Nursing Care exam 4 quiz
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A patient with GERD is experiencing severe pyrosis. Which lifestyle modification should the nurse suggest?

  • Elevate the head of the bed (correct)
  • Eat large meals before bedtime
  • Lie down immediately after eating
  • Drink caffeinated beverages

    • A nurse is caring for a patient with a nasogastric tube receiving enteral nutrition. Which intervention is the highest priority to reduce the risk of aspiration?

  • Flushing the tube with water before and after medications
  • Checking the placement of the tube before each feeding (correct)
  • Administering feedings at room temperature
  • Monitoring the patient's weight daily

    • Which of the following is a common complication of intravenous therapy that requires immediate attention?

  • Infiltration (correct)
  • Fever
  • Phlebitis
  • Tachycardia

    • The nurse is assessing a patient with melena. What is the most likely source of the bleeding?

    <p>Stomach or upper GI tract</p> Signup and view all the answers

    A patient with diarrhea is placed on the BRAT diet. Which food is appropriate for this diet?

    <p>Applesauce</p> Signup and view all the answers

    Which of the following is an important step in managing constipation?

    <p>Increase dietary fiber</p> Signup and view all the answers

    A patient is diagnosed with GERD. Which of the following is an appropriate nursing intervention?

    <p>Advise the patient to eat smaller, more frequent meals</p> Signup and view all the answers

    In managing a patient with peptic ulcer disease, which medication is commonly prescribed?

    <p>Antacids</p> Signup and view all the answers

    A nurse is educating a patient on the prevention of urinary tract infections. Which of the following should be included?

    <p>Drink plenty of fluids</p> Signup and view all the answers

    Which assessment finding would indicate dehydration in a patient with diarrhea?

    <p>Dry mucous membranes</p> Signup and view all the answers

    What is the primary goal of administering an enema?

    <p>Stimulate bowel movements</p> Signup and view all the answers

    Which symptom would suggest a complication in a patient receiving enteral nutrition?

    <p>Respiratory distress</p> Signup and view all the answers

    What type of urine sample is required for urinalysis?

    <p>Clean-catch midstream</p> Signup and view all the answers

    Which electrolyte is primarily responsible for fluid balance in the body?

    <p>Sodium</p> Signup and view all the answers

    Which of the following symptoms is associated with GERD?

    <p>Heartburn</p> Signup and view all the answers

    A patient with a colostomy is being taught stoma care. Which statement indicates effective learning?

    <p>I need to monitor the skin around the stoma for irritation.</p> Signup and view all the answers

    Which of the following foods should be avoided by a patient with diarrhea?

    <p>Dairy products</p> Signup and view all the answers

    What is the normal specific gravity range of urine?

    <p>1.005 - 1.030</p> Signup and view all the answers

    Which intervention should be included in the care plan for a patient with peptic ulcer disease?

    <p>Administering proton pump inhibitors</p> Signup and view all the answers

    A nurse is caring for a patient with a history of urinary tract infections. What is a common cause of UTI in females?

    <p>Poor perineal hygiene</p> Signup and view all the answers

    A patient with GERD is advised to avoid which of the following foods?

    <p>Chocolate</p> Signup and view all the answers

    Which fluid balance indicator is crucial to monitor in patients with diarrhea?

    <p>Skin turgor</p> Signup and view all the answers

    Which of the following conditions can lead to metabolic acidosis?

    <p>Diabetic ketoacidosis</p> Signup and view all the answers

    A nurse is educating a patient on increasing dietary fiber. Which food should be included?

    <p>Broccoli</p> Signup and view all the answers

    A patient with an ileostomy needs to be monitored for which common complication?

    <p>Dehydration</p> Signup and view all the answers

    What is a priority nursing intervention for a patient with urinary retention?

    <p>Catheterize the patient</p> Signup and view all the answers

    Which symptom should be reported immediately in a patient receiving intravenous therapy?

    <p>Fever and chills</p> Signup and view all the answers

    A nurse is assessing a patient with a jejunostomy tube. What is an important aspect of care?

    <p>Checking for tube placement and residuals</p> Signup and view all the answers

    Which electrolyte imbalance is associated with muscle cramps and weakness?

    <p>Hypokalemia</p> Signup and view all the answers

    Which intervention is essential for preventing complications in a patient with a urinary catheter?

    <p>Keeping the drainage bag below bladder level</p> Signup and view all the answers

    A patient presents with symptoms of metabolic acidosis. Which lab result supports this diagnosis?

    <p>pH 7.30</p> Signup and view all the answers

    In a patient with constipation, which dietary recommendation is appropriate?

    <p>Consume more high-fiber foods</p> Signup and view all the answers

    What is a common symptom of urinary tract infection in older adults?

    <p>Confusion</p> Signup and view all the answers

    When assessing a patient with diarrhea, which electrolyte imbalance is a concern?

    <p>Hypokalemia</p> Signup and view all the answers

    A patient receiving enteral nutrition via gastrostomy tube is at risk for which complication?

    <p>Aspiration pneumonia</p> Signup and view all the answers

    Which lifestyle change can help manage GERD symptoms?

    <p>Avoiding smoking and alcohol</p> Signup and view all the answers

    What is the best way to assess fluid balance in a patient?

    <p>Monitoring daily weights</p> Signup and view all the answers

    A patient with a history of peptic ulcer disease reports sudden, severe abdominal pain. What should the nurse suspect?

    <p>Perforation</p> Signup and view all the answers

    Which dietary advice is appropriate for a patient with constipation?

    <p>Increase fluid intake</p> Signup and view all the answers

    A patient with GERD is advised to elevate the head of the bed. This recommendation helps to:

    <p>Prevent regurgitation</p> Signup and view all the answers

    Which condition can cause hematochezia?

    <p>Lower gastrointestinal bleeding</p> Signup and view all the answers

    What is the normal pH range of urine?

    <p>4.5 to 8.0</p> Signup and view all the answers

    What complication should be monitored for in a patient with a nasogastric tube?

    <p>Aspiration</p> Signup and view all the answers

    Which symptom is commonly associated with a urinary tract infection (UTI)?

    <p>Dysuria</p> Signup and view all the answers

    A nurse is assessing a patient with melena. What does this finding suggest?

    <p>Upper gastrointestinal bleeding</p> Signup and view all the answers

    A patient reports frequent heartburn and is diagnosed with GERD. Which advice should the nurse give?

    <p>Avoid lying down after meals</p> Signup and view all the answers

    What is an important nursing intervention for a patient with diarrhea?

    <p>Implementing the BRAT diet</p> Signup and view all the answers

    A patient with chronic constipation is advised to increase their intake of which type of food?

    <p>Fiber-rich foods</p> Signup and view all the answers

    A nurse is educating a patient with a new ileostomy. Which statement indicates understanding?

    <p>I need to monitor for signs of dehydration.</p> Signup and view all the answers

    Which finding in a urinalysis would indicate a potential urinary tract infection?

    <p>Presence of leukocytes and nitrates</p> Signup and view all the answers

    A patient is experiencing pyrosis. Which condition is most likely causing this symptom?

    <p>GERD</p> Signup and view all the answers

    When administering a cleansing enema, what is the appropriate position for the patient?

    <p>Left lateral with right knee flexed</p> Signup and view all the answers

    A nurse is educating a patient on fluid and electrolyte balance. Which symptom indicates hypernatremia?

    <p>Thirst</p> Signup and view all the answers

    In a patient with chronic constipation, which non-pharmacological intervention is recommended?

    <p>Increased physical activity</p> Signup and view all the answers

    Which type of feeding tube is appropriate for long-term enteral nutrition?

    <p>Gastrostomy tube</p> Signup and view all the answers

    A patient with diarrhea is at risk for which electrolyte imbalance?

    <p>Hypokalemia</p> Signup and view all the answers

    Which of the following is a primary function of potassium in the body?

    <p>Muscle function</p> Signup and view all the answers

    A nurse is caring for a patient with a urinary catheter. Which practice helps prevent infection?

    <p>Maintaining a closed drainage system</p> Signup and view all the answers

    What is the significance of dark, tarry stools (melena)?

    <p>Upper gastrointestinal bleeding</p> Signup and view all the answers

    Which condition is indicated by a high specific gravity of urine?

    <p>Dehydration</p> Signup and view all the answers

    A patient with peptic ulcer disease is prescribed a proton pump inhibitor. The nurse knows this medication helps by:

    <p>Reducing acid production</p> Signup and view all the answers

    Which practice helps prevent catheter-associated urinary tract infections (CAUTIs)?

    <p>Using sterile technique during insertion</p> Signup and view all the answers

    A nurse is teaching a patient with constipation about dietary changes. Which food should be avoided?

    <p>Processed cheese</p> Signup and view all the answers

    Which of the following is a potential complication of an ostomy?

    <p>Stoma infection</p> Signup and view all the answers

    What is the first-line treatment for a patient with severe diarrhea?

    <p>Providing rehydration therapy</p> Signup and view all the answers

    Which symptom indicates a possible complication from intravenous therapy?

    <p>Redness and warmth at the site</p> Signup and view all the answers

    A patient with GERD is advised to avoid which type of food?

    <p>Acidic foods</p> Signup and view all the answers

    What is the primary function of calcium in the body?

    <p>Bone health and muscle function</p> Signup and view all the answers

    Which electrolyte imbalance is associated with cardiac arrhythmias?

    <p>Hypokalemia</p> Signup and view all the answers

    A nurse is educating a patient with constipation. Which advice is most appropriate?

    <p>Engage in regular physical exercise</p> Signup and view all the answers

    Study Notes

    Lifestyle Modifications for GERD

    • Suggest elevating the head of the bed to prevent regurgitation
    • Advise eating smaller, more frequent meals to prevent reflux
    • Encourage avoiding spicy foods, caffeine, and alcohol to reduce symptoms

    Risk of Aspiration

    • Ensure checking nasogastric (NG) tube placement before each feeding to prevent aspiration
    • Regularly monitor for signs of aspiration: coughing, choking, or changes in respiratory function, and adjust feeding as needed.

    Intravenous Therapy Complications

    • Infiltration: A common complication; requires immediate attention
    • Phlebitis: Inflammation of the vein, may cause pain, redness, and swelling at the IV site.

    Bleeding Source (Melena)

    • Upper gastrointestinal (GI) tract: Most likely source of bleeding with melena
    • Upper GI bleeding symptoms typically include vomiting blood or black, tarry stools.

    BRAT Diet

    • Applesauce, bananas, rice, and toast are appropriate for a BRAT diet during diarrhea
    • The BRAT diet is a low-fiber diet, designed to be easily digested

    Constipation Management

    • Increase dietary fiber intake to improve regularity
    • Encourage fluids to soften stool
    • Encourage physical activity to promote bowel movements

    Urinary Tract Infections (UTIs)

    • Drinking plenty of fluids helps prevent UTIs
    • Maintaining good perineal hygiene is crucial to prevent UTI.

    Dehydration Indicators

    • Dry mucous membranes are a key indicator of dehydration
    • Low blood pressure and rapid heart rate are also indicators of dehydration.

    Enema Administration

    • Administering an enema should aim to stimulate bowel movement.
    • Position patient in left side-lying position

    Dietary Recommendations for GERD

    • Avoid foods that are acidic or trigger reflux
    • Avoid large meals or lying down immediately after meals

    Dietary Recommendations for Constipation

    • Increase fiber intake gradually to avoid abdominal discomfort.
    • Increase fluid intake

    Dietary Recommendations for Diarrhea

    • Stay hydrated
    • Eat bland foods like bananas, rice, applesauce, and toast (BRAT diet)

    Ostomy Care

    • Monitor for signs of infection
    • Maintain a closed drainage system
    • Teach proper stoma care and skin care techniques to patient as well as their family.

    IV Therapy Complications

    • Fever and chills: Requires immediate attention
    • Assess for pain, swelling, tenderness, and warmth around IV site.

    Electrolyte Imbalance

    • Hypokalemia: Occurs with vomiting or diarrhea; manifests as muscle cramps, weakness, and cardiac arrhythmias.
    • Monitor for signs, and seek treatment immediately.
    • Hypernatremia: Occurs due to dehydration, and can present symptoms such as thirst, dry mouth and confusion.

    Peptic Ulcer Disease

    • Administer proton pump inhibitors (PPIs) as prescribed to manage symptoms.

    Urinary Retention

    • Catheterization: A possible intervention
    • Monitor I&O and check for bladder distention to evaluate urinary retention.

    Managing GERD

    • Avoid eating prior to bed time, to reduce reflux
    • Avoid smoking and drinking alcohol or carbonated beverages
    • Eat smaller, more frequent meals to reduce the amount of food in your stomach
    • Elevate the head of bed during sleep.

    Managing Constipation

    • Consume high fiber foods.
    • Consume adequate fluid intake to soften stools.
    • Exercise regularly to stimulate bowel movements.

    Managing Diarrhea

    • Consult healthcare professional for appropriate medication and therapy to deal with severe diarrhea.
    • Drink plenty of fluids (water and electrolyte solutions) to prevent dehydration.

    Managing UTIs

    • Ensure good hydration by consuming adequate fluids.
    • Avoid tight clothing.

    Lifestyle modifications for managing GERD include avoiding lying down immediately after eating, elevated head of the bed, smaller and more frequent meals.

    Managing Stoma care

    • Important to maintain cleanliness and avoid infections around the stoma.

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