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The nurse is caring for a patient that has metabolic alkalosis. Which of the following is the cause of the client's condition?
A. Excessive vomiting
B. Diabetic Ketoacidosis
C. Severe Diarrhea
D. Malnutrition
Excessive Vomiting (loss of hydrochloric acid)
Other causes are:
- Taking too many antacids (too much bicarb)
- Diuretics
A nurse is caring for a patient who was admitted for 23 hours observation. The patient is 71 years old, complaining of severe diarrhea, hypotension, weakness, and slight confusion. The nurse understands the reason this patient was admitted for close observation is to monitor which condition.
A. Respiratory Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Metabolic Acidosis
Metabolic Acidosis: S/S hypotension, confusion, weakness, Kussmaul's breathing, hyperkalemia
Excepted Causes:
Sepsis
Diabetic Ketoacidosis
Malnutrition
Severe Diarrhea
Acute/chronic kidney disease
The nurse is caring for a patient that has Respiratory acidosis. Which of the following are the excepted causes of this acid-base imbalance? Select all that applies.
A. Fever
B. Opioid overdose
C. COPD
D. Aspirin toxicity
E. Pneumonia
F. Pulmonary Embolism
G. Hyperventilation
B, C, E, F
Causes of Respiratory Acidosis: Depressed Breathing/hypoventilation (Retaining CO2)
Drugs
Edema
Pneumonia
Respiratory brain damage
Emboli
Spams (Asthma)
Sac damage (COPD)
When caring for a patient with Respiratory Alkalosis, the nurse would except to monitor for which signs and symptoms? Select all that apply.
A. Respiratory rate greater than 20
B. Respiratory rate less than 12
C. Increased HR
D. Decreased HR
E. Tetany
F. positive chvostek sign
G. Muscle weakness
A, C, E, F
Respiratory Alkalosis: Major cause hyperventilation (losing C02)
S/S: RR less than 20, Increase HR, Confusion, Tetany, +chvostek sign (hypocalcemia)
The nurse is reviewing a patient's labs. Which lab value requires the nurse's immediate attention?
A. pH 7.47
B. PaCO2 30
C. HCO3 26
D. Sa02 96%
(B) PaCO2 is lower than the normal value. This patient is already showing impaired gas exchange with lower levels of CO2. Next action for the nurse to take is to assess patient.
PH 7.35-7.45
PaCO2 35-45
HCO2 22-26
Sa02 95-100%
The nurse is reviewing morning labs of a patient that was admitted last night. What conclusion would you except the nurse interpreted from the following labs listed below?
pH 7.47, PaCO2 30, HCO3 26, Sa02 96%
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Alkalosis
D. Respiratory Acidosis
C. Respiratory Alkalosis PH increased and CO2 decreased.
The nurse is caring for a patient who has hypovolemia. Which of the following signs and symptoms should the nurse except to see in this patient?
A. Oliguria
B. Altered LOC
C. Elevated BP
D. Bounding, Peripheral Pulses
A.
Hypovolemia s/s:
Oliguria-Decreased urine output
Depressed CNS, lethargy to coma
Decreased BP and orthostatic hypotension.
Thready, PP and Tachycardia
Review the following lab results and interpret the findings:
Decreased BUN, Decreased Na, Decreased USG (urine specific gravity), Decreased HCT
A. Hypovolemia
B. Hypervolemia
C. Iron deficiency anemia
D. Malnutrition
B (Hypervolemia) TOO MUCH FLUID
Hypovolemia: Increased USG, Increased BUN, Increased Na, Increased HCT
What assessment findings would not be excepted with a patient that has fluid volume overload?
A. Pitting Edma bilateral in lower extremities
B. Increased body weight
C. Dry mucous membranes and poor skin turgor
D. Increased respiratory rate with dyspnea
C. Dry mucous membranes and poor skin turgor is s/s of hypovelmia
The nurse is administering a hypertonic solution, the understanding of this fluid type is to shift fluid from
A. Extracellular to intracellular
B. Intracellular to extracellular
C. Intravascular to interstitial
D. Interstitial to intracellular
B (hypertonic) makes the cell skinny
Based on the following lab value what signs and symptoms would you except this patient to have?
Potassium 3.6, Calcium 8, Phosphate 4, Sodium 140, Magnesium 2
A. Excess thirst
B. Depressed Respirations
C. +trousseau's sign
D. Hyporeflexia
C. Hypocalcemia S/S: +Trousseaus, +Chvostek's, Diarrhea, Tingling around mouth and arms, weak bones.
Based on the following lab value what signs and symptoms would you except this patient to have?
Potassium 2.1, Calcium 10, Phosphate 3.2, Sodium 136, Magnesium 1.5
A. Hyperreflexia of the deep tendon reflexes
B. Edema and Flushed skin
C. Increased HR with Ventricular Fibrillation
D. Decreased HR with ST Depression
D. Hypokalemia
Low & Slow Heart Rate (ST Depression), Decreased Deep Tendon Reflexes (DTR), Flaccid muscles (weakness), Slow GI-Severe Constipation or Diarrhea, Fatigue
The nurse is caring for a patient who has a Magnesium level of 3.5. What actions should the nurse take next prior to notifying MD?
A. Monitor HR and BP.
B. Listen to the BS in all 4 quadrants.
C. Check Deep Tendon Reflexes.
D. Auscultate the lungs and count RR.
D. Lung assessment is priority. Hypermagnesemia causes depressed shallow respirations, decreased DTR, Bradycardia, and hypotension, plus hypoactive bowel sounds. Mag is a smooth muscle relaxant. Use ABC's to help answer this question.
The nurse is caring for a patient who has been prescribed Lasix. What should the nurse educate to the patient about this medication?
Narrative Answer
1. Monitor potassium levels (frequent office visits)
2. Avoid potassium rich foods (sweet potatoes, yellow potatoes, oranges, mangos, bananas)
3. Monitor HR
4. Notify MD is S/S of: Hypotension, slow HR with arrythmias, frequent diarrhea, fatigue
The nurse is caring for a patient with a phosphate level of 5.0. What nursing intervention would help this patient most?
A. Educate to avoid calcium rich foods
B. Ambulate the patient TID
C. Encourage the patient to consume milk products
D. Encourage the patient to do oral care BID
(C): Encourage the patient to consume milk products
Ca low = Phosphate high
The patients BMI is 33. What should the nurse include in the patients care plan?
Narrative answer
Assess patients eating habits by assessing a 24 hour recall or have patient keep a diary
Assess Daily weights
Consult nutritionist to assist patient with meal planning
Educate a proper diet using the myplate.gov resources
Educate exercising 30 mins a day/7 days a week
Encourage the patient to avoid high fat diet (25-35%) daily and eat a high fiber diet 25-35% daily
Educate about the risk of heart disease in obese patients
The nurse is caring for a patient who has an order to place a NG-tube. Further education is needed if the nurse performs what intervention after placement of the tube.
A. Obtain an X-Ray to verify placement.
B. Collect gastric residual to assess Ph level.
C. Administer feeds with ice cold water flushes.
D. Monitor Residual amount prior to administering feeds.
C. Tepid (room temperature) water should be flushes before and after tube feed administration.
The nurse must implement aspiration precautions for a patient with a nutritional deficit. The nurse needs additional teaching about aspiration precautions if
A. places the patient in a semi-fowlers position 30-60 mins after the feed is administered
B. gives small bites of food and encourages small sips of water between each bite.
C. Gives the patient a cup of water with a straw.
D. Places the patient in a side-lying position while continuous feeds are being administered.
C. Water is the worst thing to give to a patient with aspiration risks, plus the use of a straw is contraindicated because it makes it easier to suck water into the lungs.
Water should always be thickened per the recommended consistency with thickening powder.
A patient receiving tube feedings for the first time begins to experience severe diarrhea. What is the nurses next best action?
A. Stops the feed, flush with 30 ml of water, then notify MD of formula intolerance.
B. Stops the feed immediately and flush with 20 mL of coke, then notify MD of formula intolerance.
C. Stops the feed and flush with 30 mL of water, then collect residual measurement and Ph levels, then notify MD of formula intolerance.
D. Stops the feed and flush with 30 mL of cold water, then ask the patient to take a deep breath while pulling the tube out fast and quickly, then notify MD.
A. Best Practice Guidelines
B. Coke flush must be ordered by MD, and it is only used for preventing occlusions not formula intolerance.
C & D. Collecting residual and Ph levels are not necessary at this time, plus monitoring residual and pH are checking placement guidelines. Also, cold water flushes are contraindicated.
The nurse is concerned that their patients PEG tube is becoming occluded. Which action by the nurse requires follow up?
A. The nurse flushes the tube with 30 mL of air and auscultates for 1 min, excepting to hear 5-30 gargling sounds.
B. The nurse flushes the tube with 30 mL of air followed by 30 mL's of warm water into the tube.
C. The nurse notifies the MD and recommends that all medications be changed to a liquid-form.
D. The nurse crushes each medication individually and mixes it with 10-15 mL of sterile water, then the diluted medication is inserted into the tube by gravity or push, followed by 15-30 mL of sterile water.
This question is all about occlusion of a PEG tube interventions.
A. Incorrect technique: This doesn't prevent occlusion nor is it the correct technique for checking placement either.
B. Correct technique: Flush air followed by warm water flush will help clear the tube which prevents occlusion.
Textbook guidelines:
If the tube becomes occluded, flush it with a small amount of air. If this is unsuccessful in removing the occlusion, flush the tube using a 30- to 60-mL syringe and warm water. If flushing the tube with water is ineffective, research now suggests using special enzyme solutions or declogging devices rather than carbonated beverages or juices.
C. Getting all medication switched to liquid form will help prevent occlusion plus, help with the absorption of the medication.
D. Medications are never added directly to a tube feeding; rather, they are given in liquid form or ground into powder (as permitted, depending on the medication) and dissolved in 15 to 30 mL of sterile water before instillation into the tube. The enteral tube placement is verified, the tube is flushed with a minimum of 15 mL of sterile water, and the diluted medication is then allowed to flow into the tube by gravity or pushed in gently by plunger, followed by 15 to 30 mL of sterile water to flush the tube after medication administration.
You are caring for a patient that is diabetic currently receiving dialysis treatment 3 days a week. What type of diet should this patient be on?
A. Clear liquid diet, then advance to a full liquid diet as tolerated.
B. Diabetic, Renal, and Cardiac Diet
C. Diabetic and Renal Diet
D. Thicken Liquids and Pureed Diet
B. Diabetic, Renal, and Cardiac Diet
--The patient is diabetic receiving dialysis (dialysis due to chronic kidney disease). A cardiac diet is included because it is recommended for patients that have chronic kidney disease which places strain on the patient's heart.
Below is a list of all diets with food recommendation.
- Clear liquid Diet: such as apple or cranberry juice, (JELLO) gelatin, popsicles, and clear broths). Clear-liquid diets most commonly are ordered for patients with GI problems, before surgery (preoperatively) and after surgery (postoperatively), and before some diagnostic tests.
• Full-liquid diets: consist of foods that are or may become liquid at room or body temperature. Full-liquid diets include juices with and without pulp, milk and milk products, yogurt, strained cream soups, and liquid dietary supplements. Full-liquid diets are often ordered for patients who have GI disturbances, dental work performed, or who cannot tolerate solid food when they do not need to be NPO or limited to a clear liquid diet.
• Pureed diets (blended), consist of food that is placed into a blender and made into a pulplike mixture. This type of diet is used for individuals who cannot safely chew or swallow solid food. The addition of raw eggs, nuts, and seeds should be avoided.
• Mechanical soft diets include food consistencies that have been modified, such as ground meat or soft-cooked foods. They are used for those who have difficulty chewing effectively.
• Thickened liquids are used for patients who have difficulty swallowing and are at risk for aspiration. Liquids can be thickened by adding a commercially prepared thickening agent. Nuts, seeds, and other hard or raw foods should be avoided to decrease the risk of aspiration.
• Regular diets, or general diets, are commonly referred to as diet as tolerated. There are no dietary restrictions, but foods should supply patients with a balanced diet of essential nutrients.
• Diabetic diets are prescribed to control the number of calories by controlling carbohydrate intake. Foods that have a high glycemic index and rapidly raise the body’s blood glucose concentration should be avoided. High-fiber complex carbohydrates from vegetables and fruits are preferred. Avoid simple carbohydrates, sugars, and starchy foods (such as bread or pie).
• Cardiac diets: consist of low-cholesterol and low-sodium dietary items. Cardiac diets minimize the intake of animal products, which contain cholesterol, and soups and processed foods (such as pickles and lunchmeats), which are high in sodium. Patients with hypertension, high cholesterol, atherosclerosis, chronic kidney disease, or similar diseases may be placed on some type of cardiac (low-cholesterol, low-sodium) diet.
• Renal diet: restrict potassium, sodium, protein, and phosphorus intake. Fresh fruits (except bananas) and vegetables are excellent dietary choices for people on a renal diet.
The nurse is caring for a patient receiving TPN. The nurse understands that close monitoring is necessary because the patient is at risk for
A. hyperlipidemia
B. glycemic control
C. folic acid deficiency
D. C-Diff
B. Correct
TPN risk factors are:
Catheter infection is a common and serious complication of parenteral nutrition. Other potential short-term complications of parenteral nutrition include blood clots, fluid and mineral imbalances, and problems with blood sugar metabolism.
Long-term complications may include too much or too little of trace elements, such as iron or zinc, and the development of liver disease. Careful monitoring of your parenteral nutrition formula can help prevent or treat these complications.
Nurse is caring for a patient that is receiving TPN via a central line in the right upper arm. What nursing intervention requires follow up?
A. Central line site is assessed daily and prior to use for redness, edema, bleeding, warmth, and drainage.
B. Central line dressing is changed every 5-7 days unless it becomes soiled or insert site becomes compromised.
C. Tubing is changed every 48 hours on the TPN bag to prevent infection.
D. The lumens on the central catheter should be replaced using sterile technique every 3 days.
A, B, D are correct techniques.
C. Requires follow up, the tubing must be replaced every 24 hours on the TPN bag to prevent infection.
The nurse is caring for a patient that was admitted for dehydration. The MD ordered the patient to receive IV fluids, an isotonic solution to run at 125 ml/hr and ordered an advanced as tolerated diet. What should the nurse be expected to monitor closely on this patient?
A. I & O
B. Daily Weights
C. Respiratory assessment every 1-2 hours
D. Pulse Oxygenation
This question can be placed in order.....every answer is correct. The nurse should monitor for all however, the question is designed to make you critically think. Any time a patient is receiving IV infusion of fluids your concern should be to monitor for S/S of Fluid Overload. Prioritize your care.....(use Maslow's and ABC's to help you).
Correct answer is (C). Respiratory Assessment should be performed every 1-2 hours. Monitor for crackles and shortness of air, these are the S/S of fluid overload in the lungs. This takes presidency over the other interventions so you can to action to prevent harm to your patient. If you hear crackles in the lungs and see patient having difficulty breath, then your priority is to stop the infusion, and notify MD.
2nd action. (D). Pulse Oxy. should be monitored every 4 hours while receiving IV fluids, along with all other vital signs.
3rd action. (B) Daily weights should be done daily, in the morning, prior to breakfast on the same scale. Daily weights are the most accurate assessment for fluid gain verses loss.
4th (A) Intake and Output should be monitor 24/7 of every patient receiving IV infusions.
A patient’s potassium level is 3.0. Which foods would you encourage the patient to consume?
A. Cheese, collard greens, and fish
B. Avocados, strawberries, and potatoes
C. Tofu, oatmeal, and peas
D. Peanuts, bread, and corn
B. Avocados, strawberries, and potatoes