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A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient?
Imbalanced Nutrition: More Than Body Requirements
A 56-year-old patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients?
B vitamins and folic acid
An elderly patient with severe arthritis is admitted to your unit. During the noon meal, you notice the patient has difficulty getting food onto the eating utensils, opening food containers, and bringing food to her mouth without spilling most of it. A likely nursing diagnosis for this patient is:
Feeding self-care deficit related to musculoskeletal impairment
A patient's total parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication?
Blood flow is needed for optimum wound healing, and a patient may require an increase in dietary iron. Because you know that iron absorption is enhanced by ascorbic acid (Vitamin C), you would encourage the patient to eat a diet rich in:
The nurse is caring for an 84 year-old resident on a rehabilitation wing of the nursing care center. The daughter tells the nurse that she is concerned because her mother seems to be eating more sweets and using more salt on her food. The nurse's most correct response is:
taste and smell decrease with age; up to half of all taste buds die off by age 70
To reduce the risk for diarrhea in a patient receiving tube feedings, the nurse would
begin feedings at a slow rate of administration
Water is an essential component in enteral feedings for the patient because it:
maintains the patient's hydration state
You are caring for a patient who has a nasogastric tube for intermittent feedings. Before beginning the next scheduled feeding, you plan to:
Assess residual gastric contents and verify tube placement by measuring pH
Which of the following pieces of information would be collected during admission to a hospital? (select all that apply.)
Occupation and employer of patient.
Patient's name, address, and date of birth.
Which of the following occur when a patient is discharged from a healthcare setting? (Select all that apply).
The nurse ensures that the family members are taught the knowledge and skills needed to care for the patient.
Discharge planning is performed to plan for continuity of care.
Preferably, the nurse who conducts the initial nursing assessment will determine the special needs of the patient being discharged.
The nurse concludes that effective discharge planning (hospital to home) has been conducted when the client states which of the following?
"I have the phone numbers of the home care nurse and therapist who will visit me at home tomorrow."
When patients are transferred within or among healthcare settings, which of the following is most important in ensuring continuity of care?
Accurate and complete communication
The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication?
The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient's abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding?
Hypoactive bowel sounds
Hypoactive bowel sounds are low-pitched, infrequent, and quiet. An abdominal bruit is a hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high-pitched with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched and more frequent than normal bowel sounds.
Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of:
Fruits and vegetables.
A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated?
Apply an indwelling fecal drainage device.
The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, "For 3 days prior to testing, I should avoid eating
The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occult blood testing.
A patient has a colostomy in the descending (sigmoid) colon and wishes to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, nurse should teach the patient to:
Irrigate the stoma to produce a bowel movement on a schedule.
A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume?
Yogurt and parsley
The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum?
3 to 4 inches
The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE:
Reduces the time nurses spend charting
The patient's medical record contains the following documentation:
06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge intravenous catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN
Which type of charting has the nurse used?
The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take?
Draw a line through the error and initial the change.
A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?
Data may be fragmented and scattered throughout the chart.
The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone order for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?
09/02/10 0845 morphine 4 mg intravenously q 1 hour PRN pain T.O.R.B.: Dr. D. Kelly/Kay Andrews, RN
The nurse is caring for a 42-year-old, Chinese-American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patient's discharge?
A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet she still retains some customs from her homeland. This patient is experiencing:
A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? He may:
Endure pain longer and report it less frequently than some patients do.
The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present-oriented?
"I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult."
Psyllium (Metamucil) should be mixed in at least how many ounces of liquid for administration to an adult?
Magnesium hydroxide (Milk of Magnesia and Miralax both work by:
Drawing water into the intestinal lumen to increase intracolonic pressure.
A patient who abuses alcohol is admitted with significant mental status changes and loss of balance. Which vitamin deficiency does the nurse suspect as the possible cause of this presentation?
The nurse is instructing a patient about foods high in vitamin A. The foods would include:
eggs, leafy green and yellow vegetables
The nurse is teaching a patient about a new medication, iron (Ferrous Sulfate). The nurse instructs the patient to
follow with 8 ounces of orange juice
Which of the following vitamins can be toxic if taken in excess amounts over a period of time?
Vitamins A and D
A healthy, active 72-year-old woman asks a nurse if it is safe to take dietary supplements and, if so, what should be taken? What would the nurse tell her?
Yes, take calcium, vitamin D, and vitamin B12.
A patient is taking large doses of Vitamin C. She tells you she heard it prevents colds and is wondering if this is true. You respond:
"I have also heard that vitamin C will help prevent colds; however, so far it hasn't been proven to be true."
A patient tells you that he plans to stop taking his vitamin C supplements because he is eating plenty of citrus fruits. Your best response to his statement is:
"You may stop taking the large doses of vitamin C, but taper the dosage down slowly."
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