Medical Surgical Nursing NCLEX type model
question paper part 5
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1.The nurse is caring for a patient receiving
antineoplastic medications intravenously. The nurse discovers that the
intravenous site is red, edematous, and painful. The nurse knows that
antineoplastic medications are vesicant medications and documents that the
patient has experienced which of the following events?
a. Occlusion
b. Extravasation
c. Phlebitis
d. Thrombophlebitis
ANS: B
When a vesicant medication infiltrates the tissue,
this is called an extravasation. Occlusion refers to a thrombus or fibrin
sheath that impedes the flow of IV fluids. Phlebitis occurs with redness
surrounding the vein, and extravasation leads to trauma within the vein
2. Established standards for routine replacement of
peripheral IV catheters and intravenous administration sets have recommended a
maximum of _____ hours to reduce IV fluid contamination and prevent catheter
site complications.
a. 24
b. 48
c. 72
d. 96
ANS: D
Established standards for routine replacement of
peripheral IV catheters and intravenous administration sets have recommended a
maximum of 96 hours to reduce IV fluid contamination and prevent catheter site
complications.
3. While assessing the patient, the nurse recognizes
that special caution should be taken with the IV infusion because of fluid
volume excess when the nurse notes the presence of which condition?
a. Poor skin turgor
b. Crackles in the lungs
c. Decreased blood pressure
d. Dry skin and mucous membranes
ANS: B
4. The nurse needs to specifically prevent air emboli
that may result from IV therapy. What should the nurse make sure to do to
prevent air emboli?
a. Use a needleless system.
b. Prime the tubing completely.
c. Check for medication compatibility.
d. Select a larger-gauge needle or catheter.
ANS: B
Prime the infusion tubing by filling it with IV
solution. Be certain that the tubing is clear of air and air bubbles. Large air
bubbles can act as emboli. A needleless system does not specifically prevent
the introduction of air emboli. Medication incompatibility may lead to
crystallization of the medication and may cause emboli to form from
precipitate. It will not lead, however, to air embolism. Catheter size does not
contribute to emboli formation.
5. Which of the following steps is necessary when a
patient is prepared for IV insertion?
a. Shaving the hair from the site
b. Selecting a proximal site in an extremity
c. Applying a tourniquet 4 to 6 inches above the
selected site
d. Vigorously taping and massaging the selected vein
ANS: C
Apply a flat tourniquet around the arm, above the
antecubital fossa or 4 to 6 inches (10 to 15 cm) above the proposed insertion
site. Do not shave the area. Shaving may cause microabrasions and may
predispose to infection. Use the most distal site in the nondominant arm, if
possible. Vigorous friction and multiple taping of the veins, especially in
older adults, may cause hematoma and/or venous constriction.
6. What should be the next action by the nurse, once
an over-the-needle catheter (ONC) has been inserted through the skin and into
the vein?
a. Loosen the stylet for removal
b. Check for blood return in the flashback chamber
c. Stabilize the catheter and release the tourniquet
d. Advance the catheter until the hub rests at the
insertion site
ANS: B
Observe for blood return through the flashback chamber
of the catheter or the tubing of the winged cannula, indicating that the bevel
of the needle has entered the vein. Lower the needle until almost flush with
the skin. Advance the catheter another to inch into the vein, and then loosen
the stylet site on the ONC. Only after the catheter is advanced and is in its
final position is the catheter stabilized with one hand while the tourniquet is
released. Only after the blood and the needle are observed to advance another
to inch into the vein is the stylet loosened. At that point, continue to hold
the skin taut, and advance the catheter into the vein until the hub rests at
the venipuncture site.
7. What should the nurse do once she recognizes that
the patient has phlebitis at his IV site?
a. Reduce the IV flow rate.
b. Elevate the affected extremity.
c. Place a moist warm compress over the site.
d. Adjust the additive in the current IV.
ANS: C
8. What should the nurse do upon noting bleeding
around a dressing at an IV insertion site?
a. Discontinue the IV.
b. Assess the insertion site.
c. Leave the dressing intact, but reinforce it.
d. Elevate and apply warm compresses to the extremity.
ANS: B
When blood appears on the dressing, verify that the
system is intact, and change the dressing. The IV should be discontinued in the
event of infiltration or phlebitis. If bleeding occurs around the venipuncture
site and the catheter is within the vein, gauze dressing may be applied over
the site. Be aware that if gauze dressing is used, it must be removed to
accurately assess the insertion site. Elevation is used in cases of
infiltration to reduce edema. Warm compresses are used in cases of phlebitis.
9. Which patient would a nurse anticipate would be a
candidate for a peripherally inserted central catheter (PICC)?
a. An older adult who is having cataracts removed
b. A perinatal patient who is having prolonged labor
c. A neonate requiring blood therapy
d. An adolescent who is having surgery for reduction
of a fracture
ANS: C
When a child is critically ill or when long-term IV
access is anticipated, a PICC catheter, a Broviac catheter, or an implanted
port may be used to access a larger vein. PICCs can be used to infuse IV
fluids, parenteral nutrition, blood and blood products, and medications such as
antibiotics. Gerontological veins are very fragile, with less subcutaneous
support tissue and with thinning of the skin. In older patients, use the
smallest gauge possible. For example, a 22-gauge needle is adequate for fluid and
medication therapy. PICC lines are not inserted routinely. PICCs are used when
long-term IV is needed.
10. The nurse is caring for a patient receiving
intravenous therapy. The nurse should report which of the following to the
primary care provider?
a. Completion of each liter of fluid
b. Initiation of IV fluids
c. Small infiltration
d. Extravasation
ANS: D
If a patient suffers an extravasation, the primary
care provider should be notified as soon as possible because complications of
some vesicants can be reduced by injection of specific medications, whereas
others require rapid medical intervention. It is not necessary to report when
you routinely initiate or complete IV therapy. Primary care providers do not
need to be notified of a small infiltrate, but it should be documented in the
patient’s medical record, and your facility may require completion of an event
reporting form.
11. The patient has an IV ordered to infuse at 1000 mL
over 10 hours. The infusion set has a calibration of 15 gtt/mL. At which rate
does the nurse regulate the infusion?
a. 20 gtt/min
b. 25 gtt/min
c. 30 gtt/min
d. 32 gtt/min
ANS: B
Select one of the following formulas to calculate drop
rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor
mL/min = Drops/min, or mL/hr Drop factor/60 min = Drops/min.
12. The order is for the patient to receive 500 mL
over 4 hours. The nurse has an electronic infusion device (EID) in place that
provides for the regulation of hourly infusion. The IV tubing available is 10
gtt/mL. What is the setting for the infusion device?
a. 125 mL/hr
b. 500 mL/hr
c. 21 gtt/min
d. 32 gtt/min
ANS: A
For use of EID for infusion, turn on the power button,
select the required drops per minute or volume per hour, close the door to the
control chamber, and press the start button. In this case, 500 mL/4 hr = 125
mL/hr.
13. A pediatric patient has an IV with a microdrip.
The order is for 40 mL/hr to infuse. At what rate does the nurse set the
microdrip?
a. 10 gtt/min
b. 20 gtt/min
c. 40 gtt/min
d. 80 gtt/min
ANS: C
Select one of the following formulas to calculate drop
rate based on drops per minute: mL/hr/60 min = mL/min followed by Drop factor
mL/min = drops/min, or mL/hr Drop factor/60 min = drops/min. In this case, 40
mL/hr 60 gtt/mL = 240 gtt/hr 1 hr/60 min = 40 gtt/min. When microdrip is
used, mL/hr always equals gtt/min.
14. While assessing the patient’s IV infusion, the
nurse notes that it is infusing more slowly than it should be. What should the
nurse do first?
a. Discontinue the IV.
b. Increase the rate of infusion.
c. Observe for fluid overload.
d. Check the position of the IV fluid and extremity.
ANS: D
15. The nurse caring for a patient receiving IV fluids
knows that the current recommendation for changing the tubing on a continuously
running IV is:
a. at least every 48 hours.
b. every 24 hours.
c. no more often than every 96 hours.
d. with each IV solution bag change.
ANS: C
Intravenous tubing administration sets remain sterile
for 96 hours. Thus, the INS recommends changing tubing no more frequently than
every 96 hours. When possible, schedule tubing changes when it is time to hang
a new IV container.
16. The nurse is caring for a patient diagnosed with
pneumonia who receives IV antibiotics every 8 hours. How often should the nurse
change the primary intermittent IV sets?
a. No more often than every 72 hours
b. At least every 72 hours
c. With each IV bag change
d. Every 24 hours
ANS: D
You should change primary intermittent sets every 24
hours because the IV system becomes interrupted, which increases the risk for
contamination.
17. What is an appropriate technique for the nurse to
implement when changing the dressing at a peripheral IV site?
a. Wear sterile gloves to remove the old dressing.
b. Keep one finger over the IV catheter until the tape
is replaced.
c. Cleanse with an antiseptic solution in a circular
manner toward the site.
d. Tape the connection between the IV catheter port
and the tubing.
ANS: B
Keep one finger over the catheter at all times until
the tape or dressing secures placement. If the patient is restless or
uncooperative, it is helpful to have another staff member assist with the
procedure. Perform hand hygiene. Apply disposable gloves. Apply the final swab
in a circular pattern, moving outward from the insertion site. Do not tape over
the connection of the access tubing or port to the IV catheter.
18. What should the nurse do when discontinuing a
peripheral IV?
a. Withdraw the catheter quickly.
b. Keep the hub perpendicular to the skin.
c. Apply pressure to the site for 1 minute.
d. Inspect the catheter for intactness after removal.
ANS: D
19. The patient is expected to require intravenous
therapy for several years as treatment for a chronic disease process. Which of
the following would be the best choice for venous access in this patient?
a. Peripherally inserted central catheter (PICC)
b. Nontunneled percutaneous central venous catheter
c. Subcutaneous implanted port
d. Peripheral IV
ANS: C
Implanted infusion ports are used for long-term and complex
IV therapy. When not in use, no external catheter is present, and port
manufacturers recommend that the port be heparinized every 4 weeks to maintain
patency. No other care is required for an unused port. PICCs provide
alternative IV access when the patient requires intermediate-length venous
access (>7 days to several months). These catheters are used for shorter
placements (e.g., 5 to 10 days). Use of peripheral IV therapy increases the
risk for patients to develop infection, vein sclerosis, phlebitis, and
infiltration.
20.The nurse is assisting the physician during the
insertion of a central line into the subclavian vein. How should the nurse
cleanse the area?
a. With chlorhexidine in a back and forth scrubbing
motion
b. With chlorhexidine followed by alcohol in a back
and forth scrubbing motion
c. With alcohol in a circular motion for 5 minutes
d. With antimicrobial solution that must be dabbed dry
with a sterile towel
ANS: A
Antiseptics such as chlorhexidine remove resident and
transient bacteria. Alcohol should not be applied after the application of
iodophor solution. Chlorhexidine is scrubbed in a back and forth motion for 30
seconds. Allow the antimicrobial solution to air-dry completely. This ensures
maximum antimicrobial effect.
21. The nurse is preparing to draw blood from a
central venous access device for blood cultures. Which of the following steps
is part of that process?
a. Apply sterile gloves.
b. Flush the port with 5 to 10 mL of 0.9% sodium
chloride.
c. Slowly aspirate 5 mL of blood and discard the
syringe.
d. Use the distal lumen to draw blood.
ANS: D
Use the distal (red or brown) lumen to draw blood if
the device has more than one lumen. The distal (red or brown) lumen typically
is the largest-gauge lumen. Apply clean gloves to prevent transfer of body
fluids. Do not flush before drawing blood for blood cultures. If blood cultures
have been ordered, do not discard any blood. Use the initial specimen for blood
cultures.
22. What should the nurse do to decrease the potential
for infection related to IV therapy?
a. Use the clean technique for dressing changes.
b. Change the IV tubing every 12 hours.
c. Palpate the insertion site daily through the intact
dressing.
d. After cleansing the skin, dab it dry with a sterile
gauze pad.
ANS: C
23. The nurse is caring for a patient with a
continuous intravenous infusion of 0.9% normal saline with 40 mEq of potassium
chloride added to each liter. During a routine hourly check of the infusion,
the nurse discovers that 4 hours of fluid has infused in the past 1 hour. The
nurse’s first action should be to:
a. notify the primary care provider.
b. assess the patient.
c. reduce the infusion rate.
d. notify the charge nurse.
ANS: C
If the intravenous fluid is infusing 4 times faster
than ordered, the first intervention should be to reduce the rate. Notification
of the primary care provider and the charge nurse would occur after the flow
rate is reduced and an assessment of the patient is performed. Although
assessing the patient is vitally important, you do not want to allow the fluid
to continue infusing at a rapid rate while you are performing the assessment.
24. The nurse is caring for a patient who has
experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse
anticipates what type of intravenous fluid to be ordered by the health care
provider?
a. Hypotonic or isotonic solutions
b. Hypertonic or isotonic solutions
c. Hypertonic solutions only
d. Whole blood
ANS: A
Hypotonic solutions are administered for cellular
dehydration, whereas isotonic solutions replace intravascular fluid, so both of
these might be appropriate for this patient. Hypertonic solutions pull fluid
from extravascular spaces and would not be appropriate for this patient. Whole
blood is not indicated because there is no evidence of blood loss.
25. Which of the following patients would the nurse
anticipate requiring the placement of a central venous catheter?
a. A patient in same-day surgery who might require
blood transfusions
b. A patient in the intensive care unit requiring
multiple simultaneous intravenous medications
c. A patient in the cardiac care unit diagnosed with
possible myocardial infarction
d. A patient on the surgical unit recovering from
hernia repair
ANS: B
The most likely candidate for a central venous
catheter is the patient in intensive care requiring the administration of
multiple medications. The central venous catheter will simplify the
administration of multiple medications to this critically ill patient. Because
same-day surgery patients are expected to go home at the end of the day, it
would be unlikely this patient would need a central catheter. A patient
diagnosed with myocardial infarction would be unlikely to need a central line
unless his condition deteriorated. A patient post hernia repair would be
unlikely to require a central venous line unless complications arose, which is
not indicated in this scenario.
26. The nurse assigns nursing assistive personnel
(NAP) to care for several patients with continuous IV infusions. Which of the
following can NAP assist with?
a. Changing empty IV solution containers
b. Confirming the correct IV drip rate
c. Assessing the patient for response to IV therapy
d. Informing the nurse if they notice anything
abnormal
ANS: D
27. The patient is on daily weights and is receiving
intravenous therapy. The nurse notices that the patient has gained 2 kg since
the previous morning. What else would the nurse expect to observe? (Select all
that apply.)
a. Dry skin and mucous membranes
b. Distended neck veins
c. Tenting of the skin
d. Crackles or rhonchi in the lungs
ANS: B, D
28. What should the nurse do upon noting that the
patient’s IV site is pale, cool, and edematous? (Select all that apply.)
a. Stop the infusion.
b. Elevate the extremity.
c. Start a new IV.
d. Flush the IV site.
ANS: A, B, C
Infiltration is indicated by swelling and possible
pitting edema, pallor, coolness, pain at the insertion site, and a possible
decrease in flow rate. The nurse should stop the infusion and should
discontinue the IV, elevate the affected extremity, start a new IV if continued
therapy is necessary, and document the degree of infiltration and nursing
intervention. Flushing the IV site is not recommended.
29. The nurse is preparing to start an IV on a
92-year-old patient. The nurse realizes that she may need to take which of the
following actions? (Select all that apply.)
a. Avoid using veins in the hand.
b. Avoid using veins in the dominant arm.
c. Use the largest-gauge catheter possible for maximum
flow.
d. Avoid using a tourniquet.
ANS: A, B, D
In older patients, use the smallest gauge possible.
For example, a 22-gauge needle is adequate for fluid and medication therapy;
use a 24-gauge in frail, older adults. Smaller-gauge catheters are less
traumatizing to the vein but still allow blood flow to provide increased
hemodilution of IV fluids or medications. If possible, avoid the back of the
older adult’s hand or the dominant arm for venipuncture because they interfere
with the older adult’s independence. Minimize pressure from tourniquets, or
avoid them if possible. Apply a blood pressure cuff in place of a tourniquet.
30. For which patients are electronic infusion devices
(EIDs) used? (Select all that apply.)
a. Those who require low hourly rates
b. Those who are at risk for volume overload
c. Those who have impaired renal clearance
d. Those who are receiving fluids that require a
specific hourly volume
ANS: A, B, C, D
Infusion pumps are necessary for patients requiring
low hourly rates, at risk for volume overload, with impaired renal clearance,
or receiving medications or fluids that require a specific hourly volume.
31. Central venous access devices (CVADs) can be used
in the home, in the hospital, and in long-term care facilities for patients who
require which of the following? (Select all that apply.)
a. Supplemental nutrition
b. Blood and blood products
c. Hemodynamic monitoring
d. Blood sampling
ANS: A, B, C, D
CVADs can be used in the home, in the hospital, and in
long-term care facilities for patients who require supplemental nutrition,
blood and blood products, continuous fluids, medications, hemodynamic
monitoring, and blood sampling.
32. Which of the following are CVADs? (Select all that
apply.)
a. Implanted subcutaneous ports
b. Peripherally inserted central catheter (PICC) lines
c. Saline locks
d. Heparin locks
ANS: A, B
Four types of CVADs are available: nontunneled
percutaneous central venous catheters, tunneled central venous catheters,
PICCs, and implanted subcutaneous ports.
33. Fluids that have the same osmolality as body
fluids are used most often to replace extracellular volume and are known as
_______________ fluids.
ANS: isotonic
34. _________________________ pull fluid into the
vascular space by osmosis, resulting in an increased vascular volume that
possibly will result in pulmonary edema.
ANS: Hypertonic solutions
Hypertonic solutions pull fluid into the vascular
space by osmosis, resulting in an increased vascular volume that possibly will
result in pulmonary edema.
35. The nurse is caring for a patient who will be on
long-term antibiotic therapy. The patient has had numerous IVs in the past, but
because the upcoming therapy will be given on a long-term basis, the nurse
suggests that a _________________ be inserted.
ANS: central venous access device (CVAD)
CVADs, which include nontunneled and tunneled
catheters, PICCs, and implanted ports, are designed for long-term use.
36. The nurse is caring for a patient who has a
peripheral IV. While performing her routine assessment, she notes that the insertion
site is pale, cool, and edematous. The patient indicates that the site is also
painful to the touch. The nurse recognizes these symptoms as revealing a
possible _______________.
ANS: infiltration
Infiltration is indicated by swelling and possible pitting
edema, pallor, coolness, pain at the insertion site, and a possible decrease in
flow rate.
37. ___________________ is manifested by decreased
urine output, dry mucous membranes, decreased capillary refill, a disparity in
central and peripheral pulses, tachycardia, hypotension, and shock.
ANS:Fluid volume deficit (FVD)
FVD is manifested by decreased urine output, dry
mucous membranes, decreased capillary refill, a disparity in central and
peripheral pulses, tachycardia, hypotension, and shock.
38. The nurse is caring for a patient who is receiving
IV fluids at a rate of 150 mL per hour. During her assessment, the nurse notes
that the patient is having more labored respirations, and that crackles have
developed in the patient’s lungs. The nurse reduces the IV rate and notifies
the physician. She does this while recognizing that the patient is experiencing
signs of _______________.
ANS:fluid volume excess (FVE)
FVE is manifested by crackles in the lungs, shortness
of breath, and edema.
39. While assessing the patient’s IV site, the nurse
notes that the site is reddened and warm. The patient states that it is “sore.”
The nurse recognizes these as signs of ____________.
ANS:phlebitis
Phlebitis is indicated by pain, increased skin
temperature, and erythema along the path of the vein.
40. An electronic device that delivers a measured
amount of intravenous fluid over a specified period (e.g., 100 mL/hr) using
positive pressure is called an ___________________.
ANS:electronic infusion device (EID)
An EID delivers a measured amount of fluid over a
specified period (e.g., 100 mL/hr) using positive pressure. EIDs use an
electronic sensor and an alarm that signals if the pressure in the system
changes and the desired flow rate is altered.
41. Intravenous pumps that have built-in software
programmed from health care pharmacy databases with unit-specific profiles are
known as ______________.
ANS: smart pumps
A new generation of IV infusion safety systems reduce
medication administration errors. Known as smart pumps, they are designed to
serve as a final step in preventing errors that relate directly to
administration of IV medications. They have built-in software programmed from
health care pharmacy databases with unit-specific profiles.
42. An intravenous catheter that is inserted through a
large arm vein and is advanced until the tip enters the central venous system
is known as a __________________.
ANS:peripherally inserted central catheter (PICC)
A PICC is inserted through a large arm vein (e.g.,
cephalic or basilic vein) and is advanced until the tip enters the central
venous system in the lower third of the superior vena cava.
43. Intravenous catheters that are inserted directly
through the skin and into the internal or external jugular, subclavian, or
femoral vein for up to several weeks are known as _______________.
ANS: nontunneled percutaneous venous access devices
Nontunneled percutaneous venous access devices are
inserted directly through the skin and into the internal or external jugular,
subclavian, or femoral vein. The tip of the catheter rests in the superior vena
cava. These catheters may be left for anywhere from several days up to several
weeks.
44. _________________________ are surgically inserted
through a tunnel into subcutaneous tissue, usually between the clavicle and the
nipple, into the internal jugular or subclavian vein, with the catheter tip
resting in the distal end of the superior vena cava. The subcutaneous tunnel
allows the catheter to remain in place for months to years.
ANS: Tunneled central venous catheters
Tunneled central venous catheters are surgically
inserted through a tunnel into subcutaneous tissue, usually between the
clavicle and the nipple (Figure 28-7), into the internal jugular or subclavian
vein, with the catheter tip resting in the distal end of the superior vena
cava. The subcutaneous tunnel allows the catheter to remain in place for months
to years.
45. The nurse is teaching a community group to
evaluate the nutritional content of food. If the label on a jar of peanut
butter states that each serving contains 16 g of fat and 190 calories, what is
the percentage of fat per serving?
a. 34%
b. 59%
c. 76%
d. 88%
ANS: C
One gram of fat yields 9 calories; 16 multiplied by 9
and divided by 190 (calories per serving) equals 76%.
46. What is the daily recommended intake of fibre for
a 38-year-old healthy female?
a. 21 g
b. 25 g
c. 30 g
d. 38 g
ANS: B
The recommended daily fibre intake for women aged 19
to 50 years of age is 25 g.
47. To determine the underlying factors relating to
the undernourishment of an older adult patient, what is the most appropriate
question the nurse can ask?
a. “Do you have a history of any malabsorption
diseases?”
b. “Do you have a way to get to a grocery store to buy
your food?”
c. “Are you taking any medications that alter your
taste or tolerance of foods?”
d. “Can you give me an example of what you normally
eat throughout the day?”
ANS: D
This is an open-ended question and will elicit the
most information related to the normal daily eating habits of this patient. The
most common method of obtaining information about dietary intake is the 24-hour
recall. The individual or family member is asked to recall everything eaten
within the last 24 hours. Food diaries require asking the individual or family
member to write down everything consumed for a certain period of time.
48. A woman weighs 66 kg and asks the nurse how much
protein she should include in her diet each day. What should the nurse
recommend that the woman’s diet should include?
a. 36 g protein
b. 53 g protein
c. 75 g protein
d. 98 g protein
ANS: B
The recommended daily protein intake is 0.8 to 1 g/kg
of body weight, which for this patient is 66 kg 0.8 g = 52.8 or 53 g/day.
49. During assessment of a patient who is a vegan, the
nurse observes for signs of nutritional deficiency. What is the most common
nutritional deficiency related to a strict vegan diet that would be manifested?
a. Muscle wasting
b. Bleeding gums and loose teeth
c. Pallor and changes in sensation of the extremities
d. Dry, scaly skin and cracked mucous membranes
ANS: C
Cobalamin (vitamin B12) cannot be obtained in foods of
plant origin, so the patient will be most at risk for signs of cobalamin
deficiency, such as anemia and peripheral neuropathy.
50. When assessing anthropometric measurements on a
28-year-old male, the patient asks what information is obtained from the
measurement of his midarm muscle circumference. The nurse’s response is based
on which following information regarding this measurement?
a. It is a measurement of subcutaneous fat stores.
b. It is used to calculate the body mass index (BMI).
c. It is an indicator of protein stores.
d. It is an indicator of hydration status.
ANS: C
Anthropometric measurements consist of measures of
skinfold thickness at various sites, which are an indicator of subcutaneous fat
stores; midarm muscle circumference is an indicator of protein stores
51. How often would the nurse flush a feeding tube for
the patient who is on continuous enteral nutrition (EN)?
a. Every 2 hours
b. Every 4 hours
c. Every 6 hours
d. Every 12 hours
ANS: B
Feeding tubes should be flushed every 4 hours during continuous
feeding.
52. A 72-year-old patient is seen at the clinic for
symptoms of a urinary tract infection. She is 155 cm tall and weighs 42 kg. The
nursing history reveals that she drinks tea and eats toast twice a day for her
meals because it is easy to fix and she has no appetite. Laboratory results
include hemoglobin 6.5 mmol/L (10.5 g/dL) and albumin 20 g/L (2.0 g/dL). The
nurse determines that the patient is near starvation with severe protein
depletion when which of the following additional findings is observed?
a. A small, nodular liver
b. Generalized weakness
c. Edema of the face and extremities
d. Increased blood urea nitrogen and serum creatinine
levels
ANS: C
Edema occurs when serum albumin levels and plasma
oncotic pressure decrease, as occurs when a stressor such as infection is
imposed on pre-existing poor nutritional status.
53. When using a nutrition screening tool, how can the
nurse identify a patient at nutritional risk without further assessment?
a. Pressure ulcers
b. A recent hip fracture
c. Vomiting for 3 days
d. A laparoscopic cholecystectomy 1 week ago
ANS: A
Malnutrition is a major risk factor for pressure
ulcers; therefore, the presence of a pressure ulcer indicates that the patient
is at nutritional risk.
54. In evaluating a patient outcome of “identifies
high-protein foods,” the nurse knows that the outcome has been met when for
lunch, the patient selects which of the following foods from the hospital menu?
a. Bacon and tomato sandwich, bean soup, and coffee
b. Peanut butter and jelly sandwich, French fries, and
whole milk
c. Chicken noodle soup, grilled cheese sandwich, and
apple juice
d. Barbecued chicken breast sandwich, fruit yogurt,
and skim milk
ANS: D
The poultry and dairy selected are all high in
complete protein. Although the other responses have some high-protein foods,
they are not as high in protein.
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