Nokea
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
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The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan?
- A. Eyes sunken and skin flushed
- B. Skin moist with rapid elastic recoil
- C. Serum potassium level is 3.3 mEq/L
- D. ABG results are pH 7.25, PaCO2 30, HCO3 17
Correct Answer: B
Rationale: Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving.
The client is diagnosed with acute pancreatitis. Which health-care provider's admitting order should the nurse question?
- A. Bedrest with bathroom privileges.
- B. Initiate IV therapy of D5W at 125 mL/hr.
- C. Weigh the client daily.
- D. Low-fat, low-carbohydrate diet.
Correct Answer: D
Rationale: A low-fat, low-carb diet is inappropriate during acute pancreatitis; clients are typically NPO to rest the pancreas. Bedrest, IV D5W, and weighing are appropriate.
Which monitoring approach is best for the nurse to recommend?
- A. Using the urine with a chemical reagent strip
- B. Using a glucometer to check capillary blood glucose levels
- C. Having laboratory personnel draw venous blood samples
- D. Arranging for testing by a home health agency nurse
Correct Answer: B
Rationale: A glucometer provides accurate, real-time blood glucose levels for effective diabetes management.
The client develops SIADH secondary to a pituitary tumor. The client's assessment findings include thirst, weight gain, fatigue, and a serum sodium of 127 mEq/L. Which intervention, if prescribed, should the nurse implement to treat SIADH?
- A. Elevate the head of the bed 30 degrees
- B. Administer vasopressin intravenously (IV)
- C. Restrict fluids to 800 to 1000 mL per day
- D. Give 0.3% sodium chloride IV infusion
Correct Answer: C
Rationale: Fluid restriction to 800-1000 mL/day treats mild SIADH with serum sodium >125 mEq/L by raising sodium concentration.
The client diagnosed with Cushing's disease has developed 1++ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received intravenous piggyback (IVPB) medication in 50 mL of fluid every six (6) hours for 15 doses. How many mL of fluid did the client receive?
Correct Answer: 8650 mL
Rationale: Continuous IV: 100 mL/hr × 79 hr = 7900 mL. IVPB: 50 mL × 15 doses = 750 mL. Total = 7900 + 750 = 8650 mL.