1. The nurse cheques for arrangement of a nasogastric tubing before get downing tubing feeding for a client. Which of the undermentioned consequences would bespeak to the RN that the tubing eating can get down?
The PH of the contents removed from the NG tubing is 3 ( tummy acid contents are acidic ) 2. The nurse in an outpatient clinic teaches a client with right-sided failing to walk down stepss utilizing a cane. What behaviour would bespeak by the client that instruction was successful?
The client leads with the cane. followed by her right leg and so her left leg 3. A client is admitted with IRS. The RN would expect that the client’s hx reflect which of the followers?
Pattern of jumping diarrhoea and irregularity.
4. The nurse is learning nutrition categories at the community centre. Which of the undermentioned nutrients would the nurse encourage a low-income diet to eat to fulfill indispensable protein demands?
Legumes – cheap and rich in protein
5. The nurse teaches a wellness category at the local library to a group of senior citizens. Which of the undermentioned behaviours should the RN emphasize to ease regular intestine riddance?
Eat more nutrients with increased majority – whole grains. leguminous plants. vegetables. fruits. seeds. nuts. majority promotes vermiculation
Normal unstable consumption of 1. 500 cc/day
Laxatives are used as last resort b/c they are habit forming 6. A female parent brings her 9 month old kid to the pediatrician’s office with ailments of a febrility of 102. 2 and frequent emesis. The nurse would anticipate the undermentioned physiological reaction to still be present?
Babinski’s automatic – stroking outer sole of pes upwards causes toes to hyperextend and fan and great toe to doriflex. disappears after one twelvemonth of age. 7. A client with an irregular pulsation of 81 and a K degree of 3. 0 mEq/L has digoxin ( digoxin ) ordered. Which of the undermentioned actions if taken by the RN IS BEST?
Advise the physician – hypokalemia can precipitate digoxin toxicity. Doctor should be called to obtain order for K supplement 8. The RN is caring for a patient having a eating tubing around the clock. Which of the undermentioned nursing actions is most appropriate?
Rinse the bag and alter the expression every 4 hours
9. For the nurse to fix a ng tubing as ordered. which place is best for nurse to place client?
Head of the bed- elevated 60-90 grades — facilitates get downing and motion of tubing via GI piece of land 10. The RN is supervising unstable position of a 63 year-old adult female having IV fluids station surgery. Which of the undermentioned symptoms would propose to the nurse that the patient has fluid volume overload?
Cool tegument. respiratory cracklings. pulse 86 and jumping. elevated BP. hydrops. polyuria. diarrhoea
Fixed and dilated students represent neurological exigency — contact physician 11. After abdominal surgery. a client has a ng tubing attached to low suctioning. The client becomes nauseated. and the nurse observes a lessening in the flow of stomachic secernments. Which intercession would be most appropriate?
Aspirate the stomachic contents with a syringe – to corroborate arrangement. nurse should draw out and prove pH of aspirate. consequences should be 0-4 12. A nurse is caring for a 37 year-old adult female with mets ovarian malignant neoplastic disease admitted for sickness and emesis. The physician orders TPN. nutrition consult and diet callback. Which is the best indicant that the patient’s nutritionary position has improved after 4 yearss?
The patient’s albumen degree is 4. 0mg/dl —- albumen degrees are best indexs of long-run nutritionary position.
Weight addition may be unstable keeping ( ascites )
13. When utilizing restraints for an agitated/aggressive patient. which of the undermentioned statements should NOT act upon the nurse’s actions during this intercession?
The patient’s voluntary/involuntary position – demand for restraints in based on patient’s behavioural position
Paraplegic has full usage of his upper organic structure
14. An aged client is returned to her room after and unfastened decrease and internal arrested development of the left femoral caput after a break. It is most of import for the nursing attention program to include that the client ;
Cough and deep breathe which prevent respiratory jobs due to immobility station surgery.
CNA delegated for standard process
15. Older adult female comes to an outpatient clinic because she is non experiencing good for several yearss. During admittance interview. the nurse learns that the client has a hx of CHF. low na diet. and has been taking Diuril. 500 mg PO daily for 6 months. Diagnostic trials indicate: Na 127 mEq/L. glucose 110mg/dL. and normal chest X ray. The marks and symptoms the nurse would anticipate the client to exhibit include:
Headache. lassitude and apprehensiveness — symptoms of hyponatremia along with musculus jerking. paroxysms. diarrhoea 16. The RN in the outpatient clinic teaches a client with a sprained right mortise joint to walk with a cane. What behaviour. if demonstrated by the client would bespeak the instruction was effectual?
The client holds the cane in her left manus which widens base of support 17. The nurse is executing diet learning with a 67 year-old adult male with acute urarthritis. The nurse should learn the client to restrict his consumption of:
Red meat and shellfish
Pt. Should be on low purine diet
18. A client has a hx of oliguria. HTN. and peripheral hydrops. Current lab values are: BUN-25. K+-4. 0 mEq/L. What food should be restricted in the client’s diet?
Protein – decreased production of urea N can be achieved by curtailing protein ; metabolic wastes can non be excreted by the kidneys
19. The nurse is be aftering attention for a client on BR. To advance flushing remainder and slumber for this client. it’s most of import for nurse to:
Encourage daylight activities which provide alleviation from tenseness. ensures client sleeps less during twenty-four hours and relax. 20. A 13 year-old with MD has merely developed nocturia. The client wants to cognize about external catheters. The nurse should react by stating the platinum. :
The catheter can be removed during the twenty-four hours which would appeal to a adolescent 21. Which of the undermentioned nursing intercessions is MOST of import for a 45 year-old adult female with RA?
Help her with heat application and ROM exercisings which diminishes stiffness/reduces swelling
You are fixing to administrate TPN through a cardinal line. Put the stairss for disposal in the right order.
Check the solution for cloud cover or turbidness.
Choose the right tube and filter.
Weave the IN tube through an extract pump.
Use sterile technique when managing the injection cap.
Connect the tube to the cardinal line.
Set extract pump at prescribed rate.
You are learning the client and household how to make colostomy irrigation. Put the information in the right order.
Put 500 – 100 milliliter of tepid H2O in the container.
Hang the container at about shoulder tallness.
Lubricate the pore cone and gently infix the tubing tip into the pore. fAllow the solution to flux easy and steadily for 5 – 10 proceedingss. d. Allow 30 – 45 proceedingss for emptying.
. Clean. rinse. and dry tegument. and use a new drainage pouch. _____ . You are fixing to give an enteric eating through a nasogastric tubing. Put the stairss in the right order. Assess for intestine sounds.
Auscultate tubing arrangement and look into pH.
Check for residuary volume
Flush the tubing with H2O
Administer the eating
Reflush the tubing with H2O.
A client with fractured thighbone is at hazard for fat intercalation. so fat emulsion should be used with cautiousness. Vomiting may be a job if the emulsion is infused excessively quickly. TPN is normally used for GI obstructor. terrible anorexia nervosa. and chronic diarrhoea or emesis. Focus: Prioritization
A nursing helper asks why the client with a inveterate low Ps degree needs so much aid with a activities of day-to-day life. What is your best response? The client’s skeletal musculuss are weak because of the low P. ”
The experient LPN/LVN studies that a client’s blood force per unit area and bosom rate have decreased and that when the face is assessed. one side vellications. What action should you take at this clip?
Review the client’s Ca degree
A positive Chvostek’s mark ( facial vellication of one side of the oral cavity. nose. and cheek in response to tapping the face merely below and in forepart of the ear ) is a neurologic manifestation of hypocalcaemia. The LPN/LVN is experienced and possesses the accomplishments to take accurate critical marks.
With a Mg degree this low. the client is at hazard for ECG alterations and dangerous ventricular dysrhythmias SIADH causes a comparative Na shortage due to inordinate keeping of H2O.
A client has a nasogastric tubing connected to intermittent wall suction. The pupil nurse asks why the client’s respiratory rate has increased. What your best response? “The client may hold a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism. ” The nursing assistant’s preparation and instruction include how to take critical marks and record consumption and end product. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest precedence would be… After nephrectomy. it is necessary to mensurate urine end product hourly. This is done to measure the effectivity of the staying kidney besides to observe nephritic failure early.
Dr. Marquez tells a client that an addition consumption of nutrients that are rich in Vitamin E and beta-carotene are of import for healthier tegument. The nurse teaches the client that first-class nutrient beginnings of both of these substances are: Spinach and mangoes| Typical marks and symptoms of hypovolaemic daze includes systolic blood force per unit area of less than 90 mm Hg.