question

The single best indicator of fluid status is the nurses assessment of the client:

answer

Daily body weights

question

The client is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the client is "Self-care Deficit, feeding related to unilateral weakness". An appropriate technique for the nurse to use when assisting the client w/ feeding is?

answer

place food to the unaffected side of the mouth

question

A school nurse in a high school is reviewing the nutritional needs for adolescents. The nurse is aware that in this age group:

answer

Calcium needs are increased Adolescents require an increased calcium intake for bone formation and decrease in risk for osteoporosis later in life

question

A client is suspected of having a fat-soluble vitamin deficiency. To assist the client with this deficiency, the nurse informs the client of:

answer

"More exposure to sunlight and drinking more milk could solve your nutritional problem." The Fat-soluble vitamins are A, D, E, and K. With the exception of vitamin D, which can be obtained through exposure of sunlight, these vitamins are provided through dietary intake, like milk.

question

According to the Food Guide, vegetables should be included in the average adults diet as:

answer

3-5 servings per day of vegetables

question

According to the Food Guide, fruits should be included in the average adults diet as much as:

answer

2-4 servings per day of fruit

question

how many servings of grains every day?

answer

6-11 servings per day of grains

question

For a client with a nursing diagnosis of "Fluid Volume excess," the nurse is alert to which one of the following signs and symptoms?

answer

Hypertension Also, a bounding pulse, and moist membranes are too.

question

Of the Following clients which is the most likely to be at risk for fluid volume deficit: A) 6-month old learning to drink from cup B) 12-year old who is moderately active C) 42-year old man with severe diarrhea D)90-year old with frequent headaches?

answer

C) 42-year old man with severe diarrhea

question

The nurse anticipates that the client with fluid volume deficit will manifest a(n):

answer

increased urine specific gravity

question

hypoxia

answer

insufficient oxygen anywhere in the body

question

hypoxemia

answer

low levels of oxygen in the blood

question

Which body fluid lies in the spaces between the body cells?

answer

interstitial

question

Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles?

answer

Anions, because they carry a negative charge

question

A patient is brought to the emergency department (ED) by paramedics after a person standing on the sidewalk saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP 138/84; pulse 135, regular and strong; respiratory rate 22; temperature 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect?

answer

Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include disorientation, mood changes, and tachycardia.

question

Hypocalcemia

answer

Hypocalcemia, a low calcium level, is associated with muscle spasms and tetany.

question

Hyperkalemia

answer

Hyperkalemia, a high potassium level, manifests as weakness, fatigue, and cardiac dysrhythmias.

question

Hypernatremia

answer

Hypernatremia, a high sodium level, produces extreme thirst and agitation.

question

Diffusion

answer

Diffusion is a passive process by which molecules move from an area of higher concentration to an area of lower concentration.

question

Osmosis

answer

Osmosis is the movement of water across a membrane from an area of a less concentrated solution to an area of more concentrated solution.

question

Filtration

answer

Filtration is the movement of water and smaller particles from an area of high pressure to low pressure.

question

Hydrostatic Pressure

answer

Hydrostatic pressure is the force created by fluid within a closed system.

question

The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?

answer

Diffusion

question

A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/l; PO2 = 80. The nurse interprets the findings as which of the following?

answer

Metabolic acidosis with normal oxygen levels

question

A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/l; PO2 = 80. The nurse evaluates the patient's treatment plan by examining repeat arterial blood gases (ABGs). The results are: pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/l. The nurse concludes which of the following?

answer

Complete compensation; the treatment plan is effective

question

When a patient has metabolic acidosis, which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases?

answer

Respiratory system

question

A patient's arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/l; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following?

answer

Impaired Gas Exchange

question

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question?

answer

Restrict oral intake to 900 ml every 24 hr.

question

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

answer

Active transport

question

The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 ml 0800: 45 ml 0900: 85 ml 1000: 62 ml 1100: 50 ml 1200: 48 ml 1300: 94 ml 1400: 78 ml 1500: 60 ml The nurse can conclude that the patient's urine output should be described as which of the following?

answer

within normal limits

question

Which of the following is the principle site for regulation of fluid and electrolyte balance?

answer

the kidneys

question

Which electrolyte is the primary regulator of fluid volume?

answer

sodium

question

An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 weak and thready; BP = 80/52. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/l Potassium 3.7 mEq/l Calcium 9.2 mg/dl Magnesium 1.8 mg/dl Chloride 99 mEq/l BUN 29 mg/dl The nurse recognizes that the patient is displaying symptoms associated with which of the following?

answer

hypovolemia

question

A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 weak and thready; BP = 80/52. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/l Potassium 3.7 mEq/l Calcium 9.2 mg/dl Magnesium 1.8 mg/dl Chloride 99 mEq/l BUN 29 mg/dl Which of the following is an appropriate nursing diagnosis for this patient?

answer

Deficient Fluid Volume related to abnormal fluid loss

question

Which of the following the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume?

answer

Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4 hours

question

Which laboratory results on a client's health record should alert the nurse to a potential problem? Na+ = 137 mEq/l K+ = 5.2 mEq/l Ca2+ = 9.2 mg/dl Mg2+ = 1.8 mg/dl

answer

K+ = 5.2 mEq/l

question

A patient's vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72; R = 22; and BP = 132/76. Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were: T = 100.8°F (38.2°C); P = 82; R = 24; BP = 146/88. Based on these findings, what is the priority intervention?

answer

Stop the blood transfusion immediately.

question

A patient is receiving an IV infusion of lactated Ringer's solution and 40 mEq of KCl at 100 ml/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?

answer

Phlebitis

question

The nurse assesses that her patient's intravenous solution has infiltrated into the tissues. What action should she take first?

answer

Stop the infusion immediately.

question

The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to "shut up and act your age." How should the nurse proceed?

answer

Calmly approach the child and tell him what is going to happen

question

A physician has ordered 250 ml of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate that the nurse should monitor?

answer

125 drops per minute

question

The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

answer

Hyperkalemia

question

The nurse gathers the following data: BP = 150/94; neck veins distended; P = 104; pulse bounding; respiratory rate = 20; T = 37°C (98.6°F). What disorder should the nurse suspect?

answer

Hypervolemia

question

A patient has a continuous IV infusion at 60 ml/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform?

answer

change the administration set

question

When performing a central venous catheter dressing change, which of the following steps is/are correct? Choose all that apply.

answer

Have the patient wear a mask or turn his head away from the site.

question

Impaired Gas Exchange

answer

An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange.

question

Sodium (NA+)

answer

Sodium is the major cation in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume

question

Potassium (K+)

answer

Potassium is a key electrolyte in cellular metabolism

question

Calcium (Ca)

answer

Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting.

question

Magnesium (Mg)

answer

Magnesium is a mineral used in more than 300 biochemical reactions in the body.

question

Hypovolemia

answer

Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels.

question

Hypervolemia

answer

Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse is bounding, and neck veins become distended due to increased intravascular volume.

question

Phlebitis

answer

inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord along the vein distinguishes this as phlebitis

question

The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient's care?

answer

Head of the bed elevated 80 degrees Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion.

question

While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal drainage system (CDU). Which action should the nurse take immediately?

answer

Place the disconnected end nearest the patient into a bottle of sterile water.

question

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

answer

Dry, unproductive cough is reduced, but her voluntary coughing is more productive.

question

A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient?

answer

BP will be lower than 135/85 on all occasions.

question

The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

answer

Perform a quick physical examination of breathing, circulation, and oxygenation.

question

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

answer

Cheyne-Stokes respirations

question

You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate?

answer

Decreased Cardiac Output

question

You are to connect a patient to a cardiac monitor. Which of the following actions should you take to ensure an accurate electrocardiogram tracing?

answer

Before applying the electrodes, rub the placement sites with gauze until the skin reddens.

question

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?

answer

Venturi mask

question

Which of the following provide the most reliable data about the effectiveness of airway suctioning?

answer

Breath sounds, vital signs, and pulse oximetry before and after suctioning

question

What is the rationale for wrapping petroleum gauze around a chest tube insertion site?

answer

Prevents air from leaking around the site

question

You are caring for an adult patient with a tracheostomy who is on a mechanical ventilator. His pulse oximetry reading of 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

answer

Provide endotracheal suctioning.

question

Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions?

answer

Pneumonia

question

For a patient with peripheral venous insufficiency, which of the following interventions would help to promote peripheral circulation?

answer

Teach the patient to avoid sitting with the legs crossed.

question

Which of the following blood levels normally provides the primary stimulus for breathing?

answer

Carbon dioxide

question

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

answer

Catecholamines

question

The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement:

answer

"I may need to take an iron supplement so that I am not anemic."

question

The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects?

answer

Respiratory depression

question

When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct?

answer

Place the patient in semi-Fowler's position, if possible

question

A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance?

answer

Provide the patient with a paper and pencil or letter board.

question

Which food provides the body with no usable glucose?

answer

Wheat germ

question

Which organ relies almost exclusively on glucose for energy?

answer

Brain

question

A patient with type 1 diabetes is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis?

answer

Ketones

question

Which patient is most likely experiencing positive nitrogen balance? A patient admitted:

answer

In the sixth month of a healthy pregnancy.

question

Which polysaccharide is stored in the liver?

answer

Glycogen

question

While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication?

answer

Stroke

question

Patients may be deficient in which vitamin during the winter months?

answer

D

question

Which nutrient deficiency increases the risk for pressure ulcers?

answer

Protein

question

A patient has anemia. An appropriate goal for that the patient would be for him to increase his intake of which nutrient?

answer

Iron

question

A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral?

answer

Sodium

question

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? The patient will increase his consumption of:

answer

Bananas, peaches, molasses, and potatoes.

question

During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate?

answer

Increases the rate by 35%

question

A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate?

answer

"Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have."

question

After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic?

answer

"I know that lifelong food habits are developed during this stage of life."

question

The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects?

answer

Folic acid

question

A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients?

answer

B vitamins

question

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient?

answer

Gelatin

question

A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication?

answer

Restrict his use of sodium.

question

The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which of the following nutrients?

answer

Iron

question

Which portion of a nutritional assessment must the registered nurse complete?

answer

Analyzing the data

question

Which laboratory test result most accurately reflects a patient's nutritional status?

answer

Prealbumin

question

A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient?

answer

Imbalanced Nutrition: More Than Body Requirements

question

A patient's 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication?

answer

Hypoglycemia

question

Which of the following interventions would help to prevent or relieve persistent nausea?

answer

Immediately remove any food that the patient cannot eat.

question

The structure that is responsible for returning oxygenated blood to the heart is the

answer

Pulmonary vein. The pulmonary vein carries oxygenated blood to the heart. The pulmonary artery carries deoxygenated blood from the heart to the lungs. Both venae cavae return blood to the right atrium of the heart.

question

Chemical receptors that stimulate inspiration are located in the

answer

Aorta Chemical receptors in the aorta send signals to begin the inspiration process. The brain, lungs, and heart all are affected by this chemical reaction.

question

The nurse knows that the primary function of the alveoli is to

answer

Carry out gas exchange.

question

The nurse knows that anemia will result in

answer

Hypoxemia

question

The process of exchanging gases through the alveolar capillary membrane is known as

answer

Diffusion Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Disassociation is not related to oxygenation. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. Ventilation is the process of moving gases into and out of the lungs.

question

A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find

answer

Decreased tidal volumes.

question

The nurse would expect to see increased ventilations if a patient exhibits

answer

Decreased pH.

question

The nurse recommends that a patient install a carbon monoxide detector in the home because

answer

Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.

question

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate?

answer

Left-sided heart failure

question

The nurse knows that a myocardial infarction is an occlusion of what blood vessel?

answer

Coronary artery

question

Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?

answer

Right atrium, right ventricle, left atrium, left ventricle

question

The nurse caring for a patient with ischemia to the left coronary artery would expect to find

answer

Decreased afterload.

question

Normal cardiac output is 4 to 6 L/min in a healthy adult at rest. Which of the following is the correct formula to calculate cardiac output?

answer

Cardiac output can be calculated by multiplying the stroke volume and the heart rate.

question

A patient's heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n)

answer

Decrease in cardiac output.

question

The nurse is careful to monitor a patient's cardiac output because this helps the nurse to determine

answer

Peripheral extremity circulation.

question

A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority?

answer

Have the patient sit down in the nearest chair.

question

A patient has inadequate stroke volume related to decreased preload. The nurse anticipates

answer

Verifying that the blood consent form has been signed.

question

When caring for a patient with atrial fibrillation, the nurse is most concerned with which vital sign?

answer

Oxygen saturation

question

The nurse would expect a patient with right-sided heart failure to have which of the following?

answer

Peripheral edema

question

The P wave is represented by which portion of the conduction system?

answer

SA node

question

Which statement by the patient indicates an understanding of atelectasis?

answer

"It is important to do breathing exercises every hour to prevent atelectasis."

question

The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the

answer

Oral mucosa.

question

A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to

answer

Increased metabolic demands.

question

What assessment finding is the earliest sign of hypoxia?

answer

Restlessness

question

A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child's respiratory pattern?

answer

Hyperventilation to decrease serum levels of carbon dioxide

question

A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find

answer

Crackles in the lungs.

question

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast, what should the nurse recommend?

answer

A cup of nonfat yogurt with granola, and a handful of dried apricots

question

Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is

answer

Regurgitation of the mitral valve.

question

A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?

answer

Nasal cannula

question

The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?

answer

Decreased lung defense mechanisms may cause ineffective airway clearance.

question

The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?

answer

Encourage the patient to stay up to date on all vaccinations.

question

The nurse would expect which change in cardiac output for a patient with fluid volume overload?

answer

Increased preload

question

A nurse is caring for a patient with COPD who is in recovery for a myocardial infarction. Which of the following nursing actions is the priority?

answer

Place the patient on continuous cardiac monitoring.

question

The nurse expects a patient with angina pectoris to

answer

Experience feelings of indigestion after eating a heavy meal.

question

A nonmodifiable risk factor for lung disease is

answer

Allergies

question

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal that the patient could achieve?

answer

Sleeping on two to three pillows at night

question

A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30. Which nursing diagnosis is the priority for this patient?

answer

Impaired gas exchange

question

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?

answer

Assist patient to cough, turn, and deep breathe every 2 hours.

question

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician?

answer

Hemoptysis Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest, and tachypnea are all normal findings in a patient with emphysema.

question

A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic?

answer

"Your body isn't receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult."

question

A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the nurse?

answer

No bubbling is present in the suction control chamber of the drainage device.

question

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?

answer

Administering humidified oxygen through a tracheostomy collar

question

The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse knows that teaching has been effective when the student states

answer

"I should report if I see continuous bubbling in the water-seal chamber."

question

Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?

answer

Ineffective airway clearance

question

The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to

answer

Limit the length of suctioning to 10 to 15 seconds.

question

The nurse is assessing a patient with a right pneumothorax. Which finding would the nurse expect?

answer

Absence of breath sounds on the right side

question

The nurse knows that a closed suction device would be most appropriate for which patient?

answer

A 75-year-old with aspiration pneumonia following a stroke

question

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse's first nursing action?

answer

Insert a spare tracheostomy without the obturator.

question

fats provide ____ kcal per gram?

answer

Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal per gram.

question

Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as

answer

Indispensable amino acids.

question

Fats are composed of triglycerides and fatty acids. Triglycerides

answer

Are made up of three fatty acids.

question

The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." The nurse needs to explain that

answer

Deficiencies occur when fat intake falls below 10% of daily nutrition.

question

The nurse is providing nutrition teaching to a Korean patient. In doing so, the nurse must understand that the focus of the teaching should be on

answer

Food preferences of the patient, including racial and ethnic choices.

question

In teaching mothers-to-be about infant nutrition, the nurse instructs patients to

answer

Remember that breast milk or formula is sufficient for the first 4 to 6 months.

question

The patient has a calculated body mass index (BMI) of 34. This would classify the patient as

answer

Obese

question

Dysphagia refers to difficulty when swallowing. Of the following causes of dysphagia, which is considered neurogenic?

answer

Stroke

question

Approximately two thirds of the body's total water volume exists in the _____ fluid.

answer

Intracellular

question

The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as

answer

Osmosis

question

The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to _____ pressure.

answer

Hydrostatic

question

The nurse understands that administering a hypertonic solution to a patient will shift water from the _____ to the _____ space.

answer

Intracellular; extracellular

question

Which patient is most at risk for sensible water loss?

answer

An 80-year-old patient with pneumonia

question

The nurse knows that the most abundant cation in the blood is

answer

Sodium

question

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern?

answer

Calcium of 17.5 mg/dL

question

The nurse knows that an imbalance of which ion causes acid-base impairment?

answer

Hydrogen

question

The nurse would expect a patient with respiratory acidosis to have an excessive amount of

answer

Carbon dioxide.

question

A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance?

answer

Respiratory acidosis

question

A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values?

answer

pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L

question

The nurse would not expect full compensation to occur for which acid-base imbalance?

answer

Respiratory alkalosis

question

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect?

answer

Abdominal distention

question

In which patient would the nurse expect to see a positive Chvostek sign?

answer

A 24-year-old adult admitted for chronic alcohol abuse

question

Which organ system is responsible for compensation of respiratory acidosis?

answer

Renal

question

Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis?

answer

PaCO2

question

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about?

answer

Potassium imbalance

question

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?

answer

"How many times a day do you urinate?"

FSCC Fluid Volume & Electrolyte & Acid-Base Balance and Oxygenation – Flashcards

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