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.
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
- Very underweight < 15
- Underweight 16-18.4
- Normal 18.5-24.9
- Overweight 25-29.9
- Obese 30-34.9
- Very Obese > 35
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.
- Topical tetracycline can aid healing canker sores
Which intervention is appropriate for a patient with acute gastritis?
Monitor patient for bloody diarrhea.
Rationale: A symptom of gastritis is bloody darrhea.
What is the primary cause of peptic ulcers?
A bacterial infection
Rationale: Helicobacter pylori, a bacterium, is the most common cause of peptic ulcers.
What is the purpose of H2 antagonists?
To inhibit secretion of gastric acid.
Rationale: H2 antagonists inhibit secretion of gastric acid.
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.
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.
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
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.
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.
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.
Which foods should a patient with ulcerative colitis avoid?
Rationale: Fresh fruit is high in fiber and would promote diarrhea.
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.
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.
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?
- Pain level
- Bowel sounds
- Pulse rate
Rationale: These data detect pain, dehydration, infection or shock - a priority for this intervention/TX.
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?
Rationale: Black tarry stool is referred to as melena and indicates bleeding above or within the small bowel.
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.
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?
Rationale: A dusky color indicates impaired circulation and requires immediate medical treatment to restore blood flow.
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?
Rationale: Desired Over Have
- 500/250 x 5 = 10ml
- Desired amt/have on hand x number of mililiters = dose
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.
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.
- Sedatives are potentially toxic to the cirrhosis patient due to impaired hepatic metabolism of these medications.
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
The nurse is caring for a pt with chronic pancreatitis. The nurse would expect an elevation in which lab test?
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
- Albumin / normal range 4-6 g/dL
- A low serum albumin level indicates malnutrition
IPOC for newly admitted pt with acute pancreatitis, which pt outcome should receive highest priority?
Patient expresses satisfaction with pain control.
- Because pancreatitis is very painful, patient satisfaction with pain control is a priority.
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
- Bile duct obstruction can result in jaundice and dark, amber-colored urine due to bile blockage.
Which foods would be included for a patient on a low-fat diet following a cholecystectomy?
Roast chicken, rice, gelatin dessert
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
- Pain relief allows comfortable breathing, preventing shallow respirations and guarding. Splinting make coughing more comfortable, encouraging coughing and deep breathing to keep lungs clear.
The nurse is to administer promethazine 12.5mg IM and has 50mg/mL on hand. How many mL should be drawn up?
Rationale: Desired Over Have
12.5mg/50mg x 1mL = 0.25mL