A nurse nutritionist is collecting assessment data for a patient who complains of
"tiredness" and appears malnourished. The nurse orders tests for hemoglobin and
hematocrit. What condition might these tests confirm?
A. Malabsorption
B. Anemia
C. Protein depletion
D. Reduction in total muscle mass
Give this one a try later!
b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it
indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased
indicates anemia, if increased indicates dehydration. Serum albumin tests
for malnutrition and malabsorption. Protein depletion and malnutrition are
diagnosed with serum albumin, prealbumin, transferrin, and blood urea
nitrogen tests. The creatinine test may indicate dehydration, reduction in
total muscle mass, and severe malnutrition.
,A nurse is preparing an IV solution for a patient who has hypernatremia. Which
solutions are the best choices for this condition? Select all that apply.
A. 5% dextrose in 0.9% NaCl
B. 0.9% NaCl (normal saline)
C. Lactated Ringer's solution
D. 0.33% NaCl (⅓-strength normal saline)
E. 0.45% NaCl (½-strength normal saline)
F. 5% dextrose in Lactated Ringer's solution
Give this one a try later!
d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength
normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is
used to treat SIADH and can temporarily be used to treat hypovolemia if
plasma expander is not available. 0.9% NaCl (normal saline) is used to treat
hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia.
Lactated Ringer's solution is used in the treatment of hypovolemia, burns,
and fluid lost from gastrointestinal sources. 5% dextrose in Lactated
Ringer's solution replaces electrolytes and shifts fluid from the intracellular
compartment into the intravascular space, expanding vascular volume.
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the
access site is leaking fluid during flushing. What would be the nurse's priority
intervention in this situation?
A. Remove the IV from the site and start at another location.
B. Immediately notify the primary care provider.
C. Use a skin marker to outline the area with visible signs of infiltration to allow for
assessment of changes.
D. Aspirate the catheter and attempt to flush again.
Give this one a try later!
, a. If the peripheral venous access site leaks fluid when flushed the nurse
should remove it from site, evaluate the need for continued access, and if
clinical need is present, restart in another location. The primary care
provider does not need to be notified first. The nurse should use a skin
marker to outline the area with visible signs of infiltration to allow for
assessment of changes or aspirate and attempt to flush again if the IV does
not flush easily.
A nurse caring for patients in an extended-care facility performs regular assessments
of the patients' urinary functioning. Which patients would the nurse screen for urinary
retention? Select all that apply.
A. A 78-year-old male patient diagnosed with an enlarged prostate
B. An 83-year-old female patient who is on bedrest
C. A 75-year-old female patient who is diagnosed with vaginal prolapse
D. An 89-year-old male patient who has dementia
E. A 73-year-old female patient who is taking antihistamines to treat allergies
F. A 90-year-old male patient who has difficulty walking to the bathroom
Give this one a try later!
a, c, e. Urinary retention occurs when urine is produced normally but is not
excreted completely from the bladder. Factors associated with urinary
retention include medications such as antihistamines, an enlarged prostate,
or vaginal prolapse. Being on bedrest, having dementia, and having
difficulty walking to the bathroom may place patients at risk for urinary
incontinence.
A nurse is counseling an older couple regarding sexuality. Which statement from the
couple should the nurse address?
A. "We're at the age when we should consider ceasing sexual activity."
B. "We need more time for sexual stimulation than we used to."
C. "If we are unable to have sex we can still have an intimate relationship."
D. "If we change our position we can still have sex and be more comfortable."
, Give this one a try later!
a. Sexual activity need not be hindered by age, and couples who have
been consistently sexually active throughout their lives may continue their
intimate relationship for as long as they desire. Nurses should teach
couples that adaptation to bodily changes is possible with use of
comfortable positions for intercourse and increased time for stimulation as
well as teach alternatives to coitus, such as caressing, hugging, and
stroking, when coitus is impossible because of illness or disability.
A nurse is ordered to perform continuous irrigation for a patient with a long-term
urinary catheter. What rationale would the nurse expect for this order?
A. Irrigation of long-term urinary catheters is a routine order.
B. Irrigation is recommended to prevent the introduction of pathogens into the
bladder.
C. A blood clot threatens to block the catheter.
D. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.
Give this one a try later!
c. The flushing of a tube, canal, or area with solution is called irrigation.
Natural irrigation of the catheter through increased fluid intake by the
patient is preferred. It is preferable to avoid catheter irrigation unless
necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA,
2015a). However, intermittent irrigation is sometimes prescribed to restore
or maintain the patency of the drainage system. Sediment or debris, as well
as blood clots, might block the catheter, preventing the flow of urine out of
the catheter.
Which nursing diagnosis would be most appropriate for a patient with a body mass
index (BMI) of 18?
A. Risk for Imbalanced Nutrition: More Than Body Requirements
B. Imbalanced Nutrition: More Than Body Requirements
"tiredness" and appears malnourished. The nurse orders tests for hemoglobin and
hematocrit. What condition might these tests confirm?
A. Malabsorption
B. Anemia
C. Protein depletion
D. Reduction in total muscle mass
Give this one a try later!
b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it
indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased
indicates anemia, if increased indicates dehydration. Serum albumin tests
for malnutrition and malabsorption. Protein depletion and malnutrition are
diagnosed with serum albumin, prealbumin, transferrin, and blood urea
nitrogen tests. The creatinine test may indicate dehydration, reduction in
total muscle mass, and severe malnutrition.
,A nurse is preparing an IV solution for a patient who has hypernatremia. Which
solutions are the best choices for this condition? Select all that apply.
A. 5% dextrose in 0.9% NaCl
B. 0.9% NaCl (normal saline)
C. Lactated Ringer's solution
D. 0.33% NaCl (⅓-strength normal saline)
E. 0.45% NaCl (½-strength normal saline)
F. 5% dextrose in Lactated Ringer's solution
Give this one a try later!
d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength
normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is
used to treat SIADH and can temporarily be used to treat hypovolemia if
plasma expander is not available. 0.9% NaCl (normal saline) is used to treat
hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia.
Lactated Ringer's solution is used in the treatment of hypovolemia, burns,
and fluid lost from gastrointestinal sources. 5% dextrose in Lactated
Ringer's solution replaces electrolytes and shifts fluid from the intracellular
compartment into the intravascular space, expanding vascular volume.
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the
access site is leaking fluid during flushing. What would be the nurse's priority
intervention in this situation?
A. Remove the IV from the site and start at another location.
B. Immediately notify the primary care provider.
C. Use a skin marker to outline the area with visible signs of infiltration to allow for
assessment of changes.
D. Aspirate the catheter and attempt to flush again.
Give this one a try later!
, a. If the peripheral venous access site leaks fluid when flushed the nurse
should remove it from site, evaluate the need for continued access, and if
clinical need is present, restart in another location. The primary care
provider does not need to be notified first. The nurse should use a skin
marker to outline the area with visible signs of infiltration to allow for
assessment of changes or aspirate and attempt to flush again if the IV does
not flush easily.
A nurse caring for patients in an extended-care facility performs regular assessments
of the patients' urinary functioning. Which patients would the nurse screen for urinary
retention? Select all that apply.
A. A 78-year-old male patient diagnosed with an enlarged prostate
B. An 83-year-old female patient who is on bedrest
C. A 75-year-old female patient who is diagnosed with vaginal prolapse
D. An 89-year-old male patient who has dementia
E. A 73-year-old female patient who is taking antihistamines to treat allergies
F. A 90-year-old male patient who has difficulty walking to the bathroom
Give this one a try later!
a, c, e. Urinary retention occurs when urine is produced normally but is not
excreted completely from the bladder. Factors associated with urinary
retention include medications such as antihistamines, an enlarged prostate,
or vaginal prolapse. Being on bedrest, having dementia, and having
difficulty walking to the bathroom may place patients at risk for urinary
incontinence.
A nurse is counseling an older couple regarding sexuality. Which statement from the
couple should the nurse address?
A. "We're at the age when we should consider ceasing sexual activity."
B. "We need more time for sexual stimulation than we used to."
C. "If we are unable to have sex we can still have an intimate relationship."
D. "If we change our position we can still have sex and be more comfortable."
, Give this one a try later!
a. Sexual activity need not be hindered by age, and couples who have
been consistently sexually active throughout their lives may continue their
intimate relationship for as long as they desire. Nurses should teach
couples that adaptation to bodily changes is possible with use of
comfortable positions for intercourse and increased time for stimulation as
well as teach alternatives to coitus, such as caressing, hugging, and
stroking, when coitus is impossible because of illness or disability.
A nurse is ordered to perform continuous irrigation for a patient with a long-term
urinary catheter. What rationale would the nurse expect for this order?
A. Irrigation of long-term urinary catheters is a routine order.
B. Irrigation is recommended to prevent the introduction of pathogens into the
bladder.
C. A blood clot threatens to block the catheter.
D. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.
Give this one a try later!
c. The flushing of a tube, canal, or area with solution is called irrigation.
Natural irrigation of the catheter through increased fluid intake by the
patient is preferred. It is preferable to avoid catheter irrigation unless
necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA,
2015a). However, intermittent irrigation is sometimes prescribed to restore
or maintain the patency of the drainage system. Sediment or debris, as well
as blood clots, might block the catheter, preventing the flow of urine out of
the catheter.
Which nursing diagnosis would be most appropriate for a patient with a body mass
index (BMI) of 18?
A. Risk for Imbalanced Nutrition: More Than Body Requirements
B. Imbalanced Nutrition: More Than Body Requirements
