The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. b) interruption of GI integrity Tube feedings preserve GI integrity by intraluminal delivery of nutrients. c) disturbance in the sequence of intestinal and hepatic metabolism Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. d) interruption in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

The most significant nursing problem related to continuous
tube feedings is
a) potential for aspiration
Because the normal swallowing mechanism is bypassed, consideration
of the danger of aspiration must be foremost in the mind of the nurse
caring for the patient receiving continuous tube feedings.
b) interruption of GI integrity
Tube feedings preserve GI integrity by intraluminal delivery of
nutrients.
c) disturbance in the sequence of intestinal and hepatic metabolism
Tube feedings preserve the normal sequence of intestinal and hepatic
metabolism.
d) interruption in fat metabolism and lipoprotein synthesis
Tube feedings maintain fat metabolism and lipoprotein synthesis.
by

1 Answer

Answer :

a) potential for aspiration
Because the normal swallowing mechanism is bypassed, consideration
of the danger of aspiration must be foremost in the mind of the nurse
caring for the patient receiving continuous tube feedings.
by

Related questions

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Answer: e The role of nutritional support in the cancer patient remains an important component of overall therapy. Preoperative nutritional support should be given only to those patients who do not require an emergency operation and who have severe weight loss (> 15% of pre-illness body weight) and a serum albumen < 2.9 mg%. Preoperative nutrition (enteral or parenteral) should not be given for longer than 7 to 10 days. Enteral nutrition is always the preferred route of feeding cancer patients if the GI tract is functional. There are several benefits of using the bowel lumen for nutrient delivery. The trophic effects of enteral feeding on small bowel mucosa have been well described. The integrity of the mucosal lining is maintained and it may provide an effective barrier to intraluminal

Description : Answer: e The role of nutritional support in the cancer patient remains an important component of overall therapy. Preoperative nutritional support should be given only to those patients who ... of bowel rest; this atrophy is not reversed by currently available total parenteral nutrition solutions

Last Answer : Which of the following hormones can be expected to be released as part of the stress response? a. Antidiuretic hormone (ADH) b. Aldosterone c. Insulin d. Epinephrine nswer: a, b, d ... This hormone has the exact opposite effect of insulin, which promotes glucose storage and uptake by the cells

Before the nurse can develop a relevant care plan, the nurse understands that in post-laryngectomy, the trachea and the esophagus are permanently separated. Therefore, which of the following will the nurse expect? A. No risk of aspiration during swallowing; speech is lost B. Normal speaking, breathing and swallowing are restored C. Unable to communicate with difficulty of swallowing and breathing D. Permanent tracheostomy created; normal speech is lost

Description : Before the nurse can develop a relevant care plan, the nurse understands that in post-laryngectomy, the trachea and the esophagus are permanently separated. Therefore, which of the ... with difficulty of swallowing and breathing D. Permanent tracheostomy created; normal speech is lost

Last Answer : D. Permanent tracheostomy created; normal speech is lost

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Although TPN has major beneficial effects to the patient and specific organ systems, TPN has a downside which is related to intestinal disuse. Which of the following statement(s) is/are true concerning the effects of TPN on the GI tract? a. Patients receiving TPN have an accentuated systemic response to endotoxin challenge compared to enterally fed volunteers b. TPN can result in disruption of intestinal microflora c. In experimental models, bacterial translocation from the gut is increased d. Effects of TPN on the gut may lead to multiple organ failure

Description : Although TPN has major beneficial effects to the patient and specific organ systems, TPN has a downside which is related to intestinal disuse. Which of the following statement(s) is/are true concerning the ... from the gut is increased d. Effects of TPN on the gut may lead to multiple organ failure

Last Answer : Answer: a, b, c, d A number of studies have examined the effects of TPN on intestinal function and immunity. Although most of these studies have been done in animal models, ... the release of bacteria and/or cytokines leading to pronounced systemic responses and possibly multiple organ failure

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

During which step of the nursing process does the nurse analyze data related to the patient’s health status? a) Assessment Analysis of data is included as part of the assessment. b) Implementation Implementation is the actualization of the plan of care through nursing interventions. c) Diagnosis Diagnosis is the identification of patient problems. d) Evaluation Evaluation is the determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

Description : When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a ... saline q8h as ordered The nurse may irrigate a nephrostomy tube with specific orders to do so.

Last Answer : a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for shortcourse (e.g. 3-day) therapy? a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Description : When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for ... to be significantly more effective than TMP-SMX in community-based patients and in nursing home residents.

Last Answer : a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. b) Requires a physician’s order. Teaching, as a function of nursing, is included in all state nurse practice acts. c) Must be approved by the physician. Health education is a primary responsibility of the nursing profession. d) Must focus on wellness issues. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

Description : Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of ... crater-like. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

Last Answer : a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

A 17-year-old patient involved in an automobile accident is paralyzed with multiple peripheral extremity injuries. Nutritional support is instituted with a transnasal feeding catheter. Which of the following statement(s) is/are true concerning the patient’s management? a. Feeding into the stomach results in stimulation of the biliary/pancreatic axis which is probably trophic for small bowel b. Gastric secretions will dilute the feedings increasing the risk of diarrhea c. The major risk in this patient is tracheobronchial aspiration d. Placement of the feeding catheter through the pylorus into the first portion of the duodenum reduces the risk of regurgitation and aspiration

Description : A 17-year-old patient involved in an automobile accident is paralyzed with multiple peripheral extremity injuries. Nutritional support is instituted with a transnasal feeding catheter. Which of the ... pylorus into the first portion of the duodenum reduces the risk of regurgitation and aspiration

Last Answer : Answer: a, c, d The use of transnasal feeding catheters for intragastric feeding or for duodenal intubation are popular adjuncts for providing nutritional support by the enteral route. The ... the fourth portion of the duodenum reduces the risk of regurgitation and aspiration of feeding formulas

76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Description : 76. A client is being positioned for radical vulvectomy and a couple of clinical clerks wanted to come in to watch the surgery. The circulating nurse advise them to enter the OR suite later. Foremost, this decision of the nurse is directed towards

Last Answer : D. Preserving privacy

While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient’s watcher. Your appropriate action would be A. Reprimand the nursing attendant right away B. Remind the patient that gift giving to any hospital staff is not allowed C. Review with the nursing attendant the hospital policy D. Endorse to the incoming shift for proper action

Description : While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient's watcher. Your appropriate action would be A. Reprimand the nursing attendant right away ... with the nursing attendant the hospital policy D. Endorse to the incoming shift for proper action

Last Answer : D. Endorse to the incoming shift for proper action

Medium -length nasoenteric tubes are used for: a) Feeding Placement of the tube must be verified prior to any feeding. b) Decompression A gastric sump and nasoenteric tube are used for gastrointestinal decompression. c) Aspiration Nasoenteric tubes are used for gastrointestinal aspiration. d) Emptying Gastric sump tubes are used to decompress the stomach and keep it empty.

Description : Medium -length nasoenteric tubes are used for: a) Feeding Placement of the tube must be verified prior to any feeding. b) Decompression A gastric sump and nasoenteric tube are used for ... aspiration. d) Emptying Gastric sump tubes are used to decompress the stomach and keep it empty.

Last Answer : a) Feeding Placement of the tube must be verified prior to any feeding.

A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B may cause fever, chills and body aches. The administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Which of the following statements reflect the nursing management of the patient with a white phosphorus chemical burn? a) Do not apply water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Description : Which of the following statements reflect the nursing management of the patient with a white phosphorus chemical burn? a) Do not apply water to the burn. Water should not be applied to burns from ... from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Last Answer : a) Do not apply water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Crohn’s disease is a condition of malabsorption caused by a) inflammation of all layers of intestinal mucosa. Crohn’s disease is also known as regional enteritis and can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon.

Description : Crohn's disease is a condition of malabsorption caused by a) inflammation of all layers of intestinal mucosa. Crohn's disease is also known as regional enteritis and can occur ... to lactose intolerance. d) gastric resection. Postoperative malabsorption occurs after gastric or intestinal resection.

Last Answer : a) inflammation of all layers of intestinal mucosa. Crohn’s disease is also known as regional enteritis and can occur anywhere along the GI tract, but most commonly at the distal ileum and in the colon.

Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting patients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient.

Description : Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, ... and cold are most appropriate because these patients tend to have strong reactions to medications.

Last Answer : a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for ... loss of strength and maintaining the physical, psychological and social well being of the patient.

The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

Description : The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described ... of tissue due to insufficient blood supply and may be associated with steroid use.

Last Answer : a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the top dressing B. Continue to monitor the vital signs C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision of diagnostic support and eventual release of vaccine if a case is confirmed. Until instructed otherwise by the CDC, healthcare providers should carefully establish isolation with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Description : If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office ... very different from that of chickenpox. With chickenpox, lesions appear at different developmental stages.

Last Answer : a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision ... with negative pressure, and maintain thorough lists of all those who have contact with the patient.

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

Description : The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an ... d) hypoxia. Patients receiving mitoxantrone are closely monitored for leukopenia and cardiac toxicity.

Last Answer : a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have ... ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of left-heart failure. b) Increased appetite Loss of appetite should be reported immediately. c) Weight loss Weight gain should be reported immediately. d) Ability to sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Description : The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of ... sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Last Answer : a) Persistent cough Persistent cough may indicate an onset of left-heart failure.

When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

Description : When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in ... residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.

Last Answer : a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. b) Peroneal The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes. c) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. d) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

87. When the staff nurse on duty encounters a problem that cannot be solved using nursing knowledge, skills and available resources, it is best for the nurse to consult the

Description : 87. When the staff nurse on duty encounters a problem that cannot be solved using nursing knowledge, skills and available resources, it is best for the nurse to consult the

Last Answer : C. Head nurse

Which of the following statement(s) is/are true concerning methods of nutritional support? a. Optimal results for enteral feedings are achieved with approximately half of calories supplied as carbohydrate and half as fat b. Diarrhea is the most common complication of enteral feeds and is due to the high osmolarity of the carbohydrate components c. The hyperosmolar nature of parenteral fat solutions requires central venous administration d. Approximately 25–50% of calories should be provided as fat emulsion in patients receiving total parenteral nutrition

Description : Which of the following statement(s) is/are true concerning methods of nutritional support? a. Optimal results for enteral feedings are achieved with approximately half of calories supplied as ... -50% of calories should be provided as fat emulsion in patients receiving total parenteral nutrition

Last Answer : Answer: a, b, d Most formulas for enteral feeding range from 1.0 to 2 cal/ml and include 3 to 7% protein. Most of the calories are supplied as glucose or sucrose, so that the solutions ... up to 25 to 50% of calories each day as fat emulsion may optimize the delivery of this caloric delivery

Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. b) 10-15 mm Hg water pressure. A measure of 10–15 mm Hg water pressure would indicate that the cuff is underinflated. c) 30-35 mm Hg water pressure. A measure of 30–35 mm Hg water pressure would indicate that the cuff is overinflated. d) 0-5 mm Hg water pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Description : Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the ... pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Last Answer : a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration.

The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Description : The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood ... be able to resume previous methods for control of diabetes when the stress is resolved.

Last Answer : a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip. b) pillows under the lower legs. Pillows under the legs will not prevent the hips from rotating externally. c) a hip-abductor pillow. A hip-abductor pillow is used for the patient after total hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Description : In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be ... hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Last Answer : a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Description : When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person ... 20/20 line, the person of normal vision will be standing at a distance of 20 feet from the chart.

Last Answer : a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

Description : When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. ... the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

Last Answer : a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

89. A nurse has to attend a committee meeting for two hours. She delegates her work to another nurse. What primary consideration should be observed?

Description : 89. A nurse has to attend a committee meeting for two hours. She delegates her work to another nurse. What primary consideration should be observed?

Last Answer : D. Competency to perform the given function

90. When a telephone order is made, it should be documented by the nurse who is receiving the order. The following should be included in the order to be executed except

Description : 90. When a telephone order is made, it should be documented by the nurse who is receiving the order. The following should be included in the order to be executed except

Last Answer : A. Time the call was made and its duration