IV Therapy
A client has an order to receive 1000 mL of 5% dextrose in 0.45% NaCl. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?
1. Uncaps the distal end of the tubing
2. Uncaps the spike portion of the tubing
3. Opens the roller clamp on the IV tubing
4. Closes the roller clamp on the IV tubing
4. Closes the roller clamp on the IV tubing
Identify the appropriate times to verify enteral tube placement by pH testing. (Select all that apply.)
A) Before each intermittent feeding
B) At least once every 6 hours during continuous feedings
C) Before administration of medications through the tube
D) After administration of medications through the feed
A) Before each intermittent feeding
B) At least once every 6 hours during continuous feedings
C) Before administration of medications through the tube
EJ presents to the ER with altered mental status and a respiratory rate of 15 bpm. After sending for an ABG sample the results revealed a blood pH of 7.29, a HCO3 of 25 and a PaCO2 of 50. What would be a correct interpretation of the client’s arterial blood gases?
Respiratory Acidosis
A nurse interviews an 82-year-old resident of a long-term care facility who says that she has never gotten over the death of her son 20 years ago. She reports that her life fell apart after that and she never again felt like herself or was able to enjoy life. What type of grief is this woman experiencing?
a. Abbreviated
b. Anticipatory
c. Dysfunctional
d. Inhibited
c. Dysfunctional
A high school student comes to the nurse's office to discuss her anxiety regarding an upcoming test. Her test-taking anxiety is a(an)
a) Adjustment
b) Concern
c) Threat
d) Stressor
Stressor
Explanation: Stress, coping, and adaptation are interrelated. Survival depends upon successful coping responses to ordinary and sometimes extraordinary circumstances and challenges.
A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown?
1. Using a hospital gown with snaps at the sleeves
2. Disconnecting the IV tubing from the catheter in the vein
3. Checking the IV flow rate immediately after changing the hospital gown
4. Putting the bag and tubing thru the sleeve, followed by the client's arm
2. Disconnecting the IV tubing from the catheter in the vein
The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton-pump inhibitor omeprazole (Pepcid). The pH strip reads "3." Where should the nurse expect the x-ray to determine placement of the feeding tube?
A) In the lungs
B) In the esophagus
C) In the stomach
D) In the small intestine
C) In the stomach
Dave, a 6-year-old boy, was rushed to the hospital following her mother's complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out?
Metabolic Alkalosis
A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move on." This reflects the patient's progress to which stage of death and dying?
a. Acceptance
b. Anger
c. Bargaining
d. Denial
a. Acceptance
The client is a 5-year-old child hospitalized for a surgical procedure. The client is bedwetting. The parents report this is a new behavior and their child is toilet trained. The nurse assesses the client is exhibiting the defense mechanism of
a) displacement.
b) reaction formation.
c) compensation.
d) regression.
regression.
Explanation: Regression is a maladaptive behavior in which the client returns to an earlier method of behaving as seen in the child who is now bedwetting.
A nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy at least every:
1. 1 hour
2. 2 hours
3. 3 hours
4. 4 hours
1. 1 hour
For safe administration of oral medications through a feeding tube, specific attention must be paid to: (Select all that apply.)
A) Proper placement of the tube
B) The patient's temperature
C) Whether the medication can be crushed for administration through the tube
D) The patient's electrolyte status
A) Proper placement of the tube
C) Whether the medication can be crushed for administration through the tube
A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is:
35-45
A patient tells a nurse that he has no one he trusts to make health care decisions for him should he become incapacitated. What should the nurse suggest he prepare?
a. Combination advance medical directive
b. Durable power of attorney for health care
c. Living will
d. Proxy for health care
c. Living will
The nurse is interviewing a client with complaints of chronic fatigue. The nurse understands that the client has a sedentary lifestyle and suggests that the client start low-intensity exercise. Which of the following exercises would be appropriate for the nurse to suggest the client engage in initially?
a) Brisk walking
b) Running
c) Cycling
d) Gardening
Gardening
Explanation: The nurse should suggest that the client start with gardening, which is a low-intensity exercise and is particularly good preparation for sedentary persons before they progress to more vigorous aerobic exercise. Running, cycling, and brisk walking are vigorous aerobic exercises.
Which of the following clients are most likely to develop circulatory overload? (select all that apply)
1. A premature infant
2. A 101-year-old man
3. The client on renal dialysis
4. The client with diabetes mellitus
5. A 29-year-old woman with pneumonia
6. The client with CHF
1. A premature infant
2. A 101-year-old man
3. The client on renal dialysis
6. The client with CHF
Which finding in a patient receiving enteral feedings at 80 mL/hr through a nasointestinal tube needs further follow-up?
A) Gastric residual volume is 100 mL for the last 4 hours.
B) Gastric aspirate is dark brown with a foul odor.
C) Patient had two formed stools during the previous 24-hour period.
D) Patient has active bowel sounds during morning assessment.
B) Gastric aspirate is dark brown with a foul odor.
A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided?
Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation is also known as overbreathing. When someone is hyperventilating, they tend to breathe very deeply or very rapidly.
A nurse is providing postmortem care. Which nursing action violates the standards of caring for the body after a patient has been pronounced dead and is not scheduled for an autopsy?
a. The nurse places the patient in a sitting position while the family visits.
b. The nurse places identification tags on both the shroud and the ankle.
c. The nurse removes soiled dressings and tubes.
d. The nurse makes sure a death certificate is issued and signed.
a. The nurse places the patient in a sitting position while the family visits.
The children of a 60-year-old woman are distraught at her apparent lack of recovery following a stroke several weeks earlier. The patient's daughter has frequently directed harsh criticism toward the nurses, accusing them of a substandard effort in rehabilitating her mother despite their best efforts. What defense mechanism may the patient's daughter be exhibiting?
a) Sublimation
b) Regression
c) Displacement
d) Denial
Displacement
Explanation: The daughter may be transferring her feelings about her mother's health status to the care providers, an act that involves the displacement of the emotional reaction to another person. Denial about her mother's potential for recovery may underlie her response, but this is not demonstrated as clearly as displacement.
The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home?
1) keep the affected arm immobilized
2) aspirate 3 mL of blood from the PICC line
3) maintain a continuous IV infusion
4) check the insertion site for redness and swelling
4) check the insertion site for redness and swelling
Match type of nutrition with patient.
A. Parenteral nutrition
B. PEG tube
C. NG feeding tube
1.Patient with difficulty swallowing after having a CVA and will need long-term nutritional support.
2.Patient with burns who cannot consume enough calories orally.
3.Patient with malabsorption syndrome.
B) PEG tube :Patient with difficulty swallowing after having a CVA and will need long-term nutritional support.
C) NG feeding tube :Patient with burns who cannot consume enough calories orally.
A) Parenteral nutrition :Patient with malabsorption syndrome.
Liza's mother is seen in the emergency department at a community hospital. She admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the gentleman at risk for if medical attention is not provided?
Salicylate overdose causes a high anion gap metabolic acidosis in both children and adults
Which physical disturbance is commonly assessed in patients experiencing acute grief?
a. Hypersomnia
b. Increased appetite
c. Tightness in the chest
d. Cardiovascular problems
ANS: C
Chest discomfort is common with the bereaved person. Anorexia is more common. There is no research to support the connection with cardiovascular involvement. Insomnia is more frequent than sleepiness.
Which of the following is a physiological response experienced during the exhaustion stage of general adaptation syndrome?
a) Increased mental alertness
b) Vasoconstriction
c) The initiation of neuroendocrine activity
d) Decreased blood pressure
Decreased blood pressure
Explanation: The stage of exhaustion is often accompanied by decreased blood pressure and vasodilation. Increased mental alertness and the initiation of neuroendocrine activity are associated with the alarm reaction of the GAS.