Nokea
A nurse is caring for a client who is receiving continuous enteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypophosphatemia
Correct Answer: D
Rationale: Hypophosphatemia is the hallmark of refeeding syndrome due to intracellular shifts of phosphorus during refeeding.
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A client arrives at the emergency room with symptoms of peptic ulcer disease. Which of these symptoms should the nurse identify as the priority?
- A. Hematemesis
- B. Abdominal bloating
- C. Epigastric discomfort
- D. Dyspepsia
Correct Answer: A
Rationale: Hematemesis indicates active bleeding and is the most urgent concern.
A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
- A. Place a cool cloth on the forehead.
- B. Elevate the head of the bed 30 degrees.
- C. Administer morphine 2 mg IV.
- D. Prepare for a lumbar puncture.
Correct Answer: B
Rationale: Elevating the HOB decreases intracranial pressure which may be causing the headache.
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
- A. Evaluate for asterixis
- B. Palpate for peripheral edema
- C. Evaluate for decreased level of consciousness
- D. Inspect for petechiae
Correct Answer: B
Rationale: Peripheral edema occurs with hypoalbuminemia due to decreased oncotic pressure causing fluid leakage into tissues.
A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?
- A. Aspiration
- B. Gastroesophageal reflux disease
- C. Peptic ulcer disease
- D. Dumping syndrome
Correct Answer: A
Rationale: Aspiration is the primary concern with dysphagia due to impaired swallowing reflexes.
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr