Nursing 120 Exam 2 Practice with correct answers 2024

1. A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient? a. Minor, diagnostic b. Minor, elective c. Major, emergency d. Major, palliative - answer-C. Major, Emergency A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. a. Loss of consciousness b. Relaxation of skeletal muscles c. Reduction or loss of reflex action d. Localized loss of sensation e. Prolonged pain relief after other anesthesia wears off f. Infiltrates the underlying tissues in an operative area - answer-C. Reduction or loss of reflex action D. Localized loss of sensation A nurse has been asked to witness a patient signature on an informed consent form for surgery. What information should be included on the form? Select all that apply. a. The option of nontreatment b. The underlying disease process and its natural course c. Notice that once the form is signed, the patient cannot withdraw the consent d. Explanation of the guaranteed outcome of the procedure or treatment e. Name and qualifications of the provider of the procedure or treatment f. Explanation of the risks and benefits of the procedure or treatment - answer-A. The option of nontreatment B. the underlying disease process and its natural course E. name and qualifications of the provider of the procedure or treatment F. Explanation of the risk and benefits of the procedure or treatment A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient? a. Anticoagulants b. Antacids c. Laxatives d. Sedatives - answer-A. Anticoagulants A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? a. Anesthetic agent interactions b. Impaired wound healing c. Hemorrhage d. Gas pains - answer-B. Impaired wound healing A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. a. Diazepam is given to alleviate anxiety. b. Ranitidine is given to facilitate patient sedation. c. Atropine is given to decrease oral secretions. d. Morphine is given to depress respiratory function. e. Cimetidine is given to prevent laryngospasm. F. Fentanyl citrate-droperidol is given to facilitate a sense of calm - answer-A. Diazepam is given to alleviate anxiety C. Atropine is given to decrease oral secretions F. Fentanyl citrate-- droperidol is given to facilitate a sense of calm A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? a. Lecture b. Discussion c. Audiovisuals d. Written instructions - answer-D. written instructions A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response? a. "You have a wonderful doctor." b. "Let's talk about how you are feeling." c. "Everyone wakes up from surgery!" d. "Don't worry, you will be just fine." - answer-B. "Let's talk about how you are feeling." A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response? a. "The pump allows the patient to be completely free of pain during the postoperative period." b. "The pump allows the patient to take unlimited amounts of medication as needed." c. "The pump allows the patient to choose the type of medication given postoperatively." d. "The pump allows the patient to self-administer limited doses of pain medication." - answer-d. "The pump allows the patient to self-administer limited doses of pain medication." A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that the patient will have a higher risk for postoperative complications involving which body system? a. Respiratory system b. Circulatory system c. Digestive system d. Nervous system - answer-A. Respiratory system While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating: a. Thrombophlebitis b. Atelectasis c. Infection d. Hemorrhage - answer-D. Hemorrhage A patient tells the nurse she is having pain in her right lower leg. How does the nurse determine if the patient has developed a deep vein thrombosis (DVT)? a. By palpating the skin over the tibia and fibula b. By documenting daily calf circumference measurements c. By recording vital signs obtained four times a day d. By noting difficulty with ambulation - answer-B. By documenting daily calf circumference measurements A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply. a. Maintaining sterile technique b. Draping and handling instruments and supplies c. Identifying and assessing the patient on admission d. Integrating case management e. Preparing the skin at the surgical site f. Providing exposure of the operative area - answer-A. Maintaining sterile technique B. Draping and handling instruments and supplies Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? a. Take and record vital signs every shift b. Turn, cough, and deep breathe every 4 hours c. Encourage increased intake of oral fluids d. Assess bowel sounds daily - answer-B. Turn, cough, and deep breathe every 4 hours A nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation? a. Promote respiratory function b. Maintain functional abilities c. Provide diversional activities d. Increase venous return - answer-D. Increase venous return A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI? a. 50.5 b. 52.4 c. 54.5 d. 55.2 - answer-B. 52.4 A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply. a. Absence of nausea, vomiting b. Weight gain c. Bowel sounds within normal range d. Large amount of gastric residue e. Absence of diarrhea and constipation f. Slight abdominal pain and distention - answer-A. Absence of nausea, vomiting C. Bowels sounds within normal range E. absence of diarrhea and constipation A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime. - answer-a. Stroke the underside of the patient's chin to promote swallowing. A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient? a. Administering pain medication after meals. b. Encouraging food from home when possible. c. Scheduling his respiratory therapy before each meal. d. Reinforcing the importance of his eating exactly what is delivered to him. - answer-b. Encouraging food from home when possible. A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a. Feed the patient solids first and then liquids last. b. Place the head of the bed at a 30-degree angle during feeding. c. Puree all foods to a liquid consistency. d. Provide a 30-minute rest period prior to mealtime. - answer-d. Provide a 30-minute rest period prior to mealtime. A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who is comatose and needs long-term nutritional support e. A patient who has anorexia and refuses to take foods via the oral route f. A patient with burns who has not been able to eat adequately for 5 days - answer-a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract f. A patient with burns who has not been able to eat adequately for 5 days A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore with the patient why she does not want to eat her food. d. Offer high-calorie snacks such as pudding and ice cream. - answer-a. Remove the tray from the room. A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a. Vitamin B malnutrition b. Obesity c. Dehydration d. Vitamin C deficiency - answer-a. Vitamin B malnutrition A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? a. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. b. The nurse wets a washcloth and washes the area around the tube with soap and water. c. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. d. The nurse tapes a gauze dressing over the site after cleansing it. - answer-a. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on her breakfast tray. b. The patient tells you she is hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast. - answer-d. The patient reports fullness and diarrhea after breakfast. A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? a. Auscultate the bowel sounds. b. Measure the gastric aspirate pH. c. Measure the amount of residual in the tube. d. Obtain an order for a radiographic examination of the tube. - answer-d. Obtain an order for a radiographic examination of the tube. Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18? a. Risk for Imbalanced Nutrition: More Than Body Requirements b. Imbalanced Nutrition: More Than Body Requirements c. Readiness for Enhanced Nutrition d. Imbalanced Nutrition: Less Than Body Requirements - answer-d. Imbalanced Nutrition: Less Than Body Requirements A nurse nutritionist is collecting assessment data for a patient who complains of "tiredness" and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm? a. Malabsorption b. Anemia c. Protein depletion d. Reduction in total muscle mass - answer-b. Anemia A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment? a. Use warm water or air and gentle pressure to remove the clog. b. Use a stylet to unclog the tubes. c. Administer cola to remove the clog. d. Replace the tube with a new one. - answer-a. Use warm water or air and gentle pressure to remove the clog. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? a. A 19-year-old patient who is a vegan b. An older adult patient who takes daily nutritional drinks c. A 43-year-old patient who takes ginkgo biloba and an aspirin daily d. An infant who is breastfeeding - answer-c. A 43-year-old patient who takes ginkgo biloba and an aspirin daily nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate - answer-a. Dyspnea A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. A nosebleed is noted with continued suctioning. - answer-d. A nosebleed is noted with continued suctioning. A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? a. Remove the catheter. b. Notify the primary care provider. c. Check that the airway is the appropriate size for the patient. d. Place the patient on his or her back. - answer-a. Remove the catheter. A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient - answer-b. The size of the endotracheal tube A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? a. Thoracentesis b. Pulse oximetry c. Diffusion capacity d. Maximal respiratory pressure - answer-b. Pulse oximetry A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. b. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. c. Teach the patient to take short shallow breaths when performing hygiene measures. d. Group personal care activities into smaller steps, allowing rest periods between activities. - answer-d. Group personal care activities into smaller steps, allowing rest periods between activities. A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily. - answer-b. Reduce anxiety. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a. A postoperative adult b. An adult with COPD c. A teenager with cystic fibrosis d. A child with pneumonia - answer-c. A teenager with cystic fibrosis A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale." - answer-d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale." A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a. The nurse assures that the oxygen is flowing into the prongs. b. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. c. The nurse encourages the patient to breathe through the nose with the mouth closed. d. The nurse adjusts the flow rate to 6 L/min or more. - answer-c. The nurse encourages the patient to breathe through the nose with the mouth closed. A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. Instruct the assistant to notify the primary care provider. b. Assess the patient's vital signs. c. Remove the tape, adjust the depth to ordered depth and reapply the tape. d. No action is required as depth will adjust automatically. - answer-c. Remove the tape, adjust the depth to ordered depth and reapply the tape. What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a. Checking the amount of oxygen in the cylinder before using it b. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c. Placing the oxygen cylinder on the stretcher next to the patient d. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight - answer-a. Checking the amount of oxygen in the cylinder before using it A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. Notify the health care provider. b. Apply an occlusive dressing on the site. c. Assess the patient for signs of respiratory distress. d. Put on gloves and insert the chest tube in a bottle of sterile saline. - answer-d. Put on gloves and insert the chest tube in a bottle of sterile saline. An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward. b. Hold the mask tightly over the patient's nose and mouth. c. Pull the patient's jaw backward. d. Compress the bag twice the normal respiratory rate for the patient. - answer-b. Hold the mask tightly over the patient's nose and mouth. Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use an appropriate suction pressure (80 to 150 mm Hg). f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube. - answer-a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. A nurse is caring for a client who is at risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck their chin when swallowing C. Have the client use a straw D. Encourage the client to lie down and rest after meals - answer-B. Instruct the client to tuck their chin when swallowing A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? a. Fat b. Protein c. Glycogen d. Carbohydrates - answer-D. carbohydrates A nurse is caring for a client who weighs 80kg (176lb) and is 1.6m (5ft 3in) tall. Calculate the body mass index (BMI) and determine whether this clients BMI indicates a healthy weight, underweight, overweight, or obese. - answer-a. BMI= weight(kg) divided by height (m2) A BMI greater than 30 indicates obesity A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the clients meal tray? a. Cooked barley b. Pureed broccoli c. Vanilla custard a. Lentil soup - answer-c. Vanilla custard 1. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (select all that apply) a. Older adults are more prone to dehydration than younger adults are. b. Older adults need the same amount of most vitamins and minerals as younger adults do. c. Many older men and women need calcium supplementation. d. Older adults need more calories than they did when they were younger e. Older adults should consume a diet low in carbohydrates - answer-a. Older adults are more prone to dehydration than younger adults are. b. Older adults need the same amount of most vitamins and minerals as younger adults do. c. Many older men and women need calcium supplementation. A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) a. Restlessness b. Tachypnea c. Bradycardia d. Confusion e. Hypertension - answer-a. Restlessness b. Tachypnea d. Confusion e. Hypertension A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (select all that apply.) a. Apply petroleum jelly around and inside the nares b. Remove the nasal cannula during mealtimes c. Check the position of the nasal cannula d. Report any nausea or difficult breathing e. Post "no smoking" signs in prominent locations - answer-c. Check the position of the nasal cannula d. Report any nausea or difficult breathing e. Post "no smoking" signs in prominent locations A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? a. Increase the oxygen flow b. Assist the client to fowler's position c. Promote removal of pulmonary secretions d. Obtain a specimen for arterial blood gases - answer-b. Assist the client to fowler's position 1. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (select all that apply) a. Apply the oxygen source loosely if the SpO2 decreases during the procedure b. Use surgical asepsis to remove and clean the inner cannula c. Clean the outer cannula surfaces in a circular motion from the stoma site outward d. Replace the tracheostomy ties with new ties e. Cut a slit in the gauze squares to place beneath the tube holder - answer-b. Use surgical asepsis to remove and clean the inner cannula c. Clean the outer cannula surfaces in a circular motion from the stoma site outward A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? a. "water helps clear the tube so it doesn't get clogged." b. "flushing helps make sure the tube stays in place." c. "this will help you get enough fluids." d. "adding water makes the formula less concentrated." - answer-a. "water helps clear the tube so it doesn't get clogged." A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? a. Auscultate breath sounds b. Stop the feeding c. Obtain a chest x-ray d. Initiate oxygen therapy - answer-b. Stop the feeding A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest priority before performing this procedure? a. Check how long the feeding container has been open b. Verify the placement of the NG tube c. Confirm that the client does not have diarrhea d. Make sure the client is alert and oriented - answer-b. Verify the placement of the NG tube 1. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via a NG tube. Which of the following actions should the nurse complete prior to administering the tube feedings? (select all that apply) a. Auscultate bowel sounds b. Assist the client to an upright position c. Test the pH of gastric aspirate d. Warm the formula to body temp e. Discard any residual gastric contents - answer-a. Auscultate bowel sounds b. Assist the client to an upright position c. Test the pH of gastric aspirate 1. A nurse is preparing to insert a NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply) a. Review a signal the client can use if feeling any distress b. Lay a towel across the client's chest c. Administer oral pain meds d. Obtain a Dobhoff tube for insertion e. Have a petroleum based lubricant available - answer-a. Review a signal the client can use if feeling any distress b. Lay a towel across the client's chest Which of the following interventions is of major importance during preoperative phase? - - - answer-Encouraging the patient to identify and verbalize fears While assessing a patient in the pacu a nurse notes increases wound drainage, restlessness, and decreasing blood pressure. What would the nurse interpret these findings as most likely indicating? - answer-Hemorrhage After abdominal surgery the pt has internal bleeding which is a following finding? - answer-Abdominal Distention What type of preop medication makes your mouth dry? - answer-Anticholinergics focus and goal during intraoperative phase? - answer-Ensure the patient safety during the surgery. How often should a postsurgical pt with effective cough be performed in the first 24 hour? - answer-Every 2 hours Nurse is caring for a elderly postsurgical pt. perform leg exercises Which age related change makes these exercises more important? - answer-Decreased peripheral circulation How to cough after surgery? - answer-Hold a pillow or folded bath blanket over the incision A pt has Rheumatoid arthritis and is being treated with steroids what is the apporpiate nursing diagnosis for this patient? - answer-Risk for hypoxemia The client will have an incision in the lower left abdomen which of the following measures by the nurse will help decrease discomfort in the incisonal area of the pt. - answer-Applying a splint directly over the lower abdomen Pt has a bmi of 18? - answer-Imbalanced nutrition less than body requirements following signs and symptoms of poor nutrition? - answer-Flaky facial skin, facial edema pale skin color A nurse is percussing the thorax of a pt with chronic emphysema. What percussion sound would most likely be assessed? - answer-Hyperresonance codeine for cough is a? - answer-suppressant a patient is having respiratory problems and distress what should the nurse do next? - answer-Initiate interventions to help relieve the symptoms. the chest tube is placed where? - answer-It is inserted into the space between the lining of the lungs and the ribs What is the best indication the patient is receiving adequate nutrition? - answer-Surgical incision is healing normally The nurse weighs the client daily and auscultates the clients lungs the nurse is assessing what? - answer-Fluid overload how many grams of protein will the nurse recommend to a pt that weighs 145 lbs (65.9kg) X 0.8 = - answer-53 g Alcoholics are normally deficient with what vitamin? - answer-Vitamin B Food source included in a Full liquid diet? - answer-Custard A client is receiving enteral nutrition. what should the nurse do to prevent aspiration? - answer-Elevate the head of the bed to 40 degrees a pt with a low bmi of 17 and low albumin what is the nurse expected to find? - answer-Pitting edema What health problem may occur in a person who is on a low carb diet for a long time? - answer-Metabolic acidosis. The nurse is assessing a 50 yr old male who has a circumference of 48 what is he at risk for? - answer-Cardiovascular illness. What formula should not be used for a pt who is lactose? - answer-Plyometric A pt gets diarrhea what should the nurse do first? - answer-Obtain a stool sample When using a soft silicone nasogastric tube for enteral feedings which of the following should the nurse do? - answer-flush the tubing after checking for residual volumes Anthropometric measurements provide what? - answer-Indirect measure of protein and fat storage A nurse is caring for a patient who eats limited amounts of lipids. what is the nutritional deficiency the nurse suspects? - vitamin A, K - potassium - amino acids - thiamin - answer-vitamin A, K A nurse is caring for a client who has sever burn injuries. which statement by the nurse is most accurate regarding this clients need for enteral nutritional support? - answer-his product contains protein a nurse is caring for a patient with a stage IV pressure ulcer what nutrients will the nurse increase to help heal the wound? - answer-Protein, Vitamin C, A and zinc the nurse is assessing several patients for nutritional imbalances which patient will have decrease BMR - an anxious patient - school age - elderly female - patient with pneumonia - answer-- elderly female a nurse performing a nutritional assessment needs to determine the BMI of a 5'10 - answer-25.8 . the nurse will monitor a client receiving enteral feeding for which complications (select all that apply) - aspiration - infiltration - diarrhea - blood infections - electrolyte imbalance - answer-- aspiration - infiltration - diarrhea -electrolyte imbalance a nurse is reviewing the lab values of a teenage female client and notes low hemoglobin and hematocrit levels which nutritional supplement should the nurse advise? - answer-Iron the nurse is caring for a client who is receiving TPN which of the following is appropriate nursing intervention (select all that apply) - monitor clients blood glucose ever 6 hours - start rate at 125-150 ml/hr - monitor peralbuman every 6 hours - run all antibiotics in the same lie - maintain strict aseptic technique - answer--monitor clients blood glucose ever 6 hours -Monitor prealbumin every 6 hours -maintain strict aseptic technique what category of medications may be administered by nebulizer or metered dose inhaler to open narrow airways? - answer-bronchodilators which client would the nurse use for the diagnostics of ineffective airway clearance? - 30 male with pneumonia - 50 female with asma - 80 woman with sever kyphosis - 20 female who is anxious - answer-- 30 male with pneumonia patient sent home with albuterol inhaler which teaching should the nurse include? - answer-the expansion champer spacer improves the medication delivered during an assessment the nurse finds that the patient has vesicular breath sounds over chest - answer-this is a normal finding and will continue the assessment A nurse is performing discharge instructions for a patient who is going home with oxygen which teaching should the nurse include for safety? (select all that apply) - burning candles in the room with oxygen is safe - you can use an electric razor while using your oxygen - no smoking near the oxygen - do not put any oil on the oxygen - oxygen is highly combustible - answer-- no smoking near the oxygen - do not put any oil on the oxygen - oxygen is highly combustible a client develops acute renal failure and a resulting metabolic acidosis the nurse should reconise the respiratory system compensates by? - answer-hyperventilation a nurse is assisting a respiratory therapist with therapy for patients with ineffective cough. for which patient might this therapy be recommended? - cystic fibrosis - pneumonia - post of thoracic surgery - COPD - answer-COPD the nurse is caring for a 4 patient who presents with stridor and a seal like cough - answer-Upper airway obstruction . a patient with a chronic cough has a bronchoscopy which action would be provided after the procedure? - answer-Keep NPO until gag reflux returns Patient ask nurse what a PCA pump does - answer-administer own pain medications in a time interval by the push of a button an obese client is admited for abd surgery the nurse reconsise that this client is more susceptible to what postoperation complication? - answer-Dehiscence the nurse is preparing a patient for a c-section and is teaching her the effects of regional anesthesia which of the effects would the nurse expect? (Select all that apply) - loss of consciousness - anxiety relief - reduction or loss of reflex action - localized loss of sensation - long term pain control - answer-- anxiety relief - reduction or loss of reflex action - localized loss of sensation