exam 3 chp 41,45,46,47 practice questions

Which information will the nurse teach a client prescribed B-complex vitamins? 1:the vitamins may turn the urine bright yellow 2: the daily fluid intake should be increased 3:the vitamins should be taken on an empty stomach 4:taking the vitamins with a high fat meal will increase absorption

1 rationale: bright yellow urine is an expected, insignificant side effect of vitamin B complex. -There is no need to increase oral fluids -taking the vitamins on an empty stomach may increase nausea -vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine. Taking the vitamins with a fatty meal will not improve absorption

Which is the best nursing intervention to support a hospitalized childs nutrition who is apathetic toward eating? 1:asking the parent to visit at mealtimes 2:having a nursing assistant feed the child 3:providing diversional activity at mealtimes 4:eliminating the childs between meal snacks

1 rationale: dinner is frequently a family activity. Having a parent visit during meals may provide the child with emotional social and physical support. The child will be resentful if fed by a staff member -secondary is providing diversional activity

which complication would the nurse prevent by addressing the needs of a hyperventilating client? 1:cardiac arrest 2:carbonic acid deficit 3:reduction in serum Ph 4:excess o2 sat

2 rationale: hyperventilation causes excessive loss of CO2, leading to carbonic acid deficit and respiratory alkalosis

A client states a desire to follow a total vegan diet. The client request assistance in planning a menu to ensure adequate protein quality. Which suggestion should the nurse make? 1:add milk to grains to provide complete proteins 2:use eggs with plant foods to provide essential amino acids 3:add cheese to beans to provide a balance of different proteins 4:use a mix of plant proteins to provide essential amino acids

4 Rationale: vegans only consume plant based foods. They do not eat flesh, milk, dairy products, or eggs -lactovegetarian: drink milk but avoid eggs -ovolactovegetarian: avoid meat fish and poultry but eat eggs and milk

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4 rationale: the earliest detectable sign of acute respiratory distress syndrome is an increased RR. This is followed by dyspnea, air hunger, retraction of accessory muscles, and cyanosis

What indicates that the client knows how to properly use a dry powder inhaler? 1:i will forcefully inhale the powder 2:i will exhale into the delivery device 3:i will shake the inhaler before use 4:i will submerge the inhaler into water to wash it

1 rationale: -clients should never exhale into the device because their breath will moisten the powder -inhaler should be held still and steady not shaken

In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide? 1. Supplement breast milk with corn syrup. 2. Give cow's milk during the first year of life. 3. Add honey to infant formulas for increased energy. 4. Provide breast milk or formula for the first 4 to 6 months.

4 Rationale: Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. -Infants should not have regular cow's milk during the first year of life. It is too concentrated for an infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. -children under 1 year of age should never ingest honey and corn syrup products because they are potential sources of the botulism toxin, which increases the risk of infant death.

Which vitamin is essential for the synthesis of prothrombin protein (helps blood clot) by the liver? 1:B12 2:C 3:D 4:K

4 Rationale: prothrombin is synthesized in the liver in the presence of vitamin K; Vitamin K initiates the viral process of coagulation (clotting). -Vitamin B12: needed for hemoglobin synthesis -vitamin C: plays a role in collagen formation -vitamin D: involved in calcium absorption and metabolism

The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved o2? 1:the alveoli need o2 to live 2:the alveoli have no direct effect on o2 3:collapsed alveoli increase o2 demand 4:o2 is exchanged for co2 in the alveolar membrane

4 rationale: the exchange of o2 and co2 occurs in the alveolar membrane. if the alveoli collapse, the exchange cannot occur because pulmonary ventilation is reduced. explaining this process in simple terms to a client may increase compliance with recommended breathing exercises aimed at improving o2 -alveoli do have a direct effect on o2 -the statements that alveoli need o2 to live and that collapsed alveoli increase o2 demand are nonspecific regarding the pathophysiology of the alveolar membrane

the nurse administers an older adult clients medications via gastrostomy tube in the long term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? select all that apply 1:absence of bowel sounds 2:presence of abdominal distension 3:residual capacity exceeding 300 ml 4:positive guaiac test for abdominal contents 5:seepage of feeding around tracheostomy

All of these are correct rationale: -abdominal distention: may be caused by excess feeding administration, delayed gastric emptying, or decreased bowel motility. -bowel sounds are an indication of gastrointestinal activity, absent could be caused by ileus or bowel obstruction -positive guaiac mean bleeding -seepage of feeding solution may be caused by gastric reflux placing client at risk for aspiration -residual capacity or gastric residual is assessed ever 8 hours. RV twice the infusion rate is abnormal

hypercapnia

excessive carbon dioxide in the blood EX: hypoventilation

incentive spirometry

exhale completely; take a slow deep breath; hold it as long as possible and slowly exhale

vitamin D

fatty fish, salmon, egg yolk, cheese -Enables the body to properly absorb and use calcium

complete proteins

fish, meat, poultry, eggs, milk, cheese, yogurt, and soybean products

bland diet

for ulcers, gastritis, reflux -avoid fats, citrus, spicy foods, alcohol, fried foods -avoid lying down for 3-4 hours after eating and eat small frequent meals

incomplete proteins

grains, legumes, nuts, seeds, and veggies

low sodium

high blood pressure and heart failure -limit low salt, processed food, condiments, cured or smoked meats

high potassium

if taking wasting diuretics -increase in apricots, bananas, dried fruits, oranges and grapefruit juice

enteral feeding

-used with clients who are unable to swallow or take nutrients orally but have a functioning GI -tubes inserted through the nose (NG/NI), surgically (gastrostomy/ jejunostom), and endoscopically (percutaneous endoscopic gastro/jejunostomy) -nose is short term and surgically is long term

When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? 1: Increasing carbohydrates to 55% to 60% of total intake 2: Providing vitamin and mineral supplements 3: Decreasing protein intake to 0.75 g/kg/day 4: Limiting water before and after exercise

1 Rationale: sports and regular moderate to intense exercise necessitate dietary modification to meet increased energy needs for adolescents. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocalories.

Which actions will the nurse take after noticing bibasilar crackles in a client who had an open cholescystectomy on the previous day? (select all that apply) 1: encourage turning, coughing, and deep breathing exercises 2:perform frequent breath sounds assessment 3:decrease by mouth fluid intake 4:offer a high potassium diet 5:ask the health care provider to prescribe a chest x ray

1,2 Rationale: client likely has postoperative atelectasis and requires frequent breath sounds assessment because of presence of abnormal breath sounds

Which client complication may be caused by total parenteral nutrition? (select all that apply) 1:hyperglycemia 2: infection 3:hepatitis 4:anorexia 5:dyshrthmias

1,2 rationale: TPN administers fat emulsions. -hyperglycemia related to the high concentration of dextrose in TPN is a common complication. -another complication is related to the central venous access that is needed of infusion of TPN -catheter related infections are frequently seen

Which food selections by a client with celiac disease indicates the nurses dietary teaching was successful? select all that apply 1: green beans 2:baked potatos 3:noddle pudding 4:turkey sandwich 5:whole wheat cereal

1,2 rationale: patients with celiac disease need to follow a gluten-free diet -avoid wheats, oat, barley, bread -eat fresh fruits, vegetables, nonprocessed meats

Which factor would the nurse assess for a client reporting constipation? (select all that apply) 1:diet 2:fluid intake 3:use of laxatives 4:date of last bowel movement 5:use of opioid pain medication

1,2,3,,4,5 if a client complains of constipation, the nurse would inquire factors related to constipation

which observation by the nurse indicates a client with pneumonia is able to use an incentive spirometer correctly? select all that apply 1:records the volume of the air inspired 2:performs 10 breaths per session every hour 3:inhales air fully before inserting the mouthpiece 4:takes a long, slow, deep breath keeping the mouthpiece in place 5:exhales deep breaths with the mouthpiece in their mouth

1,2,4 rationale: use of this device is to improve inspiratory muscle action and to prevent or reverse atelectasis in clients with pneumonia -exhale fully and then insert the mouthpiece and inhale

which intervention would provide safe o2 therapy? 1:check tubing for kinks 2:run wires under carpeting 3:post no smoking signs in clients room 4:place o2 tank flat in cart when not in use 5:make sure the client is using oil based products to lubricate the nose

1,3 rationale: -wires should not be kept under carpet because of heat buildup or friction that can cause a fire -o2 tanks should be placed upright in the cart or flat on floor -no use of oil due to fires but should use water based lubricants

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate head of bed to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 mL of water 4. Verify tube placement 5. Initiate feeding

1,4,2,3,5 rationale: the steps for an enteral feeding are as follows: Place patient in high-Fowler's position or elevate head of bed to at least 30 (preferably 45) degrees; verify tube placement; check for gastric residual volume; flush tubing with 30 mL of water; and initiate feeding.

partial nonrebreather mask

10-15 L/min 60%-90% -bag must stay partially inflated

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyper-oxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow

2

A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? 1. Position in semi-Fowler's 2. Flex head with chin tuck 3. Place food on left side. 4. Offer fruit juice.

2 rationale: Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger side of the mouth. Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated.

A client with stomach cancer expresses a lack of interest in food and consumes only small amounts. Which nursing intervention is best for meeting the dietary needs for this client? 1:smaller portions more frequently 2:nutritional supplements between meals 3:supplementary vitamins to stimulate appetite 4:only food the client likes in small portions at mealtimes

2 rationale: nutritional problems, especially weight loss, develop in clients with stomach cancer. Nutritional supplements provide more adequate calories and nutrients -vitamins do not stimulate appetite -offering only food the client likes in small portions does not ensure adequate nutrition

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing and unable to clear secretions. What should the nurse do first? 1:start O2 at 2L/min via nasal cannula 2:elevate the head of bed to 45 degrees 3:encourage the patient to use the incentive spirometer 4:notify the health care provider

2 rationale: the HOB needs to be elevated to help increase lung expansion and ease work of breathing, Also this makes it easier for patient to expectorate (cough)

Which assessment findings indicate that the patient is experiencing an acute disturbance in o2 and requires immediate interventions? (select all that apply) 1:spo2 value of 95% 2:retractions 3:respiratory rate of 38 b/m 4:nasal flaring 5:clubbing of fingers

2,3,4 rationale: 2: retractions is when the area between the neck and ribs are sunken in and it results in difficult breathing 3: RR: normal is 10-20 4:nasal flarring: sign of difficult breathing -clubbing of the fingers is an assessment finding associated with chronic hypoxia which does not require immediate intervention

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) 1:Head of bed elevation to 90 2:Daily oral care with chlorhexidine 3:Cuff monitoring for adequate seal 4: Clean technique when suctioning 5: Daily "sedation vacations" 6: Heart failure prophylaxis

2,3,5 Rationale:

Which action would be used to decrease risk for postoperative respiratory complication in an older client with decreased vital capacity? 1: give prescribed IV antibiotics 2:administer o2 per non-rebreather mask 3:teach the client coughing and deep breathing exercises 4:keep the client on the mechanical ventilation for many days

3 Rationale: teaching coughing and deep breathing exercises may help in preventing common postop complications such as atelectasis and pneumonia. -Antibiotics are prescribed after surgery to prevent wound infection -high levels of o2 will not prevent complication caused by decreased vital capacity and are only needed if the client develops hypoxemia -mechanical ventilation increases the risk for ventilator associated pneumonia and should be avoided

A client with COPD is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs the lungs and hears crackles and wheezes. Which action would the nurse take? 1:encourage the client to take slow deep breaths and administer 5 l o2 per nasal cannula 2:place the client in a side lying position and perform chest physiotherpay using clapping and vibration 3:raise the head of the bed to a high fowler position and administer 2 l/min per nasal cannula 4:assist the client in assuming a position of comfort and perform postural drainage

3 rationale: sitting helps breathing by increasing lung expansion; 2 L of o2 promotes respirations while preventing Co2 narcosis. -5L of o2 may cause respiratory depression and Co2 narcosis in a client with COPD

The nurse is caring for a client with severe dyspnea who is receiving o2 via venturi mask. Which action would the nurse take when caring for this clieint? 1:assess frequently for nasal drying 2:keep the mask tight against the face 3:monitor o2 sat levels when the client is eating 4:set the o2 flow at the highest setting that the client can tolerate

3 rationale: the mask cant be worn while the client is eating so u must check incase the client becomes hypoxic

The nurse is caring for an older adult client who has constipation. Which independent nursing intervention best helps reestablish a normal bowel patterns? 1:administer a mineral oil enema 2:provide 1 cup of fluid ever hour 3:manually remove fecal impactions 4:offer a cup of prune juice

4 Rationale: prune juice does not require a primary health care providers prescription and helps promotes bowel movements because it contains sorbitol that increase water retention in feces.

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) 1: Assist-control (AC) 2: Pressure support ventilation (PSV) 3: Bilevel positive airway pressure (BiPAP) 4:Continuous positive airway pressure (CPAP) 5:Synchronized intermittent mandatory ventilation (SIMV)

3,4 Rationale: Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). -The purpose of CPAP and BiPAP is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. -AC, PSV, and SIMV are invasive mechanical ventilation and are not routinely used on patients with sleep apnea. -AC delivers a set tidal volume (VT) with each breath, regardless of whether the breath was triggered by the patient or the ventilator. -Synchronized intermittent mandatory ventilation like AC delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient's respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths is determined by the patient's strength, effort, and lung mechanics. -PSV mode is often combined with SIMV mode: inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient's spontaneous breaths.

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? 1: From the tip of the nose to the earlobe 2. From the tip of the earlobe to the xiphoid process 3. From the tip of the earlobe to the nose to the xiphoid process 4. From the tip of the nose to the earlobe to the xiphoid process

4

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? 1. Polyunsaturated fats should be less than 7% of the total calories. 2. Trans fat should be less than 7% of the total calories. 3. Unsaturated fats are found mostly in animal sources. 4. Saturated fats are found mostly in animal sources.

4 Rationale: Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Diet recommendations include limiting saturated fat to less than 7% and trans fat to less than 1%.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1:slow, deep respirations 2:rapid, deep respirations 3:paradoxical respirations 4:pain, especially with inspiration

4 Rationale: rib fractures results from a blunt injury or a fall. Typical symptoms include: pain, tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest, possible bruising

Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for skin around the stoma? 1:cut an opening about 1/3 inch larger than the stomal pattern 2:avoid the use of soap and other irritating agents 3:eat yogurt and drink buttermilk and parsley 4:empty the pouch before it is one third full

4 Rationale: the weight of drainage from the stoma pulls the wafer away from the skin promoting skin breakdown. For this reason, ostomy bags should be emptied when 1/3 full. -teach the client and family caregiver to trace the pattern of the stomal area on the wafer portion of the appliance and to cut and opening about 1/8 to 1/6 inch larger than the stomal pattern to ensure the stomal tissue will not be constricted, promoting skin breakdown -irritants should not be used but soap is the agent of choice to cleanse the skin around the stoma -yogurt, buttermilk, and parsley will help with odor but not with skin breakdown

A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful? 1: Amino acids 2:triglycerides 3:dispensable amino acids 4:indispensable amino acids

4 rationale: The body does not synthesize indispensable amino acids, so these need to be provided in the diet. The simplest form of protein is the amino acid. The body synthesizes dispensable amino acids. Triglycerides are made up of three fatty acids attached to a glycerol.

After assessing several clients, the nurse would determine which client will require parenteral (outside body) nutrition? 1:a client with brain neoplasm 2:a client with anorexia nervosa 3:a client with inflammatory bowel disease 4:a client with severe malabsorption disorder

4 rationale: clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition

Simple O2 face mask

6-12l/min (35-50%)

When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water soluble vitamins? (select all that apply) 1:biotin 2:niacin 3:folic acid 4:riboflavin 5:vitamin C

All of these are correct Rationale: -Vitamin C -Vitamin B: biotin, niacin, folic acid, riboflavin, panothenic acid, folate, B6 All 9 of these are water soluble vitamins

low fiber

ulcerative colitis, crohns disease -limits fats: avoids nuts, seeds, dried fruit, whole grain

High flow nasal cannula

up to 60 L/min -used to treat respiratory failure

low-carbohydrate

used to balance food intake with insulin

high fiber

whole grains, veggies, fruits -used for constipation, hemorrhoids, colon cancer, IBS

In determining malnourishment in a patient, which assessment finding is consistent with this disorder? 1: Moist lips 2: Pink conjunctivae 3. Spoon-shaped nails 4: Not easily plucked hair

3 rationale: poon-shaped nails, koilonychia, is an indication of poor nutrition. -All the others are normal findings. Lips should be moist, conjunctivae should be pink, and hair should not be easily plucked.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1:Respiratory rate. 2:Amount of oxygen in the blood. 3:Percentage of hemoglobin-carrying oxygen. 4:Amount of carbon dioxide in the blood

3 rationale: it measures the o2 saturation of blood by determining the % of o2 carrying hemoglobin.

venturi o2 mask

precise concentration of 24%-60% (4-12L/m)

The nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods would the nurse include in the teaching? (select all that apply) 1:carrots 2:oranges 3:tomatoes 4:leafy greens 5:cantaloupe

1,4,5 Rationale: yellow and orange vegetables, such as carrots, contain large quantities of vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots are also high in vitamin A. Dark-green leafy vegetables contain large quantities of vitamin A. -oranges are considered a good source of both vitamin C and potassium -tomatoes are a good source of vitamin C

the nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods would the nurse include in the teach? (select all that apply) 1:carrots 2:oranges 3:tomatos 4:leafy greens 5:cantaloupe

1,4,5 rationale: vitamin A: yellow and orange vegetables, cantaloupe, sweet potatoes, apricots, dark leafy greens -vitamin C: tomatos, oranges (oranges are potassium too)

nasal cannula

1-6 l/m, 24-44%, low flow

Which instruction would the nurse include when teaching a client with asthma how to use a peak flow meter 1:sit up straight in a firm chair 2: check peak flow early in the morning 3:take the deepest breath you can, then blow out hard and fast 4:calculate the average of 3 readings to obtain peak flow

3 rationale: peak flow meter measures the peak expiratory flow rate and is used by taking the deepest breath possible, then forcefully exhaling as quickly as possible. -The client is taught to stand when measuring this -peak flow should be done between noon and 2pm when its at its highest -the peak flow reading is done 3 times and the highest reading is recorded as the peak flow

after assessing several clients, the nurse would determine which client will require parenteral nutrition? 1:a client with brain neoplasm 2:a client with anorexia nervosa 3:a client with inflammatory bowel disease 4:a client with severe malabsorption disorder

4

lactose or gluten free

For malabsorption syndromes caused by exposures to certain proteins ( lactose intolerance or Celiac disease). - For lactose, avoid dairy. - For gluten, avoid wheat, oats, barley and rye.

fluid restriction

For renal failure, dialysis patients and congestive heart failure. -Limit anything that is liquid at room temperature. -Healthcare prescriber will give exact amount of fluid allowed. Keep strict I & O.

Vitamin E

almonds, peanuts, soy oil -deficiency causes nerve damage

vitamin A

carrots, green leafy veggies, sweet potatoes, cantaloupe, pumpkin, salmon (accomation)

vitamin C

citrus fruits, tomatoes, broccoli, cabbage, berries

vitamin K

collard greens, kale, spinach -important for blood clotting

vitamin B12

meat, fish, eggs, dairy, poultry -condition that needs this is anemia

carbohydrates

milk, whole grains, fruit, vegetables

diabetic

need balanced intake of carbohydrates, fats, and proteins

Parenteral Nutrition (PN)

nourishment provided via IV therapy and does not have functioning GI -sepsis, head injury, or burns total PN is through a central line and administers fat emmusion

high calcium

osteoporosis -dairy, salmon, greens and need vitamin D for absorption

Which concept would be included when teaching parents about introducing a 6 month old infant to solid foods? 1:introduce one new solid food at a time 2:offer fruit juices or fruit flavored drinks 3:provide sold foods after the first birthday 4:administer iron supplements in addition to solid foods

1 rationale: The infant should be offered one new solid food at a time so that an allergic reaction is easily identified

to prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor? 1:skin condition 2:fluid and electrolyte balance 3:food intake 4:fluid intake and output

2 Rationale: monitoring fluid and electrolyte balance is the most important nursing intervention bc excess loss of fluid through the multiple loose bowel movements associated with diarrhea leads to alteration in fluid and electrolyte balance. -although skin may become excoriated with diarrhea, this is not life threatening -even though absorption of nutrients is decreased with diarrhea this is not life threatening -fluid intake and output provides information about fluid balance only, not taking into consideration the loss of electrolytes

The nurse is assesses four different clients. For which client do the findings indicate the client is at risk for heart disease? 1: color assessed: red; location assessed: face, area of trauma, sacrum, shoulders 2:color assessed: bluish; location: face, conjunctivae, nail beds, palm of hands 3:color assessed: pallor; location: face, conjunctivae, nailbeds, palm of hands 4:color assessed: yellow-orange; location: sclera, mucosa membranes, skin

2 Rationale: the nail beds, lips, mouth, and skin show cyanosis, or a bluish color. This may be due to an increased amount of deoxygenated hemoglobin, which may be due to heart or lung disease. -Client 1: shows redish color wish indicated fever or trauma -client 3: shows pallor color which indicates anemia -client 4: shows yellowish-orange which indicates jaundice or liver disease

The nurse is preparing to administer an oil retention enema and understand that it works primarily by which action? 1:stimulating the urge to defecate 2:lubricating the sigmoid colon and rectum 3: dissolving the feces 4:softening the feces

2 rationale: the primary purse is to lubricate -the secondary benefit includes stimulation and softening but it does NOT dissolve the feces

which factor elevates o2 sat? 1: nailpolish 2:carbon monoxide 3:intravascular dyes 4:skin pigmentation

2 rationale: -nailpolish interferes -intravascular lowers o2 sat -skin pigmentation overestimates the sat

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing? 1: Resting energy expenditure (REE) 2: Basal metabolic rate (BMR) 3:Nutrient density 4: Nutrients

2 rationale: The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities for a specific period of time. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in relation to kilocalories

the nurse is providing care to a client who is receiving enteral feedings via a ng tube. which serious complication would the nurse take measures to prevent? 1:skin breakdown 2:aspiration pneumonia 3:rentention ileus 4:profuse diarrhea

2 rationale: care should be take to prevent dislodging of the tube or vomitting

the nurse is teaching a student nurse about how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding. Which information would the nurse include? (select all that apply) 1:keep the head of the bed elevated at least 10 degrees 2:connect the tube feeding bag to the client and feeding pump 3:flush with warm water before feeding 4:check the prescription for the correct formula 5:set the correct rate and initiate the pump 6:check for diarrhea

2,3,4,5,6 rationale: connect the feeding bag to the client and pump and check for any residue before initiating the feeding. flush the PEG tube with 30 ml of warm water. diarrhea is a complication of tube feedings -bed needs to be elevated to atleast 30 degrees

After reviewing information about o2 for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long term continuous o2 therapy 1:partial pressure o2 (PaO2) of 72; peripheral capillary o2 saturation (SpO2) of 96 2: PaO2 of 60; SpO2 of 90 3:PaO2 of 55; SpO2 of 88 4:PaO2 of 70; SpO2 of 92

3 Rationale: this client is indicating hypoxemia and long term o2 therapy is needed. -normal Pa02 is 75-100 -normal O2 saturation: 95-100

A client with emphysema (difficult breathing) reports increased shortness of breath and becoming increasingly anxious. The nurse recognizes that this prescription is appropriate for which reason? 1:the client does not need any more the 1L/m 2:high concentrations of o2 cause alveoli to rupture 3:high concentrations of o2 eliminate the respiratory drive in some patients 4:the o2 at 1l/m should be enough to diminish the anxiety

3 Rationale: clients with emphysema are used to low levels of o2 and high levels of Co2. oxygen is the stimulus for breathing for these clients instead of the natural breathing stimuli. Too much o2 will know out the stimulus to breathe -high concentration of o2 will not cause a rupture

Which clinical manifestation would the nurse expect to find when assessing a client who is 8 hours postop creation of colostomy? 1:presence of hyperactive bowel sound 2:absence of drainage from the colostomy 3: dusky-colored, edematous-appearing stoma 4:bright, bloody drainage from the NG tube

3 Rationale:a colostomy does not function for several days postoperatively because of the lack of peristalsis (involuntary constrictions/ relaxation of the intestine muscles) -bowel sounds will be absent until peristaltic activity returns -a dusky, colored edematous stoma indicates a problem with circulation to the stoma, it should be bright red -bright, bloody draining from the NG tube indicates gastric bleeding

when a nurse needs to administer o2 of about 40% to keep a clients o2 sat greater than 94 which method would be best? 1:face tent 2:venturi mask 3:nasal cannula 4:simple face mask

3 rationale: all of the o2 methods are capable of delivering 40% but the nasal cannula is the most comfortable.

Which statement by a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery indicates effective teaching? 1:TPN provides supplemental nutrition 2:TPN provides short term nutrition after surgery 3:TPN provides nutrition when GI function is questionable 4:TPN assists people who are unable to eat but have active GI function

3 rationale: When GI absorption is inadequate, TPN is the nutritional therapy of choice because it provides needed nutrients. It is used for total, not supplemental therapy. -TPN is used with chronic or long term therapy, not for short term

The postoperative diet prescription for a client with a colostomy states, "Diet as tolerated". Which principle would the nurse include in the teaching plan to guide the clients food choices? 1:specific foods will cause most postop clients the same degree of discomfort 2:a low residue diet should be followed to avoid overstimulating the intestine 3:rigid dietary rules that limit food choices are needed to prevent postop complications 4:returning to a regular diet as soon as possible promotes physical rehab

4 Rationale: a regular diet is recommended after a colostomy because people will discover their own food intolerances. Each person reacts differently to a variety of foods. -a low residue diet is not necessary; once healing occurs, a diet with adequate residue promotes peristalsis and colostomy functioning. -rigid dietary regulations usually increases anxiety and are not needed

Which nurses action would prevent aspiration when administering medications through a NG tube? 1:place the client in the supine position 2:keep the head of bed elevated at 20 degrees 3:assess residual capacity and discarding the contents 4:verify placement of the NG tube

4 Rationale: actions to prevent aspiration includes verifying placement of the NG tube, placing patient in the high fowler position, check residual capacity BEFORE administration, and keeping the bed elevated 60-90 degrees

A nurse is reviewing results from a urine specimen. what will the nurse expect to see in a patient with a UTI? 1:cast 2:protein 3:crystals 4:bacteria

4 rationale: -crystals will be seen in renal stone formation -casts will be seen with renal disease -protein will be seen in kidney function and damage to the glomerular membrane such as glomerulonephritis

the nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. The stool is this consistency in which part of the colon 1:illeum 2:ascending 3:transverse 4:descending

4 rationale: -ileum is a component of the small intestines and produces very liquid stools -ascending colon will also be liquid because it is the first portion of the large intestine that the stool enters, and fluid has not been reabsorbed yet -transverse colon will be soft and pasty because fluid still can be absorbed in the rest of the large intestine

The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? 1. Normal weight 2. Underweight 3. Overweight 4. Obese

4 rationale: BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI from 18.5 to 24.9 is normal. BMI under 18.5 is underweight.

When the o2 sat of a client with pneumonia is at 89% to 90% while using a nonrebreather mask, which collaborative action would the nurse anticipate? 1:administration of o2 using a simple face mask 2:use of a venturi mask for administration of high-flow o2 3:continued o2 administration with the nonrebreather mask 4:o2 administration with bi-level positive pressure

4 rationale: BiPAP adds positive pressure during inspiration, decreasing some of the work of breathing and improving tidal volumes and gas exchange without some of the risks that are associated with intubation and mechanical ventilation

The patient has H. pylori. Which action should the nurse take? 1. Encourage avoidance of wheat and oats. 2:Encourage milkshakes as a nutritious snack. 3. Encourage completion of antibiotic therapy. 4:Encourage nonsteroidal anti-inflammatory drugs.

C rationale: H. pylori, a bacterium that causes up to 85% of peptic ulcers, is confirmed by laboratory tests or a biopsy during endoscopy. Antibiotics treat and control the bacterial infection. Avoidance of wheat and oats are required for patients with celiac disease who must follow a gluten-free diet. Encourage patients to avoid foods that increase stomach acidity and pain such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper). Discourage smoking, alcohol, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs).

The nurse administers an older adult clients medications via gastrostomy tube in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? select all 1:absence of bowel sounds 2:presence of abdominal distension 3:residual capacity exceeding 300 Ml 4:positive guaiac test of abdominal contents 5:seepage of feeding around tracheostomy

all of these are correct Rationale: -monitoring toleration of meds and feeding is significant for the client with Gtube. -In older adults abdominal distension may be caused by excess feeding administration rates, delayed gastric emptying, or decreased bowel motility -positive guaiac from abdominal contents indicates bleeding -seepage of feeding solution around a tracheostomy may be caused by gastric reflux, resulting in aspiration -residual capacity or gastric residual is usually assessed every 8 hours. A RV twice the infusion rate is considered abnormal and will need to be told to health care provider

low cholesterol

atherosclerosis, heart disease, stroke -limit saturated/trans fats and avoid margarine, and crisco -increase olive oil and canola oil (mono/polyunsaturated fats)

renal

restricts fluid and protein, sodium, potassium, phosphorus, salt -fresh foods instead of processed

After surgery, a client is prescribed a clear liquid diet. Which items would the nurse offer to the client? (select all that apply) 1:jello 2:broth 3:sherbet 4:ice milk 5:ginger ale

1,2,5 Rationale: -sherbet, ice milk are on a full liquid diet

A patient was admitted to the hospital with a history of liver dysfunction associated with hepatitis. With which metabolic problem does the nurse anticipate that this patient may have a problem? 1:emulsifying fats 2:digesting carbohydrates 3:manufacturing red blood cells 4:reabsorbing water in the intestines

1

a client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1:left lateral recumbent 2:back lying 3:knee-chest 4:mid fowler

1

compromised nutrition during chemotherapy can contribute to an increased risk of infection and other problems. Which action would the nurse take to offset nutritional deficiencies? 1:provide oral supplements 2:offer the clients favorite food 3:restrict intake from dairy products 4:encourage the client to drink low protein shakes

1

A client with a chronic obstructive pulmonary disease exacerbation is receiving o2 at 2 L/min per nasal cannula and has an o2 sat of 88%. Which action would the nurse anticipate taking next? 1:increasing o2 flow rate to 3 L/min 2:preparing for intubation and assisted ventilation 3:administration of an inhaled rapid acting bronchodilator 4:continuing to monitor the client with no therapy change

1 Rationale: because the clients o2 sat indicates hypoxemia, a higher flow rate of o2 is needed. The nurse will continue to monitor the o2 sat and RR and depth, because some clients with COPD will have a decrease in respiratory drive when o2 sat is in the 95-100% range. -intubation and assisted ventilation is not indicated now, however it may be needed if higher o2 flows fail to improve the clients o2 sat -inhaled bronchodilators help open airways and are frequently used for clients with COPD exacerbation, but NOT directly for increasing o2 sat

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1:o2 sat of 89% 2: body temp of 101 3:BP of 130/80 4:RR of 26b/m

1 Rationale: o2 sat of less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. -body temp indicates a fever due to pneumonia -BP is normal -RR may be due to the fever and is the secondary problem

The nurse is caring for a two day post surgery hip replacement client who has had a bowel movement. Which nursing intervention would the nurse perform next? 1:provide perineal care 2:turn and position client 3:give a complete bed bath 4:document the bowel movement

1 Rationale: providing perineal care helps preserve skin integrity for the client who is unable to provide self care

The nurse provides education to a client who is learning how to self administer gastrostomy tube feedings and would include which instruction? 1:administering water after the feeding tube is completed 2:maintaining the supine position during feeding 3:heating the feeding solution to slightly above body temp 4:determining tube placement by instilling water before the feeding

1 Rationale: water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. -To prevent regurgitation and aspiration, a fowler position is recommended -tube feedings are tolerated best at body temp -instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement

An obese client with type 2 diabetes ask about the intake of alcohol or special dietetic food in the diet. Which instruction would be included in the teaching plan? 1:alcohol can be consumed with its calories counted in the diet 2:unlimited amounts of sugar substitutes can be used as desired 3:alcohol should not be used in cooking because it adds too many calories 4:special dietetic foods are needed because many regular foods cannot be used

1 rationale: in an overweight individual with type 2 diabetes, occasional alcohol can be ingested with caloric substitution for equivalent fat exchanges in the diet because it metabolized like fat.

Which action would the nurse take first after finding a hospitalized client who is unconscious and unresponsive? 1:initiate a code 2:check for a carotid pulse 3:compress the lower sternum 4:give 2 full lung inflations

1 rationale: after the nurse has established unresponsiveness, the initial action is to initiate a code, because successful resuscitation usually requires defibrillation and a team of health care personnel -2nd: the nurse would attempt to find a carotid pulse -3rd: if not pulse was located, the nurse would initiate compressions of sternum -4th: if no additional help has arrived after 30 compressions, the nurse would provide 2 ventilations, then resume with 30 compressions with 2 ventilations

when caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? 1:elevate the head of bed between 30/45 degrees 2:decrease flow rate at night 3:check for residual daily 4:irrigate regularly with warm tap water

1 rationale: elevating the head any higher than 30/45 degrees causes and increase in sacral pressure which increases risk of skin breakdown

Which level of Maslows hierarchy of needs does the nurse fulfill by fitting a client who nearly died of asphyxiation (inflammation in airways) with an o2 mask? 1:1st level 2:second level 3:third level 4:4th level

1 rationale: the first level of Maslows hierarchy of needs includes the most basic and physiologic needs: air, water, and food. Fitting a client with an O2 mask meets this basic need.

nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include? 1. Have values for protein, vitamins, and minerals 2. Are based on percentages of fat, cholesterol, and fiber 3. Have replaced recommended daily allowances (RDAs) 4. Are used to develop diets for chronic illnesses requiring 1800 kcal/day

1 the RDIs are the first set, comprising protein, vitamins, and minerals based on the RDA. -The daily reference values (DRVs) make up the second set and consist of nutrients such as total fat, saturated fat, cholesterol, carbohydrates, fiber, sodium, and potassium. -Combined, both sets make up the daily values used on food labels. Daily values did not replace RDAs but provided a separate, more understandable format for the public.

When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include? (select all that apply) 1: change the ostomy pouch on a routine basis 2:replace the ostomy wafer weekly or sooner as needed 3:remove the ostomy pouch when showering 4:empty the ostomy pouch when 3/4 full of stool or gas 5:empty the ostomy pouch before exercise and at bedtime

1,2,5 rationale: changing the bag twice weekly is typical as well as change the skin barrier (wafer) one weekly or when needed. emptying the pouch before bedtime or exercise will prevent any leakage -instruct clients to exchange the old pouch for a new pouch after shower -if clients wait to empty the pouch until it is more than 1/2 full, leakage can increase. empty the pouch sooner than 3/4

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? 1: Press the emergency response button 2. Insert a spare tracheostomy with the obturator. 3. Manually occlude the tracheostomy with sterile gauze. 4. Place a face mask delivering 100% oxygen over the nose and mouth.

2 Rationale: the nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used. -The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed -A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. -Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient's only airway.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1: low RR 2: diminished breath sounds 3:the presence of a barrel chest 4:a sucking sound at the site of injury

2 rationale: a collapsed lung that cause chest pain and difficult breathing -look at the subject, a blunt chest injury. The word blunt will assist in eliminating option 4, which describes a sucking chest wound injury -knowing that in a respiratory injury, increased respirations will occur will assist you in eliminating option 1 -option 3 can be eliminated because a barrel chest is a characteristic finding in chronic obstructive pulmonary disease

The client reports abdominal cramping while undergoing a soapsuds enema. which action would the nurse take 1:immediately stop the infusion 2:lower the height of the enema bag 3:advance the enema tubing 2 to 3 inches 4:clamp the tube for 2 minutes and then restart the infusion

2 rationale: abdominal cramping may be due to too rapid administration of the enema solution. lowering the height of the bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort -clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve cramps

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). what statement made by the patient indicates the need for further teaching? 1: pursed lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles 2:When i am sick, i should limit the amount of fluids I drink so that i dont produce excess mucus 3:I will ensure that I receive and influenza vaccine every fall 4:I will look for a smoking cessation support group in my neighborhood

2 rationale: patients need to make sure they are adequately hydrated in order to liquefy secretions, making it easier to expectorate. fluids should not be limited or else the mucus will become too thick. All the other answers indicate an understanding of the discharge plan

In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? 1:Weight increases 2: Weight decreases 3:Weight does not change 4:Weight fluctuates daily

3 Rationale: In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person's energy demands, the individual gains weight. If kilocalories ingested fail to meet a person's energy requirement, the individual loses weight. Fluid, not kilocalories, causes daily weight fluctuations.

Which should the nurse include when teaching a client with clostridium difficle about decreasing the risk of transmission to family members? 1:increase fluid intake 2:eat a high fiber diet 3:use soap and water for hand washing 4:wash hands with an alcohol based hand sanitizer

3 Rationale: alcohol does not kill C.difficle spores. Use of soap and eater is more efficacious than alcohol based hands rubs

Which recommendation would the nurse give when teaching a class about nutrition to a group of adolescents, taking into consideration the prevalence of overweight teenagers? 1: join a gym 2:drink fewer sodas 3:decrease fast food intake 4: take a multivitamin daily

3 Rationale: eating a variety of healthful foods instead of a fast food diet that is high in fat and carbs helps decrease excess weight and increase energy with which to engage in activities. -Joining a gym is expensive and unnecessary -diet soft drinks do not contribute to obesity. -multivitamin will not promote weight loss. Best obtained in a balanced diet

A client with a chest injury has suffered flail chest. the nurse assesses the client for which most distinctive sign of flail chest? 1:cyanosis 2:hypotension 3:paradoxical chest movement 4:dyspnea, especially on exhalation

3 Rationale: flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. -Paradoxical chest movement means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands.

The nurse documents auscultation of coarse rhonchi in the anterior lung fields bilaterally that clears with coughing. Which condition would the nurse associate with these sounds? 1: parietal pleura rubbing against visceral pleura 2:random, sudden reinflation of groups of alveoli 3:turbulence due to muscular spasm and fluid or mucus in the larger airways 4:high-velocity airflow through a severely narrowed or obstructed airway

3 Rationale: loud, low pitched, rumbling coarse sounds heard over trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucus is present in the larger airways -pleural rub: produces a sound of dry or grating quality -crackles: random and sudden reinflation of groups of alveoli -wheezing: high velocity airflow through very narrowed or obstructed airways

While assessing a client, the nurse identifies adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched rumbling coarse sounds during inspiration. This sound is clearly heard while the client is coughing. Which condition would the nurse associate these sounds with? 1:inflammation of the pleura 2:reinflation of groups of alveoli 3:muscular spasms in the larger airways 4:high velocity airflow through an obstructed airway

3 Rationale: rhonchi can be heard when there are loud, low pitched, rumbling and coarse sounds during inspiration. These sounds can also be heard while the client is coughing. Rhonchi is caused by muscular spasms in the larger airway -pleura rub: inflammation of the pleura -crackling: reinflation of groups of alveoli -wheezing: high-velocity airflow through an obstructed airway

on the first postop day after a thyroidectomy, a client tolerates a full fluid diet. This is changed to a soft diet on the second postop day. The client reports a sore throat when swallowing. Which intervention would the nurse take for this client? 1:reorder the full fluid diet 2:notify the primary health care provider 3:administer analgesics as prescribed before meals 4:provide saline gargles to moisten the mucous membranes

3 Rationale: soreness is to be expected. A progression to a soft diet will provide nutrients needed for healing and energy and will stimulate the return of bowel activity. Analgesics as prescribed will reduce soreness during meals -reordering the full fluid diet is not within the legal role of the nurse. -gargling involved hyperextension of the neck, which may put tension on the suture line -soreness will be expected and not a medical emergency

Which dietary choice reflects the recommendations of the Dietary Approaches to Stop Hypertension (DASH) diet? 1:salami 2:pickles 3:salmon 4:french fries

3 Rationale: the DASH diet includes fruits, veggies, low-fat/fat-free foods, fish, poultry, and reduced sugar. Salmon is a meal choice that aligns with this diet. -Salami: processed meat, high in fat -pickles: high in sodium -french fries: high in fat and starch

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1: dry cough 2:hematuria 3:bronchospasm 4:blood streaked sputum

3 Rationale: the client should be assessed for signs of complications, which would include cyanosis (blue skin bc of low o2), dyspnea (shortness of breath), stridor (highpitched lung sounds), bronchospasm (bronchial muscle contractions), hemoptysis (cough blood), hypotension (low blood pressure) -blood-streak sputum and dry cough is expected for hours

Which assessment finding would the nurse report to the health care provider when giving immediate postoperative care to a client with a newly placed ostomy? 1:moderate edema of the stoma 2:excessive gas issuing from the stoma 3:blanching, dark red to purple color of stoma 4:small amount of blood oozing from the stoma

3 rationale: the stoma should be rosy pink to red in color. A blanching, dark red to purple stoma indicates inadequate blood supply to the stoma or bowel and should be reported to the health care provider -mild to moderate edema is normal initially and will resolve over the first 6 weeks -excessive gas is common for the first 2 weeks -it is normal to have a small amount of blood ooze from the stoma when touched because of its high vascularity

Which nursing interventions indicate client care that supports physical functioning? (select all that apply) 1:facilitate clients learning 2:alter clients undesirable behavior 3:maintain clients nutritional status 4:maintain clients regular bowel patterns 5:prevent complications in the client related to electrolyte imbalance

3,4 rationale: providing interventions to maintain the clients nutritional status and providing interventions to maintain the clients regular bowel patterns are interventions that support physical functioning. -providing interventions to facilitate a clients learning and providing interventions to alter the clients undesirable behavior are interventions to support psychosocial functioning and facilitate lifestyle changes. -providing interventions to prevent complications related to electrolyte imbalance indicates the nursing care that supports homeostatic regulation.

The nurse is caring for a client with a venturi mask who is receiving 40 % of o2. Which nursing actions are indicated? (Select all that apply) 1: keep the o2 source higher than the clients airway 2: adjust the liter flow according to the o2 sat 3: prevent the clients blanket from covering the adaptors orifices 4: ensure that the bag does not deflate completely during inspiration 5:check that the appropriate adapter to deliver the prescribed fio2 is attached to the mask

3,5 rationale: the adapters orifices allow room air to combine with o2 to provide specific o2 concentration. A venturi mask uses one of several adapters, which are usually color-coded, to deliver prescribed FiO2. -the o2 source does not need to be higher than the clients airway because its flow does not depend on gravity -the liter flow is adjusted according to the flow rate that corresponds to the % of o2 prescribed; this usually is identified on the base of each adapter -A venturi mask does not have a bag like a rebreather mask

The nurse is teaching a health class about the ChooseMyPlate program. Which guidelines will the nurse include in the teaching session? 1. Balancing sodium and potassium 2. Decreasing water consumption 3. Increasing portion size 4. Balancing calories

4 Rationale: The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars. It does not balance sodium and potassium

Which finding in a client who has home o2 therapy with a tracheostomy collar requires immediate action by the home health nurse 1:condensation in the tubing 2:o2 flow rate 9L/min 3:low fluid level in the humidifier 4: scented candle burning in the room

4 Rationale: fire spreads quickly in the presence of o2 -condensation in the tubing should be emptied but doesnt present an immediate danger -o2 flow rate for tracheostomy collars should be atleast 10L and the o2 flow rate may need to be increased, but not the first priority -water should be added to the humidifier after the candle is blown out

Which type of diet would the nurse expect the primary health care provider to prescribe for a client diagnosed with rheumatoid arthritis? 1:salt-free, low fiber 2:high calorie, low cholesterol diet 3:high protein diet with minimal calcium 4:regular diet with vitamins and minerals

4 Rationale: iron and vitamins should be encouraged to treat any underlying nutritional deficiency

Which food or drink would the nurse instruct a new client with a new colostomy to avoid because it produces large amounts of gas? 1:milk 2:cheese 3:coffee 4:cabbage

4 rationale: cabbage is a gas producing food that can cause a client with a colostomy problems with odor control and ballooning of the bag, which may break the device seal and allow leakage. -the other options should not cause gas in moderation

in providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother? 1. Calcium intake is especially important in the first trimester. 2. Protein intake needs to decrease to preserve kidney function. 3. Folic acid is needed to help prevent birth defects and anemia 4. Extra vitamins and minerals should be taken as much as possible.

4 rationale: -folic acid intake is particularly important for DNA synthesis and growth of red blood cells. Inadequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. -Protein intake throughout pregnancy needs to increase to 60 grams daily. -calcium intake is especially critical in the third trimester, when fetal bones mineralize. -Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts.

Which nursing action is most appropriate for a pregnant client at 23 weeks gestation with pica? 1:offering referral to a mental health care provider 2:explaining the potential danger of pica to the fetus 3:obtaining a prescription for an iron supplement 4:determining whether the diet is safe and nutritionally adequate

4 rationale: begin with assessing whether the diet is safe and nutritionally adequate -woman with pica may also have a nutritional deficiency -example of non-nutritive substance: soil

Which client response during the insertion of a NG tube indicate that the client is experiencing serious difficulty with the insertion? 1:choking 2:redness 3:gagging 4:cyanosis

4 rationale: if the ng tube is passed accidentally into the trachea rather than the esophagus, it will occlude the airway, causing cyanosis

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4 rationale: pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation

which assessment question should the nurse ask if stress incontinence is suspected? 1:do you think your bladder feels distended 2:do you empty your bladder completely when you void 3:do you experience urine leakage when you cough or sneeze 4:do your symptoms increase with consumption of alcohol or caffine

c rationale: stress incontinence is the involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter (EX: weak pelvic floor muscles, trauma after childbirth, sneezing, coughing, radical prostatectomy) -overflow incontinence: over distended bladder -functional: loss of continence caused by outside the body. EX: altered mobility, manual dexterity, cognitive impairment, poor motivation, environmental barriers -transient: caused by medical conditions that are treatable. -urgency: urge to pee related to overactive bladder caused by neurological problems such as bladder inflammation or outlet obstruction -reflex: involuntary loss of urine occurring at predictable intervals. Related to spinal injury between C1 and S2