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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? - ✔✔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
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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? - ✔✔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 lower- cost 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:
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
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),
Females: 0.5-1. 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. Normal pH of blood - ✔✔7.35-7. normal c02 - ✔✔ 35 - 45 Normal HCO3 - ✔✔ 22 - 28