to determine the type of antibiotic to use Erythrocyte sedimentation rate (ESR) Measures degree of inflammation (If increased, something is wrong)

Mineral Supplementation

Calcium and iron Obtained from food or supplements Excess of most minerals can be toxic Conditions that increase requirements: Pregnancy and lactation (breast-feeding) Those with inadequate diets, malabsorption issues, debilitating issues Periods of growth in adolescence (growth spurts)

urinary retention

Caused by obstruction in the urinary tract or a neurological disorder Has trouble starting a stream and once started, the stream is weak

Classifying antimicrobials

Chemical structures Mechanism of action Spectrum (broad effect for a wide variety of bacteria vs narrow effect) [broad=kill a lot; narrow=kill a little] Potency Bactericidal- kills bacteria bacteriostatic- slows growth of bacteria (Topical, cleaning products)

Broth, yea, apple juice, coffee, jello, popsicles

Clear liquids

Characteristics of normal urine

Color- pale, straw color to amber Clarity- clear to faintly hazy Odor - ammonia odor - a sweet or fruity odor is seen with diabetes or starvation - should not be fishy or fetid pH- 4.6-8.0 (usually around 6); is acidic in nature Specific gravity - 1.020-1.028 Other subs: urine should NOT have glucose, ketones, protein, blood, bacteria, leukocytes, or nitrates Most concentrated in color first thing in the morning

If screening is positive for Mal nutrition...

Complete a full nutrition assessment: health history and physical assessment

Nursing assessment for infection

Complete health history: allergies, all meds, drug interactions Obtain specimens for culture and sensitivity or blood tests to identify agent before starting therapy **(have culture before giving anabiotic therapy; 48-72 hrs)** Perform infection-focused assessment: VS, WBC count, sedimentation rate, absence of symptoms such as cough

Nursing Diagnoses

Constipation Diarrhea Bowel incontinence Self-care deficit: Toileting Diatribes body image

Full liquids

Contains all the liquids included in the clear liquid diet plus any food items that are liquid at room temperature. Add to clear liquid diet: soups, milk, milk shakes, puddings, custards, juices, some hot cereals, and yogurt

The most appropriate therapy for a patient with acute diarrhea caused by a viral infection is to a. increase fluid intake. b. administer an antibiotic. c. administer an antimotility drug. d. quarantine the patient to prevent spread of the virus.

Correct answer: a Rationale: Acute diarrhea resulting from infectious causes (e.g., virus) is usually self-limiting. The major concerns are transmission prevention, fluid and electrolyte replacement, and resolution of the diarrhea. Antidiarrheal agents are contraindicated in the treatment of infectious diarrhea because they potentially prolong exposure to the infectious organism. Antibiotics are rarely used to treat acute diarrhea. To prevent transmission of diarrhea caused by a virus, wash your hands before and after contact with the patient and when handling body fluids of any kind. Flush vomitus and stool down the toilet and wash contaminated clothing at once with soap and hot water.

The nurse determines a patient undergoing ileostony surgery understands the procedure when the patient states a. "I should only have to change the pouch every 4 to 7 days" b. "The drainage in the pouch will look like my normal stools" c. "I may not need to wear a drainage pouch if I irrigate it daily" d. "Limiting my fluid intake should decrease the amount of output"

Correct answer: a Rationale: Because ileostomy drainage is a liquid to thin paste, the patient will need to wear a drainage bag at all times. The patient should use an open-ended drainable pouch. It is worn for 4 to 7 days. Output from a sigmoid colostomy resembles normally formed stool. Some patients can regulate emptying time so they do not need to wear an ostomy pouch.

The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu a. scrambled eggs and sausage. b. buckwheat pancakes with syrup. c. oatmeal, skim milk, and orange juice. d. yogurt, strawberries, and rye toast with butter.

Correct answer: a Rationale: Celiac disease is treated with lifelong avoidance of dietary gluten (wheat, barley, oats, rye products). Although pure oats do not contain gluten, oat products can become contaminated with wheat, rye, and barley during the milling process. Gluten is found in some medications and in many food additives, preservatives, and stabilizers.

Which is the priority patient teaching strategy when limited time is available? a. Setting realistic goals that have high priority for the patient b. Referring the patient to a nurse educator in private practice c. Observing more experienced nurse-teachers to learn how to teach faster and more efficiently d. Providing reading materials for the patient instead of discussing information the patient needs to learn

Correct answer: a Rationale: Lack of time is a barrier that detracts from the effectiveness of teaching. To make the most of limited time, the nurse and the patient must set learning priorities, and the nurse must provide some teaching during every contact with the patient or caregiver. Patients dealing with common problems can benefit from peer teaching.

The percentage of daily calories for a healthy person consists of a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids. b. 65% carbohydrates, 25% protein, 25% fat, and >10% of fat from saturated fatty acids. C. 50% carbohydrates, 40% protein, 10% fat, and <10% of fat from saturated fatty acids. d. 40% carbohydrates, 30% protein, 30% fat, and >10% of fat from saturated fatty acids.

Correct answer: a Rationale: The Dietary Guidelines for Americans recommend that 45% to 65% of total calories should come from carbohydrates. Ideally, 10% to 35% of daily caloric needs should come from protein. Persons should limit their fat intake to 20% to 35% of total calories. Fats can be divided into (1) potentially harmful (saturated fat and trans fat) and (2) healthier dietary fat (monounsaturated and polyunsaturated fat). To reduce the risk of obesity, we should consume less than 10% of calories from saturated fatty acids (about 20 g of saturated fat per day in a 2000-calorie diet) and choose foods with no trans-fatty acids

Which method is best to use when confirming initial placement of a blindly inserted small-bore NG feeding tube? a. X-ray b. Air insertion c. Observing patient for coughing d. pH measurement of gastric aspirate

Correct answer: a Rationale: The nurse should obtain x-ray confirmation to determine whether a blindly placed nasogastric or orogastric tube (small bore or large bore) is properly positioned in the gastrointestinal tract before giving feedings or medications. Air insertion, observing a patient for coughing, and measuring the pH of gastric aspirate are not appropriate ways to confirm whether a blindly placed nasogastric or orogastric tube is properly positioned in the gastrointestinal tract before use

Which patient characteristic enhances the teaching-learning process? a. Moderate anxiety b. High self-efficacy c. Being in the precontemplative stage of change d. Being able to laugh about the current health problem

Correct answer: b Rationale: An important characteristic that can enhance the teaching-learning process is the patient's sense of self-efficacy. There is a strong correlation between self-efficacy and outcomes of illness management. Self-efficacy increases when a person gains new skills in managing a threatening situation, but it decreases when the person experiences repeated failure. The nurse should plan easily attainable goals early in the teaching sessions and proceed from simple to more complex content to establish the patient's perception of success

A patient is receiving peripheral parenteral nutrition. The solution is completed before the new solution arrives on the unit. The nurse gives a. 20% intralipids. b. 5% dextrose solution. c. 0.45% normal saline solution. d. 5% lactated Ringer's solution.

Correct answer: b Rationale: If a peripheral parenteral nutrition (PPN) formula bag empties before the next solution is available, a 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) should be given to prevent hypoglycemia

In contrast to diverticulitis, the patient with diverticulosis a. has rectal bleeding. b. often has no symptoms. c. usually develops peritonitis. d. has localized cramping pain.

Correct answer: b Rationale: Many people with diverticulosis have no symptoms. Patients with diverticulitis have symptoms of inflammation. Diverticulitis can lead to obstruction or perforation.

What would be the priority teaching goal for a middle-aged Hispanic woman about methods to relieve symptoms of menopause? a. Prevent the development of future disease. b. Maintain the patient's current state of health. c. Provide information on possible treatment options. d. Change the patient's beliefs about herbal supplements.

Correct answer: c Rationale: General goals of patient teaching include health promotion, disease prevention, management of illness, and appropriate choice and use of treatment options.

A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that a. chemotherapy will begin after the patient recovers from the surgery. b. both chemotherapy and radiation can be used as palliative treatments. c. follow-up colonoscopies will be needed to ensure that the cancer does not recur. d. A wound, ostomy, continence nurse will visit the patient to identify the site for the ostomy

Correct answer: c Rationale: Stage I colorectal cancer is treated with surgical removal of the tumor and reanastomosis, and so there is no ostomy. Chemotherapy is not recommended for stage I tumors. Follow-up colonoscopy is recommended because colorectal cancer can recur

The nurse has taught a family caregiver how to administer insulin. Evaluation of the caregiver's learning would include a. monitoring the patient's glucose readings. b. arranging for follow-up with a home care nurse. c. asking the caregiver to "show back" the ability to administer insulin. d. asking the caregiver what was helpful about the teaching experience.

Correct answer: c Rationale: To evaluate learning, the nurse should directly watch the caregiver administering insulin to the patient (show back)

In planning care for the patient with Crohns disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease a. often results in toxic megacolon. b. causes fewer nutritional deficiencies than ulcerative colitis. c. often recurs after surgery, while ulcerative colitis is curable with a colectomy. d. is manifested by rectal bleeding and anemia more often than is ulcerative colitis.

Correct answer: c Rationale: Ulcerative colitis affects only the colon and rectum; it can cause megacolon and rectal bleeding, but not nutrient malabsorption. Surgical removal of the colon and rectum cures it. Crohn's disease usually involves the ileum, where bile salts and vitamin cobalamin are absorbed. After surgical treatment, disease recurrence at the site is common.

A complete nutritional assessment including anthropometric measurements is most important for the patient who a. has a BMI of 25.5 kg/m?. b. reports episodes of nightly nocturia. c. reports a 5-year history of constipation. d. reports an unintentional weight loss of 10 1b in 2 months.

Correct answer: d Rationale: A loss of more than 5% of usual body weight over 6 months, whether intentional or unintentional, is a critical indicator for further assessment

What should a patient be taught after a hemorrhoidectomy? a. Take mineral oil before bedtime. b. Eat a low-fiber diet to rest the colon. c. Use oil-retention enemas to empty the colon. d. Take prescribed pain medications before a bowel movement.

Correct answer: d Rationale: After a hemorrhoidectomy, the patient usually dreads the first bowel movement and often resists the urge to defecate. Give pain medication before the bowel movement to reduce discomfort. The patient should avoid constipation and straining. A high-fiber diet can reduce constipation. A stool softener, such as docusate (Colace), is usually ordered for the first few postoperative days. If the patient does not have a bowel movement within 2 to 3 days, an oilretention enema is given.

A nursing intervention that is most appropriate to decrease post-operative edema and pain after an inguinal herniorrhaphy is to a. apply a truss to the hernia site. b. allow the patient to stand to void. c. support the incision during coughing. d. apply a scrotal support with an ice bag.

Correct answer: d Rationale: Scrotal edema is a painful complication after an inguinal hernia repair. Scrotal support with application of an ice bag may help relieve pain and edema.

A patient tells the nurse that she enjoys talking with others and sharing experiences but often falls asleep when reading. Which teaching strategy would be most effective with this patient? a. Formal lecture b. Journal writing c. Web-based program d. Small group discussion

Correct answer: d Rationale: The nurse should try to match the patient's learning style with the teaching strategy. A patient who enjoys interaction with others will likely learn best in group discussion

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply) a. persistent abdominal pain. b. marked abdominal distention. c. diarrhea that is loose or liquid. d. colicky, severe, intermittent pain. e. profuse vomiting that relieves abdominal pain.

Correct answers: a, b Rationale: With lower intestinal obstructions, abdominal distention is markedly increased, and pain is persistent. Onset of a large intestine obstruction is gradual, vomiting is rare, and there is usually obstipation, not diarrhea.

A 35-yr-old female patient is admitted to the emergency department with acute abdominal pain. Which medical diagnoses should you consider as possible causes of her pain? (select all that apply) a. Gastroenteritis b. Ectopic pregnancy c. Gastrointestinal bleeding d. Irritable bowel syndrome e. Inflammatory bowel disease

Correct answers: a, b, c, d, e Rationale: All these conditions could cause acute abdominal pain.

A patient with anorexia nervosa shows signs of malnutrition. During initial refeeding, the nurse carefully assesses the patient for (select all that apply) a. hypokalemia. b. hypoglycemia. c. hypercalcemia. d. hypomagnesemia. c. hypophosphatemia.

Correct answers: a, d, e Rationale: Refeeding syndrome is characterized by fluid retention and electrolyte imbalances (hypophosphatemia, hypokalemia, hypomagnesemia). Hypophosphatemia is the hallmark of refeeding syndrome. It is associated with serious outcomes, including dysrhythmias, respiratory arrest, and neurologic problems (e.g., paresthesias). Refeeding syndrome can occur any time a malnourished patient starts aggressive nutritional support

Assessment findings suggestive of peritonitis include (select all that apply) a. rebound tenderness. b. a soft, distended abdomen. c. dull, intermittent abdominal pain. d. shallow respirations with bradypnea. e. observing that the patient is lying still.

Correct answers: a, e Rationale: With peritoneal irritation, the abdomen is hard, and the patient has severe continuous abdominal pain that is worse with any sudden movement. Palpating the abdomen and releasing the hands suddenly causes sudden movement within the abdomen and severe pain. This is called rebound tenderness. The patient lies very still and takes shallow breaths. Abdominal distention, tachypnea, fever, and tachycardia may occur.

Place in order the substrates the body uses for energy during starvation, beginning with 1 for the first component and ending with 4 for the last component. a. skeletal protein. b. glycogen. c. visceral protein. d. fat stores.

Correct answers: b, a, d, c Rationale: Initially, the body selectively uses carbohydrates (e.g., glycogen) rather than fat and protein to meet metabolic needs. These carbohydrate stores, found in the liver and muscles, are minimal and may be totally depleted within 18 hours. After carbohydrate stores are depleted, skeletal protein begins to be converted to glucose for energy. Within 5 to 9 days, body fat is being used to supply much of the needed energy. In prolonged starvation, up to 97% of calories are provided by fat, and protein is conserved. Depletion of fat stores depends on the amount available, but fat stores typically are used up in 4 to 6 weeks. After fat stores are used, body or visceral proteins, including those in internal organs and plasma, can no longer be spared and rapidly decrease because they are the only remaining body source of energy available.

The nurse needs to include caregivers in patient teaching primarily because (select all that apply) a. caregivers provide all the care for patients after discharge. b. they might feel rejected if they are not included in the teaching. c. patients have better outcomes when their caregivers are involved d. the patient may be too ill or too stressed to fully understand the teaching. e. caregivers are responsible for the overall management of the patient's care.

Correct answers: c, d Rationale: Support provided by the caregiver is important to a patient's sense of physical, psychologic, and spiritual well-being. Whenever possible and appropriate, involve the patient's caregivers in the teaching-learning process. If the physical or psychologic condition of the patient interferes with his or her participation, the patient's caregivers can be involved.

Fat soluble vitamins

D E A K

A nurse has provided information to a patient about measures to promote a normal urinary pattern and prevent UTIs. Which statement by the patient indicates the need for further information? A. " I should take my diuretic in the morning" B. " I should drink plenty of fluids during the day" C. " I should eat foods that will make my urine acidic" D. " I should try to hold my urine as long as I can rather than going to the bathroom when I feel the urge"

D. " I should try to hold my urine as long as I can rather than going to the bathroom when I feel the urge"

The registered nurse provides education to a group of nursing students about assessment findings associated with malnutrition. Which statement made by a student indicates the need for further education? A. "Glossitis occurs" B. "Atropos papillae are present" C. "Teeth will be absent or loose" D. Bowel sounds are increased"

D. "Bowel sounds are increased"

The nurse completes a nutritional screening and identifies that a patient is at risk for malnutrition. Which is the next step for the nurse to take? A. Provide supplements between meals B. Encourage eating meals with other C. Have family members bring in food from home D. Complete a full nutritional assessment

D. Complete a full nutritional assessment

When teaching a patient to use the "MyPlate" dietary guidelines, the nurse explains that which food group should constitute the largest portion? A. Fruits B. Protein C. Grains D. Vegetables

D. Vegetables

Fat soluble vitamins

DEAK

If glucose and ketones are present in a UA, what should the nurse think

DM

Diet analysis

Data about the type and quantity of foods eaten Establishes baseline values for any health problems that may affect the patient's nutritional status and identifies need for intervention Ask about typical diet intake, food preferences, allergies 24 hour recall: foods EN and quantities from the previous day Food diary: entries for 3 to 5 days and include dietary intake for a typical weekend (doing it on the weekend illuminates fluctuations in the diet) Calorie count on paper or app and analyze it

Antidiarrheals

Decrease hyper motility Treatment depends on severity and etiology Antidiarrheals contraindicated: Those with sever dehydration, electrolyte imbalance (don't stop process) Liver and renal disorders Glaucoma (causes increased pressure)

oliguria

Decreased urine output 400mL or less urine/day

Malnutrition

Deficit, excess, or imbalance in essential components of a balanced diet Develops as a result of decreased intake of nutrients, increased nutrient requirements, and complications due to disease Common with: Illness surgery injury hospitalization Expected with: Pregnancy growth spurts Can be obese or anorexia Chemo patients are malnourished due to nausea and vomiting

Teaching Strategies

Depends on the pts Learning style Age Educational background Culture Language skills Nature of illness As well as the subject, and what you have available Can include a combo of: Discussion Demonstration-return demo (teach back) Role play (simulation) Learning materials (print, CDs/DVDs, computer programs)

Evaluation

Determine if learning/goals were achieved Evaluation strategies for teaching are: Observe pt directly (teach back) Observe verbal and nonverbal cues Discussion with pt/caregiver (teach back) Pts self-evaluation of progress Long-term evaluation: follow up and referrals after discharge

If bacteria is seen in a UA, what should the nurse think?

Did the pt clean their perineal area prior to voiding If so, it may indicate a UTI If bacteria is present but there are no nitrates = not clean perineal area prior to voiding

Referrals

Dietitian: for nutritional education and recommendations Case managers: for coordinating outpatient care such as medical equipment, IV therapy, transportation Speech therapist: for swallowing evaluations and restorative therapy Occupational therapist: for adaptive devices for meals and restorative therapy

Opioids

Diphenoxylate with atropine (Lomotil); Paregoric Works by slowing peristalsis and enhancing the anal sphincter tone by direct action on brain centers Used for moderate to sever diarrhea Most effective agent AR: dizziness, drowsiness, respiratory depression, dependence

Medication used for constipation

Docusate sodium (colace): Is a stool softener; used to treat occasional constipation. Often the FIRST method used for preventing and treating constipation Psyllium preparations (Metamucil): Absorbs large amounts of fluid to form bulkier stools Dulcolax (Bisacodyl): works fast and the suppositories work faster; causes cramping Poly ethylene glycol (Miralax): Salt draws water into the intestines; distention from excess fluid promotes peristalsis and creates watery stool

Altered patterns of urination

Dysuria Polyuria Oliguria Anuria Urgency Frequency Nocturia Hematuria Pyuria Urinary retention Enuresis

Nurse is responsible for pt and caregiver teaching

Every interaction is a potential "teaching moment" Informal and formal opportunities Teaching plans provide guidelines for specific learning needs

Consequences of altered bowel function

Fecal impaction (know facility policy) Flatulence Distinction of the abdomen Constipation Diarrhea (excessive antibiotics)

2 common ways to obtain information about diet patterns

Food diary, 24 hour recall

Care of Patients experiencing diarrhea

Frequently monitor pt and assist with toileting (assess skin) Remove cause of diarrhea if possible Assess fluid and electrolyte status - w sever diarrhea, the pt can easily become dehydrated Assess for blood in stool Assess anal area for redness and irritation

All juices, smooth dairy, cooked cereal

Full liquids

Role of Patient and Caregiver Teaching

General goals for the pt after teachings: Health promotion Disease prevention Illness management Select and use appropriate treatment options Enhanced quality of life

Teaching competencies

Good communication skills Knowledge of the subject matter

Laboratory studies (not diagnosis)

H/H (hemoglobin and hematocrit) Electrolytes (calc, potas, sodium) C-reactive protein- tends to to be positive Serum proteins Albumin (mature protein/long term): norm: 3.5-5.0 Transferrin: protein with iron: norm: 200-400 Prealbumin (nonmature protein/short term): norm: 16-30 (Never at zero) Nitrogen balance: negative means you need to do something because pt is not getting enough

**What's the number way to prevent infection**

HAND HYGIENE

Nutrition focused history questions

Have you gained or lost weight in the past month? Have you noticed any changes in appetite or food intake? Do you follow a particular diet? Have you noticed any changes in your sense of taste? Do you ever feel that your eating is out of control?

2 measurements needed to calculate BMI

Height and weight

2 nutritional tasks you can delegate to an AP

Height, weight, I&O, feeding

Troches and Lozenges

Held in the mouth while they dissolve

Stresses bran, oats, uncooked fruit, steamed veggies

High fiber diet

If bacteria, leukocyte esterase, and nitrates are found in a UA, what should the nurse think?

If all are present, that indicates a UTI

Nursing Diagnosis

Inability to self-feed Impaired swallowing Risk for aspiration Nutritionally compromised/ imbalanced nutrition

Documentation

Intake of food (% of food eaten) and liquids (in mLs); jello counts as liquid Any symptoms of aspiration (coughing, choking, drooling, runny nose, pocketing) Can be silent aspiration (asymptomatic)

If blood is in a UA, what should the nurse think?

Is the pt on the menstruating cycle or is it something more serious

If a pt is on diuretics, what will happen to their urine?

It will lightened urine (translucent) to a pale yellow Give med in the morning

If a pt is on anticoagulants, what will happen to their urine?

It will turn a red color

If a pt is on levodopa (Parkinson's), what will happen to the urine?

It will turn brown or black If urine is brown or black and pt is not on this med be concerned for liver and kidney problems/failure

If a pt is on Elavil, what will happen to the urine?

It will turn green or blue-green Elavil treats depression

If a pt is on pyridium, what will happen to the urine?

It will turn orange to orange-red (neon) Can stain Pyridium is a med to help with dysuria

Challenges to teaching

Lack of time Person feelings as teacher Nurse-pt differences in goals Pts rapid discharge from the health care system

Auditory learning style

Learns best with Attending class and workshops Discuss topics with teacher/ peers Explains new ideas to other people Use a recording device

Read/write learning style

Learns best with Lists and handouts Readings and notes Textbooks and manuals Dictionaries and glossaries

Kinesthetic learning style

Learns best with Senses and experience Real-life examples Hands-on approach Trial and error

Visual learning style

Learns best with pictures, videos, posters, slides; Gestures and picturesque lang Underlining with different colors Graphs or symbols

External feeding

Liquid foods are introduced into the G.I. tract by a tube. Tube feeding is indicated when the G.I. tract is functional but oral intake is not meeting estimated nutrient needs Maybe used with PTS with: Swallowing problems burns major trauma liver or organ failure severe malnutrition The HCP orders: the type of formula amount frequency of administration

Medications used for simple diarrhea

Loperamide (Imodium): slows GI motility by depressing muscle action; is a non narcotic so can be purchased OTC Bismuth compounds (Pepto-bishop, Kaopectate): binds and absorbs intestinal toxins; administered after each loose stool; can be used for GI upset; can be purchased OTC

No canned soups, lunch meat, or high processed foods

Low salt/sodium diet

Promoting defecation

Maintain the pts normal elimination routine Avoid meds that will can constipation (pain meds, antacids) Include high fiber foods and adequate nutrition in diet Maintain normal exercise patterns (promotes peristalsis) Assist pt with elimination as needed Remove any impaction Bowel training: Choose time compatible with pts normal pattern to eliminate defecation measures As prescribed, administer stool softeners daily or a cathartic suppository at least 30 minutes before normal defecation time Provide a hot drink or juice to stimulate peristalsis before Provide privacy and all time for defecation (no rush) Help the pt assume a position that will facilitate defecation (sitting)

Powders

May be inhaled, mixed with food, or dissolved in liquids immediately before administration

Includes clear and full liquids, with scrambled eggs, cooked veggies, & canned fruit

Mechanical soft

Solutions

Meds already dissolved in liquids Syrups: mixed wi sugar and water Suspensions: finely crushed meds in liquids Elixirs: dissolved in alcohol and water with glycerin or other sweeteners Drops: sterile solutions or suspension administered directly into eye, ear, nose or SL Injectable solutions: sterile suspensions Inhalants and sprays: med inhaled or sprayed into mouth or nose Skin preparations: meds placed on the surface of skin (lotion, cream, powder) Transdermal patches: meds absorbed through the skin Suppositories: bullet-shaped gelatin tablets administered rr tally or vaginally (have or in lateral sims)

Blood glucose testing

Monitor glucose lvls in blood Monitor response to insulin therapy Gauges amount of insulin needed for a sliding scale May be delegated Use middle or ring finger; between the tip and 1st joint Cleanse site with alcohol wipe and allow to dry Puncture site and wipe off first drop of blood Place second drop on reagent strip

Interventions

Monitor: daily or weekly weights, I&O, calorie counts, diet analysis Proper assistive devices (dentures, special/adaptive untensils) Proper environment- hygiene, noise, smells Provide assistance with eating as needed Diet: special diets, favorite foods consistent with culture and needs, small and frequent feedings Nutritional supplements:: oral, enteral, PN (parenteral nutrition through IV)

Which patients are at greater risk for HAIs

Multiple illnesses Older adults Poorly nourished Low resistance Immuno suppressed

Consideration when administering meds

Never administer meds you did not prepare yourself Verify they are for the right person Complete appropriate assessment Appropriate VS before and after Check allergies Appropriate lab data obtained Pain level assessed before and after Patient teaching If there is a question about the med order by the nurse do NOT administer med Contact HCP or pharmacist for clarification/questions Never leave meds unattended at bedside Pt has the right to refuse Do not document in MAR until pt is given to pt and they have physically taken them If you drop med, waste it; loose med, find it

2 ways to promote mealtime being more pleasant

No bad sights/smells, no interruptions, social time

Risk factors of HAIs

Number of health care employees with direct contact with the patient Types and numbers of invasive procedures Therapy received Length of hospitalization (LOS)

Assessment of nutrition

Nutrition history screening (required on admission and periodically after depending on pt condition) physical assessment laboratory studies Elimination patterns Unintentional weight loss is bad (🚩)

Refer to this specialist that helps select items to promote independent feeding

Occupations therapy

Infection

Occurs when a pathogen invades the body, begins to multiply, and produces disease

Resistance

Occurs when pathogen changes in way that decreases ability of drug to treat disease Antibiotics destroy sensitive bacteria an insensitive (mutated) bacteria remain

Superinfection

Occurs when too many normal flora are killed, giving pathogens a chance to multiply Sites: mouth, skin, respiratory tract, vagina, intestines S&S: diarrhea, bladder pain, painful urination, or abnormal vaginal discharge

Implementation for infection

Ongoing assessment: VS and symptoms of infection Monitor for allergic reaction Monitor for superinfections SE IV site for signs of tissue irritation, severe pain, extravasation Administer drug around the clock and appropriately to the order Administer as directed

3 types of nutrition supplements

Oral, EN, PN

BMI of 25.0-29.9kg/m2

Overweight

dysuria

Painful urination indication of UTI

Infection prevention and control

Patient safety (hand wash, standard precautions, appropriate handling of solid and fluid waste) Isolation and isolation precautions Sterile/surgical asepsis Immunizations Pt education Respiratory etiquette

Outcomes of infection

Patient will: Achieve a normal wbc count and differential be free from secondary infections follow any isolation measures complete prescribed therapy not have an infection

Evaluation

Patient will: Achieve and maintain optimal body weight Consume a well-balanced diet Be free from complications of malnutrition

Delegation and collaboration

Performing and interpreting a nutritional assessment cannot be delegated at an AP The nurse directs AP to: Measure height Measure weight after voiding, at the same time each day, wearing the same cloths Use bed scale according to guidelines Collect I&O data Feeding and assisting with meals

Assessing learning needs

Physical factors: age, sensory, dexterity, pain, meds Psychologic factors: anxiety, depression Sociocultural: literacy (aim for 5th grade lvl), resources, cultural beliefs and practices Learner factors Current knowledge, knowledge and skills needed, past experiences Pt priorities (ask pts to prioritize what they see as the most critical info) Readiness and motivation Health literacy (the degree to which individuals have the capacity to obtain, process, and understand basic health info needed to make appropriate health decisions) Learning style

When feeding a pt

Position yourself so pt can see you SIT don't stand Do not rush the pt Small bites Wait 10 seconds between bites Alternate foods with fluids Avoid unnecessary use of straws (aspiration and injection of air) Observe mouth for pocketing of food Provide oral care before and after to get rid of bacteria If patient has dentures ensure that they are in and well fitted Special precautions if impaired swallowing: if one sided muscle weakness, turn head to affected side to assist an airway protection chin-tucking may help prevent aspiration; blocks airway to lungs Find food the pt likes (ask for preference)

Which serum protein is the best indicator for recent or current nutritional status

Prealbumin Is a protein made by the liver

Factors contributing to resistance:

Prescribing ATB for non-bacterial infections Use of inappropriate ATB Incomplete courses of ATB

Antimicrobial agents (anti microbial therapy)

Prevent or treat infections caused by a pathogen They work in different ways: Inhibit bacterial cell wall synthesis Alter cell membrane permeability Inhibit proteins synthesis Inhibit RNA and DNA synthesis Interfere with cell metabolism Multimodal therapy is more than one anabiotic medication used on a patient

Sterilization

Process used to destroy all micro organisms including spores

Nutrient most important to wound healing and tissue growth

Protein

Clear liquids

Provide fluids to prevent dehydration and supplies some simple carbohydrates to help meet energy needs Water, tea, coffee, broth, clear juice, popsicles, carbonated drinks, and gelatin (jello)

2 times when vitamins and minerals may be required for natural reasons

Rapid growth (adolescent); pregnancy/lactation

Implementation and evaluation

Rectal suppository: drug delivery system inserted into the rectum, where dissolves for medication absorption by coming into contact with the rectal mucosa Enema: the introduction of solutions into the rectum and sigmoid colon by the anus There are different types of enemas: Cleansing hypertonic (draws fluid out of intestine) Cleansing isotonic (expands colon, peristalsis) Oil retention (lubricates rerun and colon) Medication ( antibiotic enemas used to treat local infections (worms, parasites) Carminative (stimulates peristalsis and promotes flatulence) Return-flow (stimulates peristalsis and promotes flatulence)

Infectious disease

Refers to the pathologic events that result from the invasion and multiplication of organisms in a host

Interventions

Report effects such as persistent diarrhea, constipation, abdominal pain, blood in stool, confusion, dizziness, fever Dizziness and confusion = dehydration Fever = infection Follow appropriate med administration guidelines Take with additional fluids and increase fluid intake Do not exceed recommended dosage or use more frequently than directed

HAI

Results from delivery of health services in a healthcare facility

6 rights of medication administration

Right dose, right time, right patient, right route, right documentation, right medication

Diagnostic tests

Routine specimens Culture (what bacteria is growing) and sensitivity (what antibiotic will work) Cystoscopy- sterile procedure Ultrasound and bladder scan - noninvasive X-Rays- KUB (kidney, bladder, urethra), IVP (intravenous pyelography) Blood tests: BUN/ Creatinine (shows kidney function, hydration status and how well they are working) Creatinine shows kidney function the most and best

Nutrition Care process

Screen and assess diagnose intervention evaluate

Learning goals

Should be clear and measurable Relate to your intended outcome of the learning process Guide the selection of teaching strategies Help evaluate the pts progress

Type of test using calipers to measure skin thickness at various sites

Skinfold measurements

Refer to this specialist for a swallowing evaluation

Speech therapist

Types of incontinence

Stress Urge Overflow Functional Temporary Mixed

Stress Incontinence

Stress incontinence may happen when there is an increase in abdominal pressure -- such as when you exercise, laugh, sneeze, or cough. Urine leaks due to weakened pelvic floor muscles and tissues. Causes of stress incontinence include pregnancy and childbirth, which cause stretching and weakening of the pelvic floor muscles. Other factors may also increase the risk for stress incontinence, such as being overweight, obesity, prostate surgery, and certain medications.

Assessment of the lower GI tract (BM)

Subjective data: last BM, description, pain, color, consistency, normal BM pattern, meds, medical history Objective data: senses (color, smell), any blood (GI bleed), mucus, etc Diagnostic test results: colonoscopy, stool sample Factors influencing bowel elimination: nutrition (fiber), fluid intake (6 to 8 glasses), activity and exercise, body position, person habits (change in environment), pregnancy (slows BM), pain with BM (hemorrhoids), diagnostic procedures (colonoscopy), surgery (inhibits BS- absent) and anesthesia (constipation)

Major sites for HAI infection

Surgical or traumatic wounds Urinary and respiratory tracts Bloodstream

Regulatory Mandates for Patient Teaching

TJC came up with the Speak Up program to encourage pts to be more involved in their care and to ask questions that they have a right to know AHA Patient Care Partnership Institute for Health Care Improvements National patient Safety Foundation- Ask Me

health promotion

Teach pt about diet and proper nutrition using standard guidelines Intake of grains, veggies, fruit, milk, and meat groups Adequate nutrients within caloric needs Weight management Physical activity Alcoholic beverages Ask about pt preference, culture, family, etc

Bladder retraining

Teach pts kegel exercises (strengthen pelvic muscles) Take measures to decrease risk for UTIs Maintain pts personal hygiene Encourage intake of foods/fluids that acidify the urine (cranberries, cranberry juice, meats [E. Coli=bacteria], eggs, whole-grain breads, prunes, plumes) Do not hold urine Cotton underwear (no thongs) No bubble baths Void before and after intercourse

mechanical soft diet

The diet of choice for patients with acute or chronic difficulties with chewing, such as those with jaw problems, missing teeth, poorly fitting dentures, or severe weakness or fatigue. This diet includes all of the items from the full liquid diet plus the addition of soft foods such as scrambled eggs and cottage cheese.

Immunization

The process by which an individual develops immunity against a specific agent; it is important in preventing the spread of communicable diseases The most common way is vaccination

Disinfection

The removal of pathogenic microorganisms except for sports

Vitamin therapy

Therapy indicated for certain conditions Poor nutrition intake Pregnancy Chronic disease Synthetic vitamins- same structure and function as natural vitamins Have the same physiologic effects as those from foods, should never be a substitute for a healthy diet Do not require a prescription Vary widely in number, type, and amount of specific ingredients Often marked in combinations Vitamins from food are best Not fully regulated by FDA

Measure of iron levels

Transferrin

What will you see if a patient is malnourished?

Unintended weight loss Increased susceptibility to infection, decreased wound healing and increase risk for pressure injury Weakness and fatigue Poor wound healing, exercise bruising Poor muscle mass or muscle wasting Edema Decreased H/H, iron, protein levels Hair is thin, coarse, and breaks easily Bleeding and swollen gums

Urge Incontinence

Urge incontinence is often referred to as overactive bladder: You have an urgent need to go to the bathroom and may not get there in time, leaking urine. Causes of overactive bladder include: Damage to the bladder's nerves; Damage to the nervous system; Damage to muscles Conditions such as multiple sclerosis, Parkinson's disease, diabetes, and stroke can affect nerves, leading to urge incontinence. Other conditions such as bladder infections, bladder stones, and use of certain medications can also contribute to symptoms. Involves a sudden strong urge to void followed by bladder contraction

Tablets

Used for oral, SL, buccal Enteric coated tabs delay absorption (do not crush or cut)

Most common sign that signals malnutrition may be present

Weight loss

Functional Incontinence

With functional incontinence, physical problems such as arthritis, or cognitive problems such as dementia prevent you from getting to the bathroom in time. Lack of control (immobility)

Overflow Incontinence

You may have overflow incontinence if you are not able to empty your bladder appropriately. As a result, you may have leakage once the bladder is already full. This is more common in men with symptoms of frequent dribbling of urine. Causes of overflow incontinence include: Weak bladder muscles; Blockage of the urethra, such as by prostate enlargement; Medical conditions such as tumors causing obstruction of urine flow; Constipation Pts cannot empty bladder completely

A diagnosis of AIDS is made when an HIV-infected patient has a. a CD4+ T cell count below 200/uL. b. a high level of HIV in the blood and saliva. c. lipodystrophy with metabolic abnormalities. d. oral hairy leukoplakia, an infection caused by Epstein-Barr virus.

a Rationale: AIDS is diagnosed when a person with HIV infection meets one of several criteria; one criterion is a CD4+ T cell count below 200 cells/L.

Which strategy can the nurse teach the patient to eliminate the risk for HIV transmission? a. Using sterile equipment to inject drugs b. Cleaning equipment used to inject drugs c. Taking lamivudine (Epivir) during pregnancy d. Using latex or polyurethane barriers to cover genitalia during sexual contact

a Rationale: Access to sterile equipment is an important risk-elimination tactic. Some communities have needle and syringe exchange programs (NSEPs) that provide sterile equipment to users in exchange for used equipment. Cleaning equipment before use is a riskreducing activity. It decreases the risk when equipment is shared, but it takes time, and a person in drug withdrawal may have difficulty cleaning equipment. Lamivudine alone is not appropriate for treatment in pregnancy. Barrier methods reduce but do not eliminate risk

Transmission of HIV from an infected person to another most often occurs because of a. unprotected anal or vaginal sexual intercourse. b. low levels of virus in the blood and high levels of CD4+ T cells. c. transmission from mother to infant during labor and delivery and breastfeeding. d. sharing eating utensils, dry kissing, hugging, using toilet seats, or shaking hands.

a Rationale: Unprotected sexual contact (semen, vaginal secretions, blood) with a partner infected with human immunodeficiency virus (HIV) is the most common mode of HIV transmission

Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) a. Redness or warmth at the affected site b. Purulent drainage at the incision site c. Tenderness and localized pain d. Wound with well-approximated edges e. White blood cell count 6500 cells/mm?

a, b, c, Purulent drainage, tenderness, localized pain, and redness or warmth are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing. The normal white blood count for adults is 4500 to 10,500 cells/mm3.

Emerging and reemerging infections affect health care by (select all that apply) a. reevaluating vaccine practices. b. revealing antimicrobial resistance. c. limiting antibiotics to those with life-threatening infection. d. challenging researchers to discover new antimicrobial therapies.

a, b, d Rationale: An emerging infection is an infectious disease whose incidence has increased in the past 20 years or threatens to increase in the immediate future. Reemerging infections are those infections that were previously controlled but have resurfaced. The most common reason for reemerging infectious is low vaccination rates. Ways in which emerging and reemerging infectious have affected the health care system include revising vaccine recommendations for previously controlled infections (e.g., pertussis, measles); discovery of antimicrobial-resistant organisms; and creation of new antiinfective agents to combat new organisms or antimicrobialresistant infections.

Interventions to prevent health care-associated infections include (select all that apply) a. following hand-washing protocols. b. limiting visitors to persons over age 18. c. placing high-risk patients in private rooms. d. decontaminating equipment used for patient care. e. appropriately using personal protective equipment.

a, d, e Rationale: First lines of defense to prevent the spread of HAIs include hand washing (or using an alcohol-based hand sanitizer) before and after patient contact or procedures, appropriate use of personal protective equipment such as gloves, and decontamination of equipment used for patient care

Continuous feedings

administration of formula for 10-24 hours daily, using an infusion pump to control the feeding rate Change feeding container in tubing every 24 hours (put date time and your initials) Check expiration date on formula Shake well before pouring into feeding bag administer feedings are prescribed rate; not too fast, not too slow flush tube every four hours with water (ordered amount) Do not allow feeding bag to empty; it will pump air into the stomach Always keep patient in semi-Fowlers position; head elevated at least 30° If vomiting occurs, stop feeding, please PT in side lying position Suction if needed

Learning style

an individual's preferred or optimal method of acquiring new information VARK- visual, aural, read/write, kinesthetic

emerging infection

an infectious disease that has recently increased in incidence or that threatens to increase in the immediate future Agents from unknown sources or from contact with animals, changes in known diseases, or biological warfare Risk is increased from global travel, population density, miss use of antibiotics, bioterrorism Examples: Covid, Sika, SARS, west nile virus

HIV antiretroviral drugs are used to a. cure acute HIV infection. b. decrease viral RNA levels. c. treat opportunistic diseases. d. decrease symptoms in terminal disease.

b Rationale: The goals of drug therapy in HIV infection are to (1) decrease the viral load, (2) maintain or raise CD4+ T cell counts, and (3) delay onset of HIV infection-related symptoms and opportunistic diseases.

Which statements about metabolic side effects of ART are true (select all that apply)? a. These are annoying symptoms that are ultimately harmless. b. ART-related body changes include fat redistribution and peripheral wasting. c. Lipid problems include increases in triglycerides and decreases in high-density cholesterol. d. Insulin resistance and hyperlipidemia can be treated with drugs to control glucose and cholesterol

b, c, d Rationale: Some HIV-infected patients, especially those who have been infected and have received ART for a long time, develop a set of metabolic disorders that include changes in body shape (e.g., fat deposits in the abdomen, upper back, and breasts along with fat loss in the arms, legs, and face) from lipodystrophy, hyperlipidemia (i.e., high triglyceride levels and decreases in high-density lipoprotein levels), insulin resistance and hyperglycemia, bone disease (e.g., osteoporosis, osteopenia, avascular necrosis), lactic acidosis, and cardiovascular disease

hematuria

blood in the urine

During HIV infection a. reverse transcriptase helps HIV fuse with the CD4+ T cell. b. HIV RNA uses the CD4+ T cell's mitochondria to replicate. c. the immune system is impaired predominantly by the eventual widespread destruction of CD4* T cells. d. a lone period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication

c Rationale: Immune dysfunction in HIV disease is caused predominantly by damage to and destruction of CD4+ T cells (i.e., T helper cells or CD4+ T lymphocytes)

Opportunistic diseases in HIV infection a. are usually benign. b. are generally slow to develop and progress. c. occur in the presence of immunosuppression. d. are curable with appropriate drug interventions

c Rationale: Management of HIV infection is complicated by the many opportunistic diseases that can develop as the immune system deteriorates

A patient develops food poisoning from contaminate food. What is the means of transmission for the infectious organism? a. Direct contact b. Vector c. Vehicle d. Airborne

c Contaminated food is a vehicle for transmitting an infection. Direct contact requires close proximity between the susceptible host and an infected person. A vector is a nonhuman carrier. In airborne transmission, the organism is carried through the air on a small droplet or dust particles.

What nursing intervention would be most beneficial to implement in an effort to prevent aspiration by a patient receiving tube feedings? a. Check the pH of residual betore starting each feeding. b. Hold prescribed medications until after each feeding. c. Elevate the head of the patient's bed at least 45 degrees. d. Slow the delivery of the tube feeding to 15 mL/hour.

c If the head of the bed head is elevated 45 degrees during feedings, the risk of vomiting, or regurgitating the tube feeding formula and aspirating it into the lungs, is reduced. Checking the pH of residual does not reduce the incidence of aspiration. Slowing the delivery of tube feedings may decrease the incidence of diarrhea but not aspiration. Holding prescribed medication pertains to the compatibility of medications with the tube feeding rather than the risk of aspiration.

The patient is taking diphenoxylate with atropine. The nurse monitors for which of the following to determine whether the patient is having a therapeutic effect from this medication? a. Reduction of abdominal cramping b. Minimal passage of flatus c. Decrease in loose, watery stools d. Increased bowel sounds

c. Decrease in loose, watery stools diphenoxylate with atropine is an antidiarrheal

Which technique is most appropriate when using motivational interviewing with a patient who tells you that he is ready to start a weight-loss program? a. Confirm that the patient is serious about losing weight. b. Insist that the patient consider an organized group weight-loss program. c. Focus on the patient's strengths to support his optimism that he can successfully lose weight. d. Ask a prescribed set of questions to increase the patient's awareness of his dietary behaviors.

c. Focus on the patient's strengths to support his optimism that he can successfully lose weight. Rationale: In motivational interviewing, we use nonconfrontational interpersonal communication techniques to motivate patients to change behavior. Motivational support is tailored to the stage of change that the patient is experiencing. This patient is in the preparation stage of change and needs your support of his belief that he can successfully lose weight.

Temporary incontinence

can occur in association with factors such as severe constipation, infections in the urinary tract or vagina, or medication usage

What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen? a. Set up a drug pillbox for the patient every week. b. Give the patient a video and a brochure to view and read at home. c. Tell the patient that side effects of ART are bad but that they go away. d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

d Rationale: The best approach to improve adherence to a treatment regimen is to learn about the patient's life and assist with problem solving within the confines of that life

Screening for HIV infection generally involves a. detecting CD8* cytotoxic T cells in saliva. b. laboratory analysis of saliva to detect CD4+ T cells. c. analysis of lymph tissues for the presence of HIV RNA. d. laboratory analysis of blood to detect HIV antigen and/or antibody.

d Rationale: The most useful screening tests for HIV detect HIV-specific antibodies and/or antigen.

A nurse is preparing to change a sterile dressing and has donned a pair of sterile gloves. To maintain surgical asepsis, what else must the nurse do? a. Keep the amount of splashes on the sterile field to a minimum. b. If a sneeze is imminent, cover the nose and mouth with a gloved hand. c. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing. d. Regard the outer 1 inch of the sterile field as contaminated.

d. Considering the outer 1 inch of the sterile field as contaminated is a principle of sterile technique. Moisture contaminates the sterile field. Sneezing or coughing would contaminate the sterile glove and necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would not be used to apply a dry dressing. The hand would have to be regloved.

Frequency of urination

depends on the amount of urine being produced

Organ toxicity

ear (ototoxicity): stop drug immediately S&S: hearing loss, vertigo, unsteady gait, tinnitus Hold med and notify HCP liver (hepatotoxicity) Metabolism Organ can get overwhelmed by meds kidney (nephrotoxicity) Excretion Organ can get overwhelmed by meds

polyuria

excessive urination (Hyperglycemia)

Urgency

feeling the need to urinate immediately

Urinary retention

inability to empty the bladder Due to UTI or prostate problem

enuresis

involuntary discharge of urine Bedwetting

Underweight BMI

less than 18.5

Bolus feeding method (intermittent)

need to have an HCP order specific for NPO feeding Certain amount of food given at a time (ex. q4hr) Administer with a 50 to 50 ML syringe Flushed with 30 ML to 50 ML of water before an after seed or med administration (cannot do ER or enteric-coated) Make feeding last at least 30 minutes Maintain high Fowlers position 30 minutes after feeding

Anurea

no urine output 50-100mL of urine/day (kidneys are not working) = DIALYSIS

Formal teaching

planned teaching based on learner objectives/goals Delivered to community, group, or in a planned one-on-one pt session

pyuria

pus or WBCs in the urine

Capsules

small plastic containers with something inside, usually to contain medicine

assessment of urinary system

subjective data: questions, description, retention? Objective data: amount, smell, clarity, color, I&O, consistency, etc Diagnostic test results: UA

mixed incontinence

the combination of stress incontinence and urge incontinence

Informal teaching

unplanned teaching sessions dealing with the patient's immediate learning needs and concerns (when they ask questions) Is situation and pt specific

noctouria

urination at night Increased fall risk Don't give diuretics at nighttime (give in morning)

Types of pathogens include

viruses bacteria parasites (worms) fungi (yeast,mold)