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SIMCLEXA nurse is getting ready to start an IV on a client who needs fluids and medications. Which of
the following must the nurse consider when choosing a vein to use for an IV on a client?
Select all that apply.
A) Avoid using a vein in an extremity that has a dialysis fistula
B) Keep the client's extremity raised above the level of the heart before starting the IV
C) Start the IV distally to provide additional site options if the attempt is unsuccessful
D) If having difficulty finding a vein to use, place an ice pack on the extremity
E) Shave excessive hair over a potential IV site if the hair is too thick
A&C
A) Avoid using a vein in an extremity that has a dialysis fistula (When attempting to start an
IV, it is important for the nurse to consider the site carefully. If the patient has a dialysis
fistula, edema, a restricted extremity due to a mastectomy or infected skin, the area should
be avoided. It is also useful to consider if the patient is left or right-handed when selecting
the site.)
C) Start the IV distally to provide additional site options if the attempt is unsuccessful (The
best practice is to start the IV distally, because this leaves the rest of the extremity available
for an IV if the attempt is unsuccessful.)
A 67-year-old client tells the nurse that he used to run marathons, but no longer has the
stamina to run as far. Which of the following changes in exercise tolerance are associated
with the aging process? Select all that apply.
A)
Increased total body water
B) Decreased lean muscle mass
C)Increased oxidative capacity
D) Decreased testosterone secretion
E) Increased bone loss
,B, D&E
B) Decreased lean muscle mass As a person ages, stamina and ability to exercise is
decreased. The normal aging process results in decreased muscle mass, decreased
hormone secretion, and increased bone loss that can negatively impact a person's ability to
exercise.
D) Decreased testosterone secretion This contributes to decreased ability to exercise with
age.
E)
Increased bone loss This contributes to decreased ability to exercise with age.
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A nurse is caring for a client who has a nasogastric tube in place and is receiving enteral
feedings. The nurse must administer formula to the client that has been prepared by the
hospital dietary staff and consists of milk-based, blenderized foods. This type of formula is
known as:
A) Polymeric formula
B) Specialized formula
C) Modular formula
D) Elemental formula
B
A) Polymeric formula There are four main types of enteral nutrition formulas, which are
elemental, semi-elemental, polymeric, and specialized. The type of formula prescribed is
based on the client's nutritional needs and whether there is pre-existing malnutrition.
Polymeric formulas are typically created from regular foods that have been mixed in a
blender. They contain complete nutrition.
B) Specialized formula This type of formula is specialized according to a specific health
condition, like renal disease.
C) Modular formula This type of formula is used as an addition to other foods. It is not
nutritionally complete, and the combination of ingredients varies.
D) Elemental formula This type of formula is nutritionally complete, and the protein and fat
are broken down to their simplest form so they are easy to digest.
, The nurse caring for a four-year-old knows that preschoolers sometimes have magical
thinking. The nurse accurately adapts nursing care in which of the following ways? Choose
the best answer.
A) Stating directly that procedures are never a form of punishment
B) Using fairy tale stories as a distraction
C) Involving the child with the procedure by allowing the child to choose what color bandage
to have
D) Allowing the parents to remain at the bedside and hold the child’s hand
A
A) Stating directly that procedures are never a form of punishment The nurse is addressing
the fact that a preschooler may think that what is happening is a punishment for a bad
thought he or she had earlier in the day.
B) Using fairy tale stories as a distraction Even though stories may help distract the child, it
doesn't address their concerns and anxieties that stem from magical thinking.
C) Involving the child with the procedure by allowing the child to choose what color bandage
to have Allowing a child to make decisions about their care is important, but this does not
address their belief that their thoughts can make things happen.
D) Allowing the parents to remain at the bedside and hold the child's hand It doesn't address
the particular cognitive stage of the preschooler.
The nurse is caring for a client who is recovering from a stroke. The nurse notes the client
has developed neglect syndrome. Which of the following signs does the nurse observe to
come to this conclusion? Select all that apply.
A) The client exclusively uses the unaffected side of the body
B) The client verbalizes a decreased sensation to heat and cold
C) The client turns their head to scan the room rather than moving their eyes
D) The client refuses to utilize adaptive equipment for transfers
E) The client's affected upper limb remains motionless during a meal
A&E
A) The client exclusively uses the unaffected side of the body
A client with neglect syndrome demonstrates a lack of awareness of the affected side of the
body.
B) The client verbalizes a decreased sensation to heat and cold This is an assessment
finding when the client is having a stroke.
C) The client turns their head to scan the room rather than moving their eyes This is an
appropriate finding in a client who has blindness in half their visual field following a stroke.
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