B with NGN
A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral
tube feedings. Which of the following laboratory values indicates that the client needs additional
nutrients added to the feeding?
(A) Creatinine 1.1 mg/dL
(B) Albumin 2.8 g/dL
(C) Triglycerides 100 mg/dL
(D) Alkaline phosphatase 118 units/L - ANS Albumin 2.8 g/dL
[The expected reference range for albumin is 3.5 to 5 g/dL]
(A creatinine level of 1.1 mg/dL is within the expected reference range of 0.5 to 1.1 mg/dL for a female
client, and 0.7 to 1.3 mg/dL for a male client)
(A triglyceride level of 100 mg/dL is within the expected reference range of 35 to 135 mg/dL for a female
client, and 40 to 160 mg/dL for a male client)
(An alkaline phosphatase level of 118 units/L is within the expected reference range of 30 to 120 units/L.
An elevated alkaline phosphatase level is an indication of liver or bone disorders, with a decreased level
indicating malnutrition)
Burkholderia cepacia lung infection: what type of precautions will be initiated? - ANS Contact isolation
precautions
,A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following
interventions should the nurse use to maintain surgical aseptic technique?
(A) Hold hands folded below the waist after donning sterile gloves.
(B) Pick up and pour solutions with the palm of the hand covering bottle labels.
(C) Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape.
(D) Maintain sterile objects within the line of vision. - ANS Maintain sterile objects within the line of
vision.
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. Which of the following actions should the nurse plan to take?
(A) Perform ADLs for the client to promote rest.
(B) Allow for frequent rest periods throughout the day.
(C) Use heat to reduce joint inflammation.
(D) Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. - ANS
Allow for frequent rest periods throughout the day.
[The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to
maintain muscle strength, joint function, and range of motion]
(The nurse should allow the client to perform their own ADLs to promote the client's joint mobility and
independence)
, (The nurse should use ice to reduce joint inflammation and heat to alleviate joint discomfort)
(The nurse should not administer more than 3 g of acetaminophen to the client each day to reduce the
risk of injury to the client)
A nurse is caring for a client during a follow up visit at a gastrointestinal clinic.
NURSE NOTES:
0600:
Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client
states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place,
and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood
drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaitin - ANS [ ] Administer IV fluids:
Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell
sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr.
[ ] Use humidification with oxygen therapy
[ ] Assess peripheral circulation hourly is correct
[ ] assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of
infection
(Using a blood pressure cuff on the client's arm can cause venous occlusion and increased pain.
Alternatives to monitoring blood pressure should be explored when caring for a client who has sickle cell
crisis)