116 RLE first quiz

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A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensure the availability of which medical equipment before hanging the solution?

A. Dressing tray

B. Glucometer

C. Nebulizer

D. Infusion pump
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Terms in this set (15)
A client is receiving nutrition via parenteral nutrition (PN). A nurse assess the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?

A. Fatigue, increased sweating, and heat intolerance.

B. High-grade fever, chills, and decreased urination.

C. Coarse dry hair, weakness, and fatigue.

D. Thirst, blurred vision, and diuresis.
D. Thirst, blurred vision, and diuresis.

- Signs of hyperglycemia include excessive thirst, fatigue, restlessness, blurred vision, confusion, weakness, Kussmaul's respirations, diuresis, and coma when hyperglycemia is severe.

Option A are signs of hyperthyroidism.

Option B are signs of infection.

Option C are signs of hypothyroidism.
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take?

A. Discard the residual amount and proceed with administering the feeding

B. Elevate the client's head at least 45 degrees and administer the feeding

C. Hold the feeding

D. Reinstill the amount and continue with administering the feeding
C. Hold the feeding

- Unless specifically indicated, residual amounts
greater than 100 mL require holding the feeding, but this is individualized and each agency's policy should be checked. The residual amount should be reinstilled unless it is greater than 250 ml. or per agency policy. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

Test-Taking Strategy: Note the strategic words, most appropriate. Note that the residual amount is 150 ml. Also note that options A, B, and D are comparable or alike and indicate
administering the feeding.
What are the indications of jejunostomy tube? A. As an additional procedure after major gastrointestinal surgery with prolonged recovery time. B. When the oral route cannot be accessed for nutrition. C. When nasoenteral access is impossible. D. All of theseD. All of theseThe registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A. Place the tube at the earlobe and measure by extending the tube to the tip of the nose and then down to the top of the sternum B. Mark the tube at 10 inches C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. D. Mark the tube at 32 inchesC. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. - The average length for an adult is about 22 to 26 inches.The nurse is working with a client that has a gastrostomy tube for enteral nutrition. Which intervention should least likely be done by the nurse to prevent skin breakdown related to the gastrostomy tube? A. Clean the skin around the gastrostomy tube daily. B. Always place a dressing around the site C. Check balloon inflation of the gastrostomy tube weekly. D. Rotate the gastrostomy tube a quarter turn daily.B. Always place a dressing around the site - The gastrostomy tube has a potential for skin breakdown at the site due to skin pressure or irritation. The site should be cleaned daily to stay clean and dry and the gastrostomy tube rotated a quarter turn to prevent pressure to the skin from the tube. If there is drainage, a dressing should be applied; however, it would not be applied if there is no drainage because ofthe potential for causing pressure and trapping moisture. The balloon needs to be checked and potentially reinflated because if not inflated properly, the tube can move and cause pressure and irritation at the site. The tube needs to be stabilized, and can be with a commercial device, to help keep it from moving and causing irritation.A client receiving parenteral nutrition (PN) complains of shortness of breath and shoulder pain. A nurse notes that the client has an increased pulse rate. The nurse determines that the client is experiencing which complication of PN therapy? A. Air embolism. B. Hypervolemia. C. Hyperglycemia. D. Pneumothorax.D. Pneumothorax. - Pneumothorax might happen during a parenteral therapy due to inexact catheter placement. In order to prevent this, the nurse obtains a chest x-ray after insertion of the catheter to ensure proper catheter placement.Which of the following digestive enzymes breaks down starches? A. Peptidase B. Protease C. Amylase D. LipaseC. Amylase