C2,D1,E Final
A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk? A) Assess the client's level of consciousness. B) Inspect, auscultate and palpate the client's abdomen. C) Inspect the integrity of the client's oral mucosa D)Assess the client for nausea.
A) Assess the client's level of consciousness. Decreased level of consciousness greatly increases a client's risk of aspirating; it is imperative that the nurse assess this prior to the client eating. It is appropriate for the nurse to assess the client's mouth and abdomen and assess for nausea, but none of these actions directly address the client's risk of aspiration.
A client who is bedridden and dependent has been ordered to resume an oral diet. When feeding the client, the nurse should perform what action? A) Assist the client into a high-Fowler's position. B) Suction the client's upper airway before feeding. C) Ensure that the client's food is at room temperature. D)Feed the client carbohydrate-rich foods at the beginning of the meal.
A) Assist the client into a high-Fowler's position. High-Fowler's positioning is necessary to prevent aspiration. There is no need to begin with high-carbohydrate foods. Suctioning may or may not be necessary before the client eats. Hot foods should be avoided to prevent burning, but there is no need for foods to be at room temperature.
A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? A) Attempt to irrigate the NG tube with water or normal saline. B) Turn off the suction for 30 minutes and then turn it on again. C)Instill digestive enzymes, as ordered. D) Remove the NG tube and replace it with a larger-bore tube, as ordered.
A) Attempt to irrigate the NG tube with water or normal saline.
The American Association of Critical-Care Nurses (AACN) has provided a directive regarding best practice for verification of feeding tube placement. Which practice should the nurse adopt? A) Bedside techniques, including measuring the pH and observing the appearance of fluid withdrawn from the tube, should be used to assess tube location at regular intervals. B) Aspiration of stomach contents and testing for pH is the most clinically reliable form of placement confirmation. C) Placement should be confirmed by computed tomography (CT) in all clients who possess risk factors for aspiration. D) Skin integrity at the exit site at the mouth or nose should be observed routinely to assess for a change in length of the external portion of the tube.
A) Bedside techniques, including measuring the pH and observing the appearance of fluid withdrawn from the tube, should be used to assess tube location at regular intervals.
Cross-matching of blood is ordered for a client before major surgery. What does this process do? A) Determines compatibility between blood specimens B) Determines a person's blood type C) Predicts the amount of needed blood replacement D)Specifies the donor and the recipient of the blood
A) Determines compatibility between blood specimens Before any blood can be given to a client, it must be determined that the blood of the donor is compatible with that of the client. The process of determining compatibility between blood specimens is cross-matching. The examination to determine a person's blood type is called typing.
The nurse is providing care for a client recently admitted with a diagnosis of hypercalcemia. The nurse will contact the physician if the client reports taking which medication? A) Digoxin B) Furosemide C)Acetaminophen D)Multivitamins
A) Digoxin
The nurse is caring for a client who is receiving continuous enteral feeding. The client develops nausea. Which actions should the nurse provide? Select all that apply. A) Discover if suction equipment is ready at the bedside. B)Lower the head of the bed to decrease strain on the abdomen. C) Provide an ordered antiemetic as prescribed D) Assess the gastric residual and auscultate for bowel sounds. E)Use a stylet to unclog the nasogastric tube.
A) Discover if suction equipment is ready at the bedside. B)Lower the head of the bed to decrease strain on the abdomen. C) Provide an ordered antiemetic as prescribed
The nurse is caring for a client admitted with fluid volume deficit. Which diagnostic test results does the nurse identify as supporting the client's diagnosis? Select all that apply. A) Elevated urine specific gravity B) Decreased hemoglobin level C) High hematocrit level D)Elevated blood urea nitrogen (BUN) E)Elevated red blood cell count
A) Elevated urine specific gravity This is correct. A fluid volume deficit will cause the urine to become more concentrated, raising the specific gravity. C)High hematocrit level D) Elevated blood urea nitrogen (BUN) This is correct. A fluid volume deficit will cause hemoconcentration, which can make the hemoglobin, hematocrit, and BUN levels appear to be elevated.
While managing the care of clients with tube feeding, the nurse visualizes aspirated contents, checking for color and consistency. Which statements should inform the nurse's interpretations? Select all that apply. A) Gastric fluid is green with particles, off-white, or brown if old blood is present. B) A client's intestinal aspirate appears to be straw-colored. C) Intestinal aspirate may be black if stained with bile. D) Respiratory or tracheobronchial fluid is usually off-white to tan. E)Respiratory or tracheobronchial fluid may be tinged with blood in an acutely ill client. F)A small amount of mucus may be seen immediately after NG insertion.
A) Gastric fluid is green with particles, off-white, or brown if old blood is present. B) A client's intestinal aspirate appears to be straw-colored. D) D) Respiratory or tracheobronchial fluid is usually off-white to tan.
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse provide? A) Hold the enteral nutrition and notify the primary care provider. B) Discard the residual, chart the amount, and continue the tube feeding. C) Call the primary care provider for a promotility agent. D) Replace the residual, chart the amount, and continue the tube feeding.
A) Hold the enteral nutrition and notify the primary care provider.
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse provide? A) Hold the enteral nutrition and notify the primary care provider. B) Discard the residual, chart the amount, and continue the tube feeding. C) Call the primary care provider for a promotility agent. D) Replace the residual, chart the amount, and continue the tube feeding.
A) Hold the enteral nutrition and notify the primary care provider. When the residual is greater than 500 mL, the enteral feeding should be held and the primary care provider (PCP) needs to be called for further instructions. If there had been two consecutive residuals >250 mL, the PCP would consider ordering a promotility agent. The PCP will consider decreasing the rate of the tube feeding and may or may not want the residual returned since it is so large. The nurse would not discard or replace the residual and merely chart the amount of the residual and continue the tube feeding at the ordered current rate. The excessive large residuals will increase the client's risk for aspiration.
A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend? A) If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. B) If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied. C) Replace the NG tube if the client experiences nausea within 6 hours of removal. D) If the client experiences pain during removal, apply petroleum jelly to the skin near the exit site
A) If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.
A client who is recovering from a stroke has begun tube feedings. Which step should the nurse provide when administering the tube feeding? A) Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. B) Feeds must be warmed prior to instillation to reduce the risk of nausea and vomiting. C)Continuous feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. D)Feeding intolerance is less likely to occur with larger volumes.
A) Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. Intermittent feedings are delivered at regular intervals, using gravity for instillation or a feeding pump to administer the formula over a set period of time. The steps for administering feedings are similar regardless of the tube used. Intermittent feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeding intolerance is less likely to occur with smaller volumes. Feeds are not warmed prior to instillation.
A 25 year old female presents to the emergency room with severe gastroenteritis for three days. Her laboratory findings are; ph 7.48, pCO2 44, HCO3 30. What is the disorder? A) Metabolic Alkalosis B) Respiratory Acidosis C) Metabolic Acidosis D)Respiratory Alkalosis
A) Metabolic Alkalosis
The nurse is providing care for a client admitted with fluid volume overload. Which nursing care will the nurse implement for this client? Select all that apply. A) Monitor the effects of diuretic therapy. B) Obtain a daily weight on the same scale C) Teach about foods naturally high in sodium. D) Assess intake and output results for imbalances. E) Encourage oral fluid intake of at least 2,000 mL/d.
A) Monitor the effects of diuretic therapy. This is correct. The nurse should administer ordered diuretics and monitor for effectiveness. B) Obtain a daily weight on the same scale - The nurse should assess daily weights at the same time of the day, preferably before breakfast, using the same scales and with the client wearing the same type garment. C) Teach about foods naturally high in sodium. A low-sodium diet may be ordered to restrict dietary intake of sodium. It is important for the client to understand which foods are naturally high in sodium; this group of foods is often overlooked. D) is Assess intake and output results for imbalances.
The client is to receive two units of packed red blood cells (PRBC) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBC safely? Select all that apply. A) Obtain baseline vital signs prior to beginning the transfusion. B) Verify client identification and blood product information with a second nurse. C) Wear clean gloves when spiking the blood container with the administration set. D)Set the IV infusion pump to administer the unit in 1 hour. E) Prime the blood administration set with a dextrose solution. F)Check that informed consent has been obtained from the client.
A) Obtain baseline vital signs prior to beginning the transfusion. B) Verify client identification and blood product information with a second nurse. C) Wear clean gloves when spiking the blood container with the administration set. F) Check that informed consent has been obtained from the client.
The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply. A) Offer the client fluids in small containers. B)Provide a moisturizer for the lips and mouth. C) Provide hard candies for the client to suck on. D) Remove the water pitcher from the client's bedside. E)Limit frequent oral hygiene for the client.
A) Offer the client fluids in small containers. The client has hyponatremia and is on fluid restriction. The nurse offers fluid in small containers. This action makes the container appear to have more fluid than it actually does. The nurse provides a lubricant or moisturizer for the lips and mouth as the client with hyponatremia typically experiences dry mouth. The nurse removes the water pitcher from the client's bedside to remove a visual reminder of fluid and to limit fluid intake. Hard candy increases the client's thirst. Frequent oral hygiene will assist in keeping the client's mouth moist. B) Provide a moisturizer for the lips and mouth. The client has hyponatremia and is on fluid restriction. The nurse offers fluid in small containers. This action makes the container appear to have more fluid than it actually does. The nurse provides a lubricant or moisturizer for the lips and mouth as the client with hyponatremia typically experiences dry mouth. The nurse removes the water pitcher from the client's bedside to remove a visual reminder of fluid and to limit fluid intake. Hard candy increases the client's thirst. Frequent oral hygiene will assist in keeping the client's mouth moist. D) Remove the water pitcher from the client's bedside.
The nurse is caring for a client taking furosemide. The nurse recognizes that dietary teaching is successful if the client chooses which food? A) Oranges B) Zucchini C) Green beans D) Grapes
A) Oranges This is correct. The client should increase intake of foods high in potassium, such as bananas, which provide about 500 mg each. Other foods high in potassium include baked potatoes, sweet potatoes, yogurt, white beans, halibut, avocados, and yellow and orange fruits such as oranges, apricots.
A nurse is caring for a client who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment that correlates with a fluid volume defiicit? Select all that apply. A) Reduced skin turgor B)Decreased blood pressure C) Decreased urine output D)Increased pulse rate E) Increased respiratory rate
A) Reduced skin turgor B)Decreased blood pressure C) Decreased urine output D)Increased pulse rate
A client is receiving continuous tube feeding via a nasogastric (NG) tube. What should the nurse use to determine that the NG is in correct placement? Select all that apply. A) Stop tube feedings for 1 hour after medication before testing the pH of the gastric fluid. B)Visually assess aspirate that it differs from the color and consistency of the tube feeding. C) Measure the exposed length of feeding tube and compare it to the baseline measurement. D)Obtain a chest x-ray to determine if the feeding tube is in correct placement. E)Assess if the gastric aspirate pH is 6.0 or higher to determine if it is in correct placement.
A) Stop tube feedings for 1 hour after medication before testing the pH of the gastric fluid. B) Visually assess aspirate that it differs from the color and consistency of the tube feeding C) Measure the exposed length of feeding tube and compare it to the baseline measurement.
A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this? A) The client donates his or her own blood. B) The client's family members have been donors C) The client will only need fluids, not blood. D)The client's blood has been rendered sterile.
A) The client donates his or her own blood. Some patients who know in advance that they will need blood can donate their own blood for transfusion. This is called autologous transfusion or autotransfusion. When clients receive fluids, they receive crystalloids. Family members can donate their blood and it can be used if needed for the surgery but it is considered a blood donation. Blood cannot be sterilized but medical equipment can be sterilized.
A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible? A)phlebitis B) pulmonary embolus C)thrombus formation D)air embolism
A) phlebitis The nurse should record that the client has phlebitis, which is an inflammation of the vein. Thrombus formation is a situation in which there is a stationary blood clot. Pulmonary embolus is a situation in which the blood clot travels to the lung. Air embolism is a bubble of air traveling within the vascular system.
The nurse is providing care for a client whose arterial blood gas results are pH = 7.48; CO2 = 44; NaHCO3= 29. Which conclusion about the client's condition will the nurse draw from the testing results? A) Metabolic alkalosis B) Respiratory alkalosis C) Metabolic acidosis D)Respiratory acidosis
A)Metabolic alkalosis This is correct. Normal ranges: pH = 7.35 to 7.45; CO2 = 35 to 45; HCO3 = 22 to 26. The nurse begins by evaluating the pH (which is alkalotic), followed by the CO2 (which is, in this case, within normal limits), and then the HCO3(which is alkalotic). This indicates alkalosis, caused by the metabolic excess of HCO3.
The nurse reviews a client's electrolyte levels on a laboratory report and notes the client has hyponatremia. Which symptoms will the nurse expect to find during assessment? A)Blood pressure of 100/58 mm Hg B)Edema in lower extremities C)Respiratory crackles in all lobes D)Bounding pulse at 54 beats/minute
A.Blood pressure of 100/58 mm Hg This is correct. The nurse should expect to see hypotension in a client with hyponatremia. When sodium is low, so is fluid retention; where salt goes, water follows.
Which client does the nurse expect to need teaching about the American Heart Association recommendation to limit salt intake to 1,500 mg/d? A) An adolescent client with pneumonia B) A middle-age client with hypertension C) An adult client with appendicitis D)A young-adult client with an ovarian cyst
B) A middle-age client with hypertension. This is correct. It is recommended that individuals with hypertension, individuals who are 40 years of age or older, and African Americans should consume no more than 1500 mg/d of sodium. The nurse can expect this client to need teaching.
A client is receiving intermittent NG tube feedings using an open system. Which actions should the nurse implement to reduce the client's risk for infection? Select all that apply. A) Use a new bag and tubing set for each feeding B)Cleanse the top of the feeding container with alcohol before opening it. C) Use sterile technique when adding formula to the bag. D) Replace the bag and tubing every 24 hours. E)Cleanse the client's nares and the proximal tubing with alcohol before each feeding.
B) Cleanse the top of the feeding container with alcohol before opening it. The bag and tubing should be discarded every 24 hours, but it is unnecessary to use a new system for each feeding. As well, the nurse should cleanse the top of the feeding container with a disinfectant before opening it. Sterile technique, however, is not recommended; clean technique is deemed sufficient. It is not necessary to cleanse the NG tubing and the client's nares with alcohol. D) Replace the bag and tubing every 24 hours. The bag and tubing should be discarded every 24 hours, but it is unnecessary to use a new system for each feeding. As well, the nurse should cleanse the top of the feeding container with a disinfectant before opening it. Sterile technique, however, is not recommended; clean technique is deemed sufficient. It is not necessary to cleanse the NG tubing and the client's nares with alcohol.
A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual? A)Once per shift B) Every 4 hours for the first 24 hours after tube placement and every 24 hours thereafter C) Every 4 to 6 hours D) Immediately after each flush that is administered
B) Every 4 to 6 hours Checking for residual before each feeding or every 4 to 6 hours during a continuous feeding according to institutional policy is implemented to identify delayed gastric emptying. Residuals are not measured immediately after a flush.
Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? A) Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath B) Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea C) Congestive Heart Failure related to edema D) Fluid Volume Excess related to loss of sodium and potassium
B) Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid
The nurse is caring for a client with a low serum calcium level. Which symptom of hypocalcemia is unexpected by the nurse? A) Tingling around the mouth B)Heart rate of 52 beats/min. C)Confusion and disorientation D) Muscle twitching
B) Heart rate of 52 beats/min.
The nurse is caring for a client taking the diuretic furosemide. The nurse will be most concerned about which assessment finding? A) Hypercalcemia B) Muscle spasms C) Constricted pupils D) Low urine specific gravity
B) Muscle spasms This is correct. Some diuretics, such as furosemide, a loop-diuretic, are known to deplete the serum level of potassium, making it necessary to monitor the laboratory results for changes in potassium level. Hypokalemia can cause muscle weakness and tetany, or severe muscle spasms.
The nurse provides dietary teaching for a client diagnosed with hypomagnesemia. The nurse determines the teaching has been effective if the client discusses including which foods in the daily diet? Select all that apply. A) Peanuts B)Oatmeal C) Flax seed D)Brocoli E)Bananas
B) Oatmeal This is correct. Dietary sources of magnesium include oatmeal. C) Flax seed This is correct. Dietary sources of magnesium include seeds, such as from flax, pumpkin, and sunflower. D) Brocoli This is correct. Dietary sources of magnesium include dark green vegetables, such as broccoli.
A family meeting has been called to discuss care planning for a client who has late-stage Alzheimer's disease and who has largely stopped taking food by mouth. What principle should best guide the decision around the use of tube feeding? A) Tube feeding is not an option if the client is unable to manipulate the system independently. B) Tube feeding has not been shown to increase survival rates significantly among this population. C) Tube feeding has the potential to meet the client's short- and long-term hydration and nutrition needs. D) The client will require parenteral supplements in addition to tube feeding.
B) Tube feeding has not been shown to increase survival rates significantly among this population.
A client has a physician's order for n.p.o (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? A) provide protein supplements B) replace fluid and electrolytes C) administer blood products D)treat the client's infection
B) replace fluid and electrolytes The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost due to the n.p.o. order, and the loss of fluid and electrolytes due to the nasogastric suctioning.
While reviewing laboratory results, the nurse notes that one of the clients has a low blood urea nitrogen (BUN) level. Which cause is the most likely related to the result? A) Hypernatremia B)Fluid volume excess C)Hypokalemia D)Dehydration
B. Fluid volume excess
A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure? A) If Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. B) If unable to irrigate the tube, remove it and obtain an order for replacement. C) Assist the client to a 30- to 45-degree position, unless this is contraindicated. D)Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe.
C) Assist the client to a 30- to 45-degree position, unless this is contraindicated.
Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention? A) Place the client in a protective supine position to facilitate easy removal. B) Attach a syringe and flush with 50 mL of water or normal saline before removal. C) Before removing the tube, discontinue suction and separate the tube from suction. D)Quickly and carefully remove tube while the client breathes out.
C) Before removing the tube, discontinue suction and separate the tube from suction. When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath.
What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding? A) When checking for residue, if a large amount is aspirated, replace the residue before proceeding with feeding. B) If the tube is found to be in the stomach instead of the esophagus, follow the recommended steps to replace the tube. C) If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. D) If the client complains of nausea after tube feeding, lower the head of the bed and administer an antiemetic.
C) If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. Warm water and gentle pressure should be used to unclog a tube. If a large amount of residue is accidentally aspirated, the health care provider should be notified. If the client is nauseated, the head of the bed should remain elevated and an antiemetic administered as prescribed. The tube should be in the stomach, not the esophagus.
The nurse is preparing to administer a client's ordered tube feeding and the client aspirates gastric contents. Testing of the pH yields a result of 5.3. What is the nurse's most appropriate action? A) Temporarily hold the tube feeding and recheck pH in 60 to 90 minutes. B) Assess whether the client has recently drunk any beverages. C) Proceed with the feeding as ordered. D) Liaise with the primary care provider to obtain radiographic confirmation of tube placement.
C) Proceed with the feeding as ordered. The pH of gastric contents is acidic (less than 5.5); a pH of 5.3 thus constitutes an expected finding. There is no need to delay the feeding or reconfirm tube placement
The nurse is caring for a client receiving continuous tube feeding via a nasogastric tube. The client is slumped down in the bed with feet touching the footboard. Which action should the nurse take first before pulling the client up in bed? A) Ensure that the nasogastric tube is in clear view and free of kinks B) Raise the bed to a comfortable working position. C) Stop the enteral feeding pump. D) Lower the head of the bed to flat.
C) Stop the enteral feeding pump.
During change of shift report, a nurse is informed that a client has new orders for sodium polystyrene (Kayexalate). After providing the treatment later in the shift, which documentation will the nurse make in regard to the client's care? A) Kayexalate given per order for hypokalemia; client resting comfortably. B) Kayexalate provided; monitoring client's level of consciousness every 2 hours. C) Telemetry shows normal sinus rhythm; Kayexalate provided; client had two stools this shift. D)IV D5 1/2NS with 20 mEq potassium chloride (KCl) infusing without difficulty; Kayexalate provided; adequate urine output noted.
C) Telemetry shows normal sinus rhythm; Kayexalate provided; client had two stools this shift. This is correct. This entry recognizes the risk for cardiac rhythm abnormalities with hyperkalemia and notes telemetry is in place to monitor effectively. The Kayexalate is expected to produce additional stools and reduce the serum potassium level.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: A) fluid volume deficit. B) myocardial Infarction C) fluid volume excess. D) atelectasis
C) fluid volume excess. A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.
A nurse is caring for multiple clients on a medical floor. Which client should the nurse see first? A) A middle-age client admitted with sickle cell anemia who has a client-controlled analgesia (PCA) B) A young-adult client with Crohn disease receiving an IV of 1/2NS at 100 mL/hr C) An older-adult client with a history of congestive heart failure receiving IV D5W with 20 mEq potassium chloride (KCl) at 120 mL/h D)An adult client recovering from gastric bypass surgery who has a saline lock
C. An older-adult client with a history of congestive heart failure receiving IV D5W with 20 mEq potassium chloride (KCl) at 120 mL/h This is correct. Infants, small children, frail elders, and clients with congestive heart failure are more susceptible to fluid overload than the average adult client, especially at the rate of 120 mL/hr. This makes this client the highest priority.
The nurse is providing care for a client with a history of cardiac problems. The nurse notes the client's potassium level is 3.6 mEq/L. The nurse understands that which reason supports the physician's order for a daily dose of potassium? A) The potassium is ordered to prevent the client from becoming hypokalemic. B)The physician is attempting to increase urinary output to decrease cardiac stress. C)The potassium is ordered in an attempt to prevent cardiac arrhythmias. D)The potassium is ordered in an attempt to prevent cardiac arrhythmias.
C. The potassium is ordered in an attempt to prevent cardiac arrhythmias.
A client asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond? A) "Although hepatitis is possible, AIDS is not." B) "There is only a very small chance; I know you will be safe." C) "If I were you, I would request special handling of my blood." D)"There is no way you can contract a disease by giving blood."
D) "There is no way you can contract a disease by giving blood." Blood donors are carefully assessed and screened. There is no way that donors can contract any disease by giving blood.
The nurse is providing care for an individual admitted with an acute asthma attack. Arterial blood gas (ABG) results indicate pH = 7.33; CO2 = 49; HCO3 = 26; and oxygen saturation is 87%. After initiating treatment with IV fluids, bronchodilators, and oxygen therapy at 4 L via nasal cannula (NC), the client's repeat ABG results are pH = 7.35; CO2 = 47; HCO3 = 26; and oxygen saturation is 89%. Which action should the nurse take next? A) Document the findings in the client's medical record. B) Prepare to transfer the client to the intensive care unit (ICU). C) Inform the family of the client's worsening condition. D) Assess the function of the client's oxygen delivery system.
D) Assess the function of the client's oxygen delivery system. This is correct. Normal ranges: pH = 7.35 to 7.45; CO2 = 35 to 45; HCO3 = 22 to 26. The client's repeat ABG results have improved, but the oxygen saturation remains lower than desired. It is important for the nurse to assess the functioning of the oxygen delivery system; malfunction can affect the amount of oxygen the client is receiving.
A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client? A) Administer oxygen B)Call for help. C)Elevate the affected arm. D) Discontinue the IV promptly.
D) Discontinue the IV promptly. When there is phlebitis, the nurse should discontinue the IV promptly and apply warm compresses to the affected site to provide immediate relief to the client. The nurse elevates the client's affected arm when there is infiltration. When there is pulmonary embolus, the nurse should call for help and administer oxygen.
Which task may be safely delegated to unlicensed assistive personnel (UAP)? A) Administering tube feeding to a client who has had a stroke B) Removing a client's NG tube after surgery C) Inserting a nasogastric (NG) tube into a client with persistent nausea D)Feeding a client who is at risk for aspiration
D) Feeding a client who is at risk for aspiration Assisting clients to eat may be delegated to UAP. These care providers are normally educated in the risks posed by aspiration. UAP cannot insert or remove NG tubes and they cannot administer tube feedings.
The nurse is caring for a client with a diagnosis of mild hypochloremia. Which condition will the nurse associate with the client's current diagnosis? A) Consumption of electrolyte replacement drinks B) Ingestion of large amounts of salty snacks C) Metabolic acidosis from vomiting and diarrhea D) Hyponatremia related to a heat stroke
D) Hyponatremia related to a heat stroke This is correct. The majority of chloride is bound to sodium in dietary sources, as well as in the body. A heat stroke will cause an increased amount of fluid loss through sweat. This condition is associated with the client's current diagnosis.
The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate? A) Administer a high-protein diet B) Place the client on calorie restriction C) Arrange for total parenteral nutrition (TPN). D) Increase the client's fluid intake.
D) Increase the client's fluid intake. Dehydration can cause increases in hematocrit, BUN, and creatinine. Calorie restriction, increased protein intake, and TPN are not indicated by these laboratory data.
The nurse is providing care for a client with a pH of 7.5. Which assessment finding will the nurse identify as a normal body response to the client's condition? A)More acidic urine B) Low urine level of NaHCO3 C) Deep respirations D) Slow respiratory rate
D) Slow respiratory rate This is correct. The client's pH is indicative of alkalosis. To retain CO2, the lungs slow the rate of respiration, allowing more CO2 to remain in the blood in order to increase acidity. When the kidneys sense that the blood is too alkaline, they will retain more hydrogen in the blood to increase the acidity and excrete more NaHCO3into the urine.
The nurse is reviewing laboratory values of multiple clients with fluid and electrolyte imbalance. Which laboratory value does the nurse identify as representing a therapeutic response to treatment? A) Sodium = 147 mEq B) Sodium = 149 mEq C) Sodium = 132 mEq D)Sodium = 135 mEq
D) Sodium = 135 mEq
A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe? A) sepsis B) speed shock C) thrombus D)infiltration
D) infiltration Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site, and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.
Arterial blood gases have been drawn on the client. The nurse reviews the results.• pH is 7.31• PaO2 92 mm Hg• PaCO2 50 mm Hg• HCO3 28 mEq/L (mmol/L)How will the nurse interpret these ABG results? Select all that apply. A) Complete compensation B) No compensation C) Respiratory alkalosis D)Respiratory acidosis E)Partial compensation F)Metabolic acidosis G) Metabolic alkalosis
D)Respiratory acidosis E)Partial compensation
An individual with metabolic acidosis disorder will present signs and symptoms of hyperventilation, confusion, numbness/tingling, decreased LOC, pH 7.50, HCO 26 TRUE or FALSE
TRUE
The following laboratory results correspond to an individual in respiratory acidosis. HCO3 is 24, POC2 is 58, pH is 7.24 TRUE or FALSE
True
Respiratory Alkalosis
hyperventilation, confusion, lightheadedness pH greater than 7.45 PACO2 less than 35
Metabolic Alkalosis
hypoventilation, confusion, numbness/tingling decreased LOC pH greater than 7.45 HCO3 greater than 2
Respiratory Acidosis
hypoventilation, dyspnea, anxiety, drowsiness, pH less than 7.35 PaCO3 greater than 45
Metabolic Acidosis
kussmaul respirations, headache and confusion, vomiting, pH less than 7.35 HCO3 less than 22
Jehova's Witness religious believe that the Bible prohibits the transfusion of blood even in cases of emergency, may use autologous blood, may use blood substitutes that expand blood volumes prevent shock. True or false
true
