The PH of the contents removed from the NG tube is 3 (stomach acid contents are acidic) 2. The nurse in an outpatient clinic teaches a client with right-sided weakness to walk down stairs using a cane. What behavior would indicate by the client that teaching was successful?
The client leads with the cane, followed by her right leg and then her left leg 3. A client is admitted with IRS. The RN would anticipate that the client’s hx reflect which of the following?
Pattern of alternating diarrhea and constipation.
4. The nurse is teaching nutrition classes at the community center. Which of the following foods would the nurse encourage a low-income diet to eat to satisfy essential protein needs?
Legumes – cheap and rich in protein
5. The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the RN emphasize to facilitate regular bowel elimination?
Eat more foods with increased bulk – whole grains, legumes, veggies, fruits, seeds, nuts, bulk promotes peristalsis
Normal fluid intake of 1,500 cc/day
Laxatives are used as last resort b/c they are habit forming 6. A mother brings her 9 month old child to the pediatrician’s office with complaints of a fever of 102.2 and frequent vomiting. The nurse would expect the following reflex to still be present?
Babinski’s reflex – stroking outer sole of foot upwards causes toes to hyperextend and fan and great toe to doriflex, disappears after one year of age. 7. A client with an irregular pulse of 81 and a K level of 3.0 mEq/L has digoxin (lanoxin) ordered. Which of the following actions if taken by the RN IS BEST?
Notify 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 receiving a feeding tube around the clock. Which of the following nursing actions is most appropriate?
Rinse the bag and change the formula every 4 hours
9. For the nurse to prepare a ng tube as ordered, which position is best for nurse to position client?
Head of the bed- elevated 60-90 degrees -- facilitates swallowing and movement of tube via GI tract 10. The RN is monitoring fluid status of a 63 year-old woman receiving IV fluids post surgery. Which of the following symptoms would suggest to the nurse that the patient has fluid volume overload?
Cool skin, respiratory crackles, pulse 86 and bounding, elevated BP, edema, polyuria, diarrhea
Fixed and dilated pupils represent neurological emergency -- contact doctor 11. After abdominal surgery, a client has a ng tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which intervention would be most appropriate?
Aspirate the gastric contents with a syringe – to confirm placement, nurse should aspirate and test ph of aspirate, results should be 0-4 12. A nurse is caring for a 37 year-old woman with mets ovarian cancer admitted for nausea and vomiting. The physician orders TPN, nutrition consult and diet recall. Which is the best indication that the patient’s nutritional status has improved after 4 days?
The patient’s albumin level is 4.0mg/dl ---- albumin levels are best indicators of long-term nutritional status.
Weight gain may be fluid retention (ascites)
13. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
The patient’s voluntary/involuntary status – need for restraints in based on patient’s behavioral status
Paraplegic has full use of his upper body
14. An elderly client is returned to her room after and open reduction and...