NCLEX questions for MidTerm Exam 2 with complete solution

A patient is brought to the emergency department in a comatose state after developing hyperosmolar hyperglycemic non-ketotic syndrome (HHNS). The nurse begins her care and assessment of this patient. What is the nurse's first priority in this situation? a)Providing isotonic fluid replacement b) Maintaining the patients cervical spine c) Administering insulin IM d) Monitoring serum chloride levels Correct answer- a)Providing isotonic fluid replacement In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which actions should the nurse expect to implement? Select all that apply. 1. Administer potassium supplement when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmoi/L) 2. Discontinue insulin infusion when fingerstick blood glucose is <350 mg/dl 3. Increase the insulin infusion rate when blood glucose level decreases 4. Monitor fingerstick or serum blood glucose every hour 5. Start infusion of dextrose 5% water when blood glucose is <250 mg/dl (13.9 mmoi/L) Correct answer- 1, 4, 5 Insulin shifts the potassium back into the intracellular space. As a result, serum potassium levels will then begin to decrease once insulin is started. This client is on a continuous insulin drip so serum potassium will continue to decrease. When serum potassium is normal, a potassium supplement (usually in the form of an IV piggyback) should be added to the medication regimen to prevent impending hypokalemia (K+ <3.5 mEq/L [3.5 mmoi/L]) (Option 1). Low potassium (hypokalemia) can cause muscle weakness, cramps, fatigue, and life-threatening cardiac arrhythmias. When the client is on an insulin drip, a fingerstick or serum blood glucose level should be checked at least hourly (Option 4). D5W is added to the IV fluid when blood glucose is <250 mg/dl (13.9 mmoi/L) to prevent a hypoglycemic reaction with regular (short-acting) IV insulin (Option 5). Insulin and D5W should be continued until the acidosis resolves. The insulin infusion is titrated down as blood glucose is lowered (Option 3); it is discontinued when the client is switched to subcutaneous injections. This generally occurs when blood glucose is <200 mg/dl (11.1 mmoi/L) and there is no evidence of metabolic acidosis (Option 2). The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? 1. Insert an indwelling urinary catheter for accurate output calculation 2. Obtain serum potassium level results and report to the primary health care provider 3. Prepare an insulin drip for intravenous (IV) infusion as prescribed 4. Start an IV line and infuse normal saline as prescribed Correct answer- 1 The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances. A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline Correct answer- 3, 4, 5 The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present.Option 1 would make the situation worse, and option 2 is inappropriate as the client is acidotic and needs to blow off the acid. A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose 3. Ineffective breathing pattern related to the presence of metabolic acidosis 4. Ineffective health maintenance related to the inability to manage DM during illness Correct answer- Option 1 Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1 ). The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmoi/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1 . Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis c 4. Request prescription for potassium infusion Correct answer- Option 2 Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Educational objective: Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels). A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours 2. IV bolus of 1000 ml 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy 3. IV bolus of 1000 ml 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dl (36.1 mmoi/L) 4. IV mannitol 25°/o solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure Correct answer- Option 1 The nurse should question the administration of a hypotonic IV solution (ie, 0.45o/o sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (Option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (Option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9o/o sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (Option 4) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature. The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV route [53%] 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dl (33.3 mmoi/L) [3o/o] 3. Client undergoing ultrafiltration for congestive heart failure [3°/o] .4. Client with a prescription for routine hemodialysis who has chronic renal failure [40o/o] Correct answer- Option 4: Explanation: The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. (Option 1) There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse. (Option 2) The client with hyperglycemia is at high risk for diabetic ketoacidosis or hyperglycemic hyperosmolar non ketotic coma. Both are associated with acute and chronic complications and require careful assessment and prompt nursing intervention. This client should also be assigned to a more experienced nurse. (Option 3) Ultrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse. The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1) Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis 2) Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine 3) Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime 4) 0 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dl (27.8 mmoi/L) who is to receive subcutaneous regular insulin and insulin glargine Correct answer- Option 3 Sepsis is a condition associated with a serious infection in the bloodstream. Evidence- based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome. (Option 1) Subcutaneous venous thromboembolism prophylaxis with enoxaparin following abdominal surgery is usually prescribed once every 24 hours, so administration is not urgent. (Option 2) This client has high blood pressure and needs treatment. However, this is not immediately life-threatening. If nausea, vomiting, and headache were also present, then the client would likely have hypertensive urgency or encephalopathy and need to be treated emergently. (Option 4) This client has high blood glucose and needs to be treated. However, it is not immediately life-threatening unless the client has hyperosmolar hyperglycemic syndrome or diabetic ketoacidosis The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3. Client with diabetes who has nausea, abdominal pain, and vomiting 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting Submit Correct answer- Option 2 This client is the most stable, all other clients are not. The nurse has received report on the following clients. Which client should the nurse assess first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/7 4 mm Hg 2. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea 3. Client with anemia and hemoglobin level of 7 g/dl (70 g/L) who has a pulse of 11 0/min after ambulation 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min Correct answer- Option 1: The nurse should first assess the client who had bowel surgery as hypotension can be a manifestation of bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular assessment. (Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client. (Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with moderate to severe anemia. (Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas). Educational objective: Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first? 1. 55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident ' 2. 45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dl (38.3 mmoi/L) complaining of abdominal pain and fatigue 3. 7-year-old with status asthmaticus and an oxygen saturation of 89% 4. 34-year-old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days Correct answer- Option 3. Explanation: The child with status asthmaticus is at risk for rapid deterioration of respiratory status and respiratory failure. The clinical finding of decreased oxygen saturation (normal reference is ~95o/o) indicates mild-to-moderate status asthmaticus. This client needs to be treated immediately. {Option 1) This client needs assessment and monitoring of neurological functioning following head trauma. The client is currently stable and has the least priority at this time. Development of altered mental status, spinal pain, nausea, vomiting, or loss of consciousness would shift the status to a higher priority. {Option 2) The clinical findings of fatigue, abdominal pain, and blood glucose level of 690 mg/dL (38.3 mmoi/L) indicate developing diabetic ketoacidosis. This client is at risk of life-threatening hemodynamic instability and needs immediate treatment. However, the client can be seen after the child with status asthmaticus and impending respiratory deterioration. (Severe respiratory instability takes precedence over hemodynamic instability.) {Option 4) This client's history is indicative of dehydration. She needs restoration of normal fluid balance, but she is not at risk of impending severe respiratory or hemodynamic instability, as are clients 3 and 2. Educational objective: Children age <1 0 should automatically be upgraded to 1 level higher than the triaged urgency of their medical! issues. The combination of status asthmaticus and an oxygen saturation ~92% qualifies for the highest priority level of triage at any age. The registered nurse is triaging pediatric clients in the emergency department. Which client is a priority for diagnostic testing and definitive care? 1. 4-year-old with right-sided abdominal mass reporting fatigue 2. 5-year-old with chronic constipation reporting abdominal pain and no bowel movement for 2 days 3. 1 0-year-old with sickle cell anemia reporting generalized pain of "1 0" and brownish urine 4. 13-year-old with type 1 diabetes reporting nausea, vomiting, and abdominal pain Correct answer- Option 4: Explanation: A client with type 1 diabetes experiencing nausea, vomiting, and abdominal pain is a priority due to the possibility of diabetic ketoacidosis (DKA). Medication (insulin) noncompliance is common in teenagers. The body breaks down fat for fuel and the resulting byproducts, acidic ketones, can cause abdominal pain. Osmotic diuresis (polyuria) results from the elevated glucose levels. The client experiences rapid respirations (Kussmaul's sign) that help compensate for the metabolic acidosis by blowing off carbon dioxide. DKA is a serious condition that can lead to death. If it is ruled out, other pathologies (eg, appendicitis) should be explored. (Option 1) A 4-year-old with an abdominal mass and fatigue likely has Wilms' tumor. Unnecessary abdominal palpation should be avoided to prevent tumor spillage. This client is not the first priority. (Option 2) This child with chronic constipation likely has a stool impaction. The child may need an enema or suppository. (Option 3) This child is experiencing vasoocclusive crisis, which is caused by the occlusion of blood vessels from the sickling of red blood cells when a person with sickle cell disease is exposed to a trigger. Vasoocclusion leads to ischemia and severe pain. Bilirubin released from the destroyed red blood cells results in jaundice and a brownish hue to the urine. These are expected findings. Treatment includes fluids, analgesics, oxygen, folic acid, and blood transfusion (if needed}. Which client with an endocrine problem is most appropriate for the charge nurse to delegate to the licensed practical nurse (LPN)? 1. A client experiencing Addisonian crisis with a prescription for hydrocortisone IV 2. A client with Cushing syndrome who needs intermittent urinary catheterization 3. A client with diabetic ketoacidosis on insulin intravenous (IV) infusion 4. A client with thyrotoxicosis and new-onset atrial fibrillation Correct answer- Option 2: Explanation: Registered nurses (RNs) are able to delegate tasks to LPNs. The nurse delegating a task remains legally responsible for the client's total care during the shift, and may be held liable for delegating inappropriately. Routine procedures such as urinary catheterization fall well within the LPN scope of practice, the other clients are in crisis, requiring acute care. (Options 1, 3) LPNs are trained in many nursing skills; these include but are not limited to nasotracheal suctioning, Foley catheter and nasogastric tube insertion, dressing changes, and subcutaneous, intramuscular, and oral medication administration. However, IV medication administration is typically reserved for the RN. (Option 4) Frequent assessment of unstable clients or clients with changes in condition is an exclusive RN task. Other key components of RN practice that should not be delegated or assigned include planning, implementation of complex care, evaluation, and teaching. A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? 1. pH 7.26, PaC02 56 mm Hg (7.5 kPa), HC03 23 mEq/L (23 mmoi/L) 2. pH 7.30, PaC02 30 mm Hg (4.0 kPa), HC03 15 mEq/L (15 mmoi/L) 3. pH 7.40, PaC02 40 mm Hg (5.3 kPa), HC03 24 mEq/L (24 mmoi/L) 4. pH 7.58, PaC02 48 mm Hg (6.4 kPa), HC03 44 mEq/L (44 mmoi/L) Correct answer- Option 2. The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaC02 30 mm Hg [4.0 kPa], HC03 15 mEq/L [15 mmoi/L]). The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply. 1 . Abdominal pain 2. Blood glucose level >600 mg/dL (33.3 mmoi/L) 3. History of type 2 diabetes 4. Kussmaul respirations 5. Neurological manifestations Correct answer- Options 2, 3, and 5 Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dl (33.3 mmoi/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4). The nurse is caring for a newly admitted client with worsening cerebral edema from increased intracranial pressure (ICP). The client is intubated and is on mechanical ventilation. Which of the following nursing interventions may help reduce ICP? Select all that apply. .1. Hyperventilate before and after suctioning 2. Maintain a quiet environment .3. Maintain neutral midline head positioning 4. Perform as many nursing interventions as possible together 5. Suction for 30 seconds to remove endotracheal tube secretions at regular intervals Correct answer- Options 1, 2, and 3 Most nursing activities will increase ICP in critically ill clients. The goal of treatment is to reduce ICP while still managing the client's basic needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes before continuing with nursing care. Nursing interventions should be performed in small clusters and spaced out during the shift (Option 4). Metabolic demands such as pain, straining, agitation, shivering, fever, hypoxia, and seizures also increase brain blood supply and raise ICP. Important nursing interventions to control these include the following: • Elevate head of the bed to 30 degrees with the head in a neutral position (Option 3) • Administer stool softeners to reduce the risk of Valsalva maneuver • Manage pain well without sedating the client too much • Treat fever aggressively (cool sponges) but avoid having the client shiver or shake • Keep the client in a calm environment with minimal noise and disturbances (eg, alarms, television, hall noise) (Option 2) • Ensure adequate oxygenation to the brain (avoid hypoxia) • Hyperventilate and preoxygenate the client for brief periods such as before suctioning to help reduce ICP. C02 is a potent cerebral vasodilator. Reducing C02 by hyperventilation causes vasoconstriction and reduces ICP (Option 1 ). • Administer medications as prescribed by the health care provider to reduce ICP; these include mannitol and corticosteroids. Mannitol is an osmotic diuretic that can help reduce cerebral edema and ICP through use of a hyperosmolar solution to draw water from the brain and extracellular fluid, allowing for excretion. (Option 5) Suctioning should occur for a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP. Educational objective: Metabolic demands such as pain, straining, agitation, shivering, fever, hypoxia, and seizures increase brain blood supply and raise ICP. Nursing interventions should focus on preventing these. An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action? 1 . Assess the client's level of orientation 2. Assess the insulin pump infusion site 3. Check the prescribed insulin pump settings 4. Consult the diabetic resource nurse or educator Correct answer- Option 1 Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate. {Option 2) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action. {Option 3) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action. {Option 4) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority. The nurse is assessing a client who had an esophagogastroduodenoscopy (EGO) 2 hours ago. Which finding requires an immediate report to the health care provider? 1. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg 2. Gag reflex has not returned 3. Sore throat when swallowing 4. Temperature spike to 101.2 F (38.4 C) Correct answer- Option 4 Explanation: Time: 3 seconds Updated: 04/26/2017 A sudden temperature spike 1-2 hours after an esophagogastroduodenoscopy (EGO) could be a sign of perforation or a developing infection. The nurse should notify the health care provider immediately. (Option 1) This blood pressure drop could be due to several things (sedation, blood loss, sepsis), but without any other symptoms indicating an emergency condition, it is still within the normal range. (Option 2) The gag reflex may take a few hours to return as the EGO involves applying a topical anesthetic to the throat. Absent gag reflex after a prolonged period (6 hours) would require reporting to the health care provider. (Option 3) A sore throat is expected after certain procedures (EGO, intubation) due to local irritation. Warm saline gargles could provide some relief. Educational objective: Fever after an esophagogastroduodenoscopy (EGO) or colonoscopy could be a sign of infection from perforation and should be reported. A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. "Enteral feedings have no complications." 2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." 3. "Enteral feedings provide higher calorie content." 4. "Risk of hyperglycemia is lower with enteral feedings than with TPN." Correct answer- Option 2. Explanation: Time: 2 seconds Updated: 03/24/2017 Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective: The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream. The nurse is caring for a client with acute pancreatitis. Which subjective and objective assessments would the nurse report immediately? 1. Client is lying with knees drawn up to the abdomen and trunk flexed 2. Client states, "My lips are tingling and numb." 3. Foul-smelling, fatty stool 4. Temperature of 102.2 F (39 C) and increasing abdominal pain Correct answer- Option 4 Explanation: Time: 2 seconds Updated: 07/17/2017 A high-grade fever or abrupt increase in temperature with worsening abdominal pain could be an indication of a pancreatic abscess, a significant complication of acute pancreatitis. A pancreatic abscess requires immediate intervention (eg, antibiotics, surgical drainage) to reduce the risk of rupture and sepsis; therefore, the health care provider should be notified immediately (Option 4). (Option 1) Clients with acute pancreatitis will position themselves in a side-lying position with knees drawn up to the abdomen and trunk flexed to decrease the pain. (Option 2) An early indicator of hypocalcemia, a possible electrolyte disorder of pancreatitis, is numbness and tingling of the lips and fingers. The nurse should further evaluate the client for possible signs of tetany by assessing for a positive Chvostek's sign or Trousseau's sign. Once further assessment is completed, the findings should be reported. (Option 3) The stool in acute pancreatitis is expected to be fatty and foul-smelling. Educational objective: An abrupt increase in temperature or high-grade fever during an episode of acute pancreatitis must be reported to the health care provider immediately as this may be an indication of a pancreatic abscess. The abscess must be treated promptly to prevent sepsis. An elderly client with staphylococcal pneumonia treated with intravenous antibiotic therapy for 3 days becomes extremely short of breath and restless and is difficult to arouse. Which additional assessment findings indicate to the nurse that the client can be developing sepsis? Select all that apply. 1 . Absent bowel sounds 2. Capillary refill 5 seconds 3. Diminished breath sounds in bases 4. Serum glucose level 180 mg/dL (1 0.0 mmoi/L} 5. Urine output 1 mL/kg/hr Correct answer- Sepsis is a systemic inflammatory response to an infection and can occur as a complication of pneumonia in clients who do not respond to antibiotic therapy. It is caused by the entry of bacteria from the alveoli into the bloodstream. Manifestations characteristic of sepsis include heart rate >90 beats/min, temperature >100.9 F (38.3 C), systolic blood pressure <90 mm Hg, altered mental status, and hyperglycemia (>140 mg/dl [7.8 mmoi/L]) in the absence of diabetes. The assessment findings most important for the nurse to report to the health care provider include the following: • Absent bowel sounds. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the gastrointestinal tract to the vital organs. • Capillary refill 5 seconds. Prolonged capillary refill (>3-4 seconds in an adult) indicates inadequate blood flow to peripheral tissues. • Serum glucose >140 mg/dl (7.8 mmoi/L). Gluconeogenesis occurs in response to the physiologic stress of infection. Insulin resistance is associated with anaerobic metabolism. (Option 3) Diminished breath sounds in the bases are expected in an elderly client with pneumonia. (Option 5) Urine output of 1 mUkg/hr is within the normal range (0.5-1.0 mUkg/hr). Educational objective: Sepsis is a complication of pneumonia that can progress to septic shock and/or multisystem organ dysfunction syndrome. To limit progression, the nurse assesses oxygenation (pulse oximeter, arterial blood gases), airway (patency), breathing (respiratory pattern and rate), circulation (vital signs), tissue perfusion (eg, level of consciousness, capillary refill, skin temperature and color, bowel sounds), and urine output. A client in the critical care unit has a central venous catheter (CVC). The site around the CVC becomes red and inflamed. The client reports chills and nausea and has a temperature of 102 F (38.8 C). The nurse should prepare to implement which prescription first? 1. Administer broad-spectrum intravenous (IV) antibiotic through a new IV site 2. Document the occurrence and notify the hospital's infection control nurse 3. Give ondansetron (Zofran) 4 mg IV push to relieve client's nausea 4. Obtain blood cultures and send tip of the discontinued CVC to the lab for culture Correct answer- Option 4 Explanation: The client is exhibiting signs and symptoms