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The nurse is planning care for a pt w/eating disorder. Pt weight 40kg, height 68in. Serum lab data: k 2.6, Na+ 126, Cl 95, CA+ 10.8. Which intervention is the most important for the pt?
Maintain IV dextrose and electrolytes
Rationale: The priority is to provide nourishment and correct electrolyte imbalance, which can be life threatening.
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Which patient is considered obese?
a. 25 y/o woman w/body weight 5% above ideal
b. 45 y/o man w/waist-to-hip ratio of 0.5
c. 50 y/o man w/BMI of 31
d. 16 y/o girl w/anorexia nervosa weighing 98lbs
A 50 y/o old man with BMI 31
- Rationale:
- Very underweight < 15
- Underweight 16-18.4
- Normal 18.5-24.9
- Overweight 25-29.9
- Obese 30-34.9
- Very Obese > 35
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A pt is diagnosed w/aphthous stomatitis (canker sore). An appropriate nursing action would be... ?
Teach pt to apply topical tetracycline several times a day to sore.
- Rationale:
- Topical tetracycline can aid healing canker sores
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Which intervention is appropriate for a patient with acute gastritis?
Monitor patient for bloody diarrhea.
Rationale: A symptom of gastritis is bloody darrhea.
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What is the primary cause of peptic ulcers?
A bacterial infection
Rationale: Helicobacter pylori, a bacterium, is the most common cause of peptic ulcers.
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What is the purpose of H2 antagonists?
To inhibit secretion of gastric acid.
Rationale: H2 antagonists inhibit secretion of gastric acid.
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Patient just returned from surgery after total gastrectomy and begins to vomit bright red blood. What is a priority action for the nurse to take?
Place patient onto side.
Rationale: To protect the airway, the patient must be placed onto his/her side.
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For the patient with dumping syndrome, which foods would the nurse instruct the patient to avoid?
Coffee and glazed doughnuts
Rationale: Fluid and fat intake promote rapid gastric emptying.
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To deliver 1000ml of 5% dextrose in 0.45 normal saline (at 150ml/hr using 10 drop tubings), the nurse would monitor the IV infusion at how many drops per minute?
25 drops per minute
- (150 x 10) / 60min = 25
- (volume x calibration) / minutes = gtt/min
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The nurse is collecting data on a patient admitted with a history of severe diarrhea. Findings include cool, pale skin, red tongue with furrows, BP 102/74, pulse 106, RR 20, T 99.9*F.
Which action should the nurse take now?
Report finding to registered nurse.
Rationale: Report findings because symptoms of dehydration are present along with elevated vital signs.
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Which statement about laxative use would the nurse include in a teaching plan to promote patient understanding?
Regular laxative use can be harmful.
Rationale: Laxatives should be used only occasionally to prevent dependence and complications.
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Which interventions should the nurse include in IPOC for a pt after appendectomy (post-op) to prevent respiratory complications?
- Pain control
- Early ambulation
- Coughing, deep breathing
- Incentive spirometer
Rationale: Control pain and promote lung expansion with activity or coughing and deep breathing.
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Which foods should a patient with ulcerative colitis avoid?
Fresh fruits
Rationale: Fresh fruit is high in fiber and would promote diarrhea.
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Following a teaching session, which of the following statements would indicate to the nurse that the patient understood the teaching for postoperative care to prevent respiratory complications after a hernia repair?
"I will deep breathe every hour while awake."
Rationale: Coughing is contraindicated to prevent damaging the repair, but deep breathing should be done.
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The nurse would evaluate the patient as understanding teaching for celiac disease if the patient selected which foods to eat?
Hard boiled eggs, bacon, and blueberries
Rationale: This is the only selection that does not contain a type of grain that must be avoided.
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The nurse is caring for a patient with a small-bowel obstruction. The pt is NPO with an orogastric tube providing low intermittent suction. Which ongoing data would be a priority for the nurse to monitor and collect?
- I&O
- Pain level
- Bowel sounds
- Pulse rate
- Temperature
Rationale: These data detect pain, dehydration, infection or shock - a priority for this intervention/TX.
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The nurse is caring for a patient who has a sudden onset of diarrhea. Which term should the nurse use to document the patient's black, tarry stool?
Melena
Rationale: Black tarry stool is referred to as melena and indicates bleeding above or within the small bowel.
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Which dietary habit might increase risk for development of colon cancer?
High-fat, low fiber intake
Rationale: A high-fat, low fiber diet increases the risk of colon cancer.
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The nurse is caring for a 1-day post-op patient who has a new end colostomy. Which finding would be a priority for the nurse to report?
Dusky color
Rationale: A dusky color indicates impaired circulation and requires immediate medical treatment to restore blood flow.
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A patient with Crohn's disease is to receiv e sulfasalazine (Azulfidine), 500mg oral suspension qid. The oral suspension is available as 250mg/5ml. How many mililiters should the nurse give for the 0800 dose?
10ml
Rationale: Desired Over Have
- 500/250 x 5 = 10ml
- Desired amt/have on hand x number of mililiters = dose
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Which condition places a patient with cirrhosis at the most risk for bleeding?
Low vitamin K
Rationale: Vitamin K is needed for blood clotting, a low level increases the risk of bleeding.
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The nurse is caring for a patient with cirrhosis. The nurse would cautiously use sedatives for the patient based on which of the following?
Sedatives are potentially toxic to the cirrhosis patient.
- Rationale:
- Sedatives are potentially toxic to the cirrhosis patient due to impaired hepatic metabolism of these medications.
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Which clinical manifestations of acute hepatitis A would the nurse expect a patient to report?
- Headache, nausea, and flu-like symptoms
- Rationale: Symptoms of Hep A
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The nurse is caring for a pt with chronic pancreatitis. The nurse would expect an elevation in which lab test?
Serum amylase
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A patient with acute pancreatitis is NPO and has been receiving only IV hydration. Which lab result indicates the need to consult dietary for nutritional support?
Serum albumin 2.9 g/dl
- Rationale:
- Albumin / normal range 4-6 g/dL
- A low serum albumin level indicates malnutrition
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IPOC for newly admitted pt with acute pancreatitis, which pt outcome should receive highest priority?
Patient expresses satisfaction with pain control.
- Rationale:
- Because pancreatitis is very painful, patient satisfaction with pain control is a priority.
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The nurse is collecting data for a patient who develops jaundice and dark, amber-colored urine. What is most likely the cause?
Bile duct obstruction
- Rationale:
- Bile duct obstruction can result in jaundice and dark, amber-colored urine due to bile blockage.
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Which foods would be included for a patient on a low-fat diet following a cholecystectomy?
Roast chicken, rice, gelatin dessert
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The nurse is caring for a patient who had an open cholecystectomy 24 hours ago. Which actions should the nurse take to assist the pt to maintain an effective breathing pattern?
- Provide analgesics for pain relief
- Encourage coughing and deep breathing
- Assist with splinting during coughing
- Rationale:
- Pain relief allows comfortable breathing, preventing shallow respirations and guarding. Splinting make coughing more comfortable, encouraging coughing and deep breathing to keep lungs clear.
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The nurse is to administer promethazine 12.5mg IM and has 50mg/mL on hand. How many mL should be drawn up?
0.25 mL
Rationale: Desired Over Have
12.5mg/50mg x 1mL = 0.25mL
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