NSG 3100 Exam 4 | Latest Update | Questions and Answer Solutions | GRADED A.

NSG 3100 Exam 4 (Latest Update) Questions and Answer Solutions (GRADED A). When the client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? Neurological While assisting the client with meal selection, the nurse realizes that clients who practice Islam or Judaism share an avoidance of: pork products. The client wants to increase intake of an antioxidant in her diet. The nurse recommends including vitamin C, which is best found in: Correct Answer: tomatoes. For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with: Correct Answer: metabolic acidosis. Which of the following techniques used by the new staff nurse for administering medications via an enteral tube requires correction by the charge nurse? Correct Answer: Adding the medications to the tube feeding After a surgical procedure, the client is advanced to a full liquid diet. The nurse is able to recommend which one of the following foods for this client? Correct Answer: Yogurt While doing a nutritional assessment of a low-income family, the community health nurse determines that the family's diet is inadequate in protein content. The nurse suggests which of the following lowercost foods to increase protein content? Correct Answer: Beans The client has had throat surgery and is placed on a clear liquid diet. The nurse should offer the patient: Correct Answer: apple juice. The majority of body fluid is located in which area? Correct Answer: Intracellular The nurse recognizes that the client, on the basis of the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the physician is: Correct Answer: Lactated Ringer solution. One of the first indications of fluid volume deficit is: Correct Answer: tachycardia. For the client with a vitamin D deficiency and inadequate calcium intake, the nurse observes for: Correct Answer: Chvostek sign Chvostek sign an abnormal reaction to the stimulation of the facial nerve. A nasogastric tube is inserted in order for the client to receive intermittent tube feedings. The action by the nurse that requires correction by the unit manager is: Correct Answer: instilling air into the NG tube to check for placement. The mucous membranes of a normally hydrated individual are: Correct Answer: moist. Of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is: Correct Answer: 42-year-old with severe vomiting. The single best indicator of fluid status is the nurse's assessment of the client's: Correct Answer: daily body weight The nurse is inserting a nasogastric tube. During the insertion, the client starts to gag and becomes dyspneic. Which action should the nurse take? Correct Answer: Withdraw the tube and start again. It is recommended that adults consume approximately how much of their diet from carbohydrates? Correct Answer: 50% A critical measure for clients with hypocalcemia and hypomagnesemia is: Correct Answer: implementing seizure precautions. For the client who needs fluid replacement, which of the following should be avoided? Coffee Albumin levels indicate prolonged malnutrition. True Causes of hyponatremia include Excessive diaphoresis Diuretics Wound drainage Hyponatremia low sodium causes of hypernatremia Fever Diarrhea Excessive sodium intake Hypernatremia high sodium An example of hemoconcentration seen in dehydration is increased hematocrit levels. T or F True Signs of fluid overload High BP Pitting edema in lower extremities Mental confusion Moist crackles Which is a sign/symptom of hypernatremia? Thirst hypokalemia low potassium Causes of hypokalemia Prolonged NGT suction Heavy perspiration Diarrhea Potassium must always be diluted appropriately and never given IV push. T or F True Signs and symptoms of hypokalemia Muscle weakness Leg cramps Decreased deep tendon reflexes Weak irregular pulses Hypocalcemia deficient calcium in the blood Signs and symptoms of hypocalcemia Numbness and tingling of extremities Positive Chvostek's sign Cardiac dysrhythmias respiratory acidosis A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2. Causes of respiratory acidosis Aspiration of foreign body Overdose of narcotics or sedatives Chronic lung disease metabolic alkalosis metabolic condition in which the pH of tissue is elevated beyond the normal range cause of metabolic alkalosis Vomiting Antacids Potassium draining diuretics dysphagia difficulty swallowing A client with dysphagia can be observed doing this while eating Coughing/gagging Improving appetite includes what actions? Small portions Oral hygiene Relieve illness symptoms Which of the following foods are high in vitamin C? Broccoli Signs of malnutrition Spoon shaped nails Lack of SQ fat Dull/dry hair Which of the following foods would be included in a full liquid diet? Ice cream What is the most accurate way to verify tube placement prior to initiating enteral feeding? Xray When administering a tube feed by gravity, the nurse would adjust the flow rate by raising and lowering the syringe. T or F True Prior to administering a bolus tube feeding, the nurse should do what? Make sure the feeding is at room temperature Check residual contents of the stomach Perform hand hygiene Hypertonic IV solutions cause a shift from: intracellular to extracellular Calculate the total intake: 8 oz coffee, 4 oz orange juice, 16 oz soda. 840 mLs Which nursing intervention is most appropriate for the pt. developing respiratory alkalosis? Encouraging slow, deep breaths Trousseau's sign is performed by tapping the client's cheek and observing for facial muscle twitching. T or F False T or F: Never reinsert the stylet of a small bore feeding tube while the tube is in place. True How to calculate BMI [weight lbs/(height in inches)^2] x 703 BMI ranges -Underweight: 18.5 -Healthy weight: 18.5-24.9 -Overweight: 25-29.9 -Obese: 30-39.9 -Extreme obesity: 40+ Risk factors for nutritional problems Diet history, Medical history, and Medication history What does low albumin indicate? Prolonged protein deficiency Malnutrition biochemical data Labwork 24-hour food recall client recalls all the food and beverages consumed during a typical 24-hour period Food frequency record a checklist that indicates how often general food groups or specific foods are eaten food diary A record of the kinds and amounts of all foods and beverages consumed for a given time diet history a comprehensive assessment of a client's food intake that involves an extensive interview by a nutritionist or dietitian What system does a B12 deficiency effect Neuro Client teachings for overweight individuals Discuss lifestyle factors Choose goal weight Low calorie caffeine free beverages Drink more water Smaller plates Walk Chew more thoroughly Exercise Reduce stress clear liquid diet Coffee Tea Sodas Broth Juice Gelatin full liquid diet Al foods on liquid plus: Milk Pudding Ice cream Vege juice Cream of wheat Butter Eggs Peanut butter Yogurt Soft diet Foods on clear and full liquid diets and: easy to chew foods Types of NG tubes Levin (single lumen-suction), Salem sump (double lumen-suction), Senstaken (triple lumens-irrigation/suction) How to measure fluid volume of ice chips 1/2 volume of ice chips Convert mLs to oz 30 mLs=1 oz parenteral nutrition nourishment provided via IV therapy total perenteral nutrition (TPN) Only through central lines Severe malnutrition normal fluid intake 2-3 L/day insensible water loss Skin Lungs Stool Sensible weight loss Urine Sweat fluid volume deficit DEHYDRATION: fluid intake is not sufficeint to meet the fluid needs of the body Symptoms of dehydration Tachycardia, hypotension, decreased skin turgor, weakness, thready pulse, dry mucous membranes, oliguria Increased BUN, H and H, Sodium, urine specific gravity Normal BUN levels Males: 0.6-1.2 Females: 0.5-1.1 Isotonic fluid volume excess tx Diuretics Fluid restriction Sodium restriction Normal sodium levels 135-145 mEq/L normal potassium levels 3.5-5 Nursing interventions hyponatremia Fluid intake and output monitoring Lab data Increase salt intake Limit water intake Nursing interventions hypernatremia Monitor fluids Behavior changes Labs Diet Interventions hypokalemia Heart rate digitalis toxicity monitoring potassium supplements education Hyperkalemia treatment cardiac and ecg diuretics no potassium supp labs education hypocalcemia tx monitor heart/respirations mental status calcium supp education hypercalcemia tx exercise fluids fiber cran juice education hypocalcemia drug calcium gluconate hypercalcemia drug calcitonin normal chloride levels 98-106 normal phosphate levels 2.0-4.5 Normal pH of blood 7.35-7.45 normal c02 35-45 Normal HCO3 22-28 cause of resp alkalosis hyperventilation resp acidosis cause hypoventilation narcotics od metabolic alkalosis levels raised ph raised bicarbonate metabolic acidosis levels low ph low bicarb resp acidosis levels low ph high co2 cause of metabolic acidosis prolonged diarrhea cause of metabolic alkalosis ng tube antacids isotonic solutions shift no shift hypertonic solutions pulks from cells into veins hypotonic solutions shift veins to cells