Unit 4- Nutrition and Fluid and Electrolytes Flashcards
To help minimize calcium loss from a hospitalized client’s bones, the nurse should:
A.Encourage the pt to walk
B. Continue to keep the pt on bedrest
C. Have the client increase their water intake.
D. Ask the pt to increase they potassium intake.
A.Encourage the pt to walk
Explanation:
Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss.
The nurse is teaching a patient with diverticulitis about increasing fiber intake. Which of the following foods should the nurse recommend?
a. White bread
b. Cream of wheat
c. Carrots
d. Bananas
Answer: d
A high-fiber diet consists of fiber rich-fruits such as bananas, oranges, apples, dark vegetables, whole breads, and grains and nuts. White bread, cream of wheat, and carrots are low in fiber.
A patient is prescribed furosemide and is at risk of hypokalemia. Which food choice would be beneficial to manage this potential side effect?
a. Applesauce
b. Oranges
c. Cauliflower
d. Blueberries
Answer: b
Furosemide is a loop diuretic that can contribute to low potassium levels. Foods high in potassium include bananas, oranges, potatoes, cooked spinach, cooked broccoli, and peas. Applesauce, cauliflower, and blueberries are foods recommended on a low-potassium diet.
A patient is a newly diagnosed diabetic. The nurse prioritizes education focused on which of the following nutritional choices?
a. Limiting carbohydrates
b. Increasing simple sugars
c. Maintaining 2500 calorie diet
d. Limiting sodium intake
Answer: a
The body turns carbohydrates into glucose and eating too many carbohydrates can cause the blood glucose levels to elevate. Diabetics should avoid simple sugars. Diabetic diets recommend less than 2500 calories. Sodium intake is not the main focus of a diabetic diet.
The client in low in Vitamin A which foods would you recommend for the patient?
A. Chicken breast
B. Carrots
C.Tomatoes
D. Watermelon
B. Carrots
FROM THE BOOK
Foods rich in vitamin A include liver, milk, egg yolk, and dark, leafy green vegetables. Yellow and orange vegetables and fruits (such as sweet potatoes, pumpkin, carrots, and apricots) also are good sources.
What macronutrient or vitamins promotes healing ? Select all that apply
A. Apples
B. Zinc
C. Protein
D. Grapes
E. Vitamin C
B, C, E
The nurse evaluates that nutritional education for a patient on a clear liquid diet has been effective when the patient selects which food item to comply with this order?
a. Pudding
b. Ice cream
c. Chicken broth
d. Rice
Answer: c
Chicken broth is a clear liquid and is easily digestible. Pudding and ice cream are opaque and would be part of a full-liquid diet. Rice is not included in a liquid diet.
The nurse instructs a patient with renal failure who is receiving hemodialysis about the type of diet needed to be consumed. The nurse determines that the patient understands the education if the patient selects which diet?
a. High in calories
b. Low in sodium, phosphorus, and protein
c. Low in fiber
d. High in potassium
Answer: b
Clients with kidney problems have difficulty maintaining fluid and electrolyte balance. There are challenges with excreting sodium, phosphorus, and protein, as well as potassium.
The nurse has placed a nasogastric tube for a patient requiring enteral feeding. The nurse validates placement through pH measurement and using clinical judgment. What gold standard should be used to confirm placement prior to using the tube?
a. Auscultation
b. Presence of bowel sounds
c. X-ray
d. Patient affirmation
Answer: c
The gold standard for confirming tube placement is by x-ray All of the other methods have more room for error and are not recommended.
Which of the following nutrients is most helpful in preventing birth defects and should be taken by women of childbearing age?
a. Folic acid
b. Magnesium
c. Calcium
d. Selenium
a. Folic acid
Folic acid has been shown to reduce neural tube defects of the brain and spinal cord by more than 70% and is the most recommended nutrient to be taken to prevent birth defects.
FROM THE BOOK
Folic acid supplements taken before and during pregnancy have been a major factor in the decline of neural tube defects in newborns. Dietary sources of folic acid include leafy green vegetables (kale, spinach, Brussels sprouts), oranges, strawberries, dried beans, peas and nuts, and enriched breads and cereals and other fortified grain products.
The nurse is reviewing discharge instructions for a patient on a low-fat diet. The nurse determines that the patient understands the dietary instructions if the patient selects which of the following food choices containing unsaturated fat?
a. Beef
b. Hydrogenated oil
c. Ice cream
d. Almonds
Answer: d
Beef and ice cream are high in saturated fat; hydrogenated oil is high in trans fat. Almonds contain unsaturated fat, which helps to lower LDL cholesterol, reduce inflammation, and build stronger cell membranes in the body
The nurse is caring for a patient with hypocalcemia who does not like milk. Which food should the nurse encourage the patient to consume?
a. Cod
b. Eggs
c. Spinach
d. Tomatoes
Answer: c
Dark leafy vegetables such as spinach, kale, turnip greens, broccoli, Brussels sprouts, and cabbage are sources high in calcium.
The nurse is assessing the intravenous (IV) site in the right antecubital and notices that the area about 1 inch around it is cool, swollen, firm, and tender to touch. Which action should the nurse take first?
a. Take patient’s temperature.
b. Apply an ice pack to site.
c. Stop infusion and remove IV catheter.
d. Call the primary care provider immediately.
Answer: c
The area around an IV infiltration is cool, swollen, firm, and tender to touch. The first intervention to take for an infiltrated IV is to stop the infusion and discontinue the IV/remove the catheter. Applying cold compresses may be appropriate for hyperosmolar fluids but only after the IV infusion has been stopped. Taking the temperature would be an assessment to make if the complication of infection is suspected. The primary care provider does not need to be notified unless grade 3 or 4 infiltrations are noted (> 6 inches edema).
What is infiltration?
A. When the IV is patent
B. When the IV is being infiltrated with flush
C. Coolness and tenderness at the IV site
D.Extreme heat of the IV site
C. Coolness and tenderness at the IV site
What does IV mean?
A. Intravenous
B. Intravasucibulator
C. Intrapersonal
D. interpersonal
A. Intravenous
How should an good IV present itself?
A.Redness
B. Swelling
C. Patent
D. Filtrated
C. Patent
A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which assessment cues should the nurse recognize as additional evidence for a nursing diagnosis of Fluid Volume Overload (Hypervolemia)? (Select all that apply.)
a. Third spacing/edema
b. Potassium intake
c. Bounding, rapid pulse
d. Crackles in lungs
e. Dry mucous membranes
Answer: a, c, d
Which dietary supplement should the nurse suggest to the client who needs to increase his or her intake of calcium?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
D. Vitamin D
The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
A .Weight loss
B . Flat neck and hand veins
C . An increase in blood pressure
D. a decreased central venous pressure (CVP)
Answer: C) An increase in blood pressure
Rational: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid colume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Options 1, 2, and 4 identify signs noted in fluid volume deficit.
A nurse is reviewing laboratory results and notes that a client’s serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the serum level. Which food item does the nurse instruct the client to avoid.
A. Peas
B. Nuts
C. Cauliflower
D. Processed oat cereals
D. Processed oat cereals
Rational: The normal serum sodium level is 135 - 145. a serum sodium level of 150 indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid food high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Processed food are high in sodium content.
A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expected to notes in the client?
A. Twitching
B.Hypoactive bowel sounds
C.Negative Trouseau’s sign
D.Hypoactive deep tendon reflexes
A. Twitching
Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes and a positive Trouseau’s or Chvosteck’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
A. Extreme thirst
B. Decreased urinary output
C. Hyperactive bowel sounds
D. Increased specific gravity of the urine
C. Hyperactive bowel sounds
Rational: Hyponatremia is evidenced by serum sodium level lower than 135. Hyperactive bowel sounds indicated hypernatremia. Options 1, 2, and 4 are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted.
A nurse is reading a physician’s progress notes in the lcient’s record and reads that the physician had documented “insensible fluid loss of approximately 800 mL daily.” The nurse interprets that this type of fluid loss can occur through:
A.The skin
B. Urinary output
C. Wound drainage
D.The gastrointestinal tract
A.The skin
Rational: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and lungs.
What lab would you pull if a patient is dehydrated?
A. Serum sodium level of 167
B. Serum magnesium levels of 2.3
C.Serum chloride levels of 100
D. Serum calcium levels of 12
A. Serum sodium level of 167
What lab would you pull if a patient is malnourished?
A. Potassium levels of 4.5
B. Albumin levels of 1.3
C. Vitamin deficiency
D. B12
B. Albumin levels of 1.3
What are vitamins are vegans at risk for a deficiency for?
A. Vitamin B12
B. Vitamin A
C. Vitamin E
D. Vitamin K
A. Vitamin B12
WHY
because VIT B12 is mainly found in animal products and VEGANS RESTRICT ANYTHING FROM ANIMAL PRODUCTS. yOUR NURSING INTERVENTION WOULD BE TO PUT THEM ON SUPPLEMENTS OF B12.
