Med Surg Exam 2

oral hygiene

A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? chewing gum back rubs hair care oral hygiene

Gelatin desert, carbonated beverages, and apple juice Clear liquid diets contain only foods that are clear liquids at room or body temperature, such as gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. A full liquid diet includes all fluids and foods that become liquid at room temperature. This would include ice cream, chocolate milk, and liquid dietary supplements. Solid food examples are desserts, egg substitutes, and hot cereals. High-calorie, high-protein supplements are considered full liquids.

A client has been prescribed a clear liquid diet. Which food or fluids should the nurse serve the client? Gelatin desert, carbonated beverages, and apple juice High-calorie, high-protein supplements Hot cereals, ice cream, and chocolate milk Milk, frozen dessert, and egg substitutes

low prealbumin levels Prealbumin levels are a good indicator of a client's short-term nutritional status; decreased levels are suggestive of malnutrition. Protein in the client's urine, low blood sugars, and increased white blood cells are not necessarily indicative of malnutrition. Proteinuria is urine having an abnormal amount of protein. The condition is often a sign of kidney disease. Random blood sugar can be affected by food intake. White blood cells are indicative of infection.

A client has developed an abscess following abdominal surgery, and the client's food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support? proteinuria low random blood glucose levels increased white blood cells low prealbumin levels

Thicken liquids with commercial products.

A client has developed dysphagia secondary to a cerebrovascular accident. Which precautions should the nurse initiate to prevent choking during meals? Provide thin liquids. Advise the client to consume foods that thicken saliva, such as milk. Thicken liquids with commercial products. Include sticky foods like peanut butter.

Gastrostomy tube When enteral feeding is required for a long-term period, an enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). NG, NI, and Salem Sump tubes will not meet a client's long-term nutritional needs.

A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs? Gastrostomy tube Nasogastric tube Nasointestinal (NI) tube Salem sump tube

Metabolic alkalosis Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the pH is high.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Respiratory acidosis

increasing ventilation through the lungs.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: decreasing the excretion of H+ ion into the urine. preventing excretion of acids into the urine. increasing the excretion of HCO3− into the urine. increasing ventilation through the lungs.

fluid and electrolyte levels.

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: ability to reposition. fluid and electrolyte levels. nausea or vomiting. pain level during infusion.

Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Decreased potassium levels Increased sodium levels Decreased oxygen levels Increased potassium levels

anorexia The nurse should document the loss of appetite following prolonged illness as anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal sensations.

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition? emaciation cachexia anorexia nausea

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 client who is bedridden and dependent has been ordered to resume an oral diet. When feeding the client, the nurse should perform what action? Feed the client carbohydrate-rich foods at the beginning of the meal. Assist the client into a high-Fowler's position. Ensure that the client's food is at room temperature. Suction the client's upper airway before feeding.

Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time.

A client who is recovering from a stroke has begun tube feedings. Which principle should the nurse follow when administering the tube feeding? Continuous feedings are the preferred method of introducing the formula over a set period of time via gravity or pump. Feeds must be warmed prior to instillation to reduce the risk of nausea and vomiting. Feeding intolerance is less likely to occur with larger volumes. Intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time.

Discontinue the IV.

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 complains of coldness around the infusion site. What is the nurse's most appropriate action? Flush with 3-mL normal saline. Discontinue the IV. Attempt to aspirate. Slow the rate of infusion by 50%.

Sacral area The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? Sacral area Face Abdomen Hands

"I need to get your weight at this time with our scales."

A nurse is caring for a client who has been admitted on the medical surgical unit. Which statement by the nurse about obtaining an initial weight is correct? "I can use the weight we got in the clinic before you came to the hospital." "It is not necessary to get your weight until the morning." "Please tell me what your current weight is." "I need to get your weight at this time with our scales."

Pregnant or lactating women Strict vegetarians Adolescents Vitamin deficiencies are inherent with a few populations. Adolescents often eat fast food or skip breakfast and are prone to having vitamin deficiencies. Pregnant or lactating women have higher nutritional demands and may not consume enough vitamins to meet the demand. The vegan or total vegetarian diet includes only foods from plants: fruits, vegetables, legumes (dried beans and peas), grains, seeds and nuts and they lack protein vitamins. Middle aged adults and non-smokers are not at risk.

A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply. Pregnant or lactating women Middle-age adults Strict vegetarians Non-smokers Adolescents

vegetable plate for a client who practice Hinduism

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate? grilled pork chop for a client who practices Orthodox Judaism grilled shrimp for a client who practices Orthodox Judaism vegetable plate for a client who practice Hinduism toast with coffee for a client who practices the restored gospel of Jesus Christ

Every 4 to 6 hours

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual? Every 4 to 6 hours Immediately after each flush that is administered Every 4 hours for the first 24 hours after tube placement and every 24 hours thereafter Once per shift

distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? nausea and vomiting distended neck veins fingerprinting over sternum muscle twitching

Metabolic alkalosis Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

negative nitrogen balance.

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of: positive nitrogen balance. anabolism. digestion. negative nitrogen balance.

extracellular fluid volume excess

Edema happens when there is which fluid volume imbalance? extracellular fluid volume excess water deficit extracellular fluid volume deficit water excess

Infection Factors that increase a person's basal metabolic rate (BMR) include growth, infections, fever, emotional tension, extreme environmental temperatures, and elevated levels of certain hormones (epinephrine and thyroid hormones). Aging, prolonged fasting, and sleep all decrease BMR.

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? Prolonged fasting Advanced age Long periods of sleep Infection

muscle cramping and tetany Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? nausea, vomiting, and constipation muscle weakness, fatigue, and constipation muscle cramping and tetany diminished cognitive ability and hypertensio

Sodium is regulated by the renin-angiotensin-aldosterone system.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Sodium is regulated by the renin-angiotensin-aldosterone system. If sodium is low, it means that there is not enough water. Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). Sodium is not regulated by natriuretic peptides.

fluid volume excess.

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: fluid volume deficit. atelectasis. myocardial infarction. fluid volume excess.

Check the medical record for the client's prescribed diet.

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take? Replace the client's meal tray with soft foods available on the unit. Offer the client a sip of liquid in between each bite. Chop the client's food to make it easier to swallow. Check the medical record for the client's prescribed diet.

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 take? Discard the residual, chart the amount, and continue the tube feeding. Replace the residual, chart the amount, and continue the tube feeding. Call the primary care provider for a promotility agent. Hold the enteral nutrition and notify the primary care provider.

vitamin C

The nurse is caring for a client who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which nutrient would be associated with this condition? vitamin B1 vitamin C calcium folic acid

Speak to the client but limit the need for the client to respond verbally while chewing and swallowing.

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate? Create a positive social environment by asking the client about childhood food memories. Arrange food items in a clock face pattern and inform the client which time on a clock corresponds to each food item. Encourage the client to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm. Speak to the client but limit the need for the client to respond verbally while chewing and swallowing.

Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? Cardiac dysrhythmias Fluid volume excess Tetany Pulmonary embolus

The renal system retains more water. When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? Urine becomes more diluted. The renal system retains more water. The frequency of voiding increases. The client has a decreased sensation of thirst.

"When I take my medication, I will eat a banana or take it with a glass of orange juice." The client demonstrates that the teaching was effective by identifying bananas and orange juice as foods rich in potassium. The desired effect of the medication is to excrete sodium to avoid the accumulation of fluid in the lungs. To increase the amount of salt in the diet would be counterproductive. Dairy products such as milk and cheese are not potassium-rich foods. Eating small frequent meals versus three meals per day is irrelevant in increasing potassium level.

The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. Which statement made by the client indicates that education was effective? "When I take my medication, I will eat a banana or take it with a glass of orange juice." "It would be better to eat small frequent meals each day instead of three large meals." "Because I am losing sodium with the medication, I need to increase my salt intake." "I am going to increase my intake of dairy products like milk and cheese."

sternum

The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess? sternum thigh hand abdomen

intracellular

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? interstitial intracellular intravascular extracellular

"Watery plasma, or serum, portion of blood."

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response? "Fluid outside cells." "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid in the tissue space between and around cells."

0.45% NaCl

What commonly used intravenous solution is hypotonic? 0.9% NaCl lactated Ringer's 10% dextrose in water 0.45% NaCl

low calcium.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: low calcium. high sodium. low potassium. high magnesium.

isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? hypertonic colloid hypotonic isotonic

vitamin B12

Which vitamin is found only in animal foods? vitamin C vitamin D vitamin A vitamin B12