RNSG 1533 Exam 2: Nutrition, Elimination, Fluid & Electrolytes

The results of a patient's recent endoscopy indicate peptic ulcer disease (PUD). Which teaching would the nurse provide to the patient based on this diagnosis? A. "It would be beneficial for you to stop drinking alcohol." B. "You'll need to drink at least 2 to 3 glasses of milk daily." C. "Many people find that a minced or pureed diet eases their symptoms of PUD." D. "You can keep your present diet and minimize symptoms by taking medication."

A. "It would be beneficial for you to stop drinking alcohol." Alcohol increases the amount of stomach acid produced, so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some dietary modifications to minimize symptoms. Milk may worsen PUD.

A patient is admitted to the emergency department with a stab wound to the abdomen. Vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9°F (36.6°C). Which fluid, if ordered by the health care provider, would the nurse question? A. 0.45% saline B. 0.9% saline C. Packed red blood cells D. Lactated Ringer's solution

A. 0.45% saline

Which serum potassium result best supports the need for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours? A. 3.0 mEq/L B. 3.5 mEq/L C. 4.6 mEq/L D. 5.3 mEq/L

A. 3.0 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus, the patient's potassium level must be low. The only low value shown is 3.0 mEq/L.

The stable patient has a gastrostomy tube for enteral nutrition. Which care could the RN delegate to the LPN/VN? (Select all that apply.) A. Administer bolus or continuous feedings. B. Evaluate the nutrition status of the patient C. Administer medications through the gastrostomy tube. D. Monitor for complications related to receiving enteral nutrition. E. Teach the caregiver about feeding via the gastrostomy tube at home.

A. Administer bolus or continuous feedings. C. Administer medications through the gastrostomy tube. For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutrition status of the patient, monitor for complications related to enteral nutrition, and teach the caregiver about feeding via the gastrostomy tube at home.

Which findings will the nurse expect when caring for a patient with chronic kidney disease (CKD)? (Select all that apply.) A. Anemia B. Dehydration C. Hypertension D. Hypercalcemia E. Increased fracture risk F. Elevated white blood cells

A. Anemia C. Hypertension E. Increased fracture risk When the kidney fails, erythropoietin is not excreted, so anemia is expected. Dehydration and hypercalcemia are not expected in chronic renal disease. Fluid volume overload with hypertension and hypocalcemia are expected. Hypocalcemia from chronic renal disease stimulates the parathyroid to release parathyroid hormone, causing calcium liberation from bones increasing the risk of pathological fracture. Although impaired immune function should be expected, elevated white blood cells would indicate inflammation or infection not associated with chronic renal failure itself but a complication.

A patient with stage 3 chronic kidney disease (CKD) is being taught about a low-potassium diet. The nurse recognizes the patient understands the diet when the patient selects which foods to eat? A. Apple, green beans, and a roast beef sandwich B. Granola made with dried fruits, nuts, and seeds C. Watermelon and ice cream with chocolate sauce D. Bran cereal with ½ banana and milk and orange juice

A. Apple, green beans, and a roast beef sandwich When the patient selects an apple, green beans, and a roast beef sandwich, the patient shows understanding of the low-potassium diet. Granola, dried fruits, nuts and seeds, milk products, chocolate sauce, bran cereal, banana, and orange juice all have high levels of potassium, at or above 200 mg per 1/2 cup.

A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complications most important for the nurse to monitor for? A. Dysrhythmias B. Muscle weakness C. Increased urine output D. Anemia and leukopenia

A. Dysrhythmias A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa often have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function.

A client visits his provider's office, stating that he doesn't feel himself. Lab test show a low potassium level. Which of the following physiological responses should the nurse expect related to the clients hypokalemia? A. cardiac dysrhythmias B. hypoglycemia C. hyperreflexia D. Increased appetite

A. cardiac dysrhythmias ​Low potassium levels affect cardiovascular function, causing ventricular dysrhythmias, ECG changes, and a weak and irregular pulse.

When comparing colostrum with mature breast milk, colostrum has higher amounts of A. protein, fat-soluble vitamins, and minerals B. at, fat-soluble vitamins, and minerals. C. protein, calories, and fat. D. calories, fat, and lactose

A. protein, fat-soluble vitamins, and minerals Colostrum is higher in protein, fat-soluble vitamins, and minerals than mature milk. Mature breast milk is higher in calories, fat, and lactose, but lower in protein, fat-soluble vitamins, and minerals.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia? (Select all that apply.) A. Weakness B. Paresthesia C. Facial spasms D. Muscle tremors E. Depressed reflexes

A. weakness E. Depressed reflexes Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

A patient with type 2 diabetes and chronic kidney disease has a serum potassium level of 6.8 mEq/L. Which finding will the nurse monitor for? A. Fatigue B. Dysrhythmias C. Hypoglycemia D. Elevated triglycerides

B. Dysrhythmias Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when the serum potassium level reaches 7 to 8 mEq/L. Fatigue and hypertriglyceridemia may be present but do not require urgent intervention. Hypoglycemia is a complication related to diabetes control, not hyperkalemia. However, administration of insulin and dextrose is an emergency treatment for hyperkalemia.

A nurse is developing a plan of care for a child recently diagnosed with diabetes insipidus. Which aspect of care should be included? A. Teach the child and family how to do required urine testing. B. Encourage the child to wear medical identification. C. Reassure the child and family that this is usually not a chronic or life-threatening illness. D. Discuss with the child and family ways to limit fluid intake.

B. Encourage the child to wear medical identification. Because of the unstable nature of the child's fluid and electrolyte balance, wearing medical identification is an extremely important intervention. With diabetes insipidus, the child should have unrestricted access to fluid. There is no required urine testing with diabetes insipidus. Diabetes insipidus is both lifelong and life-threatening. The medication must be taken and the effects monitored closely.

A nurse is making a home visit to a client who receives diuretics daily for heart failure. Which of the following signs would the client manifest with hypokalemia? A. Pitting edema B. Fatigue C. Dyspnea D. Oliguria

B. Fatigue ​The nurse should expect to find the client with fatigue due to muscle weakness with hypokalemia.

To initiate the milk ejection reflex, the mother should A. drink plenty of fluids. B.wear a firm-fitting bra. C.place the infant to the breast. D. apply cool packs to her breasts.

C.place the infant to the breast. Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm-fitting bra, drinking plenty of fluids, and applying cool packs to the breasts will not assist in the let-down reflex.

A frail elderly patient with stage 3 chronic kidney disease is cared for at home by their family. The patient has a history of taking many over-the-counter medications. Which over-the-counter medications would the nurse teach the patient to avoid? A. Aspirin B. Acetaminophen C. Diphenhydramine D. Aluminum hydroxide

D. Aluminum hydroxide Antacids (that contain magnesium and aluminum) should be avoided because patients with kidney disease are unable to excrete these substances. Also, some antacids contain high levels of sodium that further increase blood pressure. Acetaminophen and aspirin (if taken for a short period of time) are usually safe for patients with kidney disease. Antihistamines may be used, but combination drugs that contain pseudoephedrine may increase blood pressure and should be avoided.

The nurse preparing to give a dose of calcium acetate to a patient with chronic kidney disease (CKD). Which laboratory result will the nurse monitor to determine if the desired effect was achieved? A. Sodium B. Potassium C. Magnesium D. Phosphorus

D. Phosphorus Phosphorus and calcium have inverse or reciprocal relationships, meaning that when phosphorus levels are high, calcium levels tend to be low. Therefore, administration of calcium should help to reduce a patient's abnormally high phosphorus level, as seen with CKD. Calcium acetate will not have an effect on sodium, potassium, or magnesium levels.

A nurse is evaluating an infant brought to the clinic with severe diarrhea. What signs and symptoms should the nurses identify as indicating the infant has severe dehydration? A. Tachycardia, decreased tears, 5% weight loss and skin tenting B. Normal pulse rate, decreased blood pressure, intense thirst, and increased crying C. Irritability, moderate thirst, a flat fontanel, and sucking on his hands D. Tachycardia, capillary refill greater than 3 seconds, and sunken eyes and fontanel

D. Tachycardia, capillary refill greater than 3 seconds, and sunken eyes and fontanel Tachycardia, capillary refill greater than 3 seconds, and sunken eyes and fontanel are the symptoms of severe dehydration. In severe dehydration, tachycardia, decreased tears, a 15% weight loss, and skin tenting are present. Tachycardia, orthostatic hypotension and shock, and intense thirst would be expected. Crying may or not be present or increased due to lack of energy. The infant would be extremely irritable, with sunken eyes and fontanel.

What is the first step in assisting the breastfeeding mother? A.Discuss the hormonal changes that trigger the milk ejection reflex. B.Help her obtain a comfortable position, and place the infant to the breast. C.Provide instruction on the composition of breast milk. D.Assess the woman's knowledge of breastfeeding.

D.Assess the woman's knowledge of breastfeeding. The nurse should first assess the woman's knowledge and skill in breastfeeding to determine her teaching needs.

A nurse is teaching a client who has chronic renal failure about limiting foods high in potassium. Which of the following should the nurse instruct the client to avoid? (select all that apply) ​ A. Orange juice ​ B. Tomatoes ​ C. Bananas ​ D. Corn flakes ​ E. Raisins

​ A. Orange juice ​ B. Tomatoes ​ C. Bananas ​ E. Raisins Orange juice is considered to be high in potassium and should be avoided by a client who is on a potassium restricted diet. Tomatoes are considered to be high in potassium and should be avoided by a client who is on a potassium restricted diet. Bananas are considered to be high in potassium and should be avoided by a client who is on a potassium restricted diet. ​Corn flakes are not considered to be high in potassium and are safe to eat by a client who is on a potassium restricted diet. ​Raisins considered to be high in potassium and should be avoided by a client who is on a potassium restricted diet.

A patient with stage 2 chronic kidney disease is scheduled for an outpatient diagnostic procedure using contrast media. Which priority action would the nurse perform? A. Assess the patient's hydration status. B. Insert a urinary catheter for the expected diuresis. C. Evaluate the patient's lower extremities for edema. D. Check the patient's urine for the presence of ketones.

A. Assess the patient's hydration status. Preexisting kidney disease is the most important risk factor for the development of contrast-associated nephropathy and nephrotoxic injury. If contrast media must be administered to a high-risk patient, the patient needs to have optimal hydration. The nurse should assess the hydration status of the patient before the procedure is performed. Indwelling catheter use should be avoided whenever possible to decrease the risk of infection.

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (select all that apply) A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confusion E. Hypotension

A. Dyspnea C. Jugular vein distention D. Confusion Dyspnea is a clinical manifestation of fluid volume overload. Gastrointestinal bloating is not a clinical manifestation of heart failure. Jugular vein distention is a clinical manifestation of fluid volume overload. Confusion is a clinical manifestation of fluid volume overload. Hypertension, not hypotension, is a clinical manifestation of fluid volume overload. Hypotension is a manifestation of a hemolytic transfusion reaction.

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instruction about desmopressin acetate would be most appropriate? A. Expect to have some nasal irritation while using this drug. B. Monitor for symptoms of hypernatremia as a drug side effect. C. Report any decrease in urinary output to the health care provider. D. Drink at least 3000 mL of water per day while taking this medication.

A. Expect to have some nasal irritation while using this drug. Desmopressin acetate is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Diuresis will be decreased and is expected. Inhaled desmopressin can cause nasal irritation, headache, nausea, and other signs of hyponatremia, not hypernatremia. Drinking too much water or other fluids increases the risk of hyponatremia. The patient should follow the provider's directions for limiting fluids and be taught to seek medical attention if they have severe nausea; vomiting; severe headache; muscle weakness, spasms, or cramps; sudden weight gain; unusual tiredness; mental/mood changes; seizures; and slow or shallow breathing.

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care would the incoming nurse plan to deliver? (Select all that apply.) A. Giving the patient insulin if needed B. Ensuring that the next bag has been ordered C. Checking amount of solution left in the bag D. Assessing the insertion site and change the tubing E. Verifying the accuracy of the new solution and ingredients

A. Giving the patient insulin if needed B. Ensuring that the next bag has been ordered C. Checking amount of solution left in the bag D. Assessing the insertion site and change the tubing E. Verifying the accuracy of the new solution and ingredients The nurse must identify the amount of PN left in the bag when initiating care and request more if needed. Abrupt withdrawal of PN can cause hypoglycemia. The nurse would anticipate pharmacy preparation of a new bag may take significant time especially if additives are ordered. PN solutions are changed every 24 hours. The label on the bag must be verified with the order to ensure accuracy. The patient would receive insulin if hyperglycemic related to dextrose content in the PN or underlying diabetes. Sliding-scale coverage or addition of regular insulin to the PN would be provided if ordered. The insertion site should be monitored, and the tubing changed every 24 hours.

The nurse is caring for an infant who is receiving IV therapy. Which assessment finding indicates fluid excess? (Select all that apply) A. Heart rate of 190/min during sleep B. Periorbital edema C. Swelling at the IV site D. Urine-specific gravity greater than 1.030 E. Crackles upon auscultation

A. Heart rate of 190/min during sleep B. Periorbital edema E. Crackles upon auscultation Fluid volume excess is due to water and sodium retained in high proportions. Manifestations include increased blood pressure, pulse, and respirations. Pulse volume is directly related to circulating volume. With fluid volume excess, the pulse is full and bounding. With fluid volume deficit, the blood pressure will be decreased, and the pulse will be fast, weak, and thready. This heart rate is too high for any infant who is sleeping. This heart rate may be anticipated in an infant who is crying. The nurse should assess the infant for other signs/symptoms of fluid overload, such as respiratory distress, periorbital edema, tachypnea, crackles, and an increase in weight). Note: if the infant does not have fluid overload, but the heart rate is 190/min during sleep, the nurse should check the infant's temperature. An elevated temperature will elevate the heart rate. Periorbital edema, or edema around the eyes, is a sign of fluid overload in an infant. Edema is often generalized. Fluid may accumulate in tissues that surround the eyes. A weight gain of more than 30 g (1 ounce) in 24 hr is also a sign of fluid volume excess Edema at the IV site indicates a localized accumulation of fluid due to infiltration. Although this is a concern, this finding does not suggest fluid volume excess. This finding would suggest infiltration. The IV should be removed and restarted at another site. Urine-specific gravity measures the concentration of all chemical particles in the urine. A therapeutic range is 1.010 to 1.030. A urine-specific gravity greater than 1.030 indicates dehydration, and a gravity of less than 1.010 indicates fluid volume excess. Pulmonary edema occurs with increased interstitial volume which can occur with fluid volume excess, especially with use of hypotonic IV solutions. Additionally, the infant may be experiencing tachypnea.

A nurse is admitting a client who has a serum calcium level of 12.3 mg/dL and initiates cardiac monitoring. Which of the following findings should the nurse expect during the initial assessment? A. Lethargy B. Hyperactive deep tendon reflexes C. Prolonged ST segment D. Hyperactive bowel sounds

A. Lethargy A serum calcium level of 12.3 mg/dL is above the expected reference range. The nurse should monitor the client for lethargy, generalized weakness, and confusion.

A patient with dehydration is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions? (Select all that apply.) A. Lung sounds B. Bowel sounds C. Blood pressure D. Serum sodium level E. Serum potassium level

A. Lung sounds C. Blood pressure D. Serum sodium level Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

The patient with systemic lupus erythematosus is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions would be included in the plan of care? (Select all that apply.) A. Obtain daily weights. B. Limit fluids to 1000 mL/day. C. Administer diuretics as ordered. D. Monitor for signs of hypernatremia. E. Minimize turning and range of motion. F. Elevate the head of the bed at 10 degrees or less.

A. Obtain daily weights. B. Limit fluids to 1000 mL/day. C. Administer diuretics as ordered. F. Elevate the head of the bed at 10 degrees or less. The care for the patient with SIADH will include limiting fluids to 1000 mL/day or less to decrease weight, increase osmolality, and improve symptoms and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Measure weights daily and maintain accurate intake and output. Monitor for signs of hyponatremia. Frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

A patient with a history of peptic ulcer disease presents to the emergency department with severe abdominal pain and a rigid, board-like abdomen. The health care provider suspects a perforated ulcer. Which interventions would the nurse anticipate? A. Providing IV fluids and inserting a nasogastric (NG) tube B. Administering oral bicarbonate and testing the patient's gastric pH level C. Performing a fecal occult blood test and administering IV calcium gluconate D. Starting parenteral nutrition and placing the patient in a high Fowler's position

A. Providing IV fluids and inserting a nasogastric (NG) tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.

The nurse is caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply.) A. The potassium level may be increased if the patient has nephropathy. B. The patient has been eating excessive amounts of foods that increase potassium levels. C. The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. D. There may be excess potassium being released into the blood as a result of massive blood transfusion. E. The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

A. The potassium level may be increased if the patient has nephropathy. D. There may be excess potassium being released into the blood as a result of massive blood transfusion. E. The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal problems, or cell death. Diabetes, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have a nasogastric tube and not be eating.

A patient reporting nausea receives a dose of metoclopramide. What potential adverse effect would the nurse tel the patient to report? A. Tremors B. Constipation C. Double vision D. Numbness in the finders and toes

A. Tremors Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide

The nurse is reviewing the EKG strip of a client with prolonged vomiting. Which abnormality on the client's EKG should the nurse interpret as a sign of hypokalemia? A. U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

A. U wave Hypokalemia is an abnormally low potassium concentration in the blood. It may result from excessive potassium loss by the renal or gastrointestinal route or from decreased intake. Hypokalemia can cause several changes in the electrocardiogram (EKG). The EKG changes associated with hypokalemia are: the P wave is normal and upright, there is a prominent U wave and a prolonged P-R interval, the ST segment is depressed, and the T wave is flattened.

The nurse is teaching a parents' class about when to call the pediatrician's office if vomiting and diarrhea in their toddlers. Instruction by the nurse is correct if the nurse includes which information? (Select all that apply.) A. if the toddler has a fever (>39° C [102° F]) B. If their child's fontanel appears sunken C. When the diarrhea has been present for 24 hours D. If their child doesn't urinate for longer than 4 hours E. If crying produces no tears F. If severe abdominal cramps occur

A. if the toddler has a fever (>39° C [102° F]) C. When the diarrhea has been present for 24 hours D. If their child doesn't urinate for longer than 4 hours E. If crying produces no tears F. If severe abdominal cramps occur If crying produces no tears, the pediatrician should be notified. When the diarrhea has been present for 24 hours, the pediatrician should be notified. If the toddler has a fever >39° C (102° F), the pediatrician should be notified. If severe abdominal cramps occur, the pediatrician should be notified. If their toddler doesn't urinate for longer than 6 hours, the pediatrician should be notified. The fontanels disappear by 18 months of age.

A nurse is reviewing the serum calcium level of a client who had a total thyroidectomy. The serum calcium level is below normal. Which of the following client manifestations may indicate the first sign of hypocalcemia? A. tingling in the toes and fingers B. muscle twitching C. hyperactive bowel sounds C. loss of bone density

A. tingling in the toes and fingers The client's first sign of hypocalcemia following a total thyroidectomy is tingling of toes and fingers.

A nurse is reviewing the lab results of a client who has fluid volume deficit. The nurse would expect which of the following findings? A. urine specific gravity 1.035 B. hematocrit 44% C. BUN 19 mg/dL D. sodium 155 mEq/L

A. urine specific gravity 1.035 A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030. A client experiencing fluid volume deficit would manifest an increased hematocrit. A client experiencing fluid volume deficit would manifest an increased BUN. A client experiencing fluid volume deficit would manifest a sodium level within the expected reference range.

A nurse is caring for a client who has chronic renal failure and states she has heartburn. The provider prescribes aluminum hydroxide. The client asked the nurse, " why can't I take the antacid Magaldrate (Riopan) my husband has at home?" The nurse explains to the client that the aluminum hydroxide is the preferred antacid because it lowers which of the following? A. Serum phosphorus levels B. Serum potassium levels C. Serum magnesium levels D. Serum calcium levels

A.Serum phosphorus levels Aluminum-based formulas are also a phosphate binder, helping to lower serum phosphorus levels in clients who have chronic renal failure.

The nurse is preparing to administer famotidine to a patient after a laparotomy. The patient states they do not have heartburn. What response by the nurse is most appropriate? A. "It will prevent air from accumulating in the stomach, causing gas pains." B. "It will reduce the amount of acid in the stomach while you are not eating." C. "It will prevent the heartburn that occurs as a side effect of general anesthesia." D. "The stress of surgery is likely to cause stomach bleeding if you do not receive it."

B. "It will reduce the amount of acid in the stomach while you are not eating." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

A nurse is admitting a 6-month-old infant who has dehydration. When she tracks the client urinary output, which of the following amounts should indicate to the nurse that the treatment has corrected the fluid imbalance? A. 0.5 mL/kg/hr B. 2 mL/kg/hr C. 7.5 mL/kg/hr D. 1 mL/kg/hr

B. 2 mL/kg/hr ​The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An infant who is not dehydrated should produce this amount of urine.

The nurse has measured the urinary output for the 12-hour shift and has 340 mL for a 12-kg toddler. What is the normal range of urinary output for this child for a 12-hour shift so the nurse can evaluate the output obtained? A. 238 to 366 mL B. 288 to 432 mL C. 246 to 398 mL D. 274 to 416 mL

B. 288 to 432 mL The normal urinary output for infants and toddlers is greater than 2 to 3 mL/kg/hr, so the calculation would be: 12 kg × 2 mL/hr and 12 kg × 3 mL/hr 24 to 36 mL/hr. Since the output is for 12 hours, 24 mL/hr would be multiplied by 12 hours, and 36 mL/hr would also be multiplied by 12 hours. The answer is 288 to 432 mL for the 12-hour shift. The amount the toddler urinated falls within the range.

A preschooler with vomiting and diarrhea lost 0.5 kg of weight since being weighed in the pediatrician's office prior to admission to the hospital. How much fluid would the nurse calculate that this child has lost? A. 250 mL B. 500 mL C. 1000 mL D. 750 mL

B. 500 mL One milliliter of body fluid is approximately equal to 1 g of body weight, so a weight loss or gain of 1 kg represents 1 L, or 1000 mL. A half-kilogram loss would be 500 mL.

A nurse is monitoring the output of an adult client wha had a colon resection. Which of the following total output in 24hr indicates oliguria? A. 720mL B. 550mL C. 480mL D. 600mL

B. 550mL The client's urinary output indicates oliguria, which is less than 500 mL total in 24 hr or less than 30 mL per hr.

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 am. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? A. 7:00 am, 10:00 am, and 1:00 pm B. 8:00 am, 12:00 pm, and 4:00 pm C. 9:00 am, 12:00 PM, and 3:00 pm D. 10:00 am, 12:00 pm, and 3:00 pm

B. 8:00 am, 12:00 pm, and 4:00 pm A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus, if the tube were inserted at 4:00 am, it would be due to be checked at 8:00 am, 12:00 pm, and 4:00 pm.

Which patient has the most significant risk factors for chronic kidney disease (CKD)? A. A 50-yr-old white woman with hypertension B. A 61-yr-old Native American man with diabetes C. A 28-yr-old black woman with a urinary tract infection D. A 40-yr-old Hispanic woman with cardiovascular disease

B. A 61-yr-old Native American man with diabetes The nurse identifies the 61-year-old Native American with diabetes as the most at risk. Diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD 6 times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non-Hispanics. Blacks have the highest rate of CKD because hypertension is significantly increased in blacks. A UTI will not cause CKD unless it is not treated or UTIs occur recurrently.

A preschooler with severe vomiting and diarrhea was admitted to the hospital. The vomiting has stopped, and rehydration was begun intravenously. When should the nurse begin feeding the child solid food? A. When the parents give their permission to feed their child B. After the child has been rehydrated C. When the IV rehydration can be stopped D. After the diarrhea has stopped for 24 hours

B. After the child has been rehydrated Feeding of solids or formula is started as soon as the child is rehydrated. Children should be encouraged to eat frequently—every 3 to 4 hours. Parents should be instructed that although stool output may increase, feeding will not prolong diarrhea, and the child will be absorbing necessary nutrients and calories. Parents should be instructed that although stool output may increase, feeding will not prolong diarrhea, and the child will be absorbing necessary nutrients and calories. The intravenous solutions may run a little longer to ensure that the child remains hydrated. It is not up to the parents to decide when resumption of solid food begins.

The nurse is caring for a patient admitted to the medical unit with hypokalemia. The best foods to offer the patient are? (Select all that apply.) A. Apple B. Banana C. Orange juice D. Chocolate milk E. Cooked broccoli

B. Banana C. Orange juice D. Chocolate milk E. Cooked broccoli Milk products, oranges, and bananas are all high in potassium. Cooked broccoli is high in potassium. Apples are low in potassium.

The breastfeeding mother should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate? A. Move the breast in the baby's mouth B. Break the suction by inserting your finger into the corner of the infant's mouth. C.Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. D.Elicit Moro's reflex in the baby to wake the baby up and remove the breast when he cries.

B. Break the suction by inserting your finger into the corner of the infant's mouth. Inserting a finger into the corner of the baby's mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose the grasp on the nipple and areola, resulting in "chewing" on the nipple and sore nipples. Moving the breast in the mouth may cause the infant to lose the grasp on the nipple and areola, resulting in "chewing" on the nipple and soreness.

A patient who has sustained severe burns in a motor vehicle accident is starting PN. Which principle would guide the nurse's administration of PN? A. Administration of PN requires clean technique B. Central PN requires rapid dilution in a large volume of blood C. Peripheral PN delivery is preferred over the use of a central line D. Only water-soluble medications may be added to the PN by the nurse

B. Central PN requires rapid dilution in a large volume of blood Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN, and the nurse may not add any medications to PN.

Which priority focused assessments would the nurse perform when caring for a patient recently started on parenteral nutrition (PN)? A. Skin integrity and skin turgor B. Electrolyte levels and daily weights C. Auscultation of lung and bowel sounds D. Peripheral edema and level of consciousness

B. Electrolyte levels and daily weights The use of PN necessitates frequent and thorough assessments. Key assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral edema, level of consciousness, and lung sounds, may be variously performed, but close monitoring of fluid and electrolyte balance supersedes these in importance related to the PN.

The patient with a history of irritable bowel disease and gastroesophageal reflux disease (GERD) is admitted with diverticulitis and has received a dose of Mylanta 30 mL PO. The nurse would determine the medication was effective when which symptom has resolved? A. Diarrhea B. HeartburnCorrect Answer C. Constipation D. Lower abdominal pain

B. Heartburn Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of gastrointestinal discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

A patient is admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medication would the nurse hold until the health care provider is consulted? A. Antibiotics B. Loop diuretics C. Bronchodilators D. Antihypertensives

B. Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

A 4-year-old has had diarrhea for several days, and her perineum is inflamed and almost excoriated. What nursing actions are indicated? (Select all that apply.) A. Gently wash the perineum with cold water and mild soap after each stool. B. Place the child without underwear for brief periods to allow air to the area. C. Turn the child at least every 2 hours. D. Apply an ointment to the inflamed area to provide a moisture barrier.

B. Place the child without underwear for brief periods to allow air to the area. C. Turn the child at least every 2 hours. D. Apply an ointment to the inflamed area to provide a moisture barrier. Applying an ointment to the inflamed area to provide a moisture barrier is important. Placing the child without underwear for brief periods to allow air to the area often helps heal the area. Turning the child at least every 2 hours keeps pressure off the skin and facilitates circulation to the affected area. Gently wash the perineum with warm water and mild soap after each stool.

Which statements are appropriate to include when teaching a patient about hypercalcemia? (Select all that apply.) A. Have patient restrict fluid intake to less than 2000 mL/day. B. Renal calculi may occur as a complication of hypercalcemia. C. Weight-bearing exercises can help keep calcium in the bones. D. The patient should increase daily fluid intake of 3000 to 4000 mL. E. Any heartburn can be managed with an as needed calcium-containing antacid.

B. Renal calculi may occur as a complication of hypercalcemia. C. Weight-bearing exercises can help keep calcium in the bones. D. The patient should increase daily fluid intake of 3000 to 4000 mL. A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

A nurse is caring for a client who has been diagnosed with SIADH and has a sodium level of 123mEq/L. Which of the following nursing actions should the nurse expect to implement? A. Maintain an IV of 0.45% sodium Chloride B. Restrict oral fluids to 800-1000 mL/day C. Ensure the client receives a 2g sodium diet D. Administer desmopression acetate (DDAVP) 0.2mg orally

B. Restrict oral fluids to 800-1000 mL/day ​Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and therefore the sodium level in the blood. This dilutional hyponatremia does not occur only in clients who have SIADH, but also can result in clients with excess fluid volume (e.g., heart failure, liver cirrhosis, nephrotic syndrome). In addition to restricting oral fluids, increasing the sodium in the diet, and administering hypertonic IV fluids can be helpful. Medications such as tolvaptan (Samsca) or conivaptan (Vaprisol) may be useful in promoting fluid excretion without excreting sodium. The use of these medications is restricted to hospitalized clients because close monitoring of sodium levels is required.

An important consideration in positioning a newborn for breastfeeding is: A. keeping the infant's head slightly lower than the body. B. placing the infant at nipple level facing the breast. C. limiting the amount of areola the infant takes into the mouth. D. using the forefinger and middle finger to support the breast.

B. placing the infant at nipple level facing the breast. Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. The infant's head should be higher than the body. The thumb and forefinger or middle finger should be used to support the breast. The amount of areola the infant takes into the mouth should not be limited.

The nurse is providing discharge teaching to a client who will be performing intermittent self-catheterization. Which of the following statements should the nurse include in the teaching? A. You sterile technique during the insertion procedure. B. Inflate the catheter balloon with 20 cc of sterile water. C. Advance the catheter 5cm (2in) after urine begins to flow. D. Lubrication of the catheter tip prior to the insertion is not necessary.

C. Advance the catheter 5cm (2in) after urine begins to flow. the nurse should instruct the client to advance the catheter 5 cm (2 in) farther after urine begins to flow to ensure it is completely in the bladder.

The patient with chronic gastritis is being put on medication therapy to eradicate Helicobacter pylori. Which drugs does the nurse anticipate being ordered? A. Antibiotic(s), antacid, and corticosteroid B. Antibiotic(s), aspirin, and antiulcer/protectant C. Antibiotic(s), proton pump inhibitor, and bismuth D. Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

C. Antibiotic(s), proton pump inhibitor, and bismuth To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

A nurse is teaching a client who has CKD about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following should the nurse include in the teaching? A. CAPD filters the client's blood through an artificial device called a dialyzer. B. CAPD is the dialyzed treatment of choice for clients who have a history of abdominal trauma C. CAPD requires the client to follow fewer dietary and fluid restrictions than hemodaylisis D.​CAPD is the treatment of choice for clients who have acute renal conditions.

C. CAPD requires the client to follow fewer dietary and fluid restrictions than hemodaylisis ​CAPD requires the client to follow fewer dietary and fluid restrictions than with hemodialysis. ​CAPD's advantages include fewer fluid and dietary restrictions as compared to hemodialysis.

A nurse is admitting a 2-year-old client who has acute gastroenteritis. Which of the. following should be the nurse's initial action? A. Initiating isotonic fluids with 20mEq/L potassium chloride B. Administering a promethazine suppository C. Ensuring the toddler is voiding D. Collecting a stool sample

C. Ensuring the toddler is voiding When a toddler has a diagnosis of gastroenteritis, the nurse should collect a urine specimen prior to administering potassium. The nurse should anticipate a decreased serum potassium level. However, the nurse should also validate that the kidneys are able to produce urine and excrete potassium. If kidney function is altered, potassium will not be excreted and the toddler will develop hyperkalemia. Administering potassium prior to validating renal functioning can jeopardize the toddler's safety. The nurse should begin IV fluids without the potassium. The potassium should be added after the toddler's first void.

The nurse determines a patient has experienced the beneficial effects of famotidine when which symptom is relieved? A. Nausea B. Belching C. Epigastric pain D. Difficulty swallowing

C. Epigastric pain Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. It is not indicated for nausea, belching, and dysphagia.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? A. Fluid movement from the blood vessels into the cells B. Fluid movement from the interstitial spaces into the cells C. Fluid movement from the interstitial spaces into the plasma D. Fluid movement from the blood vessels into the interstitial spaces

C. Fluid movement from the interstitial spaces into the plasma In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

A patient who has dysphagia after a stroke is receiving enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). What intervention would the nurse include in the plan of care? A. Use 30 mL of normal saline to flush the tube every 4 hours. B. Avoid flushing the tube any time the patient is receiving continuous feedings. C. Flush the tube before and after feedings if the patient's feedings are intermittent. D. Flush the PEG with 100 mL of sterile water before and after giving medications.

C. Flush the tube before and after feedings if the patient's feedings are intermittent. The nurse would flush feeding tubes with 30 mL of water, not normal saline, every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL are excessive and may cause fluid overload in the patient.

A patient with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which provider prescription would the nurse question? A. Limit foods high in potassium. B. Calcium gluconate IV piggyback. C. Give a potassium-sparing diuretic daily. D. Administer intravenous insulin and glucose.

C. Give a potassium-sparing diuretic daily. Potassium-sparing diuretics inhibit the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. A potassium-sparing diuretic is contraindicated in a patient with hyperkalemia. Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? A. Decreased urine specific gravity B. Decreased hgb C. Increased BUN D. Increased urine ketones

C. Increased BUN Increased BUN is an expected finding of fluid volume deficit due to the hemoconcentration of substances in the blood from excessive water loss. Increased urine specific gravity is an expected finding of fluid volume deficit. Increased Hgb is an expected finding of fluid volume deficit. Increased ketones in the urine is an expected finding of diabetic ketoacidosis.

How can the nurse help the mother who is nursing and has engorged breasts? A. Assist her to remove her bra, making her more comfortable. B. Suggest that she switch to bottled formula just for today. C. Instruct and assist the mother to massage her breasts. D. Apply heat to her breasts between feeding and cold to the breasts just before feedings.

C. Instruct and assist the mother to massage her breasts. Massage of the breasts causes release of oxytocin and increases the speed of milk release. Engorgement is more likely to increase if breastfeeding is delayed or infrequent. A well-fitting bra should be worn both day and night to support the breasts. Cold applications are used between feedings to reduce edema and pain. Heat is applied just before feedings to increase vasodilatation.

Which nursing intervention is most appropriate when caring for a patient with dehydration? A. Monitor skin turgor every shift. B. Auscultate lung sounds every 2 hours. C. Monitor daily weight and intake and output. D. Encourage the patient to reduce sodium intake.

C. Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, while weight gain would indicate restoration of fluid volume.

A patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD would be used with caution? A. Sucralfate B. Cimetidine C. Omeprazole D. Metoclopramide

C. Omeprazole There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine.

After receiving a dose of metoclopramide, which assessment finding would indicate the medication was effective? A. Decreased blood pressure B. Absence of muscle C. Relief of nausea and vomiting D. No further episodes of diarrhea

C. Relief of nausea and vomiting Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

When assessing a patient admitted with nausea and vomiting, which finding best supports the patient problem of deficient fluid volume? A. Polyuria B. Bradycardia C. Restlessness D. Difficulty breathing

C. Restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

A nurse is preforming an admission assessment on a client. Which of the following finding is an indicator of dehydration A. ​Red mucous membranes B. ​Jugular vein distention C. Skin tenting present D. ​Blood pressure 178/90 mm Hg

C. Skin tenting present ​A client who has dehydration has poor skin turgor, or skin tenting, which the nurse should observe for over the sternum or the back of the hand.

The nurse receives a provider's prescription to change an IV from 5% dextrose in 0.45% saline with 40 mEq KCl/L to 5% dextrose in 0.9% saline with 20 mEq KCl/L. Which serum laboratory values best support the indication for this change? A. Sodium, 136mEq/L; potassium 3.6 mEq/L B. Sodium, 145mEq/L; potassium 4.8 mEq/L C. Sodium, 133mEq/L; potassium 4.5 mEq/L D. Sodium, 144mEq/L; potassium 3.7 mEq/L

C. Sodium, 133 mEq/L; potassium, 4.5 mEq/L The normal range for serum sodium is 136 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

A 2-month-old breastfed infant is successfully rehydrated with oral rehydration solutions (ORS) for acute diarrhea. What instructions to the mother about breastfeeding should be included by the nurse? A. Express breast milk, and dilute with sterile water before feeding. B. Stop breastfeeding until diarrhea is absent for 24 hours. C. Stop breastfeeding until breast milk is cultured. D. Continue breastfeeding.

D. Continue breastfeeding. Breastfeeding should continue. Culturing the breast milk is not necessary. Breastfeeding can continue along with ORS to replace the continuing fluid loss from the diarrhea. Breast milk should not be diluted.

The new mother is taught to continue feeding on one breast until empty in order for the infant to get the hindmilk. One advantage of the infant receiving sufficient amounts of hindmilk is that it contains A. the majority of immunoglobulins. B. lower amounts of cholesterol. C. higher amounts of fat. D. higher amounts of protein.

C. higher amounts of fat. More fat is present in the hindmilk. Immunoglobulins are more abundant in colostrum. Protein amounts are the same throughout the mature breast milk. Cholesterol amounts are the same throughout breast milk.

When planning the care of a patient with dehydration, what urine output would the nurse instruct the assistive personnel (AP) to report? A. 60 mL in 90 minutes B. 1200 mL in 24 hours C. 300 mL per 8-hour shift D. 20 mL for 2 consecutive hours

D. 20 mL for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

A patient with a 25-year history of type 1 diabetes is reporting fatigue, edema, and an irregular heartbeat. On assessment, the nurse notes newly developed hypertension and uncontrolled blood glucose levels. Which diagnostic study is most indicative of chronic kidney disease (CKD)? A. Serum creatinine B. Serum potassium C. Microalbuminuria D. Calculated glomerular filtration rate (GFR)

D. Calculated glomerular filtration rate (GFR) The best study to determine kidney function or CKD that would be expected in the patient with diabetes is the calculated GFR that is obtained from the patient's age, gender, race, and serum creatinine. It would need to be abnormal for 3 months to establish a diagnosis of CKD. A creatinine clearance test done with a blood sample and a 24-hour urine collection is also important. Serum creatinine is not the best test for CKD because the level varies with different patients. Serum potassium levels could explain why the patient has an irregular heartbeat. The finding of microalbuminuria can alert the patient with diabetes about potential renal involvement and potentially failing kidneys. However, urine albumin levels are not used for diagnosis of CKD.

A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solutions (ORS). The child's mother calls the clinic nurse to report the child has occasional vomiting. What is the appropriate recommendation by the nurse? A. Alternate giving the child ORS and carbonated drinks. B. Maintain the child on NPO for 8 hours and resume ORS if vomiting subsides. C. Bring the child to the hospital for intravenous fluids. D. Continue to give the child ORS frequently in small amounts.

D. Continue to give the child ORS frequently in small amounts. Vomiting is not a contraindication to the use of ORS unless it is severe. The mother should continue to give the ORS in small amounts and at frequent intervals. NPO status is not indicated. Frequent intake of ORS in small amounts is recommended. A school-age child with mild dehydration can be rehydrated safely at home with oral solutions. Carbonated drinks should not be given to the child. They may have a high carbohydrate content and contain caffeine, which is a diuretic.

When teaching the patient about the diet for diverticular disease, which foods would the nurse recommend? A. White bread, cheese, and green beans B. Fresh tomatoes, pears, and corn flakes C. Oranges, baked potatoes, and raw carrots D. Dried beans, All Bran (100%) cereal, and raspberries

D. Dried beans, All Bran (100%) cereal, and raspberries A high-fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

The nurse is caring for a patient with a suspected bowel obstruction. The nurse auscultating the abdomen anticipates which type of bowel sounds will be heard? A. Low-pitched and rumbling above the area of obstruction B. High-pitched and hypoactive below the area of obstruction C. Low-pitched and hyperactive below the area of obstruction D. High-pitched and hyperactive above the area of obstruction

D. High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

A toddler is hospitalized with severe dehydration. The nurse should assess the child for which possible complication? A. Hypertension B. A rapid, bounding pulse C. Decreased specific gravity D. Hypokalemia

D. Hypokalemia Hypokalemia is a concern in severe dehydration. A rapid, thready pulse would be seen in severe dehydration. The urine would be concentrated, so the specific gravity would increase. The child needs to be monitored for hypotension.

A 2-month-old infant has been brought to the emergency department because of diarrhea and vomiting for the past 48 hours. Why should the pediatric nurse expect the infant to be at a greater risk for fluid and electrolyte imbalances than older children? A. Infants have a lower metabolic rate than older children. B. Infants have a decreased surface area. C. The infants' daily exchange of extracellular fluid is decreased. D. Immature renal function is common in infants.

D. Immature renal function is common in infants. Infants' kidneys are unable to concentrate or dilute urine, conserve or excrete sodium, and acidify urine, and their bodies have a higher percentage of fluid per weight than older children. There is an increased amount of extracellular fluid in the infant. Forty percent of a neonate's body fluid is extracellular fluid, compared with 20% in an adult. Fluid is lost from the extracellular space first. Infants have a higher metabolic rate. Infants have a proportionately greater body surface area, which allows for greater insensible water loss.

A 17-year-old is diagnosed with syndrome of inappropriate antidiuretic hormone (childhood SIADH) due to a brain tumor. What nursing care is indicated in the care of this adolescent? A. Preventing any weight gain due to fluid retention and any elevation of sodium levels. B. Restoring protein loss and replenishing the decreased erythrocyte level. C. Keeping the urine specific gravity between 1.020 and 1.030 and prevention of respiratory infections. D. Maintaining a balanced intake and output and a urine specific gravity between 1.010 and 1.020.

D. Maintaining a balanced intake and output and a urine specific gravity between 1.010 and 1.020. Essential care includes maintaining a balanced intake and output, a urine specific gravity between 1.010 and 1.020, and reducing fluid intake initially. Daily weights and a diet with increased sodium are indicated but not salty foods that can cause increased thirst. Weight gain is seen early in the illness, and elevated sodium levels are desired. The urine specific gravity should be between 1.010 and 1.020. Respiratory infections are not an issue with SIADH. Protein loss is not an issue; loss of sodium is. Erythrocytes are not involved with this condition.

A patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would the nurse identify as an adverse effect related to this therapy? A. Sodium falling to 138 mEq/L B. Potassium rising to 4.1 mEq/L C. Magnesium rising to 2.9 mg/dL D. Phosphorus falling to 2.1 mg/dL

D. Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs because of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 3.0 to 4.5 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

A patient was admitted with epigastric pain from a gastric ulcer. Which assessment finding warrants an urgent change in the plan of care? A. Back pain 3 or 4 hours after eating a meal B. Chest pain relieved with eating or drinking water C. Burning epigastric pain 90 minutes after breakfast D. Rigid abdomen and vomiting following indigestion

D. Rigid abdomen and vomiting following indigestion A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3 to 4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1 to 2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

A nurse in a community clinic is assessing an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for? A. Hypothermia B. Protruding eyeballs C. Elevated blood pressure D. Swollen tongue

D. Swollen tongue An older adult clients, a swollen tongue is an indication of dehydration.

A woman returns to the clinic with her 4-month-old infant for a well-baby visit. She tells the nurse that she cannot afford formula anymore and has started the baby on whole milk. The nurse should assist the woman in finding funding for the formula because unmodified cow's milk A. cannot be sterilized properly. B. contains higher levels of lactose. C. may contain bacteria that will cause diarrhea in infants. D. is not recommended for children under 12 months.

D. is not recommended for children under 12 months. Unmodified cow's milk contains too much protein, potassium, and sodium and lacks enough fatty acids, iron, and vitamin E. It may cause GI bleeding and anemia. Pasteurization takes care of the bacteria. The problem is in the content of the milk compared with formula. The lactose contents of formula and unmodified cow's milk are about the same.

A patient who is unable to swallow is prescribed EN through a gastronomy tube. Which task is appropriate for the nurse to delegate to the AP? A. Irrigate the tube between feedings B. Provide wound care at the gastrostomy site C. Give proscribed liquid medications through the tube D. position the patient with a 45-degree head of bed elevation.

D. position the patient with a 45-degree head of bed elevation. AP may position the patient receiving enteral feedings with the head of bed elevated. The LPN/VN or an RN could perform the other activities.

A nurse is caring for a client with CKD. When teaching about foods to avoid that contain phosphorus he should recommend that the client avoid which of the following? ​ A.Milk ​ B.Nuts ​ C.Orange juice ​ D.Whole grain bread ​ E.Poultry

​ A.Milk ​ D.Whole grain bread ​ E.Poultry ​All animal products, including dairy, are a source of phosphorous and should be avoided by a client who is on a phosphorous restricted diet. ​​ Nuts are not a food source high in phosphorous and are safe for clients on a phosphorous restricted diet. ​​​Orange juice is not a food source high in phosphorous and is safe for clients on a phosphorous restricted diet. Whole grains are a source of phosphorous and should be avoided by a client who is on a phosphorous restricted diet. All animal products, including poultry, are a source of phosphorous and should be avoided by a client who is on a phosphorous restricted diet.

A nurse is reviewing the arterial blood gas lab report for a client who has chronic renal failure. Which of the following is an expected finding? ​A. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg ​ B. pH 7.30, HCO3 26 mEq/L, PaCO2 50 mm Hg ​ C. pH 7.50, HCO3 20 mEq/L, PaCO2 32 mm Hg ​ D. pH 7.55, HCO3 30 mEq/L, PaCO2 31 mm Hg

​A. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg ​The client with renal failure would be in metabolic acidosis (low HCO3, low pH, and low or normal PaCO2. Normal lab values include pH 7.35-7.45, HCO3 21-28 mEq/L, and PaCO2 35-45 mm HG.