Nokea
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
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A patient with heart failure is prescribed furosemide (Lasix). Which of the following electrolyte imbalances should the nurse monitor for?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: B
Rationale: Furosemide, a loop diuretic, increases potassium excretion, leading to hypokalemia, which can cause arrhythmias. Hyperkalemia, hypernatremia, and hyponatremia are less likely with furosemide.
The nurse observes a certified nursing assistant (CNA) placing a hot water bottle directly on the skin of a 90-year-old client. What action should the nurse take initially?
- A. Report the act to the patient care supervisor
- B. Interrupt the procedure
- C. Talk to the CNA when the procedure is finished
- D. Notify the physician
Correct Answer: B
Rationale: Direct placement of a hot water bottle on the skin risks burns, especially in an elderly client with fragile skin. Interrupting the procedure immediately prevents harm. Reporting, discussing later, or notifying the physician are secondary to stopping the unsafe action.
The nurse may observe which one as typical manifestation(s) of ketoacidosis:
- A. Slow, bounding pulse.
- B. Deep, rapid respirations.
- C. Diaphoresis, cold clammy skin.
- D. Dilated pupil, hypotension.
Correct Answer: B
Rationale: Deep, rapid respirations are the body's effort to get rid of excess acid through breathing, a hallmark of ketoacidosis.
An adult who is scheduled for several diagnostic tests says to the nurse, 'I am worried about too much exposure to x-rays.' When responding to the client, the nurse understands that which of the tests scheduled for the client will involve x-ray exposure? Select all that apply.
- A. CT scan
- B. MRI exam
- C. Cardiac catheterization
- D. Thyroid scan
- E. Barium enema
- F. Nerve conduction tests
Correct Answer: A,C,E
Rationale: CT scans, cardiac catheterization, and barium enemas use x-rays for imaging, unlike MRI (magnetic fields), thyroid scans (radioisotopes), or nerve conduction tests (electrical).
This is caused by presence of large amounts of:
- A. Undigested fats
- B. Blood
- C. Undigested foods
- D. Bilirubin
Correct Answer: A
Rationale: Because of the lack of the pancreatic enzyme lipase, fats remain unabsorbed and are excreted in excessive amounts in the stool, causing steatorrhea.