NUR 355 Exam 5 - Questions And Accurate
Solutions
What can be used to assess for dehydration? Correct Answer -
- labs: urine specific gravity- expected range is 1.005-1.030
- vitals: hypotension, tachycardia, tachypnea, fever
- physical assessment: poor skin turgor
How do you assess for dysphagia? Correct Answer - -Assess
ability to swallow before feeding (facial droop, drooling, weak voice,
gag reflex, cough reflex, watery eyes)
-Swallow study with different textures
-SPEECH THERAPY should be consulted before feeding...consult
EARLY
- Lungs are clear upon auscultation after eating
Nursing considerations for an NG tube include? Correct Answer -
- check placement with KUB x-ray
- aspirate stomach contents and check pH
- hold feedings if residual is greater than 250mL (may differ
depending on facility)
- Assess for skin breakdown around nares
What types of patients are candidates for NG tubes? Correct
Answer - oral/facial trauma or surgery, esophageal abnormality,
high aspiration risk, malnutrition
What is a laparoscopy? Correct Answer - MIS (minimally
invasive surgery) technique using gas to insufflate the peritoneum
and instrument manipulated through ports with video camera
guidance
, What is the expected ammonia range? Correct Answer - 10-80
mcg/dL
What are some nursing considerations surrounding laparoscopic
surgery? Correct Answer - patient will experience gas pains
which may be primarily around shoulders: ensure the patient is
ambulating if possible to help with discomfort
Where is McBurney's point? significance? Correct Answer -
1/3 the distance from anterior superior iliac spine to umbilicus; RLQ
point that hurts in appendicitis
What are assessment findings for acute pancreatitis? Correct
Answer - - LUQ epigastric pain that intensifies while consuming
fatty foods
- abdominal fullness: gas and bloating
- hiccups
- fever, tachycardia, hypotension
Nursing interventions for pancreatitis? Correct Answer - - NPO
status and IV fluids
- ICU level care if other organs are involved
- treat the cause
What are some risk factors for pancreatitis? Correct Answer -
being male, alcohol consumption, and gallstones
Assessment findings for chronic pancreatitis? Correct Answer -
- upper abdominal pain that radiates to the back
- N/V/D
- pain worsened after eating or drinking
- weight loss
- pale/clay colored stool
- steatorrhea
Solutions
What can be used to assess for dehydration? Correct Answer -
- labs: urine specific gravity- expected range is 1.005-1.030
- vitals: hypotension, tachycardia, tachypnea, fever
- physical assessment: poor skin turgor
How do you assess for dysphagia? Correct Answer - -Assess
ability to swallow before feeding (facial droop, drooling, weak voice,
gag reflex, cough reflex, watery eyes)
-Swallow study with different textures
-SPEECH THERAPY should be consulted before feeding...consult
EARLY
- Lungs are clear upon auscultation after eating
Nursing considerations for an NG tube include? Correct Answer -
- check placement with KUB x-ray
- aspirate stomach contents and check pH
- hold feedings if residual is greater than 250mL (may differ
depending on facility)
- Assess for skin breakdown around nares
What types of patients are candidates for NG tubes? Correct
Answer - oral/facial trauma or surgery, esophageal abnormality,
high aspiration risk, malnutrition
What is a laparoscopy? Correct Answer - MIS (minimally
invasive surgery) technique using gas to insufflate the peritoneum
and instrument manipulated through ports with video camera
guidance
, What is the expected ammonia range? Correct Answer - 10-80
mcg/dL
What are some nursing considerations surrounding laparoscopic
surgery? Correct Answer - patient will experience gas pains
which may be primarily around shoulders: ensure the patient is
ambulating if possible to help with discomfort
Where is McBurney's point? significance? Correct Answer -
1/3 the distance from anterior superior iliac spine to umbilicus; RLQ
point that hurts in appendicitis
What are assessment findings for acute pancreatitis? Correct
Answer - - LUQ epigastric pain that intensifies while consuming
fatty foods
- abdominal fullness: gas and bloating
- hiccups
- fever, tachycardia, hypotension
Nursing interventions for pancreatitis? Correct Answer - - NPO
status and IV fluids
- ICU level care if other organs are involved
- treat the cause
What are some risk factors for pancreatitis? Correct Answer -
being male, alcohol consumption, and gallstones
Assessment findings for chronic pancreatitis? Correct Answer -
- upper abdominal pain that radiates to the back
- N/V/D
- pain worsened after eating or drinking
- weight loss
- pale/clay colored stool
- steatorrhea
