Select Correct Answer Question & Answer Guide (With Explanation)

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What This Question Is About

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Structure your response with introduction, analysis, and conclusion.

Key Explanation

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Original Question

select correct answer/s and provide rationale 1. A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply). a. Distended neck veins b. Hyperthermia c. Tachycardia d. Syncope e. Decreased skin turgor rationale: 2. A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? a. Administer antihypertensive on schedule b. Check the client’s weight each morning c. Notify the provider of a urine output greater than 30ml/hr. d. Encourage independent ambulation four times a day rationale: 3. When teaching a patient about foods that affect fluid balance, the nurse would advise the patient to decrease? a. Na+ b. K+ c. Ca++ d. Mg++ 4. What food would the nurse provide for a patient who has hypokalemia? a. Canned vegetables b. Cheese c. Bread d. Bananas rationale: 5. A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply). a. Hyperreflexia b. Confusion c. Positive Chvostek’s sign d. Bone pain e. Nausea and vomiting rationale: 6. The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient’s medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125 rationale: 7. A patient who has just been started on tube feedings of full-strength formula has multiple stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the tube feeding. b. Check gastric residual volumes more frequently. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube. rationale: 8. After change-of-shift report, which patient will the nurse assess first? a. A 32-yr-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. A 25-yr-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition c. A 38-yr-old woman whose gastrostomy tube is plugged after crushed medications were administered d. A 40-yr-old man with continuous enteral feedings who has developed dyspnea rationale: 9. The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient’s lungs. In which order will the nurse take action? 1. Check the patient’s oxygen saturation. 2. Notify the patient’s health care provider. 3. Measure the tube feeding residual volume. 4. Stop administering the continuous feeding. a. 1, 2, 4, 3 b. 2, 4, 1, 3 c. 4, 2, 1, 3 d. 4, 1, 3, 2 rationale: 10. A nurse is planning a high-energy diet for a patient. What nutrient provides energy to the body and should be increased in the diet? a. Carbohydrates b. Vitamins c. Minerals d. Water rationale:

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