Exam 4 Week 8

A patient experiencing constipation is placed on psyllium (Metamucil). When teaching the patient about the medication, the nurse should include (Select all that apply.): a. Drink plenty of fluids to produce the desired effect of the medication. b. Mix with a glass of water or fruit juice before taking. c. Have liver functions performed monthly. d. Take at bedtime and avoid taking with meals. e. Warm the liquid, add the medication, and let stand for an hour before taking.

A, B Patients on psyllium (Metamucil) should be instructed to drink plenty of fluids, to take the medication in the morning or with meals, and to mix with a full glass of cool liquid (water, milk, or fruit juice) just prior to taking. The patient does not need to have liver studies performed, as the medication is not hepatotoxic.

The nurse should implement which nursing interventions for the patient posthemorrhoidectomy? (Select all that apply.) a. Assess for bleeding and pain. b. Provide adequate fluid intake. c. Monitor electrolytes. d. Encourage sitz baths. e. Give anti-inflammatory medications.

A, B, D Post-hemorrhoidectomy, the patient should be assessed for bleeding and pain. The patient is given analgesics, stool softeners, sitz baths, and increased fluids (at least 2000 mL daily). Changes in electrolytes and need for anti-inflammatory medications are not expected.

The nurse is teaching a community group to prevent traveler's diarrhea. The nurse's teaching plan should include (Select all that apply.): a. Wash hands before eating and frequently to prevent the spread of microorganisms. b. Do not consume food left out at room temperature. c. Take antibiotics every day you are on holiday. d. Drink only bottled water. e. Do not eat in local restaurants.

A, B, and D to prevent traveler's diarrhea, the nurse should include proper hand hygiene, using bottled water, and consuming food maintained at proper temperatures. Taking prophylactic antibiotics can create resistant strains of microorganisms. Eating in local restaurants is not prohibited as long as precautions about cleanliness and complete cooking of food are followed.

Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply. a. Bowel Incontinence b. Risk for Deficient Fluid Volume c. Disturbed Body Image d. Social Isolation e. Risk for Impaired Skin Integrity

A, C, D, E Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, client may not feel as comfortable around others. In option 5, increased tissue contact with fecal material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

An 80-year-old patient with a history of renal insufficiency is receiving intravenous fluids at 100 mL/hour. Which interventions should the nurse include in the plan of care? (Select all that apply.) a. Monitor oral and intravenous intake and output. b. Increase oral fluids and insert an indwelling catheter. c. Monitor serum creatinine levels and electrolytes. d. Strain urine for kidney stones. e. Assess breath and heart sounds.

A, C, E Rapid fluid replacement in a patient with renal insufficiency increases risk for fluid overload. The nurse should monitor total intake and output, serum creatinine, electrolytes, breath and heart sounds. There is no indication that oral fluids should be increased and placement of an indwelling catheter should be avoided if possible. Increasing fluids will not cause kidney stones to form.

A patient is admitted with gnawing, burning, hunger-like pain in the epigastric region that sometimes radiates to the back. The patient reports that this pain occurs 2-3 hours after meals and in the middle of the night. Which test result is most significant? a. a positive urea breath test b. blood-urea nitrogen (BUN) level of 29 mg/dL c. urine-specific gravity of 1.025 d. serum ammonia level of 18 mcg/dL

A. A positive urea breath test H. pylori infection occurs in 70% of people with peptic ulcer disease (PUD). A noninvasive method of detecting H. pylori infection includes a urea breath test. All other labs are insignificant.

The nurse is instructing a patient who is experiencing diarrhea associated with a microorganism not to use antidiarrheals. The patient asks, "Why can't I take something to stop the diarrhea?" The nurse's best response is: a. "Antidiarrheals will slow the elimination of the microorganism." b. "Antibiotics are always used to treat the microorganisms, but antibiotics might worsen diarrhea." c. "You are taking potassium to stop your diarrhea." d. "Your physician does not want you to take antidiarrheals."

A. Antidiarrheals will slow the elimination of the microorganism : Antidiarrheal medications can prolong the discomfort by slowing the elimination of the bacteria from the bowel. Antibiotics may be given, but the antibiotics alter the normal flora of the bowel, and can worsen diarrhea. Potassium is given to achieve electrolyte balance. The nurse should answer the patient's question rather than referring to the physician.

When teaching a class to teenagers on risk factors for oral cancer, the nurse would be certain to include which of the following information? (Select all that apply.) a. Avoid use of smokeless tobacco products. b. Avoid alcohol consumption. c. Avoid eating food that has been charcoal-broiled. d. Chew only sugarless gum. e. Avoid carbonated beverages.

A. Avoid use of smokeless tobacco products B. Avoid alcohol consumption Smokeless tobacco products alcohol consumption increase the risk of oral cancer on the lips, tongue, or throat; therefore, it is important to avoid chewing tobacco and to avoid alcohol consumption. Grilled foods, sugared gum, and carbonated beverages have no effect on the development of oral cancer.

If the pH of aspirate from a small-bore jejunal feeding tube is 6.4, what is the next appropriate nursing action? a. Collaborate with the physician regarding x-ray for placement. b. Administer the tube feeding as ordered. c. Re-check the finding in 15-30 minutes. d. Pull the tube back about one finger-length.

A. Collaborate with the physician regarding x-ray for placement. Evidence-based practice strongly suggests that checking gastric aspirate is the best method for determining tube placement prior to initiation of feeding. An aspirate ph of 6.0 or less is indicative of correct placement for a jejunal feeding tube, so feeding can be initiated. Since this pH is higher tube placement should be checked by x-ray. Rechecking will not change the finding and pulling the tube back is not indicated without and x-ray.

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which condition? a. Constipation b. Diarrhea c. Incontinence d. Hemorrhoids

A. Constipation : Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result—if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool (option 2). Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence (option 3). Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool (option 4).

A patient with intractable nausea and vomiting has a serum blood urea nitrogen (BUN) of 46 mg/dL and a urine-specific gravity of 1.061. The patient's neck veins are flat, and the vitals signs are BP 90/60, pulse 104, temperature 98.4°F, and respirations 18. The nurse would provide care based upon which priority patient concern? a. Deficient Fluid Volume b. Risk for Fluid Volume Imbalance c. Impaired Comfort D. decreased nutritional intake

A. Deficient Fluid Volume This patient demonstrates signs and symptoms that indicate dehydration, such as an elevated BUN and urine-specific gravity, low blood pressure, elevated pulse, and flat neck veins. This patient has an actual fluid volume deficit therefore a risk concern is not valid. Comfort is always relevant, but does not address the patient's fluid status, and is not a priority at this time. The data presented for this patient do not suggest that the patient has an actual nutritional imbalance.

The intake and output (I & O) record of a client with a nasogastric tube that has been attached to suction for 2 days shows greater output than input. Which nursing diagnoses are most applicable? Select all that apply. a. Deficient Fluid Volume b. Risk for Deficient Fluid Volume c. Impaired Oral Mucous Membranes d. Impaired Gas Exchange e. Decreased Cardiac Output

A. Deficient Fluid Volume C. Impaired Oral Mucous Membranes E. Decreased Cardiac Output Rationale: Options 1, 3, and 5 relate to fluid volume deficit. The data indicate an actual problem, which excludes option 2. Option 4 relates more to fluid volume excess.

A patient with cancer is experiencing an electrolyte imbalance, which is manifested by muscle spasms and numbness in the left hand. The nurse determines that these signs/symptoms represent which electrolyte imbalance? a. hypocalcemia b. hypercalcemia c. hypophosphatemia d. hyperphosphatemia

A. Hypocalcemia Muscle spasms and numbness along with positive Trousseau and Chvostek signs are characteristic signs of hypocalcemia. Signs and symptoms of hypophosphatemia are paresthesia, confusion, and seizures. Signs and symptoms of hyperphosphatemia are tetany and paresthesia.

The nurse knows that the teaching of a patient with acute gastritis has been effective when the patient states: a. "I won't use aspirin or NSAIDs for routine pain relief." b. "My diet should consist mostly of bland foods." c. "I will return for yearly upper endoscopy exams." d. "I will try to drink only diet soft drinks."

A. I won't use NSAIDs for routine pain relief. The development of acute gastritis is caused by a variety of factors, including ingestion of aspirin or other NSAIDs, corticosteroids, alcohol, caffeine, and foods contaminated with certain bacteria. It is more important for the patient to discover personal food intolerances than to avoid all but bland foods. Upper endoscopy is a diagnostic tool to identify gastric mucosa for changes, but does not need to be done on an annual basis. In general, soft drinks with high caffeine content should be avoided.

A patient is receiving D5NS, which is infusing at 75 mL/hour to treat dehydration. Because of the body's response to the infusion of this type of solution, what is the most appropriate nursing action? a. Monitor heart rate and quality as well as urinary output. b. Review potassium and sodium levels to detect electrolyte imbalances. c. Assess bowel motility and elimination patterns that can result from prolonged dehydration. d. Observe level of consciousness to detect neurological changes associated with dehydration.

A. Monitor Heart Rate and Quality as well as urinary output. When a hypertonic solution is introduced into the extracellular space (ECS), there is a potential for overhydration. The hyperosmolarity of the plasma and the interstitial space pull fluid from the cell, yielding increased circulating blood volume and contracted cells. In the case of overhydration, the patient's heart should be monitored to ensure its ability to contract in response to the increase in circulating blood volume. Urinary output is an indirect measurement of cardiac function. Once the heart is unable to compensate for the additional circulating blood volume, the contractility decreases, decreasing the amount of blood flow to the renal system, yielding oliguria. The nurse should monitor the patient's labs; however, this patient is at risk for developing heart failure, so the most appropriate action is to monitor the heart rate and urinary output. Dehydration does not necessarily cause changes in motility. Furthermore, dehydration is often the result of changes in bowel and elimination patterns, such as vomiting and diarrhea. The nurse should observe for changes in level of consciousness due to dehydrated cells, but this action does not supersede answer the monitoring of heart rate and quality and urinary output.

Which nursing diagnosis would be most appropriate for a patient with bulimia nervosa? a. Oral Mucous Membrane, Impaired b. Nutrition, Imbalanced: More Than Body Requirements c. Fluid Volume, Excess d. Nausea

A. Oral Mucous Membrane, impaired Impaired Oral Mucous Membrane can be related to lacerations of the palate and oral mucositis. Nutrition, Less than Body Requirements, not More than Body Requirements, is a primary nursing diagnosis. Risk for Deficient Fluid Volume, not Fluid Volume Excess, related to consistent self-induced vomiting or abusive laxative/diuretic use, is a primary nursing diagnosis. Nausea is not consistent with bulimia.

When formulating a teaching plan for a patient who is obese, the nurse identifies which techniques as appropriate behavioral change strategies for weight reduction? (Select all that apply.) a. Shop from a prepared list and on a full stomach. b. Eat meals while reading and watching TV, so as to offer distraction. c. Eat slowly by taking small bites, allowing 20 minutes for a meal. d. Use small plates and cups to make servings of food look larger. e. Use favorite treats as a reward for reaching a goal.

A. Shop from a prepared list and on a full stomach. C. Eat slowly by taking small bites, allowing 20 minutes for a meal. D. Use small plates and cups to make servings of food look larger. Shopping from a prepared list on a full stomach, eating slowly, and using smaller plates are all good behavioral change strategies for the patient trying to lose weight. The patient should avoid eating in front of the television and using food as rewards.

A person diagnosed with osteoporosis needs adequate amounts of which vitamin for calcium absorption from the small intestine? A. Vitamin D B. Biotin C. Vitamin C D. Vitamin B12

A. Vitamin D The effects of osteoporosis may be lessened through the adequate intake of calcium and vitamin D. Without vitamin D, the body cannot absorb calcium. Other factors affecting the absorption of calcium include lactose intake, acidity of digestive mass, binders, dietary fat, high-fiber intake, high intakes of phosphorous or magnesium, sedentary lifestyle, and drug-nutrient interactions.

Because a patient who is ingesting a diet appropriate for weight reduction lost 10 pounds within 30 days, the nurse teaches the patient that which outcome might exist? a. losing lean muscle mass b. unable to maintain weight loss c. using a starvation diet d. depression

A. losing lean muscle mass. The recommended weight loss is 1-2 pounds per week. A patient risks loss of lean tissue and nutrient deficiency with weight loss that exceeds that rate. Maintenance of weight loss is related to sustained lifestyle changes. A starvation diet results in more rapid weight loss. Depression can result in weight loss, but this patient is on a diet.

The nurse is caring for a patient experiencing peritonitis. The patient develops a temperature of 103°F (39.4°C), is restless, and has a urinary output of 75 mL in eight hours. Blood pressure is 80/40. The nurse should develop a plan of care related to: a. shock. b. appendicitis. c. diarrhea. d. bowel obstruction.

A. shock The patient experiencing peritonitis can develop an abscess, which can lead to shock. The patient developing shock can present with oliguria, hypotension, fever, restlessness, confusion, and hypovolemia.

A healthcare provider has instructed a patient with a potassium level of 3.3 mEq/L to consume a high-potassium diet. What food choices should the nurse include in the teaching plan for the patient? (Select all that apply.) a. tomatoes b. apples c. bananas d. beans e. avocados

A. tomatoes, C. Bananas, E. Avocados Tomatoes, bananas, and avocado contain high levels of potassium, and are safe to eat in the case of hypokalemia. Apples are high in fiber. Beans are high in protein

An elderly patient with arthritis expresses surprise that bacteria cause ulcers. The nurse responds that: (Select all that apply.) a. "This is an unusual problem in the elderly." b. "Bacteria are a frequent factor in ulcer formation." c. "These infections can be treated with antibiotics." d. "Medications used to treat arthritis can also be a factor in developing ulcers." e. "The bacteria can be spread from person to person by oral contact."

B , C , D , E H. Pylori is a frequent cause of ulcers in all age groups, but especially in the elderly. It causes damage to the gastric mucosa. The first line of treatment is antibiotics and elimination of medications that might also be a factor, commonly aspirin or NSAIDs. The H. Pylori bacteria are spread by oral-oral or fecal-oral contact.

The nurse is obtaining a nutritional history on an older adult patient. Which statement by the patient would indicate an educational need? a. "When I get hungry at bedtime, I generally eat a banana." b. "I usually use the store brand canned vegetables when I shop." c. "I know that I need to limit foods like bologna, ham, and salami." d. "I will contact Meals on Wheels if I need help with food."

B, " I usually use the store brand canned vegetables when I shop" Rationale: Older patients should be advised to eat a well-balanced diet including fresh fruits and vegetables rather than canned products, which are usually high in sodium and lose nutritional benefits during the canning process. They should also be advised to avoid processed foods such as bologna, ham, and salami and to avoid foods high in fat.

The nurse would assess for signs of hypomagnesemia in which clients? Select all that apply. a. A client with renal failure. b. A client with pancreatitis. c. A client taking magnesium-containing antacids. d. A client with excessive nasogastric drainage. e. A client with chronic alcoholism.

B, D, E Rationale: Options 1 and 3 relate to hypermagnesemia.

The nurse teaches a patient care technician about the safety precautions associated with management of patients who have dehydration. Which precautions should be included in the teaching plan? (Select all that apply.) a. Requesting administration of chemical restraints to prevent or reduce the risk of self-inflicted injury b. Using of assistive devices to help coordinate movement and balance c. Swiftly raising the patient from supine to sitting to promote somatic movement. d. Allowing the patient to rest in the bed during the day rather in a recliner, to maintain safety. e. Moving the patient from one position to another in stages to ensure safety.

B, E The use of assistive devices fosters independence, and provides less restriction. Helping the patient to move from one position to another in stages ensures safety; it allows the patient time to adjust to position changes. Patients should never move swiftly. This action could quickly reduce the patient's blood pressure, causing a fall. The patient should rest in a recliner during the day. Sitting up in the recliner prevents orthostatic blood pressure changes. Chemical restraints are used as a last resort for patients who are severely confused, and who might inflict self-directed harm. Moreover, chemical restraints can make the patient drowsy, adding to gait and balance instability, which could cause falls.

Which rationales support the premise that Activity Intolerance is an appropriate nursing diagnosis for many individuals with obesity? (Select all that apply.) a. Most suffer from depression. b. They fatigue quickly. c. Blood glucose is elevated. d. Tachycardia is common. e. Shortness of breath is common.

B, they fatigue quickly D. Tachycardia is common e. Shortness of breath is common Rationale: Obese individuals can find activity difficult due to fatigue, tachycardia, or shortness of breath upon exertion. Gradual increases in activities that are acceptable to the patient are planned. Not all people who are obese are also depressed or have elevation of glucose.

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? a. Prepare to irrigate the colostomy. b. After assessing the stoma and surrounding skin, notify the surgeon. c. Assess bowel sounds and administer antiemetic. d. Administer a bulk-forming laxative, and encourage increased fluids and exercise

B. After assessing the stoma and surrounding skin, notify the surgeon. The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated.

If the hypothalamus is not functioning normally and releases too little antidiuretic hormone, the individual is suffering from what? A. Hypothermia B. Dehydration C. Edema D. Homeostasis

B. Dehydration Antidiuretic hormone signals the kidneys to retain water when blood sodium levels are too high or blood pressure is too low. The retained water is then recycled for use throughout the body. Hypothermia is feeling intensely cold. Edema occurs when too much water is retained in the interstitial compartments of the body. Homeostasis is physiologic equilibrium.

What subjective and/or objective assessment data would lead the nurse to believe the patient was experiencing malnutrition? a. Body weight of more than 90% of ideal b. Dull, dry, and brittle hair c. Dry skin and mucous membranes d. Calcified toenails

B. Dull, dry, and brittle hair Manifestations and complications of malnutrition include dull, dry, and brittle hair; wasted appearance; pale mucous membranes; and possibly peripheral or abdominal edema. Dry skin and hair and calcified toenails have other etiologies.

The patient with polyps has watched a video on primary prevention of colon cancer. The nurse can evaluate teaching effectiveness when the patient states, "I should: a. "follow a low-sodium, low-fat, high-fiber diet." b. "eat less saturated fat and red meat and more fruits and vegetables." c. "avoid foods containing gluten and fats" d. "consume less carbohydrates and avoid foods with tyramine."

B. Eat less saturated fat and red meat, and more fruits and vegetables" The dietary recommendations for the prevention of colorectal cancer include consuming a diet high in fruits and vegetables and low in saturated fat and red meat.

The nurse teaching a patient with gastroesophageal reflux disease (GERD) includes which instructions? a. This is a benign disease requiring no treatment. b. Elevate the head of the bed on 6-8-inch blocks. c. Stop taking the prescribed proton pump inhibitor once symptoms are relieved. d. Peppermint and chocolate candies can help relieve symptoms.

B. Elevate the head 6-8 inch blocks Elevating the head of the bed on 6-8-inch blocks is often beneficial in reducing acid reflux. GERD is a chronic illness that necessitates lifestyle changes to manage the long-term effects of the disorder. Proton pump inhibitors should be taken for a prolonged period to prevent and manage symptoms. Peppermint, chocolate, alcohol, and fatty foods relax the lower esophageal sphincter or delay gastric emptying, so they should be avoided.

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? a. "I need to drink one and a half to two quarts of liquids each day." b. "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." c. "If my bowel pattern changes on its own, I should call you." d. "Eating my meals at regular times is likely to result in regular bowel movements."

B. I need to take a laxative such as Milk of Magnesia if I don't have a BM every day The standard of practice in assisting older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults (option 2). In addition, a normal stool pattern for an older adult may not be daily elimination.

A patient who is taking ranitidine (Zantac) as ordered reports to the nurse that the pain is worse than ever. The nurse should: a. tell the patient to double the dose for the next 48 hours and report any changes after that time. b. inform the primary healthcare provider of the patient's symptoms. c. inform the patient that taking the medication after a meal increases its effectiveness. d. ask the patient how many tablets have been taken.

B. Inform the primary healthcare provider of the patient's symptoms. An increase in pain might indicate progression of the condition, or that the medication is not the treatment of choice. The nurse should inform the healthcare provider of the change in the patient's condition before giving instructions about changing the dosage. Ranitidine (Zantac) should be taken before meals, not after. The patient has already informed the nurse about taking the medication as ordered, so the nurse does not need to repeat the question.

A nurse is caring for a patient whose sodium level is 118 mEq/L. Which nursing diagnosis is a priority for this patient? a. Deficient, Fluid Volume b. Injury, Risk for c. Disturbed Sensory Perception d. Comfort, Impaired

B. Injury, Risk For This patient's sodium level is critically low. Because one of the primary functions of sodium is nerve impulse transmission, the patient might develop personality changes, lethargy, muscle twitching, tremors, and seizures. Also, hyponatremia results in movement of fluid into the cell, resulting in cellular edema. Safety takes priority over the other options. Hyponatremia could be a symptom of isotonic dehydration; however, deficient fluid volume is not a priority for this patient whose sodium level is 118 mEq/L. The patient might experience sensory impairment due muscle twitches and tremors, but this option does not take priority over safety. The patient's comfort will be altered, particularly if the patient's condition progresses to muscle twitches and seizures, but this option does not take priority over safety. While all of the nursing diagnoses could apply to this patient, the risk of injury related to impaired movement and seizures places the patient at greatest risk more rapidly and to a greater extent.

An elderly man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representative of a sodium imbalance? a. Hyperreflexia b. Mental confusion c. Irregular pulse d. Muscle weakness

B. Mental Confusion Sodium contributes to the function of neural tissue. Because calcium contributes to the function of voluntary muscle contraction, options 1 and 4 are more appropriate for calcium imbalances. Option 3: Because potassium and calcium contribute to cardiac function, irregular pulse is more likely to be associated with those alterations.

A patient with a history of peptic ulcer disease suddenly begins to complain of severe abdominal pain. The nurse should (Select all that apply.): a. administer the prescribed oral proton pump inhibitor. b. obtain an order for a narcotic analgesic. c. withhold oral food and fluids. d. place the patient in Fowler's position. e. notify the physician.

B. Obtain an order for a narcotic analgesic. C. Withhold oral food and fluids E. Notify the physician The patient with a history of peptic ulcer disease who suddenly complains of severe abdominal pain may be experiencing perforation of the ulcer through the mucosal wall. This is a lethal complication and may require surgery. The patient should be kept NPO, the physician notified and an order obtained for intravenous narcotic analgesics for pain management. Proton pump inhibitors are administered intravenously to decrease acid content. Placing the patient in Fowler's or semi-Fowler's position allows peritoneal contaminants to pool in the pelvis.

The client's arterial blood gas results are pH 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid-base imbalance? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

B. Respiratory Acidosis Because of CO2 retention the PaCO2 is elevated. CO2 is involved in production of acid, which will result in a decreased pH. HCO3 will vary. Option 1: Metabolic acidosis involves a loss of bicarbonate, but no retention of CO2. Option 3: Metabolic alkalosis involves a loss of acid or retention of HCO3, but no retention of CO2. Option 4: Respiratory alkalosis involves a loss of CO2 resulting in an increased pH.

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? a. Start an IV. b. Review the results of serum electrolytes. c. Offer the woman foods that are high in sodium and potassium content. d. Administer an antiemetic.

B. Review the results of serum electrolyte. Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in options 1, 3, and 4, assessment is needed initially.

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? a. The client will wear a medical alert bracelet for antibiotic allergy. b. The client will return to his or her previous fecal elimination pattern. c. The client verbalizes the need to take an antidiarrheal medication prn. d. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

B. The client will return to his or her previous fecal elimination pattern. Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug (option 1). Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock (option 3). Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not (option 4).

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding? a. Increased blood pressure b. Weak, rapid pulse c. Moist mucous membranes d. Jugular vein distention

B. Weak, rapid pulse All other options are indicative of fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit.

In the patient diagnosed with ulcerative colitis, the nurse should evaluate the patient for: a. signs and symptoms of infection. b. characteristics of stool. c. weight gain. d. respiratory complications.

B. characteristics of stool The patient with ulcerative colitis can experience 5-10 bloody stools containing mucus as well as anemia, hypovolemia, fecal urgency, tenesmus, and left lower quadrant cramping relieved by defecation.

The nurse administers an IV solution of D5 1/2NS to a postoperative client. This is classified as what type of intravenous solution? The nurse is administering which type of solution? a. Hypotonic b. Hypertonic c. Isotonic d. Normotonic

B. hypertonic D5 ½ NS is a hypertonic solution.

An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis? a. pH 7.54; PaCO2 28 mmHg; HCO3 22 mEq/L b. pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L c. pH 7.31; PaCO2 35 mmHg; HCO3 20 mEq/L d. pH 7.50; PaCO2 37 mmHg; HCO3 28 mEq/L

B. pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L Because of the retention of CO2, the clinical profile of respiratory acidosis includes decreased pH < 7.35, PaCO2 > 42 mmHg, with varying levels of HCO3 related to hypoventilation. Option 1 is respiratory alkalosis, which occurs because of blowing off of CO2 resulting in a decreased level of acid and retention or production of bicarbonate resulting in pH >7.45, PaCO2 < 38 mmHg, HCO3 > 26 mEq/L related to hyperventilation. Option 3: Metabolic acidosis occurs because of a gain of hydrogen ions or a loss of HCO3 with a pH < 7.35, normal PaCO2 of 35-45 mmHg, and HCO3 < 22 mEq/L, often caused by diarrhea, bicarbonate infusion, or retention related to kidney failure. Option 4: Metabolic alkalosis is caused by gain of bicarbonate or loss of hydrogen ions related to vomiting, gastric suction, or loss of upper gastrointestinal secretions by various other methods.

The nurse has instructed the patient who is experiencing diarrhea associated with irritable bowel syndrome on dietary changes to prevent diarrhea. The nurse knows the patient understands the dietary changes if the patient selects which menu choice? a. yogurt, crackers, and sweet tea b. salad with chicken and whole wheat crackers c. bacon, lettuce, and tomato with mayonnaise, and a soft drink d. tuna on white bread, and green grapes

B. salad with chicken and whole wheat crackers. : Bacon, lettuce, and tomato with mayonnaise is high in fat, and the soft drink is hyperosmolar, both contributing to diarrhea. Salad with whole wheat crackers might decrease diarrhea due to increased fiber. Dairy increases diarrhea. Foods high in carbohydrates increase diarrhea. Green grapes can increase diarrhea.

The nurse realizes the patient understands the teaching about dumping syndrome when the patient says: a. "I must drink liquids only with meals." b. "I must avoid most dairy products." c. "I should eat a low-carbohydrate diet." d. "I should sit up for half an hour after eating."

C. " I should eat a low-carbohydrate diet " Carbohydrates are restricted, but fats and proteins, including dairy products, are increased to slow gastric emptying. Lying down is also encouraged to slow gastric emptying. Liquids and solids are taken at separate times instead of together during a meal.

The arterial blood gases (ABGs) of a patient with type 1 diabetes mellitus include a pH of 7.24, a CO2 of 52.6 mmHg, and a HCO3 of 23.6 mEq/L. The nurse monitors for which signs or symptoms? a. warm, flushed skin and increased depth and rate of respirations b. decreased respiratory effort, and hypokalemia and hypocalcemia c. pale, dry skin and shallow and rapid respirations d. increased rate and depth of respirations, hypokalemia, and hypocalcemia

C. Dry pale skin with shallow rapid respirations The patient's pH indicates respiratory acidosis. The patient's elevated CO2 suggests acidosis of respiratory origin, yielding respiratory acidosis. In respiratory acidosis, patients exhibit pale-to-cyanotic skin and rapid, shallow respiration. When interpreting ABG results, the student should start with the pH. The safe pH range is 7.35-7.45. A pH lower than 7.35 indicates acidosis. A pH greater than 7.45 implies alkalosis.

The nurse is teaching a patient with peptic ulcer disease about dietary guidelines following hospital discharge. What guidance will the nurse give the patient about dietary intake? a. Consume at least three servings of dairy products daily. b. Eat no more than two eggs per day. c. Eat anything that is tolerated. d. Avoid spicy foods.

C. Eat anything that is tolerated There is no particular diet that patients with peptic ulcer disease should follow. Each patient needs to determine those foods that are tolerated well and cause no discomfort. Many patients do well eating several small meals per day. Patients should be advised that a healthy diet is one of variety, balance, and moderation.

The nurse has identified Nutrition: Less Than Body Requirements as a major nursing diagnosis for a patient who has undergone a partial gastrectomy. As part of a discharge plan, the nurse should include which instruction? a. Eat bland food, because it is not as difficult to digest as other foods. b. Increase the amount eaten at each meal by one tablespoon. c. Eat small, frequent meals. d. If vomiting occurs, do not eat any more that day.

C. Eat small ,frequent meals. The patient has decreased stomach capacity, so smaller, more frequent meals of regular foods are recommended. Large quantities of food are not well tolerated, so the patient should increase the quantity at a pace suitable to the patient's tolerance for food. Bland foods are not necessary, nor is abstinence from food on the day vomiting occurs.

Which statement indicates that an obese patient needs further teaching about the effective management of weight problems? a. "I need to find some physical activities I can do." b. "When I find myself feeling stressed, I will try walking for 10 minutes." c. "I will buy foods in the health food section of the grocery store." d. "I am going to try to limit intake of sweets to a small portion once each day."

C. I will buy foods in the health food section of the grocery store. Weight management is complex for obese individuals. Patients need to reduce caloric intake and increase physical activity along with learning those things that can trigger eating at times when they are not hungry. It is not necessary to purchase foods at a health food store; it is more important to make healthy choices.

Because an anxious patient experiencing metabolic acidosis has a history of renal insufficiency and is ingesting prednisone 4 mg daily for treatment of emphysema, the nurse performs which priority intervention? a. Administer sodium bicarbonate (NaHCO3) immediately. b. Assess for the degree of damage associated with the emphysema. c. Inform the patient that renal insufficiency is causing the metabolic acidosis. d. Suspend administration of the prednisolone (Prednisone).

C. Inform the patient that renal insufficiency is causing the metabolic acidosis The patient's metabolic acidosis is related to renal insufficiency. The patient's kidneys are unable to reabsorb HCO3 ions and excrete hydrogen ions. NaHCO3 is administered cautiously only if serum bicarbonate levels are low. In a case of metabolic acidosis, the cause is identified and treated. Once the cause is treated, the disorder resolves. Introducing NaHCO3 can result in metabolic alkalosis. Due to the retention of CO2, patients with emphysema experience respiratory acidosis. Prednisolone (Prednisone) can cause alkalosis in patients with hypokalemia.

A pregnant patient from a rural part of the state tells you at her first check-up (16 weeks' gestation) that the cornstarch she uses to make gravy looks delicious to her. She has eaten tablespoons of it mixed with small amounts of water several times. She asks you if this is normal. You explain she is actually deficient in which of the following? A. Selenium B. Magnesium C. Iron D. Phosphorous

C. Iron This patient is most likely deficient in iron. Pica, an unusual behavior characterized by craving nonfood substances such as ice, clay, dirt, and cornstarch, is seen most often among iron-deficient pregnant women of rural and lower socioeconomic status.

The oxygen saturation of a 72-year-old patient with dementia decreased from 94% to 89%. The patient is receiving D5LR at 75 mL/hour. After auscultating crackles, the nurse should perform which action? a. Inform the physician. b. Decrease the rate to 50 mL/hour. c. Perform a head-to-toe assessment. d. Obtain a set of vital signs.

C. Perform a head-to-toe assessment Due to the crackles in the right base, the patient's age, and continuous intravenous fluid, this patient is more likely to have fluid volume overload. The nurse should continue the assessment by inspecting the patient's body from head to toe to detect other aberrant findings, gathering vital signs, and reviewing the patient's medications, then call the physician to relay the change in the patient's status. The nurse does not have prescriptive authority to order medication changes; therefore, the nurse should not decrease the rate of intravenous fluid without a physician's order

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? a. Soapsuds b. Retention c. Return flow d. Oil retention

C. Return Flow This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief.

The nurse is planning care for a patient with a hernia. The most appropriate nursing diagnosis for this patient is: a. Imbalanced Nutrition, Less Than Body Requirements. b. Risk for Deficient Fluid Volume. c. Risk for Ineffective Gastrointestinal Tissue Perfusion. d. Infection related to strangulation.

C. Risk for ineffective gastrointestinal tissue perfusion The nurse should always assess the patient with a hernia for obstruction and strangulation. The most appropriate nursing diagnosis is Risk for Ineffective Gastrointestinal Tissue Perfusion related to gastrointestinal obstruction/strangulation.

Which finding is most likely to validate that a client is experiencing intestinal bleeding? a. Large quantities of fat mixed with pale yellow liquid stool b. Brown, formed stools c. Semisoft tar-colored stools d. Narrow, pencil-shaped stool

C. Semisoft tar- colored stools Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant, option 2 is normal stool, and option 4 is characteristic of an obstructive condition of the rectum.

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? a. The stoma extends 1/2 in. above the abdomen. b. The skin under the appliance looks red briefly after removing the appliance. c. The stoma color is a deep red-purple. d. An ascending colostomy delivers liquid feces.

C. The Stoma color is a deep red-purple. An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.

An elderly patient with cancer being treated with chemotherapy is at risk for the development of oral mucositis. The patient is also receiving total parenteral nutrition (TPN). The most appropriate nursing intervention for this patient is: a. Brush teeth with a soft toothbrush only once per day. b. Rinse patient's mouth with a gentle mouthwash four times per day. c. Assess and document condition of oral mucosa. d. Consult with dentist to determine optimal topical agent for treatment.

C. assess and document condition of oral mucosa It is important for the nurse to assess and document the condition of the mouth and mucous membranes each time oral care is performed. Oral care needs to be performed several times per day with a soft swab if a soft toothbrush is too irritating. Most mouthwashes contain alcohol and should be avoided for its painful effect.

Which nursing diagnosis is most appropriate for a patient with hyperkalemia? a. Impaired Tissue Perfusion, Risk for related to cardiac insufficiency b. Impaired Comfort, Risk for related to cardiac palpitations c. Decreased Cardiac Output, Risk for related to dysrhythmias d. Injury, Risk for related to muscle weakness

C. decreased cardiac output, risk for related to dysrhythmias The patient with a significantly elevated potassium level can develop fatal heart rhythms. Because one of the functions of potassium is maintaining the action potential of skeletal muscles, muscle weakness can occur, but this does not take priority over the life-sustaining function of the heart. The patient can experience an alteration in comfort due to cardiac palpitations, but this will resolve once hyperkalemia is addressed. Impaired tissue perfusion can occur because of the decreased cardiac output. Correcting the potassium imbalance will increase cardiac output and expand tissue perfusion.

A patient with atrial fibrillation and a serum potassium level of 3.0 mEq/L takes digoxin (Lanoxin) ASA (aspirin), KCL (potassium chloride) and warfarin (Coumadin) daily. The patient reports visual disturbances. The nurse suspects problems with which medication? a. aspirin b. potassium chloride c. digoxin d. warfarin

C. digoxin Rationale: Hypokalemia increases sensitivity of the heart to digoxin (Lanoxin), resulting in toxicity. The patient is complaining of visual disturbances, a characteristic of digoxin toxicity. This question is asking specifically for a medication side effect. Hypokalemia does not interfere with the absorption of warfarin (Coumadin), or impact its metabolism. There is no evidence that visual disturbances are associated with Warfarin, aspirin, or potassium toxicity.

The patient with inflammatory bowel disease had surgery to create a continent Koch ileostomy yesterday. The patient refuses to look at the stoma when the nurse is teaching stoma care. The best nursing intervention for the nurse to take is to: a. notify the physician that the patient is depressed. b. continue patient teaching to meet care goals. c. encourage the patient to verbalize feelings related to the stoma. d. offer the patient a mirror so he can examine the stoma later when he wishes to do so.

C. encourage the patient to verbalize feelings related to the stoma. Patients who have a stoma often experience alterations in body image. The nurse should encourage the patient to verbalize feelings related to disease process and stoma. The nurse can take action in this case.

In the patient who has had surgery for a small bowel obstruction, the nurse should assess for which most serious complication? a. pain b. fluid and electrolyte imbalance c. hypovolemic shock d. alteration in mobility

C. hypovolemic shock Hypovolemia and hypovolemic shock with multiple-organ dysfunction are significant complications of bowel obstruction, and can lead to death. Renal insufficiency from hypovolemia can lead to acute renal failure. Pulmonary ventilation can be impaired because abdominal distention elevates the diaphragm and interferes with respiratory processes. Fluid and electrolyte imbalances may occur, but are more easily treated than shock. Pain and alteration in mobility are common in all surgical procedures.

A patient with ulcerative colitis having 10 stools per day asks the nurse, "Why didn't the doctor order a diet?" The nurse instructs the patient that the purpose of an NPO order is to: a. reduce nausea and vomiting. b. prevent an ileus. c. promote bowel rest. d. decrease the need for medication to halt the inflammatory process.

C. promote bowl rest Maintaining NPO status will promote bowel rest. The patient with ulcerative colitis will not have nausea and vomiting, an ileus, or a decrease for medication to stop the inflammatory process.

The nurse established a diagnosis of Impaired Verbal Communication for a patient who had surgery for oral cancer and is now having difficulty speaking. Appropriate nursing interventions include: a. assuring the patient that clear speech will be possible after speech therapy. b. providing adequate pain control so the patient does not use pressured speech. c. remaining alert to nonverbal cues. d. consulting with family members about preoperative speech patterns.

C. remain alert to nonverbal cues Patients with difficulty speaking often get frustrated, so the nurse should be alert to nonverbal communication cues. The patient's speech should be assessed prior to surgery. Speech therapy might be indicated as part of the post-surgery treatment plan, but speech might never return to normal. Pain control is important, but will not have a significant impact on speech.

A patient has been diagnosed with colon cancer of the rectum. While completing the preoperative checklist, the patient asks the nurse, "Where will my stoma be?" The nurse's best response is: a. "The right upper quadrant." b. "The left upper quadrant." c. "The right lower quadrant." d. "The left lower quadrant."

D, the left lower quadrant A patient with cancer of the rectum will have an abdominoperineal resection. The anal canal will be closed and a stoma will be formed from the proximal sigmoid colon in the left lower quadrant of the abdomen.

Following a cerebrovascular accident (CVA), an elderly patient exhibits signs and symptoms of dysphagia. The nurse is most likely to meet the patient's nutritional needs by utilizing: a. NPO status until dysphagia resolves. b. total parenteral nutrition (TPN). c. regular diet with limited fluids. d. a small-bore nasoenteric feeding tube.

D. A small bore nasoenteric feeding tube Dysphagia (difficulty swallowing) can occur as a result of a CVA. The patient cannot remain NPO due to a need for nutrition, so a small-bore nasoenteric tube may be placed to meet nutritional needs until the dysphagia resolves or is determined to be a permanent condition. As long as the patient has a functioning GI system, there is no need for TPN. A regular diet will result in choking and possible aspiration.

An adolescent patient with anorexia nervosa has a BMI of 16.5. Which goal is appropriate for this patient? a. weight gain of at least 2 pounds a week b. a "contract" to eat at least 1000 calories per day c. verbalization of fears about obesity d. commitment to individual and family counseling

D. Commitment to individual and family counseling Successful intervention with a patient with anorexia nervosa requires long-term involvement of family and social support persons along with commitment to therapy to address issues that have contributed to the disorder. Weight gain of more than a pound a week is not a reasonable early goal, due to the large amount of food required. The diet needs to focus on quality of nutrients, not quantity, in the early recovery stage. Fears about obesity can be addressed in counseling.

A patient with Alzheimer disease has arterial blood gases that include pH 7.42, CO2 49 mmHg, and HCO3 38 mEq/L. How should the nurse interpret the arterial blood gas results? a. compensated respiratory acidosis b. uncompensated respiratory acidosis c. compensated metabolic acidosis d. compensated metabolic alkalosis

D. Compensated metabolic alkalosis Metabolic alkalosis is considered compensated when the pH returns to normal, but the HCO3 and CO2 remains slightly elevated. Normal arterial HCO3 is 22-26, and the normal arterial CO2 (PaCO2) is 35-45. The pH is normal; however, the HCO3 is elevated, and the CO2 is slightly elevated, indicating compensated metabolic alkalosis. The CO2 is elevated in an effort to compensate for the metabolic alkalosis. The student should understand that the CO2 will only be elevated when compensating for a metabolic disturbance, and when the disorder is of a respiratory origin. The HCO3 will be elevated to compensate for a respiratory disorder, and when the disorder is of a metabolic origin.

Twenty-four hours after initiating a tube feeding, a patient receiving a full-strength formula experiences diarrhea. What nursing action will resolve this problem? a. Elevate the head of the bed 30 degrees. b. Request a formula in which the sodium-potassium ratio is balanced. c. Administer the minimum dosage of a laxative to increase peristalsis. d. Decrease the rate of the flow of the feeding.

D. Decrease the flow rate of the feeding. When enteral feedings are initiated, the formula is often diluted, and it is run slowly to determine how the patient tolerates the feeding. The head of the bed should be elevated 30 degrees to prevent aspiration. An excess of electrolytes would cause edema. Peristalsis accelerates with the formula, and can be slowed by using a formula with added fiber.

A patient receiving 2 mg of bumetanide (Bumex) intravenously to treat congestive heart failure-induced fluid imbalance has a serum potassium of 3.1 mEq/L. The nurse should suspend the administration of which medication? a. oral potassium b. oral calcium c. spironolactone (Aldactone) d. digoxin (Lanoxin)

D. Digoxin Because Digoxin increases contractility, it can be used in the treatment of congestive heart failure. In the presence of hypokalemia, digoxin (Lanoxin) toxicity is likely to occur. The potassium level is 3.1 mEq/L; thus, oral potassium is not contraindicated. Furthermore, this patient does not exhibit a need for calcium. Bumetanide (Bumex), a loop diuretic, may be used in combination with a potassium-sparing diuretic, spironolactone (Aldactone).

An elderly home care patient known to the nurse calls the nurse to report 24 hours of nausea and two episodes of vomiting during that time. What nursing action is indicated? a. Have the patient take a few sips of water and go to bed in a darkened room to prevent nausea. b. Have the patient drink a small glass of a sports drink to replace lost electrolytes. c. Have the patient drink a high-protein supplement as soon as the nausea stops. d. Have the patient describe which foods, fluids, and medications were consumed in the 24 hours prior to the onset of symptoms.

D. Have the patient describe which foods, fluids and medications were consumed in the 24 hours prior to the onset of symptoms. When the patient reports symptoms, it is the responsibility of the nurse to gather assessment data before providing interventions. In this case, the nurse needs to determine whether any foods or fluids might have caused the problem, or whether there are other possibilities for the patient's symptoms. Treatment may include sips of water to prevent dehydration, but keeping the head elevated at least slightly is preferable to lying down. Consuming a sports drink is not appropriate until there is a determination of the cause of the nausea and vomiting. High-protein supplements are not part of the treatment plan for nausea or vomiting.

Which client statement indicates a need for further teaching regarding treatment for hypokalemia? a. "I will use avocado in my salads." b. "I will be sure to check my heart rate before I take my digoxin." c. "I will take my potassium in the morning after eating breakfast." d. "I will stop using my salt substitute."

D. I will stop using my salt substitute. Salt substitutes contain potassium. The client can still use it within reason. Option 1: Avocado is higher in potassium than most foods. Option 2: Hypokalemia can potentiate digoxin toxicity and checking the pulse will help the client avoid this. Option 3: It is important to take potassium with food to avoid gastric upset.

The nurse caring for a patient with esophageal cancer affecting the middle portion of the esophagus would immediately report which finding? a. cough b. anorexia c. weight loss d. increased difficulty swallowing solid foods

D. Increased difficulty swallowing solid foods. Increased difficulty swallowing may indicate advancement of the tumor. Cough, anorexia, and weight loss are commonly noted in the patient with esophageal cancer but would not need to be reported immediately.

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? a. Oil retention b. Return flow c. High, large volume d. Low, small volume

D. Low, small volume Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3).

The nurse is planning care for an elderly patient experiencing diarrhea related to Clostridium difficile. In planning care for this patient, the nurse would develop a priority nursing goal to: a. Control diarrhea by adding fiber to the diet. b. Use standard precautions. c. Position the patient to promote comfort. d. Maintain fluid and electrolyte balance.

D. Maintain fluid and electrolyte balance The goal would be for the patient to maintain adequate fluid volume as evidenced by adequate fluid and electrolyte balance. Pain management is not a priority problem. Finding a position of comfort is important but is not of the highest priority. Adding fiber will not control this diarrhea.

A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority? a. Renal b. Cardiac c. Gastrointestinal d. Neuromuscular

D. Neuromuscular The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems.

A patient who ingests calcium 600 mg daily with vitamin D for an electrolyte imbalance is experiencing chronic constipation. What should the nurse include when instructing the patient about the side effects of calcium? a. "Avoid exposure to sun while taking calcium." b. "Increase your intake of foods high in vitamin C." c. "Decrease the amount of fluids you are drinking." d. "Oral administration of calcium can cause constipation."

D. Oral administration of calcium can cause constipation. Oral administration of calcium can cause constipation. There is no reason to suggest that the patient avoid sunlight. Increasing fluids can help constipation. Increasing intake of foods high in vitamin C will not cure constipation.

The nurse is caring for a patient who is receiving parenteral nutrition. Which outcome criterion would be realistic for this patient? a. The patient consumes six small meals per day. b. Serum albumin levels remain below 3 mg/dL. c. Blood glucose levels remain elevated. d. Catheter site will be free of signs and symptoms of infection.

D. catheter site will be free of signs and symptoms of infection. Patients receiving parenteral nutrition are receiving nutrition intravenously. Although some patients might continue to eat, expecting that they would eat six small meals per day is not realistic. A serum albumin level below 3 mg/dL indicates severe malnutrition and is not a goal for this patient. Hyperglycemia can be a problem for the patient on TPN, and should be carefully monitored. Disruption of the skin barrier and administration of a solution high in glucose present a risk for infection in patients receiving TPN.

The nurse teaches a group of patients who are obese that which criteria is required before gastric reduction surgery is performed? a. agrees to follow a strict diet after surgery b. has a good support system c. can show a strong family history of obesity d. has a BMI over 40 kg/m2

D. has a BMI over 40kg/m2 Surgical treatment of obesity is usually reserved for those with a BMI over 40 kg/m2 (200% of body weight). The surgery carries substantial risk, and following surgery, the patient will need to undergo dietary modification and make lifestyle changes for the surgery to be successful. A thorough psychological evaluation is performed prior to surgery. A family history of obesity might be present, but is not a requirement for surgery.

Because a middle-aged, female patient's waist/hip ratio is 1.1, the nurse is most likely to teach which preventative measure? a. Report signs and symptoms of Cushing disease. b. Monitor blood pressure, lipid intake, and weight. c. Characteristic has no implications if it is genetic or familial. d. Monitor high levels of high-density lipoprotein (HDL).

D. monitor blood pressure, lipid intake and weight. Females with a waist/hip ratio greater than 0.8 are at greater risk for cardiovascular disease. Therefore, the nurse teaches the patient to ingest a balanced diet, exercise regularly, and monitor the blood pressure and serum lipid levels. Excess storage around the waist is part of the profile of Cushing disease, but is not as significant or as common as the development of cardiovascular disease. Cardiovascular disease has a familial characteristic. The high-density lipoproteins should be monitored as part of a routine assessment of cardiovascular status.

A sprinter on a track-and-field team loses body water through insensible perspiration after a 400-meter race. Through which organ(s) does the majority of this water loss, or output, occur? A. Kidney Incorrect B. Skin C. Large intestine D. Lungs E. a, c, and d F. b and d

F. B and D Insensible water loss occurs through the lungs as breaths are expelled and through the skin. After a sprint race, an athlete would be breathing heavily and sweating. Sweating helps the body rid itself of excess heat. Athletes, in general, need more than the adequate intake of water since they lose more water through insensible perspiration and sweat.

A tear in the mucosa near the esophagogastric junction

Mallory Weiss tear

What is the function of the small intestines?

Primarily absorption of nutrients

What is the function of the large intestines?

Reabsorption of water

Bile and pancreatic enzyes are added where?

Smell intestines

Digestion Begins where?

The mouth due to mechanical breakdown and enzymatic breakdown.

The nurse teaches a patient who is obesethat a daily multivitamin with minerals is prescribed for reason? a. Patient is malnourished. b. Patient is consuming excess carbohydrates. c. Vitamins are utilized to promote weight loss. d. The vitamins and minerals will improve the status of the immune system.

a. the patient is malnourished The obese patient can be medically malnourished due to excess consumption of calories yet still lack consumption of foods that contain the necessary vitamins and minerals. Vitamins do not promote or enhance weight loss, and are not useful in treating non-specified medical conditions