Download NSG 3100 Exam 4: Fluid, Electrolyte, Acid-Base Balance, and Nutritional Assessment and more Exams Nursing in PDF only on Docsity!
NSG 3100 Exam 4 202 5/2026 with
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When the client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? - ANSWER Neurological While assisting the client with meal selection, the nurse realizes that clients who practice Islam or Judaism share an avoidance of: - ANSWER 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: - ANSWER Correct Answer: tomatoes. For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with: - ANSWER 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? - ANSWER 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? - ANSWER 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 lower-cost foods to increase protein content? - ANSWER Correct Answer:
Beans The client has had throat surgery and is placed on a clear liquid diet. The nurse should offer the patient: - ANSWER Correct Answer: apple juice. The majority of body fluid is located in which area? - ANSWER 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: - ANSWER Correct Answer: Lactated Ringer solution. One of the first indications of fluid volume deficit is: - ANSWER Correct Answer: tachycardia. For the client with a vitamin D deficiency and inadequate calcium intake, the nurse observes for: - ANSWER Correct Answer: Chvostek sign Chvostek sign - ANSWER 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: - ANSWER Correct Answer: instilling air into the NG tube to check for placement. The mucous membranes of a normally hydrated individual are: - ANSWER Correct Answer:
Wound drainage Hyponatremia - ANSWER low sodium causes of hypernatremia - ANSWER Fever Diarrhea Excessive sodium intake Hypernatremia - ANSWER high sodium An example of hemoconcentration seen in dehydration is increased hematocrit levels. T or F - ANSWER True Signs of fluid overload - ANSWER High BP Pitting edema in lower extremities Mental confusion Moist crackles Which is a sign/symptom of hypernatremia? - ANSWER Thirst hypokalemia - ANSWER low potassium Causes of hypokalemia - ANSWER Prolonged NGT suction Heavy perspiration Diarrhea Potassium must always be diluted appropriately and never given IV push. T or F - ANSWER
True Signs and symptoms of hypokalemia - ANSWER Muscle weakness Leg cramps Decreased deep tendon reflexes Weak irregular pulses Hypocalcemia - ANSWER deficient calcium in the blood Signs and symptoms of hypocalcemia - ANSWER Numbness and tingling of extremities Positive Chvostek's sign Cardiac dysrhythmias respiratory acidosis - ANSWER A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2. Causes of respiratory acidosis - ANSWER Aspiration of foreign body Overdose of narcotics or sedatives Chronic lung disease metabolic alkalosis - ANSWER metabolic condition in which the pH of tissue is elevated beyond the normal range cause of metabolic alkalosis - ANSWER Vomiting Antacids Potassium draining diuretics
Calculate the total intake: 8 oz coffee, 4 oz orange juice, 16 oz soda. - ANSWER 840 mLs Which nursing intervention is most appropriate for the pt. developing respiratory alkalosis? - ANSWER Encouraging slow, deep breaths Trousseau's sign is performed by tapping the client's cheek and observing for facial muscle twitching. T or F - ANSWER False T or F: Never reinsert the stylet of a small bore feeding tube while the tube is in place. - ANSWER True How to calculate BMI - ANSWER [weight lbs/(height in inches)^2] x 703 BMI ranges - ANSWER - Underweight: <18.
- Healthy weight: 18.5-24.
- Overweight: 25 - 29.
- Obese: 30 - 39.
- Extreme obesity: 40+ Risk factors for nutritional problems - ANSWER Diet history, Medical history, and Medication history What does low albumin indicate? - ANSWER Prolonged protein deficiency Malnutrition biochemical data - ANSWER Labwork
24 - hour food recall - ANSWER client recalls all the food and beverages consumed during a typical 24 - hour period Food frequency record - ANSWER a checklist that indicates how often general food groups or specific foods are eaten food diary - ANSWER A record of the kinds and amounts of all foods and beverages consumed for a given time diet history - ANSWER 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 - ANSWER Neuro Client teachings for overweight individuals - ANSWER 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 - ANSWER Coffee Tea Sodas Broth
total perenteral nutrition (TPN) - ANSWER Only through central lines Severe malnutrition normal fluid intake - ANSWER 2 - 3 L/day insensible water loss - ANSWER Skin Lungs Stool Sensible weight loss - ANSWER Urine Sweat fluid volume deficit - ANSWER DEHYDRATION: fluid intake is not sufficeint to meet the fluid needs of the body Symptoms of dehydration - ANSWER Tachycardia, hypotension, decreased skin turgor, weakness, thready pulse, dry mucous membranes, oliguria Increased BUN, H and H, Sodium, urine specific gravity Normal BUN levels - ANSWER Males: 0.6-1.2 Females: 0.5-
Isotonic fluid volume excess tx - ANSWER Diuretics Fluid restriction Sodium restriction
Normal sodium levels - ANSWER 135 - 145 mEq/L normal potassium levels - ANSWER 3.5- 5 Nursing interventions hyponatremia - ANSWER Fluid intake and output monitoring Lab data Increase salt intake Limit water intake Nursing interventions hypernatremia - ANSWER Monitor fluids Behavior changes Labs Diet Interventions hypokalemia - ANSWER Heart rate digitalis toxicity monitoring potassium supplements education Hyperkalemia treatment - ANSWER cardiac and ecg diuretics no potassium supp labs education hypocalcemia tx - ANSWER monitor heart/respirations
resp acidosis cause - ANSWER hypoventilation narcotics od metabolic alkalosis levels - ANSWER raised ph raised bicarbonate metabolic acidosis levels - ANSWER low ph low bicarb resp acidosis levels - ANSWER low ph high co cause of metabolic acidosis - ANSWER prolonged diarrhea cause of metabolic alkalosis - ANSWER ng tube antacids isotonic solutions shift - ANSWER no shift hypertonic solutions - ANSWER pulks from cells into veins hypotonic solutions shift - ANSWER veins to cells
