Semester 1 Unit 4 Exam

The process of maintaining optimal blood glucose levels A. nutrition B. glucose regulation C. elimination D. acid-base balance

B. glucose regulation

Sensation of thirst occurs when the body senes that extracellular fluid is A. at hemostasis B. hypertonic C. hypotonic D. hyperglycemic

B. hypertonic (detected by the hypothalamus)

True or False: MNA (Mini Nutritional Assessment) and NSI (nutrition screening initiative) were developed primarily for the use of pregnant clients

FALSE These screening tools were developed primarily for use with elderly clients

main electrolytes inside the cells A. sodium B. calcium C. potassium D. chloride

C. potassium

What is defined as "the excretion of waste products"?

Elimination

The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet

b. Low sodium diet

The typical fluid replacement for the patient with a fluid volume deficit is: (a) Lactated ringers (b) 0.45% saline (c) dextran (d) 5% dextrose in 0.45% saline

(a) Lactated ringer

Visual impairment can be a result of what? (2)

-Impaired glucose regulation -Impaired nutrition

Renal function is most efficient when the woman lies in the____________ and least efficient in ________________

-lateral recumbent position(AKA sims position -supine position

Match the following: 1. BG < 70mg/dL 2. BG < 50mg/dL 3. BG 70-140 mg/dL (pre and post prandial) 4. BG post prandial >140 mg/dL 5. BG post prandial > 180 mg/dL A. Hypoglycemia B. Hyperglycemia C. Euglycemia D. Severe hypoglycemia E. Severe hyperglycemia

1--> A 2--> D 3--> C 4--> B 5--> E

Match the following 1. 60% of total body weight 2. 80% of total body weight 3. 40% of total body weight A. Elderly B. Adult C. Infant

1. B 2. C 3. A

Match the following 1. Na+ < 135 mEq/L Osm < 280 mosmol/kg 2. Na+ > 145 mEq/L Osm > 300 mosmol/kg 3. Na+ = 135-145 mEq/L Osm = 280-300 mosmol/kg..... A. Optimal Osmolality B. Too concentrated C. Too dilute

1. C 2. B 3. A

What is normal post-prandial blood glucose?

100-140 mg/dL

Meconium is greenish black and viscous and contains occult blood. Most healthy term infants pass meconium within the first _______ of life A. hour B. 6-12 hours C. 12-24 hours D. 46-48 hours

12 to 24

What is normal fluid intake from just fluids (not food) per day in mL?

1200 mL

What is the normal range for BMI?

19-24

What is considered normal bicarb?

22-26

What is normal HCO 3-?

22-26

Normal HCO3 (bicarbonate)

22-26 mEq/L

During an 8-hour shift a client drinks two 6-oz (180-mL) cups of tea and vomits 125 mL of fluid. Intravenous fluids absorbed equaled the urinary output. What is the client's fluid balance during this 8-hour period? Record your answer using a whole number. ______ mL

235 mL

What is considered overweight range for BMI?

25-29.9

Overweight BMI? Obesity class 1 BMI? Obesity class 2 BMI? Obesity class 3 BMI?

25-29.9 30-34.9 35-39.9 BMI> 40

What is normal fluid and food intake and output per day in mL?

2500 mL

Normal Osm levels

280-300mosmol/kg

What BMI is considered obesity class I?

30-34.9

What BMI is considered obesity class II?

35-39.9

What is considered normal PaCO2?

35-45

What is normal CO 2?

35-45

Normal PaCO2 (Partial Pressure of Carbon Dioxide in Arterial Blood) range ?

35-45 mm Hg

What is considered normal range for pH?

7.35-7.45

What is normal fasting blood glucose?

70-99 mg/dL

What is average daily urine output?

800-1000 mL per day

In children BMI greater than what is considered obese?

95th percentile 85-95 is classified as overweight

What is considered underweight for BMI?

< 18.5

What is hyperglycemic fasting blood glucose?

<100 mg/dL

What is considered acidic pH?

<7.35

What is hypoglycemic fasting blood glucose?

<70 mg/dL

What BMI is considered obesity class III?

>40

What is considered alkalotic pH?

>7.45

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. 65-year-old with pulmonary fibrosis B. 24-year-old with uncontrolled type 1 diabetes C. 45-year-old who has been vomiting for 3 days D. 54-year-old who takes sodium bicarbonate for indigestion

A 65-year-old with pulmonary fibrosis The low pH and elevated Pco 2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.

Which diagnosis indicates that the nurse should assess the patient most carefully for development of metabolic acidosis? Type B chronic obstructive pulmonary disease (COPD) and pneumonia Acute meningococcal meningitis A pancreatic fistula that is draining Severe hyperaldosteronism

A pancreatic fistula that is draining The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from bicarbonate loss. Type B COPD and pneumonia cause respiratory acidosis by impairing carbonic acid excretion. Meningitis can stimulate hyperventilation, which causes respiratory alkalosis. Aldosterone facilitates renal excretion of hydrogen ions; hyperaldosteronism would cause metabolic alkalosis.

After assessing a client's condition, the nurse suspects that the client has diabetes mellitus. Which statement made by the client would be most appropriate in helping the nurse reach this conclusion? Select all that apply. A. "I am 55 years old." B. "I quite often feel thirsty." C. "I eat food every 2 hours." D. "I have excessive sweating." E. "I sometimes experience shortness of breath."

A. "I am 55 years old." B. "I quite often feel thirsty." C. "I eat food every 2 hours." Diabetes mellitus is more common in older clients. Clients with diabetes mellitus may feel excessive thirst due to frequent urination and may also experience excessive hunger. Excessive sweating and respiratory disorders are mostly observed in clients with hyperthyroidism.

The daughter of a​ wheelchair-bound older client is concerned because her mother has been experiencing urinary incontinence. Which statement should the nurse use to explain the condition to the ​daughter? A. "Mobility issues may cause urinary incontinence. B. "Renal blood flow and ability to concentrate urine decrease in the elderly. C. "The kidneys reach maximum size at ages 35 to 40. D. "The frequency of voiding varies in the elderly and may cause urinary incontinence."

A. "Mobility issues may cause urinary incontinence." Both mobility and neurological issues may cause urinary incontinence. The other explanations do not address the daughter​'s concern regarding her mother​'s urinary incontinence.

When should solids foods be introduced ? A. 6 months B. 12 months C. 18 months D. 24 months

A. 6 months

The nurse thinks the patient has hypoxemia what could help the nurse confirm this A. ABG levels B. Pulse oximetry reading

A. ABG levels

ADH causes A. water resorption B. potassium and sodium to be excreted C. potassium and sodium to be absorbed D. sodium retention

A. ADH causes water retention, resulting in decreased urine output.

Which patient adaptation would cause the most concern? A. Anuria B. Dysuria C. Diuresis D Enuresis

A. Anuria

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? (Select all that apply.) A. Body mass index (BMI) of 17 B. Waist-to-hip ratio of 1.0 C. Weight loss of 6% since last month's visit D. Prealbumin level of 16 mg/dL E. Hematocrit level of 50% F. Hemoglobin level of 8.2 g/dL

A. Body mass index (BMI) of 17 C. Weight loss of 6% since last month's visit F. Hemoglobin level of 8.2 g/dL A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.

An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? A. Breathe into cupped hands. B. Pant using rapid, shallow breaths. C. Use a rapid deep-breathing pattern. D. Hold the breath for as long as possible.

A. Breathe into cupped hands. Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.

*A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the infant's first stool. What should the nurse do next? A. Document the stool in the infant's record. B. Send the stool to the laboratory per protocol. C. Assess the infant for an intestinal obstruction. D. Notify the health care provider that a tarry stool has been passed.

A. Document the stool in the infant's record. The neonate's first stool, which is thick and greenish-black, is called meconium; the appearance of meconium is an expected occurrence that should be documented. This stool is expected; there is no reason to suspect intestinal obstruction. Meconium stool on the first day of life is expected and does not require further examination. Meconium is not indicative of bleeding; it contains bile and other waste products produced by the fetus. Passage of meconium does not require notification of the health care provider.

The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse identifies some appropriate recommendations for the patient. (Select all that apply): A. Drink 6 to 8 glasses of noncaffeinated fluids daily. B. Exercise daily. C. Increase fiber in the diet. D. Void when the urge is felt. E. Eat fruit twice daily.

A. Drink 6 to 8 glasses of noncaffeinated fluids daily. D. Void when the urge is felt. Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do nothing to prevent a urinary tract infection.

When ECF levels of H+ are increased what is the likely outcome ? A. hyperkalemia B. hypokalemia. C. hypernatremia D. hyponatremia

A. hyperkalemia When ECF levels of H+ are increased, H+ enters the cell in exchange for potassium. This may result in hyperkalemia. Conversely, with decreased H+ levels, H+ enters plasma in exchange for potassium. This is why alkalosis can cause hypokalemia.

A client with a history of heart failure and atrial fibrillation reports a nine-pound (four kilogram) weight gain in the last two weeks. Which factor does the nurse consider as the most likely cause of this sudden weight gain? A. Fluid retention B. Urinary retention C. Renal insufficiency D. Abdominal distention

A. Fluid retention With the client's history and the large weight gain, fluid retention is the most likely cause of the increase in weight. Urinary retention occurs in the bladder, not the tissues, and does not account for the large weight gain. Renal insufficiency can occur with heart failure, but it is not the primary etiological factor of the sudden weight gain. Abdominal distention usually is caused by gas in the intestine and should not contribute to this large a weight gain. If the abdomen is enlarged, assessment by ballottement should be done to determine whether enlargement is caused by fluid in the peritoneal cavity (ascites).

It is most important for the nurse to include which risk factors in a teaching plan associated with the development of type 2 diabetes mellitus? (Select all that apply.) A. Hypertension B. History of pancreatic trauma C. Weight gain of 30 pounds during pregnancy D. Body mass index greater than 25 kg/m E. Triglyceride levels between 150 and 200 mg/dL F. Delivery of a 4.99-kg baby

A. Hypertension D. Body mass index greater than 25 kg/m F. Delivery of a 4.99-kg baby Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL.

**A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention the nurse should expect the primary healthcare provider to prescribe for this client? A. Intravenous (IV) fluids B. Potassium C. NPH insulin (Novolin N) D.Sodium polystyrene sulfonate (Kayexalate)

A. Intravenous (IV) fluids IV fluids are given to combat dehydration in ketoacidosis and to keep an IV line open for administration of medications. After electrolyte levels are evaluated, potassium may be added along with insulin. In acidosis, potassium ions initially shift from the intracellular to extracellular compartment, resulting in hyperkalemia; as acidosis is corrected, hypokalemia may occur, and then potassium may be administered. NPH insulin is an intermediate-acting insulin; rapid-acting insulin is indicated in an emergency. Sodium polystyrene sulfonate is not indicated; abnormally high serum potassium levels will revert once dehydration is corrected.

Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time? A. Ketone bodies in the urine B. Blood glucose level of 155 mg/dL C. Pulse rate of 66 beats per minute D. Weight gain of 1 pound over the previous week's weight

A. Ketone bodies in the urine Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake. Assessing for ketones in the urine may indicate insulin deficiency.

The nurse recognizes that additional teaching about fluid intake and urinary incontinence is necessary when the patient said, "If I drink: A. Less, I will reduce the risk of loss of bladder control." B. More, it will help prevent irritation of my bladder." C. Less, it can contribute to a urinary tract infection." D. More, I am less likely to become dehydrated."

A. Less, I will reduce the risk of loss of bladder control."

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

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

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.

Primary prevention for nutrition (select all that apply) A. My plate B. Physical exercise for 30 minutes most days of the week C. genetic screening D. BMI E. Lipid F. Blood sugar

A. My plate B. Physical exercise for 30 minutes most days of the week

What is glucose regulation achieved through? (select all that apply) A. Nutrient intake B. Buffer system C. Hormonal signaling D. Glucose uptake by the cell

A. Nutrient intake C. Hormonal signaling D. Glucose uptake by the cell

What would be the best nursing action to facilitate bladder continence for the patient who is cognitively impaired? A. Offer toileting reminders every 2 hours B. Provide clothing that is easy to manipulate C. Encourage avoidance of fluid between meals D. Explain the need to call for the nurse for help with toileting

A. Offer toileting reminders every 2 hours

a concentration of dissolved particles in solution mainly determined by sodium, glucose, and urea A. Osmolality B. Osmosis C. Diffusion D.Active transport

A. Osmolality

Thirst is triggered by ...Select all that apply A. Osmolality of fluids B. Fluid volume C. Hormones D. Skin turgor E. Dietary habits

A. Osmolality of fluids B. Fluid volume C. Hormones E. Dietary habits

Appropriate approaches used by the long-term care nurse to provide education for a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply.) A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. C. Avoid discussion of the patient's favorite foods. D. Remind the patient that a lot of damage has already occurred. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes.

A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes. Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

Patient with DM comes in due to poor controlled blood sugars. What is most important to asses during physical exam (select all that apply) A. Skin B. Mucosal membranes C. Cognition D. Visual acuity

A. Skin D. Visual acuity

Number one cause of bladder and prostate cancer A. Smoking B. Ignoring urinary urge C. Genetics D. aging process

A. Smoking (powerpoints)

The nurse provides a list of appropriate food choices to a client with newly diagnosed diabetes. The client reviews the list and says, "I do not like and refuse to eat asparagus, broccoli, and mushrooms." In response, the nurse teaches the client about the food exchange list. The nurse evaluates that teaching was effective when the client states, "Instead of asparagus, broccoli, and mushrooms, I will eat which foods?" A. String beans, beets, or carrots." B. Corn, lima beans, or dried peas." C. Baked beans, potatoes, or parsnips." D Corn muffins, corn chips, or pretzels.

A. String beans, beets, or carrots." String beans, beets, and carrots are in the vegetable exchange, as are asparagus, broccoli, and mushrooms. Corn, lima beans, dried peas, baked beans, potatoes, or parsnips are starchy vegetables and are listed as bread exchanges. Corn muffins, corn chips, or pretzels are from the bread exchange list.

A client with renal failure is prescribed hemodialysis by the health care provider. Which independent nursing intervention is the priority for this​ client? A. Maintaining aseptic technique B. Assessing medication reactions C. Assessing urinalysis findings D. Percussing the kidneys for tenderness or pain.

A. The nurse caring for a client who is prescribed hemodialysis must maintain aseptic technique. Hemodialysis increases the client​'s risk of infection. While the other choices are independent nursing​ actions, they are not the priority for this client

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? A. Vitamin B12 B. Vitamin C C. Vitamin D D. Omega-3 fatty acids

A. Vitamin B12 Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

Maintaining physiological balance of body fluid and electrolytes is a dynamic interplay between (Select all that apply) A. intake and absorption B. distribution C. output D. vitamins

A. absorption B. distribution C. output

Label the following pH as Acidotic, optimal, or Alkalotic A. 7.3 B. 7.35 C. 7. 4 D. 7. 45 E. 7.46

A. acidotic B. normal C. normal D. normal E. alkalotic Acidotic: < 7.35 Optimal: 7.35-7.45 Alkalotic: > 7.45

The nurse and provider suspect the patient is malnourished. Which diagnostics test should the nurse anticipate will be ordered A. albumin B. Hemoglobin Ā1c C. specific gravity D. blood glucose

A. albumin D. blood glucose

When teaching a patient on toilet training you can educate the parent on signs of readiness such as (select all that apply) A. child is waking up from a nap or overnight dry B. child wets the bed and is ashamed to tell you C. child is aware of urge to void D. child tells you when he/she needs to go E. child is dry for at least 2 hours during the day

A. child is waking up from a nap or overnight dry C. child is aware of urge to void D. child tells you when he/she needs to go E. child is dry for at least 2 hours during the day Four markers signal a child's readiness to toilet train: (1) waking up dry from a nap or overnight sleep (2) being aware of the urge to void or stool (3) communicating the need to go, (4) being dry for at least 2 hours during the day

Pregnant women are most likely at risk for (select all that apply) A. cystitis B. UTI C. retention D. frequency

A. cystitis C. retention D. frequency (in class discussion)

What needs to be within normal range for optimal fluid and electrolyte balance (select all that apply) A. fluid volume B. osmolality C. electrolytes D. vitamin b

A. fluid volume B. osmolality C. electrolytes Optimal balance occurs when both of the following characteristics are present: • Intake and absorption of fluid and electrolytes match the output of fluid and electrolytes. • Volume, osmolality, and electrolyte concentrations of fluid in the various body fluid compartments are within their normal ranges.

Secondary Prevention for blood glucose regulation (select all that apply) A. hemoglobin Ā1C B. Cholesterol C. Exercise D. Blood pressure E. microalbuminuria F. Dental, foot and eye examaintion

A. hemoglobin Ā1C B. Cholesterol D. Blood pressure E. microalbuminuria F. Dental, foot and eye examaintion

hypertonic solution is useful in the treatment of (select all that apply) A. hyponatremia B. trauma patients with head injury C. hypernatremia D. who need fluids maintained

A. hyponatremia B. trauma patients with head injury A hypertonic solution initially raises the osmolality of ECF and expands volume. The higher osmotic pressure draws water out of the cells into ECF. It is useful in the treatment of hyponatremia and trauma patients with head injury. Hypertonic solutions require frequent monitoring of BP, lung sounds, and serum sodium levels because of the risk for intravascular fluid volume excess.

Patient complains of nausea, changes in bowel eliminations and unplanned weight loss. What examination findings does the nurse expect to find? Select all that apply A. impaired skin integrity B. poor skin turgor C. moist pink mucosa D. dull dry hair E. dry oral mucosal membranes F. poor dentation G. dull eyes H. fruity breath odor I. poor overall demeanor

A. impaired skin integrity B. poor skin turgor D. dull dry hair E. dry oral mucosal membrane F. poor dentation G. dull eyes I. poor overall demeanor (these are all examination findings for a patient with poor nutrition)

Kidneys role (select all that apply) A. maintain electrolyte and acid-base balance B. maintain glucose regulation C. regulate extracellular fluid volume D. excrete waste products E. conserves essential nutrients

A. maintain electrolyte and acid-base balance C. regulate extracellular fluid volume D. excrete waste products E. conserves essential nutrients

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? A. pH: 7.28; PCO 2: 28; HCO 3: 18 B. pH: 7.30; PCO 2: 54; HCO 3: 28 C. pH: 7.50; PCO 2: 49; HCO 3: 32 D. pH: 7.52; PCO 2: 26; HCO 3: 20

A. pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis.

Fluid and electrolyte output is via (select all that apply) A. respiration B. urine C. saliva D. feces E. skin

A. respiration B. urine D. feces E. skin

Individuals with incontinence are at a high risk for: A. skin break down B. dehydration C. hypoglycemia D. polyuria

A. skin break down

Risk factors for impaired nutrition (select all that apply) A. socioeconomic status B. race, and ethnicity C. Smokers D. very young children and elderly adults

A. socioeconomic status B. race, and ethnicity D. very young children and elderly adults

Which electrolyte is most abundant in ECF A. sodium B. calcium C. potassium D. chloride

A. sodium

main electrolytes outside the cells A. sodium B. calcium C. potassium D. chloride

A. sodium

When considering electrolytes which are of greatest importance? (select all that apply ) A. sodium B. calcium C. potassium D. chloride

A. sodium B. calcium C. potassium (powerpoints)

Most common reported symptoms associated with malnutrition? (select all that apply ) A. unplanned weight change B. pitting edema C. excessive thirst D. changes in appetite or intake E. Nausea or vomiting F. difficulty chewing or swallowing G. Abdominal pain H. changes in bowel elimination

A. unplanned weight change D. changes in appetite or intake E. Nausea or vomiting F. difficulty chewing or swallowing G. Abdominal pain H. changes in bowel elimination

Osmolaity is mainly determined by ( select all that apply) A. urea B. sodium C. potassium D. glucose

A. urea B. sodium D. glucose (powerpoints)

*Who are at increased risk for impaired glucose metabolism (Jeopardy question ) A. very young and very old population B. elderly populaion C. obese population D. Neonates

A. very young and very old population

Population at greatest risk for problems with nutrition are? A. very young children and elderly B. low income families C. Drug and EtOH addicts D. Smokers

A. very young children and elderly

A nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin-dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply. A.Leg ulcers B. Loss of visual acuity C. Increased creatinine clearance D. Prolonged capillary refill in the toes E. Decreased sensation in the lower extremities

A.Leg ulcers B. Loss of visual acuity D. Prolonged capillary refill in the toes E. Decreased sensation in the lower extremities Ulcers of the legs are a common response to the microvascular and macrovascular changes associated with diabetes. Retinopathy, damage to the microvascular system of the retina (e.g., edema, exudate, and local hemorrhage), occurs as a result of occlusion of the small vessels, causing microaneurysms in the capillary walls. Macrovascular changes in the distal capillary beds interfere with blood flow to the distal extremities. Decreased sensation in the lower extremities is a complication of diabetes. Consistent hyperglycemia causes a buildup of sorbitol and fructose in the nerves that causes impairment via an unknown process. Creatinine clearance decreases, not increases, as renal function deteriorates in response to microvascular damage to the small blood vessels that supply the glomeruli.

The major buffer system in ECF is A.carbonic acid-bicarbonate B. Hydrogen C. Hydrochloric acid D. H20

A.carbonic acid-bicarbonate The major buffer system in ECF is carbonic acid-bicarbonate. Other buffers include phosphate, protein, and hemoglobin

A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

ANS: A Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values? a) pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L b) pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L c) pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d) pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L

ANS: B Compensated metabolic alkalosis should show alkalosis pH and HCO3- (metabolic) values, with a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal = 7.35 to 7.45), PaCO2is acidic (normal 35 to 45 mm Hg), and HCO3- is elevated (normal = 22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L is uncompensated metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L is compensated respiratory acidosis.

What is a substance that releases H+ called?

Acid

What subject has no secondary prevention measures?

Acid-base balance

The average adults daily fluid intake Ā. 500ml B. 2500ml C. 3500ml D. 4500ml

B. 2500ml (2-3 liters daily)

Process to control changes in the pH by neutralizing acids A. Acid production B. Acid buffering C. Acid excretion D. Acid exchange

B. Acid buffering Acid production: generation of acid through cellular metabolism Acid excretion: removal of acid from the body

A nurse is caring for an infant whose vomiting is intractable. Which complication is most likely to occur? A. Acidosis B. Alkalosis C. Hyperkalemia D. Hypernatremia

B. Alkalosis Excessive vomiting causes an increased loss of hydrogen ions (hydrochloric acid), leading to metabolic alkalosis, an excess of base bicarbonate. Acidosis is caused by retention of hydrogen ions and a loss of base bicarbonate, which is more likely to occur with diarrhea. Hypokalemia, not hyperkalemia, will occur. With the loss of chloride ions, hyponatremia is more likely to occur.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A. Caucasian female who is 39 weeks gestation. B. An African-American female who is breastfeeding. C. An Asian female diagnosed with hypoglycemia. D. A Hispanic female who has a BMI of 24.1.

B. An African-American female who is breastfeeding. Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

act chemically to change strong acids into weaker ones or bind them to neutralize them A. Bases B. Buffers C. weak acids D. strong acids

B. Buffers Buffering is the primary regulator of acid-base balance. Buffers act chemically to change strong acids into weaker ones or bind them to neutralize them.

Primary prevention for blood glucose regulation (select all that apply ) A. Blood pressure screening B. Diet C. Exercise D. Weight control

B. Diet C. Exercise D. Weight control

The patient talks with the nurse about bladder health. One of the most important recommendations the nurse can make for bladder health is A. Eat foods high in fiber. B. Drink 6 to 8 glasses of noncaffeinated fluids daily. C. Exercise in the morning and evening. D. Visit the urologist once yearly.

B. Drink 6 to 8 glasses of noncaffeinated fluids daily. Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.

The process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes A. Nutrition B. Fluid and Electrolyte balance C. Glucose regulation D. Elimination

B. Fluid and Electrolyte balance

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? A. Skin condition B. Fluid and electrolyte balance C. Food intake D. Fluid intake and output

B. Fluid and electrolyte balance

Process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes A. Glucose regulation B. Fluid and electrolyte balance C. Acid-base balance D. Nutrition

B. Fluid and electrolyte balance

Pt comes in with complaints of extreme thrist and fatigue. The nurse notices that patient has lost weight since last visit and also notes a fruity odor to breath. What is most likely the underlying cause ? A. Influenza virus B. Hyperglycemia C. Malnutrition D. Hypoglycemia

B. Hyperglycemia Signs and symptoms of hyperglycemia : Polyuria Polydipsia Dehydration Fatigue Fruity odor to breath Kussmaul breathing Weight loss Hunger Poor wound healing

A nurse is teaching the parents of an 8-year-old child with recently diagnosed type 1 diabetes about their child's care. What significant complication associated with type 1 diabetes should the nurse include in the teaching plan? A. Obesity B. Ketoacidosis C. Resistance to treatment D. Hypersensitivity to other drugs

B. Ketoacidosis Ketoacidosis is a complication of type 1 diabetes; children require close blood glucose monitoring because of the demands of growth and their erratic diets. Obesity is more often associated with children who have type 2 diabetes. Resistance to treatment during the school-aged years is not common; problems are related to the changing requirements associated with growth. Hypersensitivity to other medications is unrelated to either type 1 or type 2 diabetes.

Fluids and Electrolyte balance is primarily regulated by A. Cardiovascular system B. Kidneys C. Lungs D. GI system

B. Kidneys

A patient is experiencing an acid-base imbalance due to impaired lung function. Which organ do you think would compensate for the lung impairment? A. Brain B. Kidneys C. Heart D. Cardiovascular system

B. Kidneys Organs involved in acid-base balance are the lungs and kidneys

Which organs should you be concerned with in a patient with impaired acid-base balance (select all that apply) A. Brain B. Lungs C. Heart D. Kidneys

B. Lungs D. Kidneys

Requires collections and evaluations of data in four areas: clinical, dietary, body composition, and biochemical A. WIC program B. NSI C. Katz test D. MNA

B. NSI

The science of optimal cellular metabolism and its impact on health and disease A. Glucose regulation B. Nutrition C. Acid base balance D. Elimination

B. Nutrition

What is the most common adaptation associated with excessive production of the hormone ADH? A. Diuresis B. Oliguria C. Retention D. Incontinence

B. Oliguria

moving from an area of low concentration to an area of high concentration A. Osmolality B. Osmosis C. Diffusion D.Active transport

B. Osmosis

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations? A. Irritability, polydipsia, and polyuria B. Polyuria, polydipsia, and polyphagia C. Nocturia, weight loss, and polydipsia D. Polyphagia, polyuria, and diaphoresis

B. Polyuria, polydipsia, and polyphagia Excessive thirst (polydipsia), excessive hunger (polyphagia), and frequent urination (polyuria) are caused by the body's inability to metabolize glucose adequately. Although polydipsia and polyuria occur with type 1 diabetes, lethargy occurs because of a lack of metabolized glucose for energy. Although polydipsia and weight loss occur with type 1 diabetes, frequent urination occurs throughout a 24-hour period because glucose in the urine pulls fluid with it. Although polyphagia and polyuria occur with type 1 diabetes, diaphoresis occurs with severe hypoglycemia, not hyperglycemia.

An older male client is experiencing dysuria and urinary retention. Which condition in the client​'s history may be causing these clinical​ manifestations? A. Anuria B. Prostatic hyperplasia C. Polyuria D. Renal failure

B. Prostatic hyperplasia Prostatic hyperplasia​ (enlargement of the​ prostate) can cause urinary​ retention, dribbling at the end of​ urination, incontinence, and nocturnal enuresis. Renal failure does not cause dysuria or retention. Polyuria is a term that describes an increase in urination. Anuria is the absence of urination.

Which constituent, if found in urine, would indicate an abnormality? A. Electrolytes B. Protein C. Water D. Urea

B. Protein

The nurse is caring for a 50-year-old man who has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that is high in: A. Iron B. Protein C. Calories D. Carbohydrate

B. Protein These laboratory results are indicative of low protein levels. Protein intake is essential for cellular ability to manufacture other forms of proteins, such as carrier proteins, and to enable tissue growth and repair. Iron supplementation is indicated for anemia. This patient has a BMI of 31, which is obese. High calorie and high carbohydrates would lead to further weight gain.

The nurse thinks the patient has hypoxia what could help the nurse confirm this A. ABG levels B. Pulse oximetry reading

B. Pulse oximetry reading

When assessing a patient with impaired glucose regulation what history is least relevant? A. Hx of vascular dz B. Recent travel outside the country C. Diet D. Weight changes E. Pregnancy

B. Recent travel outside the country Relevant Hx: -Hx of vascular dz -Diet -Weight changes -Pregnancy -current medication -family hx of DM, HTN, cardiovascular dz, & CA

The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation? A. Confusion and reliance on another person for insulin injections B. Requirements for intensive therapy with small, frequent insulin doses C. Visual impairment affecting the ability to draw up insulin accurately D. Frequent episodes of hypoglycemia

B. Requirements for intensive therapy with small, frequent insulin doses The pen injector allows greater accuracy with small doses of less than 5 units. It is not recommended for those with cognitive or visual impairments or those who suffer frequent hypoglycemic episodes.

*Extracellular fluid includes (select all that apply) A. fluid within the cells B. fluid outside the cells C. intravascular fluid D. Interstitial fluid

B. fluid outside the cells C. intravascular fluid D. Interstitial fluid

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother? A. Importance of a well-balanced diet B. Signs of dehydration in infants C. The need for cleanliness of feeding utensils D. Effect of antibiotics on viral gastroenteritis

B. Signs of dehydration in infants It is most important for the mother to learn that immediate treatment is necessary for an infant with vomiting or diarrhea. Because infants have a greater proportion of body fluid to tissue than adults, they cannot maintain fluid balance in the event of a large loss of fluid through vomiting or diarrhea. An infant's diet consists almost totally of milk; teaching the mother about a well-balanced diet is irrelevant at this time. Although cleanliness is important, diarrhea may occur despite cleanliness. Antibiotics are not administered for viral gastroenteritis.

During an office​ visit, a client reports infrequent and difficult bowel movements. Which teaching topic is appropriate for this​ client? ​(Select all that​ apply.) A. The importance of cooking and storing food correctly B. The importance of staying active C. The use of laxatives or stool softeners D. The avoidance of raw​ fruit, vegetables, and meat when traveling abroad E. The importance of consuming adequate amounts of fluid and fiber

B. The importance of staying active C. The use of laxatives or stool softeners E. The importance of consuming adequate amounts of fluid and fiber Being active and consuming adequate fluids and fiber in the diet can prevent constipation. Clients at high risk of constipation may prevent it by taking daily laxatives or stool softeners. Cooking and storing food​ properly, and avoiding raw foods during travel would address​ diarrhea, not constipation.

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? A. The nurse should minimize the use of tape on the skin. B. The nurse should keep the client adequately hydrated. C. The nurse should change the dressings as soon as they get wet. D. The nurse should provide rest for the client throughout the day.

B. The nurse should keep the client adequately hydrated. The best practice of the nurse to improve perfusion of the wound to promote healing for an older client after surgery is to keep the client adequately hydrated. The nurse should minimize the use of tape on the skin to protect the fragile skin of the client. The nurse should also change the dressing as soon as they get wet during the protection of fragile skin. The nurse should provide rest to the client throughout the day to conserve the energy required for healing.

The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when she makes this statement: A. The patient must remain in the restraints all day. B. The patient needs to be toileted to maintain a regular toileting schedule. C. The patient needs to be provided with adult briefs for incontinence. D. The patient will use the call bell when he or she feels the urge to void.

B. The patient needs to be toileted to maintain a regular toileting schedule. The correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or she will not be able to use the call bell.

A person of Northern heritage is at an increased risk for which of the following: (Select all that apply.) A. Vitamin c deficiency B. Type 1 diabetes C. Celiac disease D. Type 2 diabetes E. Hypertension F. Metabolic syndrome

B. Type 1 diabetes C. Celiac disease Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, Hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

Older patient notes they having been noticing large amounts of urine on their pjs and sheets when they wake up in the morning. This is most likely which type of urinary incontinence? A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient

B. Urge Urge incontinece → Large amount of urine at unexpected times including sleep

Patient complains of nocturia and urinary frequency. which lab test are likely to be ordered (select all that apply) A. Blood glucose level B. Urinalysis C. Cultures D. BUN/Creatinine E. GFR

B. Urinalysis C. Cultures D. BUN/Creatinine E. GFR Issues with elimination--> Laboratory tests: Urinalysis Cultures BUN/Creatinine GFR

**What should the nurse monitor to best assess a patient's renal perfusion? A. Blood pressure every 15 minutes B. Urinary output every hour C. Body weight every day D. I&O every 24 hours

B. Urinary output every hour

A patient is admitted to the emergency department with dehydration. Arterial blood gas (ABG) results reveal that the patient has metabolic acidosis. Which of the following signs or symptoms is the most likely cause of this imbalance? A.Hypoventilation B. Vomiting and diarrhea C.Serum potassium is 5.1 mEq/L. D. Arterial oxygen saturation is 91%

B. Vomiting and diarrhea Vomiting and diarrhea cause too much acid, the buffers have been overwhelmed, and body fluids have too much acid. Acid excretion is not able to keep up with acid production or intake. Hypoventilation leads to respiratory acidosis Hyperventilation leads to respiratory alkalosis. Oxygen saturations below 95% indicate that the patient may need supplemental oxygen and may contribute to imbalance; however, a low reading alone is not enough to determine the cause.

MNA (Mini Nutritional Assessment) A. identifies mothers who are having issues breast feeding and who need more information about supplemental feeding B. a simple and quick method of identifying individuals with nutritional risk or with malnutrition C. Provides formula and food stamps for pregnant women or women with children 10 years or younger D. addresses nutritional concerns associated with chronic diseases that are frequently seen in older adults.

B. a simple and quick method of identifying individuals with nutritional risk or with malnutrition

As sodium increases so does osmolality. Causing what? (select all that apply) A. Low BP B. increased blood volume C. Decreased blood volume D. Elevated BP

B. increased blood volume D. Elevated BP Water will move towards sodium and as the sodium and water content of plasma increases so does blood volume and blood pressure

What exercise would you recommend to a female patient that will help to prevent or reduce accidental urine loss A. yoga B. kegel C. cycling D. swimming

B. kegel

Aldosterone causes the body to (select all that apply) A. retain potassium B. retain sodium C. retain water D. excrete sodium and potassium

B. retain sodium C. retain water

During a focused physical assessment of the urinary​ system, a female American Muslim client seems nervous and upset. Which step should the nurse​ take? (Select all that​ apply.) A.Obtain a translator to ensure clear and accurate communication B.Present the assessment as a natural process C.Discuss other topics to distract the client during the assessment D.Comfort the client and incorporate play into the assessment E.Have a clinician of the same sex perform the assessment

B.Present the assessment as a natural process C.Discuss other topics to distract the client during the assessment E.Have a clinician of the same sex perform the assessment Some of the steps the nurse can take while performing this assessment include presenting the assessment as a natural​ process; discussing other topics to distract the​ client; and practicing culturally competent care by having a clinician of the same sex perform the assessment. There is no indication that the client does not speak English. Incorporating play into the physical examination is appropriate for a pediatric​ client, not an adult.

What is a substance that takes up H+ called?

Base

What ABG lab is related to metabolic process?

Bicarb

What happens to the body when ECF is hypertonic (select all that apply) A. sensation of thirst B. increased saliva production C. decreased saliva production D. mouth drys

Body is dehydrated --> A. sensation of thirst C. decreased saliva production D. mouth drys

The mother of a​ 2-month-old infant is concerned that her son defecates too frequently. Which response by the nurse addresses this mother​'s ​concern? A. "The increased frequency in defecation means your baby is at risk of weight loss." B. "Your baby should be able to control defecation by now." C. "Frequent bowel movements can occur with breastfeeding. close double quote" D. "Feces containing less water may be difficult for infants to expel."

C. "Frequent bowel movements can occur with breastfeeding. close double quote Frequent bowel movements often occur with​ breastfeeding; therefore, this response is the most appropriate. There is no indication that the infant is losing weight. Control of defecation is not expected at 2 months of age. While feces that contain less water may be difficult to​ pass, the infant is not experiencing hard stools.

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is A. 500 to 1500 mL. B. 1200 to 2200 mL. C. 2000 to 3000 mL. D. 3000 to 4000 mL.

C. 2000 to 3000 mL.

physiologic and psychologic readiness occurs around what age A.12-18 months B. 18-24 months C. 24 -30 months D. 30-36 months

C. 24 -30 months anal and urethral sphincters is achieved sometime after the child is walking, probably between 18 and 24 months of age...this does not mean the child is ready for toliet training

**At what age is a screening colonoscopy done at? A. 25 B. 35 C. 45 D. 50

C. 45 (then repeat every 10 years through age 75)

Normal physiology of gas exchange includes all of the following EXCEPT A. Ventilation B. Perfusion C. Acid excretion D. Transportation

C. Acid excretion Normal physiology of gas exchange Ventilation--> Transport--> Perfusion

The process of regulating the pH, bicarbonate concentration, and partial pressure of carbon dioxide of body fluids A. Gas exchange B. Perfusion C. Acid-base balance D. Cognition

C. Acid-base balance

All of the following are secondary prevention for elimination issues EXCEPT: A. Colonoscopy B. Occult blood screening C. Avoidance of environmental contamination D. Prostate examination

C. Avoidance of environmental contamination Secondary Prevention: Colonoscopy Occult blood screening Prostate examination

While obtaining the client's health history, which factor does the nurse identify that predisposes the client to type 2 diabetes? A. Having diabetes insipidus B. Eating low-cholesterol foods C. Being 20 pounds (9 kilograms) overweight D. Drinking a daily alcoholic beverage

C. Being 20 pounds (9 kilograms) overweight Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply. A. Pulse quality B. Pulse pressure C. Bounding pulse D. Presence of dependent edema E. Neck vein distention in the upright position

C. Bounding pulse D. Presence of dependent edema E. Neck vein distention in the upright position Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.

Any issues with the following concept will lead to impaired elimination (select all that apply) A. Nutrition B. Cognition C. Mobility D. Fluid and electrolytes E. Acid-base balance F. All of the above

F. All of the above Interrelated Concepts: -Nutrition -Cognition -Mobility - Fluid and electrolytes - Acid-base balance

When planning care for a diabetic patient with microalbuminuria, it is important to include which goal to reduce the progression to renal failure? A. Decrease the total percentage of calories from carbohydrates B. Decrease the total percentage of calories from fruits C. Decrease the total percentage of calories from proteins D. Decrease the total percentage of daily caloric intake

C. Decrease the total percentage of calories from proteins Restriction of dietary protein to 0.8 g/kg body weight per day is recommended for clients with microalbuminuria to reduce the progression to renal failure. All other choices can increase blood glucose and total body weight but are not specific for progression to renal failure.

Larger molecules and electrolytes move by (select all that apply) A. Osmolality B. Osmosis C. Diffusion D.Active transport

C. Diffusion D.Active transport

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? A. Crohn disease B. Cushing disease C. End-stage renal disease D. Gastroesophageal reflux disease

C. End-stage renal disease One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn disease have diarrhea, resulting in potassium loss. Clients with Cushing disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

An additional nursing diagnosis appropriate for a patient with the nursing diagnoses Bowel Incontinence and Total Incontinence would be Risk for: A. Disuse Syndrome B. Deficient Fluid Volume C. Impaired Skin Integrity D. Imbalanced Nutrition Less than Body Requirements

C. Impaired Skin Integrity

86 year old client would like to schedule a screening colonoscopy. What would the nurses response be? A. Has it been over 10 years since your last screening B. Sure, when would you like to come in C. It is not recommended patients older than 85 to have a screening colposcopy done D. Only people who have family hx of colon cancer need this done.

C. It is not recommended patients older than 85 to have a screening colposcopy done

The nurse is caring for a 25-year-old woman who is requesting information to lose weight. What information will the nurse include in a weight-loss plan? A. Weigh yourself at the same time every morning and evening. B. Stick to a 600- to 800-calorie diet for the most rapid weight loss. C. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. D. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

C. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely calorie-restricted diets are not necessary for patients in the overweight category of obesity and need to be closely supervised. Patients should weigh weekly rather than daily.

All of the following are primary prevention for elimination issues EXCEPT: A. Hydration B. Adequate dietary fiber C. Low lipid diet D. Regular toileting practices E. Regular exercise F. Avoidance of environmental contamination

C. Low lipid diet Primary prevention: Hydration Adequate dietary fiber Regular toileting practices Regular exercise Avoidance of environmental contamination

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis? A. Hypocapnia B. Hyperkalemia C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 50 mm Hg is elevated more than the expected value of 35 to 45 mm Hg; hypercapnia, not hypocapnia, is present. The client's serum potassium level is within the expected level of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). With respiratory acidosis the pH will be less than 7.35.

Pt notes she is urinating more frequently than normal and will only sometimes notices large amounts or urine at unexpected times. Which type of urinary incontinence is this? A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient G. Overflow bladder

C. Overactive bladder Overactive bladder→ there is urinery frequency and urgency with or without urge incontinence

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration? a. Sunken eyes b. Dry, flaky skin c. Change in mental status d. Decreased bowel sounds

c. Change in mental status

The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to an inability to swallow the oral form? A. Elevate the head of the bed. B. Have a padded tongue blade at the bedside. C. Position the client face down or in a side-lying position. D. Apply pressure and massage the injection site for 5 minutes.

C. Position the client face down or in a side-lying position. Intramuscular injection of glucagon often causes vomiting, increasing the patient's risk for aspiration. Elevating the head of the bed, instituting the use of a padded tongue blade, or applying pressure at or massaging injection site is not a safe nursing practice.

Which is a major contributing factor to overflow incontinence? A. Coughing B. Mobility deficits C. Prostate enlargement D. Urinary tract infection

C. Prostate enlargement

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis The pH indicates acidosis [1] [2]; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.

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

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

*A female client is experiencing problems with urinary elimination. After an initial assessment​ interview, the nurse performs a physical examination. Which specific assessment will the nurse​ include? A. Perianal assessment B. Inguinal area assessment C. Skin assessment D. Dietary assessment

C. Skin assessment A focused nursing assessment of the urinary system includes a skin​ assessment, an abdominal​ assessment, a urinary meatus​ assessment, a kidney​ assessment, and a bladder assessment.​ Dietary, perianal, and inguinal area assessments would be appropriate for a client experiencing an alteration in bowel function.

If a patient has a colostomy in the area known as the "ascending colon," what would the nurse expect of the stool in the colostomy device? A. Stool would be dark. B. Stool would be formed. C. Stool would be loose. D. Stool would have flecks of blood

C. Stool would be loose. Stool in the ascending colon is watery, or loose. Stool should not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be formed, because the colon has not reabsorbed the water yet.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis? A. The fat-forming ketoacids were broken down. B. The irregular heartbeat produced oxygen deficit. C. The decreased tissue perfusion caused lactic acid production. D. The client received too much sodium bicarbonate during resuscitation efforts.

C. The decreased tissue perfusion caused lactic acid production. Cardiac arrest causes decreased tissue perfusion, which results in ischemia and cardiac insufficiency. Cardiac insufficiency causes anaerobic metabolism, which leads to lactic acid production. Fat-forming ketoacids occur in diabetes. An irregular heartbeat does not cause acidosis. Too much sodium bicarbonate causes alkalosis, not acidosis.

**(in class discussion and NCLEX question) The nurse is assessing a newborn and anticipates that the newborn has renal impairment. Which finding supports the nurse's conclusion? A. The newborn has odorless urine. B. The newborn has colorless urine. C. The newborn first voids after 76 hours. D. The newborn's urine has a specific gravity of 1.020.

C. The newborn first voids after 76 hours. A newborn should void within 24 hours. However, in this case, the newborn first voids after 76 hours, indicating renal impairment. The urine should be colorless and odorless. This indicates that the urine is normal and the child has normal renal function. The normal specific gravity of urine is 1.020.

The kidneys regulate fluids and electrolytes by A. Glycogenesis B. Kerb cycles C. The renin-angiotensin-aldosterone system D. glycolysis

C. The renin-angiotensin-aldosterone system

A cardiac patient talks with the nurse about bowel elimination. The nurse stresses to the patient not to strain during bowel movements. Straining can put pressure on the vagas nerve and cause bradycardia. This is known as A. First-degree heart block. B. Eupnea. C. Valsalva maneuver. D. Tachypnea

C. Valsalva maneuver. The Valsalva maneuver happens when the cardiac patient strains to have a bowel movement. First-degree heart block is not brought on by straining. Eupnea means normal respirations and tachypnea means fast respirations; neither has any connection to straining during a bowel movement.

Secondary prevention in nutrition A. My plate B. Physical exercise for 30 minutes most days of the week C. genetic screening D. BMI E. Lipid F. Blood sugar

C. genetic screening D. BMI E. Lipid F. Blood sugar screening at birth--> genetically and glucose screening Screening for adults--> lipids and BMI

Hypotonic solutions (e.g., 0.45% NaCl) are useful in treating patients with (select all that apply) A. hyperkalemia B. who need fluids replaced C. hypernatremia D. who need fluids maintained

C. hypernatremia D. who need fluids maintained infusing a hypotonic solution dilutes ECF, lowering serum osmolality. Osmosis then produces a movement of water from ECF to interstitial spaces and cells, causing cells to swell. After achieving equilibrium, ICF and ECF have the same osmolality. Hypotonic solutions (e.g., 0.45% NaCl) are useful in treating patients with hypernatremia and are a good maintenance fluid because normal daily losses are hypotonic. They are not good for replacement because they can deplete ECF and lower BP. Because hypotonic solutions have the potential to cause cellular swelling, monitor patients for changes in mentation that may indicate cerebral edema.

Basic therapeutic diets include all of the following except: A. low salt B. low fat C. low protein and low fat D. calorie reduction E. consumption of fiber F. dietary supplements G. tube feeding

C. low protein and low fat

Patient scores a 7 on the NSI test. What would you expect the nurse to say to the patient next A. come back in 6 months for recheck B. come back in 3 months for recheck C. you are going to need to see your doctor or a dietitian. D. we will see you next year at your annual physical

C. you are going to need to see your doctor or a dietitian. 0-2 Good! Recheck nutrition score in 6 months 3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizen center or health department can help. 6 or more You are at high nutritional risk. Bring this checklist the next time you see you doctor, dieting or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health -Remember that warning signs suggest risk, but do not represent diagnosis of any condition

What causes respiratory alkalosis?

CO 2 loss

What causes respiratory acidosis?

CO 2 retention

What are macronutrients? (3)

Carbs, proteins, fats

What obesity class is considered morbidly obese? What is the BMI?

Class III, >40

A 6-month-old infant has severe diarrhea. The major problem associated with severe diarrhea is: A) Pain in the abdominal area B) Electrolyte and fluid loss C) Presence of excessive flatus D) Irritation of the perineal and rectal area

Correct Answer: B Explanation: Diarrhea can result in serious fluid and electrolyte or acid-base imbalances. Infants and older adults are particularly susceptible to associated complications.

An assessment is completed by the nurse and a nursing diagnosis for the oriented adult female client is identified as "Stress incontinence related to decreased pelvic muscle tone". An appropriate nursing intervention based on this diagnosis is to: A) Apply adult diapers B) Catheterize the client C) Initiate a bladder emptying program D) Teach Kegel exercises

Correct Answer: D Explanation: Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress incontinence, overactive bladders, and mixed causes of urinary continence.

A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise? A. "Jogging for 20 minutes 5 to 7 days a week would most efficiently help you to lose weight." B. "One hour of vigorous exercise daily is needed to prevent progression of disease." C. "Avoid all forms of exercise because of your diabetic complications." D. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you."

D. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you." Exercise is not contraindicated for this client, but modifications are necessary to prevent further injury. Swimming or water aerobics provides support for the joints and muscles while increasing the uptake of glucose and promoting cardiovascular health. Jogging, vigorous exercise, or no exercise would increase the pathologies of this patient.

A nurse is monitoring a client's laboratory results for a fasting plasma glucose level. Within which range of a fasting plasma glucose level does the nurse conclude that a client is considered to be diabetic? A. 50 to 60 mg/dL (2.2 to 3.3 mmol/L) B. 80 to 99 mg/dL (4.5 to 5.5 mmol/L) C. 100 to 125 mg/dL (5.6 to 6.9 mmol/L) D. 126 to 140 mg/dL (7.0 to 7.8 mmol/L)

D. 126 to 140 mg/dL (7.0 to 7.8 mmol/L) Results in the range 126 to 140 mg/dL (7.0 to 7.8 mmol/L) indicate diabetes. Results in the range 40 to 60 mg/dL (2.2 to 3.3 mmol/L) indicate hypoglycemia. Results in the range 80 to 99 mg/dL (4.5 to 5.5 mmol/L) are considered expected (normal). Results in the range 100 to 125 mg/dL (5.6 to 6.9 mmol/L) indicate prediabetes according to the American Diabetes Association. (Results in the range of 6.1 to 6.9 mmol/L indicate prediabetes according to the Canadian Diabetes Association Guidelines.)

Expected weight gain during pregnancy? A. 10-15lbs B. 15-25 lbs C. 15-30 lbs D. 15-40 lbs

D. 15-40 lbs

The state of being underweight is described as a BMI less than? A. 15 B. 17 C. 17.5 D. 18.5

D. 18.5

What is the percentage of total body water in a premature newborn? A. 55% B. 65% C. 75% D. 85%

D. 85% The total body water in a premature newborn is 85%. In full-term infants, body water ranges from 70% to 80%. The total body water in a child between the ages of 1 and 12 is approximately 64%.

Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis? A. Administration of oxygen by nasal cannula at 15 L/min B. Intravenous infusion of 10% glucose C. Implementation of seizure precautions D. Administration of intravenous insulin

D. Administration of intravenous insulin The Kussmaul's respirations pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1 to 6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells.

Patient is experiencing incontinence after starting a new medication due to a cold and cough this is mostly likely which type of incontinence? A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient

F. Transient Transient incontience→ occurs due to a situations that will pass such as infection, cold with cough, or new medication

*(skills) The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? A. Be sure to aspirate prior to injecting insulin. B. Massage the site after injecting insulin. C. Use a 1-inch needle for the injection. D. Allow the insulin to warm to room temperature before injecting it.

D. Allow the insulin to warm to room temperature before injecting it. Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.

A male client is experiencing bowel issues that alternate between episodes of constipation and episodes of diarrhea. Which diagnostic test does the nurse anticipate will be ordered for this​ client? A. Cystoscopy B. Renal ultrasound C. Urinalysis D. Blood test

D. Blood test Blood tests are used for the identification of systemic causes of alterations in bowel function. A​ cystoscopy, urinalysis, and renal ultrasound would be anticipated for a client who is experiencing alterations in urinary function.

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

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

All the following statements are true about my plate EXCEPT: A. serves as a reminder to make healthy food choices B. is a visual cue that identifies the 5 basic food groups C. The vegetables and grains portion are the largest of the four sections D. Fruits and vegetables take up 3/4 of the plate

D. Fruits and vegetables take of 3/4 of the plate Fruits and vegetables take up half the plate

Elderly patient notes she has been experiencing urinary incontinence bc she is wheel chair bound and has trouble making it to the toilet on time. This is which type of urinary incontinence? A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient G. Overflow bladder

D. Functional Functional incontinece→ Untimely unrination becuase of physical disability, external obstical, or congition problems that prevents a person from reaching the toliet on time

A nurse is reviewing the laboratory report of a 13-year-old adolescent with type 1 diabetes. What test is considered the most accurate in the evaluation of the effectiveness of diet and insulin therapy over time? A. Blood pH B. Serum protein level C. Serum glucose level D. Glycosylated hemoglobin

D. Glycosylated hemoglobin The glycosylated hemoglobin (GHb) test provides an accurate long-term index of the child's average blood glucose level for the 10- to 12-day period before the test; the more glucose the red blood cells were exposed to, the greater the GHb percentage. A high blood pH may indicate developing ketoacidosis, but it reflects short-term variations. Serum protein readings do not reflect the effectiveness of glucose management. Serum glucose readings reflect short-term (hours) variations

At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing? A. Polydipsia B. Ketoacidosis C. Glycogenesis D. Hypoglycemia

D. Hypoglycemia The time of the client's response corresponds to the expected peak action (4 to 12 hours after administration) of the intermediate-acting insulin that was administered in the morning; this can result in hypoglycemia. Hypoglycemia triggers the sympathetic nervous system; epinephrine causes diaphoresis and nervousness. Osmotic diuresis causes thirst; this is related to hyperglycemia, not to hypoglycemia. Warm, dry, flushed skin and lethargy are associated with ketoacidosis. Glycogenesis, the formation of glycogen in the liver, is unrelated to nervousness and cool, moist skin.

Pt comes in with complaints of a headache and weakness. The nurse notices that patient is diaphoretic. What is most likely the underlying cause ? A. Influenza virus B. Hyperglycemia C. Constipation D. Hypoglycemia

D. Hypoglycemia Signs and symptoms of hypoglycemia: Reduced cognition Temors Diaphoresis Weakness Hunger Headache Irritability Seizure

Which nursing diagnosis would be most appropriate for the patient who states, "It burns and stings every time I pass urine." A. Urinary Retention B. Reflex Incontinence C. Stress Incontinence D. Impaired Urinary Elimination

D. Impaired Urinary Elimination

Nurse is educating a pregnant patient about nutrition. Which state will the nurse most likely say A. Its ok to continue all vitamins and herbal supplements while pregnant B. exercise is very important C. Its ok to eat what ever you want during your 1st trimester, its only your second and third trimester we need to start thinking about nutrition D. Nutrient needs before conception is important

D. Nutrient needs before conception is important--> during the 1st trimester fetal and organ development begins

Who is most likely NOT at risk for incontinence: A. a child B. elderly patient C. Pt with Crohn's dz D. Pt with asthma E. Pt with altered mobility F. Pregnant female

D. Pt with asthma Patients at risk: Children Older adults Pregnancy Older women with weakened pelvic floor muscle Male patient with prostate hyperplasia Crohn's dz Stroke Spinal cord injury Brain injury Pt with altered mobility Neurological impairment Congential defect Cogntive impairment

A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? A. Serum chloride level of 90 mmol/L B. Serum calcium level of 8 mg/dL C. Serum sodium level of 132 mmol/L D. Serum potassium level of 2.5 mmol/L

D. Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters.

Which clinical manifestation of decreased renal function in the diabetic clinic should the nurse anticipate as a potential problem? A. Elevated specific gravity B. Ketone bodies in the urine C. Glucose in the urine D. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg

D. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration.

Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted? A. Ketone bodies in the urine have been absent for 3 hours. B. Blood osmolarity has decreased from 350 to 330 mOsm. C. Serum potassium level has increased from 2.8 to 3.2 mEq/L. D. The Glasgow Coma Scale is unchanged from 3 hours ago.

D. The Glasgow Coma Scale is unchanged from 3 hours ago. Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement. Ketone bodies, blood osmolarity, and serum potassium levels are consistent with improvement.

Which nursing diagnosis would be the most appropriate for the patient who states, "I can't hold my water once I feel like I have to go." A. Reflex Incontinence B. Stress Incontinence C. Total Incontinence D. Urge Incontinence

D. Urge Incontinence

NSI (nutrition screening initiative) A. is used as a diagnosing tool B. a simple and quick method of identifying individuals with nutritional risk or with malnutrition C. Provides formula and food stamps for pregnant women or women with children 10 years or younger D. addresses nutritional concerns associated with chronic diseases that are frequently seen in older adults.

D. addresses nutritional concerns associated with chronic diseases that are frequently seen in older adults. -*Remember that warning signs suggest risk, but do not represent diagnosis of any condition

A patient is having her first severe, acute asthma episode. It began 2 hours ago. What blood gas values should the nurse expect to see? A. pH high, PaCO2 high, HCO3- high B. pH low, PaCO2 low, HCO3- low C. pH low, PaCO2 high, HCO3- high D. pH low, PaCO2 high, HCO3- normal

D. pH low, PaCO2 high, HCO3- normal A severe acute asthma episode impairs the excretion of carbonic acid, causing respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3- normal. A high pH occurs with alkalosis, not acidosis. ANSs that include abnormal levels of HCO3- are not correct for the 2-hour time frame.

The nurse will most likely be identifying __________ when assessing a patient with impaired nutrition A. fluid retention B. absent abdominal sounds C. signs of dehydration D. strength and weaknesses

D. strength and weaknesses

The father of a​ 3-year-old boy is concerned that his son still wets the bed at night. Which explanation by the nurse is most appropriate regarding​ bedwetting? A. "By 24​ months, children are capable of holding urine beyond the urge to void. B."Sometimes children experience nocturia C."Oliguria is not uncommon in children. D."Children often achieve daytime bladder control prior to nighttime control.

D."Children often achieve daytime bladder control prior to nighttime control. Bladder control is attained by ages 2 to 5​ years, often with daytime control attained prior to nighttime control. The other statements by the nurse do not address the father​'s concern.

What does an occult blood test do?

Detects GI bleeding (does not determine location)

A nurse is planning to teach an adolescent about diabetes and self-administration of insulin. What should the nurse do first? Establish realistic goals. Assess the adolescent's intellectual ability. Determine what the adolescent knows about diabetes. Gather the equipment that will be needed for the demonstration.

Determine what the adolescent knows about diabetes. Before developing and instituting a teaching plan, the nurse must assess the adolescent's attitudes, experience, knowledge, and understanding of the health problem. Before realistic goals can be set there must be an assessment. The adolescent's intellectual ability is only one aspect of the information the nurse must collect and can be assessed as the nurse is determining what the adolescent knows about diabetes. Performing a demonstration is premature until readiness for learning has been established.

Pt complains of wetting the bed at night and also noticing urinary incontinence while jogging. Which type of urinary incontinence is this? A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient G. Overflow bladder

E. Mixed Mixed incontinence→ is a mix of stress incontinence and urge incontinence

Keeping within the body material which are normally excreted A. Defecation B. Micturition C. Voiding D. Incontinence E. Retention

E. Retention

A primigravida client with type 1 diabetes is attending her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur? A. Tenth and twelfth weeks of gestation B. Eighteenth and twenty-second weeks of gestation C. Twenty-fourth and twenty-eighth weeks of gestation D. Thirty-sixth and fortieth weeks of gestation

Eighteenth and twenty-second weeks of gestation At the end of the second trimester and the beginning of the third trimester, insulin needs increase because of an increase in maternal resistance to insulin. During the earlier part of pregnancy, fetal demands for maternal glucose may cause a tendency toward hypoglycemia. During the last weeks of pregnancy, maternal resistance to insulin decreases, and insulin needs decrease accordingly.

True or false: bladder training is usually accomplished before bowel training

FALSE Bowel training is usually accomplished before bladder training because of its greater regularity and predictability. The sensation for defecation is stronger than that for urination and easier for children to recognize. A well-balanced diet that includes dietary fiber helps keep stool soft and supports the development and maintenance of regular bowel movements.

True or False It is only necessary to screen women for nutrition needs during the first trimester

FALSE screening nutrient needs occur BEFORE conception, DURING pregnancy, and DURING lactation

Which characteristic does the nurse anticipate finding in the newborn of a mother with diabetes? 1 Irritability 2 Flushed skin 3 Hyperreflexivity 4 High-pitched cry

Flushed skin

What causes metabolic alkalosis?

HCO 3 excess or H+ loss

What causes metabolic acidosis? (2)

HCO 3 loss or H+ retention

History for elimination

Hx related to renal and GI system Medications Prior surgeries Pregnancies Digestions and absorption issues Recent travel outside of country Smoking Food allergies Unexpected weight loss

List the following potassium ranges: Hypokalemia? Optimal? Hyperkalemia?

Hypokalemia → K+ < 3.5 mEq/L Optimal → 3.5-5.0 mEq/L Hyperkalemia→ K+ > 5.0 mEq/L

Output amounts

Insensible loss (sweating) 900mL Feces 100mL Urine 1500mL 2500mL total

A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse A. Intravascular to interstitial as a result of glycosuria B. Extracellular to interstitial as a result of hypoproteinemia C. Intracellular to intravascular as a result of hyperosmolarity D. Intercellular to intravascular as a result of increased hydrostatic pressure

Intracellular to intravascular as a result of hyperosmolarity The osmotic effect of hyperglycemia pulls fluid from the cells, resulting in cellular dehydration. Hyperglycemia pulls fluid from the interstitial compartment to the intravascular compartment. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds that of other osmotic forces. An increase in hydrostatic pressure results in an intravascular-to-interstitial shift.

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? Request an order for pain medication and oxygen at 6 L/min. Lubricate the patient's lips and allow continued hyperventilation. Have the patient breathe into a paper bag to stop hyperventilating. Contact the physician immediately regarding this complication.

Lubricate the patient's lips and allow continued hyperventilation. Hyperventilation is a compensatory response to metabolic acidosis and should be allowed to continue because it helps move the blood pH toward the normal range. Lubricating the lips is a supportive nursing intervention that prevents drying and cracking of the lips during hyperventilation. Although pain and hypoxia can trigger hyperventilation, they are not the cause in this patient. Interventions to stop hyperventilation are not appropriate when it is a compensatory response. Hyperventilation is an expected beneficial compensatory response to metabolic acidosis and does not require contacting the physician.

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. Which assessment findings indicate that the client may be experiencing hypokalemia? A. Tingling of the fingertips and toes B. Dry and sticky mucous membranes C. Abdominal cramping and irritability D. Muscle weakness and cardiac dysrhythmias

Muscle weakness and cardiac dysrhythmias Muscle weakness and cardiac dysrhythmias are related to potassium depletion in the skeletal and cardiac muscles; the sodium-potassium pump facilitates conduction of nerve impulses and muscle activity. Tingling of the fingertips and toes is related to hypocalcemia or hyperkalemia, not hypokalemia. Dry and sticky mucous membranes are related to hypernatremia, not hypokalemia. Abdominal cramping and irritability are related to hyperkalemia, not hypokalemia.

Normal range for Na (optimal osmolality)? What is too high Na or too low Na called?

Na+ = 135-145 mEq/L Osm = 280-300 mosmol/kg Hypernatremia Hyponatremia

What are examples of electrolytes? (4)

Na, K, Ca, Mg

Which assessment finding in a client signifies a mild form of hypocalcemia? A. Seizures B. Hand spasms C. Severe muscle cramps D. Numbness around the mouth

Numbness around the mouth A numbness or tingling sensation around the mouth or in the hands and feet indicates mild-to-moderate hypocalcemia. Seizures, hand spasms, and severe muscle cramps are associated with severe hypocalcemia.

____________ is unexpected leakage of small amount of urine becuase of a full bladder A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient G. Overflow bladder

Over flow bladder→ is unexpected leakage of small amounts of urine becuase of a full bladder

What ABG lab is related to respiratory process?

PaCO2

Clinical manifestations for elimination

Pain Blood in urine Urine color Urine amount Abdominal distended Dysuria Frequency Urgency Nocturia Altered bowel sounds Hemorrhoids Difficulty with flatus

What is dysuria?

Painful urination

The patient has severe metabolic alkalosis. Which intervention has the highest priority? Raise the side rails on the patient's bed. Measure the urine output and skin turgor. Teach the family about metabolic alkalosis. Administer intravenous NaHCO3 as ordered.

Raise the side rails on the patient's bed. Severe metabolic alkalosis causes a decreased level of consciousness; raising the side rails is a safety intervention in that situation. Safety interventions are a higher priority than teaching. An order to administer intravenous NaHCO

Once a client tolerates clear liquids, how should you introduce regular diet?

Slowly

Which electrolyte deficiency triggers the secretion of renin? a. Sodium b. Calcium c. Chloride d. Potassium

Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

A client is to be on a 1500 calorie diet. For breakfast the client consumes 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat), ¾ cup cornflakes (15 grams of carbohydrate, 2 grams of protein), and half an orange (5 grams of carbohydrate). How many calories will the nurse document that the client has ingested? A. 08 B. 258 C. 416 D. 456

The client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram.

True or False: Insufficient nutrition and excessive nutrition are both classified as malnutrition?

True

What are micronutrients? (2)

Vitamins and minerals

The nurse should ask which of the following questions to detect the risk factors for metabolic acidosis? (Select all that apply.) Have you been vomiting today? When did your kidneys stop working? How long have you had diarrhea? Are you still feeling short of breath? What type of antacid did you take? Which weight loss diet are you using?

When did your kidneys stop working? How long have you had diarrhea? Which weight loss diet are you using? Risk factors for metabolic acidosis include decreased excretion of metabolic acid from oliguria or anuria (kidneys are not working); excessive production of metabolic acid from starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from diarrhea. Vomiting (loss of acid) causes metabolic alkalosis, as does overusing bicarbonate antacids. Shortness of breath might be related to a cause of respiratory acidosis. recent hx of vomiting and diarrhea use of medication use of EtOH

The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a. Aldactone (Spironolactone) b. Dicumarol (Bishydroxycoumarin) c. Reserpine (Serpasil) d. Cimetidine (Tagamet)

a. Aldactone (Spironolactone)

When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? a. Alveolar macrophages b. Impaction of particles c. Reflex bronchoconstriction d. Mucociliary clearance mechanism

a. Alveolar macrophages

Which scenario is a perfect example of primary prevention? a. An infant receives the rotavirus vaccination in the hospital setting. b. An adult in the early stages of Parkinson disease is advised to perform adequate exercise. c. An older adult permanently paralyzed due to brain hemorrhage is transferred to a long-term care facility. d. An older adult with Parkinson disease is administered carbidopa- levodopa to slow the progression of the disease.

a. An infant receives the rotavirus vaccination in the hospital setting.

The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3-4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? a. Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel. b. Some people have a slower bowel than others, and this is nothing to be concerned about. c. The foods you eat contribute to peristalsis, so you should eat more fiber in your diet. d. Bowel peristalsis is slow because you are not walking. Get more exercise during the day.

a. Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel.

During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth

a. Hair loss and hair that is easily removed from the scalp

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. Which physiologic imbalance would the nurse most likely encounter? Select all that apply. a. Hypovolemia b. Hyperkalemia c. Hypercalcemia d. Metabolic acidosis e. Decreased hematocrit

a. Hypovolemia d. Metabolic acidosis

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

a. Increase fiber intake. b. Increase water consumption.

The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. Which physician order should the nurse question? a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b. Furosemide (Lasix) 20 mg PO now c. Oxygen via face mask at 8 L/min d. KCl 20 mEq PO two times per day

a. Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr

When conducting a health history assessment, which information would be viewed as most important as related to the patient's elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient's preferences for toileting

a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine d. Discomfort or pain with elimination e. List of medications taken by patient

Which ion is the regulator of extracellular osmolarity? a. Sodium b. Potassium c. Chloride d. Calcium

a. Sodium

Which information will the nurse include when teaching an unlicensed health care worker about blood pressure measurement? Select all that apply. a. Support the client's arm at heart level when taking BP. b. Have the client rest for 5 minutes before measuring BP. c. Choose a larger BP cuff size for thinner clients. d. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. e. Automatic BP machines are preferable to manually taking BPs.

a. Support the client's arm at heart level when taking BP. b. Have the client rest for 5 minutes before measuring BP.

The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.

a. Test for skin tenting. b. Measure rate and character of pulse. f. Observe for flatness of neck veins when supine.

During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight.

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils

a. Tremors b. Nervousness e. Profuse perspiration

The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient's care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

a. Urine output is very small today.

An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

a. Vitamin D deficiency d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

Which action by the nurse will be most effective in determining whether fluid overload is improving when caring for a client who was admitted with heart failure? a. Weighing the client b. Monitoring the intake and output c. Assessing the extent of pitting edema d. Asking the client about subjective symptoms

a. Weighing the client

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to perform in order to detect development of the highest risk acid-base imbalance? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases

b. Level of consciousness

What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. You have a greater susceptibility for development of the disease because of your family history. b. Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes. c. Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%. d. Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic.

a. You have a greater susceptibility for development of the disease because of your family history.

*A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3−) in arterial blood.

a. acid-base balance b. oxygenation status c. acidity of the blood d. bicarbonate (HCO3-) in arterial blood Rationale: Arterial blood gases (ABGs) are measured to determine oxygenation status, ventilation status, and acid-base balance. ABG analysis includes measurement of the partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), bicarbonate (HCO3-), and arterial oxygen saturation (SaO2) in arterial blood. The overall balance of electrolytes cannot be determined with ABGs.

The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.

a. fluid restriction.

The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CÓ levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CÓ levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CÓ levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CÓ levels in the blood are low, increasing acid load.

a. increasing respiratory rate and depth when CÓ levels in the blood are high, reducing acid load.

A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

a. metabolic acidosis. The pH and HCO3 indicate that the patient has a metabolic acidosis. The other options are incorrect.

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion.

a. osmosis.

To promote the release of surfactant, the nurse encourages the patient to a. take deep breaths. b. cough five times per hour to prevent alveolar collapse. c. decrease fluid intake to reduce fluid accumulation in the alveoli. d. sit with head of bed elevated to promote air movement through the pores of Kohn.

a. take deep breaths.

**An older woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. decreased central venous pressure.

a. weight loss. b. dry oral mucosa. e. decreased central venous pressure.

*The nurse would not expect full compensation to occur for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

b) Respiratory alkalosis Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.

*The nurse would not expect full compensation to occur for which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

b) Respiratory alkalosis Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.

The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action? a. Speak with the patient's family about food choices. b. Establish a bowel and bladder program for the patient. c. Speak with the patient about past elimination habits. d. Establish a bedtime ritual for the patient.

b. Establish a bowel and bladder program for the patient.

Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.) a. Baking soda is an effective and inexpensive antacid. b. I should take my insulin on time every day. c. My aspirin is on a high shelf away from children. d. I have reliable transportation to dialysis sessions. e. Fasting is a great way to lose weight rapidly.

b. I should take my insulin on time every day. c. My aspirin is on a high shelf away from children. d. I have reliable transportation to dialysis sessions.

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? a. To prevent another problem, I should eat less sodium during diarrhea. b. My blood became too acid because I lost some base in the diarrhea fluid. c. Diarrhea removes fluid from the body, so I should drink more ice water. d. I should try to slow my breathing so my acids and bases will be balanced.

b. My blood became too acid because I lost some base in the diarrhea fluid.

The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report immediately to the physician? a. Swollen ankles in patient with compensated heart failure b. Positive Chvostek sign in patient with acute pancreatitis c. Dry mucous membranes in patient taking a new diuretic d. Constipation in patient who has advanced breast cancer

b. Positive Chvostek sign in patient with acute pancreatitis (Can lead to seizures)

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? a. Restrict the client's fluid intake. b. Regularly offer the client a urinal. c. Apply incontinence pants. d. Insert an indwelling urinary catheter.

b. Regularly offer the client a urinal.

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dL? a. Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity. b. The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel. c. Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP. d. The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis.

b. The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel.

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient's son uses a marked pillbox to set up the patient's medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

b. The patient has lost 10 pounds (4.5 kg) during the last month.

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response? a. The patient is angry about the dementia diagnosis. b. The patient is losing sphincter control due to the dementia. c. The patient forgets where the bathroom is located due to the dementia. d. The patient wants to leave the hospital.

b. The patient is losing sphincter control due to the dementia.

Based on priority for care, which client condition would the nurse assign a red tag? a. Closed fractures b. Third-degree burns over 25% of total body surface area c. Severe abdominal pain d. Bruises and superficial lacerations

b. Third-degree burns over 25% of total body surface area

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet

b. Tingling of fingertips d. Numbness around mouth e. Cramping in feet

At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland

b. Tumor that secretes excessive antidiuretic hormone (ADH) (Causes renal reabsorption of water)

The home health nurse is caring for a patient with a diagnosis of acute immunodeficiency syndrome (AIDS) who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has highest risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign e. Flat neck veins when upright f. Decreased patellar reflexes

b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau sign

The registered nurse (RN) delegates a task to the licensed practical nurse (LP). Which client task can be assigned to the LPN? a. Dehydration: Evaluate whether fluid electrolyte needs are being addressed with intravenous therapy. b. Wound care: Perform sterile dressing changes on acute and chronic wounds. c. Pain: Notify the primary health care provider if client reports pain. d. Presbycusis: Help with hearing aid placement.

b. Wound care: Perform sterile dressing changes on acute and chronic wounds.

The nurse expects the long-term treatment of a patient with hyperphosphatemia secondary to renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.

b. calcium supplements.

Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking β-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

c. 42-year-old woman with systemic lupus erythematosus and renal failure

When the registered nurse (RN) is assigning staff members to the care of clients on the unit, which situation represents an effective delegation decision by the RN? a. The licensed practical nurse (LPN) will sit with a confused client. b. The unlicensed assistive personnel (UAP) will feed a stroke client. c. An RN will administer enemas to a cardiac client until the enemas are clear. d. The licensed practical nurse (LPN) will initiate intravenous steroids to a client with emphysema.

c. An RN will administer enemas to a cardiac client until the enemas are clear.

Which assessment would the nurse use to evaluate the severity of dehydration in a hospitalized infant with dry mucous membranes, absence of tears when the infant cries and poor skin turgor? a. Daily serum electrolytes b. Respiratory rate and rhythm c. Change in weight from prior measurement d. Alterations in heart sounds since admission

c. Change in weight from prior measurement

During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein

c. Essential fatty acid

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? a. Cardiogenic shock b. Hypervolemic shock c. Hemorrhagic shock d. Septic shock

c. Hemorrhagic shock The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

Which physical findings that are typical in older adults would the nurse include when preparing to teach a community health program for senior citizens? a. Increased skin elasticity and an increase in testosterone production b. Impaired fat digestion and an increase in pepsin production c. Increased blood pressure and decreased cardiac output d. An increase in body warmth and some swallowing difficulties

c. Increased blood pressure and decreased cardiac output

A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Decreased hunger sensation b. Report of no urine output c. Increased respiratory rate d. Decreased thirst

c. Increased respiratory rate

Which diagnosis is suspected by the nurse when the laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pcó of 45 mm Hg, HCO of 58 mEg/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L)? a. Hypocapnia b. Hyperkalemia c. Metabolic alkalosis d. Respiratory acidosis

c. Metabolic alkalosis

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO > 89mm Hg, PCO 235 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? a. Respiratory alkalosis b. Poor oxygen perfusion c. Normal acid-base balance d. Compensated metabolic acidosis

c. Normal acid-base balance

The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency

c. Oliguric renal disease

The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis

c. Protein in the urine during a random urinalysis

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis

The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas

c. Small intestine

The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58

c. Urine output 8 mL/hr

The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms

c. Weak, irregular pulse and poor muscle tone

Which strategy would the nurse provide unlicensed assistive personnel when caring for a child admitted to the hospital with severe diarrhea? a. Limiting fluid intake b. Counting the number of wet diapers c. Weighing the child at the same time every day d. Encouraging a bananas, rice, applesauce, and toast (BRAT) diet

c. Weighing the child at the same time every day

The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.

c. arterial oxygen partial pressure.

The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's. d. 5% dextrose in 0.45% saline.

c. lactated Ringer's.

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO high, HCO high b. pH low, PaCO low, HCO low c. pH low, PaCO high, HCO high d. pH low, PaCO high, HCO normal

c. pH low, PaCO high, HCO high

Which response would a nurse give to the daughter of an 80-year-old client admitted to the hospital with severe dehydration who asks how her mother could have become dehydrated? a. "The body's fluid needs decrease with age because of tissue changes. b. "Access to fluid may be insufficient to meet the daily needs of the older adult." c. "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." d. "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."

d. "The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased."

During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall

d. 24-hour recall

The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness

d. Decreased level of consciousness

Which of the following would be a potential cause for respiratory acidosis? a. Diarrhea b. Vomiting c. Hyperventilation d. Hypo-ventilation

d. Hypo-ventilation

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. Is there a place that I can dispose of my unused morphine pills? b. I want to lose at least 20 pounds without getting sick this time. c. I think I have asthma because I cough when dogs are near. d. I ran out of money and am cutting my insulin dose in half.

d. I ran out of money and am cutting my insulin dose in half.

The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the priority nursing intervention? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient's heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

d. Institute fall precautions due to potential postural hypotension and weak leg muscles.

The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman

d. Middle-aged Native American woman

What is a primary prevention tool used for colon cancer screening? a. Abdominal x-rays b. Blood, urea, and nitrogen (BUN) testing c. Serum electrolytes d. Occult blood testing

d. Occult blood testing

Which electrolyte found in intracellular fluid would the nurse consider most important? a. Sodium b. Calcium c. Chloride d. Potassium

d. Potassium

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? a. The nurse understands the client has pain due to a tracheostomy. b. The nurse identifies the client is anxious about the cardiac catheterization. c. The nurse realizes the client has diarrhea and needs the bedpan frequently. d. The nurse identifies the client is not aware of perineal care and has impaired skin integrity.

d. The nurse identifies the client is not aware of perineal care and has impaired skin integrity.

The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. Your weight is within normal limits. Continue maintaining with current lifestyle choices. b. You are a little overweight. Cut down on calories and increase your activity, and you should be fine. c. You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery. d. You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.

d. You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight.

A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. increased CO2 and decreased O2 in the blood. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. decrease in intrathoracic pressure relative to pressure at the airway.

d. decrease in intrathoracic pressure relative to pressure at the airway.

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compresses to the insertion site. b. attempt to force 10 mL of normal saline into the device. c. place the patient on the left side with head-down position. d. instruct the patient to change positions, raise arm, and cough.

d. instruct the patient to change positions, raise arm, and cough

A patient has the following arterial blood gas results: pH 7.52, PaCÓ 30 mm Hg, HCǑ− 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis. The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

What are the 3 arterial blood gas (ABG) labs?

pH Bicarb PaCO2

During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adult

Intracellular is responsible for about ____% of body weight while extra cellular is responsible for about _____%

intracellular --> 40% extracellular-->20%

Which types of solutions are ideal for fluid replacement for patients with ECF volume deficits? A. hypertonic B. isotonic c. hypotonic

isotonic solutions the ideal fluid replacement for patients with ECF volume deficits. Examples of isotonic solutions include 0.9% NaCl and lactated Ringer's solution. Hypotonic solutions (e.g., 0.45% NaCl) --> treat hypernatremia and are a good maintenance fluid because normal daily losses are hypotonic. They are not good for replacement because they can deplete ECF and lower BP

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1 pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) 2 pH 7.35, CO 2 47 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) 3 pH 7.46, CO 2 30 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) 4 pH 7.50, CO 2 50 mm Hg, HCO 3 - 22 mEq/L (22 mmol/L

pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO 3 - will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO 2 ranges from 35 to 45 mm Hg, and HCO 3 - ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO 2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? A. pH: 7.28; PCO 2: 28; HCO 3: 18 B. pH: 7.30; PCO 2: 54; HCO 3: 28 C. pH: 7.50; PCO 2: 49; HCO 3: 32 D. pH: 7.52; PCO 2: 26; HCO 3: 20

pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis.

Hypoventilation leads to _____________, Hyperventilation leads to _____________

respiratory acidosis respiratory alkalosis

Patient complains of small amounts of urinary incontinence while exercising this is an example of which type of incontinence? A. Stress B. Urge C. Overactive bladder D. Functional E. Mixed F. Transient

stress in continence→ Small amount of urine during coughing, sneezing, or exercising