exam 4

the nurse is caring for a client diagnosed with an acute myocardial infarction requiring strict monitoring of intake and output. calculate the intake for the shift. 550ml of urine, 1/4 cup of grapes, 200 ml liquid stool, 4oz jello, 250 ml of IV normal saline, 1 cup apple juice

610

a nurse is admitting a client to a long term facility. what should the nurse plan to use to assess the client for risk of pressure injury development?

Braden scale

a young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. which response by the nurse is appropriate?

I respect your wish not to look at it right now

which body fluid is within the cells, constituting about 70% of the total body water?

ICF

the client is scheduled to receive dressing changes and warm soakes twice a day for an abcess to the lower extremity. the pt has not been tolerating the dressing changes and soaks due to acute pain. what action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

administer analgesics 30 mins prior to the treatment to act on pain receptors

a nurse is changing a client's peripheral IV dressing. which step is recommended in this procedure?

apply chlorhexidine to the site in order to disinfect

a dietitian is providing an in-service for the nurses on a medical -surgical unit. during the inservice, the dietitian informs the group that there are 6 classes of nutrients, and three supply the body with energy.

carbs, protein, lipids

a full thickness or third degree burn develops a leathery covering called

eschar

endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their ecf. this electrolyte imbalance is

hyponatremia

a nurse is administering a prescribed dose of IV fluids to a young client with anorexia at the health care facility. which information regarding contributing factors should the nurse include when educating the family?

illness can contribute to anorexia

the nurse is caring for a client who had surgery 24 hrs ago and is experiencing severe pain. the client states "my pain medication is effective, but will this pain ever get better and go away"?

incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe.

based on the knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. why would the nurse do this?

infants have more total body fluid and ecf than adults

a student is learning how to administer IV fluids, including accessing a vein. what is the most potentially harmful risk for the client when accessing the vein?

infection

in planning to meet the nutritional needs of a critically ill client in the icu, which factor will increase the client's basal metabolic rate?

infection

a nurse is initiating a peripheral venous access IV infusion prescribed for a client preoperative. in what position would the nurse place the client to perform this skill?

low fowler

what should the nurse consider when teaching a man with well-defined muscle mass about meal planning?

men have a higher need for proteins

the nurse observes the client for signs of stage 1 pressure injury development, which most likely will include which finding?

nonblanchable redness

which location might the nurse use to assess the condition of an insertion site for a central venous access device?

over the jugular vein

a nurse is caring for a client who is not able to take food orally for 10 days and who will be on IV therapy during that period. the nurse knows that the client will likely receive which type of nutrition?

peripheral parenteral nutrition

a hospitalized client has been NPO with only IV fluid intake for a prolonged period. what assessments might indicate protein calorie malnutrition?

poor wound healing, apathy, adema

the nurse is responding to a client's call light. the client states "I was getting out of bed and caught my IV on the side rail" the nurse determines that the IV has been almost completely pulled out. which action is most appropriate?

remove the IV and reinsert another in a different location

a client with partial-thickness burns is encouraged to increase the proteins in the diet. which food selection from the hospital menu indicates that the client understands how to choose foods high in protein?

scrambled eggs with cheese

the nurse is monitoring a blood transfusion for a client with anemia. 5 mins after the transfusion begins, the client reports feeling short of breath and itchy. which action should the nurse take?

stop the transfusion and notify the provider

a nurse is caring for an adult who had MOHs surgery on the nose. the client asks "is there anything I can do to prevent getting skin cancer again"? how should the nurse respond?

there are preventative measures you should take to limit exposure to UVA and UVB rays, sunscreen, protective clothing. however, since you have already had skin cancer you are at higher risk and should continue to inspect your skin for suspicious findings and see your derm as recommended.

a client is underweight. which is the best goal for the client and nurse to construct and mutually agree to implement?

to consume 80% of the diet tray for each meal

a family meeting has been called to discuss care planning for a client who has late stage alzheimer disease and who has largely stopped taking food by mouth. what principle should best guide the decision around the use of tube feeding?

tube feeding has not been shown to increase survival rates significantly among this population

a nurse is assessing the nutritional needs of clients. which criteria indicates that a client most likely needs total parenteral nutrition

wasting syndrome from AIDs

a client is 6 weeks pregnant and is in a clinic for her first prenatal exam. the client asks the nurse how her nutritional needs have changed. what is the best response?

you will need an increase in calories, protein, calcium, folic acid, and iron

which nutritional guideline should a nurse provide to a client who is entering the second trimester of her pregnancy?

you'll need to eat more calories and to make sure you eat a balanced diet high in nutrients

the nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal ph. place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2

-h2co3 level in the blood decreases -ph becomes more alkaline -blood level co2 decreases -decreased respirations -carbon dioxide retention -carbonic acid formed

a nurse has received a physician order to insert a ng tube in an adult client. what is the correct order ?

-measure the insertion distance. -insert the tube to the pharynx -have the client tuck his chin to chest -have the client take small sips of water -insert the tube to the indicated mark -aspirate a small amount of stomach contents to check ph

the nurse is preparing to administer an intermittent feeding to a client who has nasogastric feeding tube. place the following steps in the correct order

-position the client with head of the bed elevated 30 to 45 degrees -verify correct tube placement -aspirate all gastric contents -verify that gastric residual volume is less than 200 ml -flush the tube with 30 ml -administer the feeding

the nurse is caring for 4 clients. the nurse recognizes that which client's lifestyle choice contributes most highly to risk for development of cardiometabolic syndrome?

28 you old who eats fast food daily

a nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the GI tract?

300 mL

for which of the following clients should the nurse anticipate the need for a pureed diet?

a man who's stroke has resulted in difficulty swallowing

what is the initial purpose of the action in which the nurse is engaging, during the preparation for the administration of the prescribed IV solution?

allowing for effective access to the solution

the nurse is providing care for several clients on a busy floor. the nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. which action should the nurse take before entering the client's room to begin?

arrange for another nurse to monitor the nurse's other assigned clients

a nurse is caring for a client with phlebitis. the nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. which actions should the nurse perform to avoid further complications and provide relief to the client?

discontinue the IV promptly

the nurse just completed a dressing change and returned the client to a comfortable position. what should the nurse do next?

document the color, odor, amount, and type of wound drainage

the nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. which nursing measure should the nurse implement to assist the client in improving his nutritional intake?

encourage his daughter to prepare food at home and bring it to the client.

which of the following statements is an appropriate nursing diagnosis for a client 80 yrs of age diagnosed with CHF with symptoms of edema, orthopnea, and confusion?

extracellular volume excess related to heartd failure, as evidence by edema and orthopnea.

a nurse is assessing a client's nutritional status. which findings should lead the nurse to suspect poor nutritional status?

flaky facial skin, facial edema, and pale skin color

a client has been prescribed a clear liquid diet. which food or fluids should the nurse serve the client?

gelatin desert, carbonated beverages, apple juice

many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid base balance. what describes complications related to liver disease?

increased plasma levels of antidiuretic hormone lead to water excess.

the nurse is caring for a client on the unit. during change of shift, another nurse is observed doing what is pictured in the image. what is the most important reason this technique does not adhere to the standards of care for dressing changes?

increases the risk of infection by contaminating the wound

a nursing instructor is explaining the difference between infiltration and phlebitis to a student. which statement is most appropriate?

infiltration occurs when fluid escapes into the tissue. while phlebitis is inflammation of the vein

a client has a physician order for NPO following abdominal surgery to repair a bowel obstruction. the client requires IV therapy for what purpose?

replace fluid and electrolytes

the nurse is caring for a 70 ur old client with a body mass index of 34.8. which risk factor should the nurse discuss with this client?

risk of heart disease

the nurse is caring for a client with a knee sprain. what guidelines will the nurse teach the client about using an ice pack at home?

there should be a cloth barrier around the ice pack for each 20 minute therapy.

a client with a superficial (2nd degree) burn is being discharged to home. for which reason should the nurse recommend that the client consume vit c daily?

to promote healing of the burn