Module 8: Circulation and Perfusion and Nutrition

A client is admitted to the emergency department with complaints of severe, radiating chest pain, and a myocardial infarction is suspected. The nurse immediately applies oxygen to the client and plans to take which action next? 1. Obtain a 12-lead electrocardiogram (ECG). 2.Call radiology to prescribe a chest radiograph. 3.Call the laboratory to prescribe stat blood work. 4.Notify the coronary care unit to inform them that the client will need admission.

1. Obtain a 12-lead electrocardiogram (ECG).

The nurse has determined that an unconscious client is at risk for nutritional problems. Which outcome indicates to the nurse that the goals have not yet been fully met? 1.Stable weight 2.Intake equaling output 3.Total protein concentration of 4.5 g/dL (45 g/L) 4.Blood urea nitrogen (BUN) level of 20 mg/dL (7.1 mmol/L)

3.Total protein concentration of 4.5 g/dL (45 g/L)

The nurse notes that a new postoperative client is experiencing tachycardia and tachypnea. The nurse takes the client's blood pressure and notes that it is 88/60 mm Hg. The nurse should take which immediate action? 1.Check the hourly urine output. 2.Turn the client onto the right side. 3.Check the intravenous (IV) site for infiltration. 4.Elevate the client's feet, keeping the head slightly elevated.

4.Elevate the client's feet, keeping the head slightly elevated.

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provider prescribes an enteral tube feeding of a standard formula to run at 40 mL/hour. A nursing student is assigned to care for the client, and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which statement, if made by the student, indicates an understanding of this dietary treatment? 1."Enteral tube feedings frequently cause sepsis." 2."Enteral feedings should be refrigerated until just before use." 3."The caloric value of enteral feedings is generally 5 to 10 calories per milliliter." 4."Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

"Enteral feedings require the normal digestive capabilities of the gastrointestinal tract."

A nasogastric (NG) tube is used for which purposes? Select all that apply. 1. To decrease the risk of aspiration 2. To provide nutrition by acting as a permanent feeding tube 3. To administer medications to clients who are unable to swallow 4. To prevent surgical anastomoses from healing without distention 5. To irrigate the stomach and remove toxic substances, such as in poisoning 6. To decompress the stomach by removing fluids or gas to decrease abdominal discomfort

1. To decrease the risk of aspiration 3. To administer medications to clients who are unable to swallow 5. To irrigate the stomach and remove toxic substances, such as in poisoning 6. To decompress the stomach by removing fluids or gas to decrease abdominal discomfort

The nurse checks the gastric residual of a client receiving continuous nasogastric tube feedings at 50 mL per hour through a feeding pump and notes that the residual is 175 mL. Which action should the nurse take? 1. Turn the feeding pump off. 2. Give the client sips of oral fluids. 3. Increase the rate of the tube feeding. 4. Administer a laxative in liquid form through the nasogastric tube.

1. Turn the feeding pump off.

A postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. Which assessment is most important for the nurse to make before advancing the diet to solids? 1.Ability to chew 2.Food preferences 3.Cultural preferences 4.Presence of bowel sounds

1.Ability to chew

The nurse is performing a cardiovascular assessment on a client with heart failure. Which item should the nurse check to gain the best information about the client's left-sided heart function? 1.Breath sounds 2.Peripheral edema 3.Hepatojugular reflux 4.Jugular vein distention

1.Breath sounds

A nursing student is caring for a client who has been admitted to the hospital with malnutrition. The nursing instructor determines that the student has made a correct assessment of malnutrition consequences if the student documents which noted findings? Select all that apply. 1.Cachexic 2.Lethargic 3.Lean extremities 4.Intolerant to heat 5.Dry, flaking skin 6.Poor wound healing

1.Cachexic 2.Lethargic 5.Dry, flaking skin 6.Poor wound healing

Which actions should the nurse include when caring for a client with continuous tube feedings through a nasogastric (NG) tube? Select all that apply. 1.Check the residual every 4 hours. 2.Check for placement every 4 hours. 3.Hang a new feeding bag every 72 hours. 4.Check skin integrity at the site of NG tube insertion. 5.Check for placement before administering medications.

1.Check the residual every 4 hours. 2.Check for placement every 4 hours. 4.Check skin integrity at the site of NG tube insertion. 5.Check for placement before administering medications.

The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? 1.Iron deficiency 2.Protein deficiency 3.Fatty acid deficiency 4.Vitamin K deficiency

1.Iron deficiency

The nurse is giving a presentation on good nutrition to a group of teenage mothers. Which level of prevention is the nurse implementing? 1.Basic level 2.Primary level 3.Secondary level 4.Tertiary level

2.Primary level

The nurse is explaining the process of bariatric surgery to a severely obese client who has attended a medically supervised weight loss program for approximately 6 months. The client is considering this procedure. What are some conditions that may interfere with a client's commitment to lifelong behavioral changes and that may lead to poor surgical outcomes? Select all that apply. 1.Anxiety 2.Untreated depression 3.Binge eating disorders 4.Drug and alcohol abuse 5.Lack of family resources 6.Inability to comply with nutritional recommendations

2.Untreated depression 3.Binge eating disorders 4.Drug and alcohol abuse 6.Inability to comply with nutritional recommendations

The nurse is providing care to a client who is receiving enteral feedings through a nasogastric tube. The nurse has followed the procedure to the point of aspirating the contents of the stomach. When checking for residual feeding, the nurse aspirates 75 mL of stomach contents. Which is the best nursing action related to this finding? 1. Assess bowel sounds. 2. Delay the feeding 1 hour. 3. Administer the prescribed feeding. 4. Notify the primary health care provider.

3. Administer the prescribed feeding.

The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority? 1.Diarrhea 2.Nutrition 3.Aspiration 4.Deficient fluid volume

3.Aspiration

The nurse hears the alarm sound on the telemetry monitor, quickly looks at the monitor, and notes that a client is in ventricular tachycardia. The nurse rushes to the client's room, and on reaching the client's bedside, the nurse should perform which action first? 1.Open the airway. 2.Begin chest compressions. 3.Determine unresponsiveness. 4.Deliver 2 effective breaths.

3.Determine unresponsiveness.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1.Oranges 2.Broccoli 3.Margarine 4.Cream cheese 5.Luncheon meats 6.Broiled haddock

3.Margarine 4.Cream cheese 5.Luncheon meats

The nurse is performing a nutritional assessment on a newly admitted client with a diagnosis of recent weight loss and malnutrition. Which finding is consistent with a diagnosis of malnutrition? 1.Moist skin 2.Muscle growth 3.Increase in subcutaneous fat 4.Decreased pigmentation of the hair

4.Decreased pigmentation of the hair

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1."I should increase my sodium intake during pregnancy." 2."I should lower my blood volume by limiting my fluids." 3."I should maintain a low-calorie diet to prevent any weight gain." 4."I should drink adequate fluids and increase my intake of high-fiber foods."

4."I should drink adequate fluids and increase my intake of high-fiber foods."

A client is diagnosed with a moderate case of acute ulcerative colitis. The nurse doing dietary teaching should give the client examples of foods to eat that represent which therapeutic diet? 1.High fat with milk 2.Low fiber with milk 3.High protein with milk 4.Low fiber without milk

4.Low fiber without milk