Adult Health: Complex Exam 3; 2022/2023 with Complete Solutions
___ is used when the patient is unable to take in nutritional support orally;
... [Show More] administration of nutritionally balanced and liquified foods {{Ans- enteral tube feeding
___ will be inserted stomach, jejunum, duodenum {{Ans- enteral tube
Clients receiving an enteral tube feeding MUST have ___ {{Ans- a functioning GI tract
When patients are receiving tube feedings, the head of the bed should be elevated to at least ___-___ degrees {{Ans- 30-45
Tube patency must be assessed at least every ___ and/or before and after tube is used for a feeding {{Ans- 4 hours
Assess ___, ___, ___, ___, ___, ___, ___ every 4 hours, even if patient is on continuous feeds
{{Ans-
- shape & feel of abdomen
- bowel sound presences (all quadrants)
- tenderness upon palpation
- stability of tube (look at marker outside tube)
- daily weights
- accurate I&O
- glucose checks for first 24 hours
pH ___ indicates that the tube is in the stomach (gastrostomy tube) {{Ans- <4
pH ___ indicates the tube is in the jejunum (jejunostomy tube) {{Ans- >6
3 complications of enteral feedings
{{Ans-
- overfeeding (nausea, vomiting, abdominal distention)
- diarrhea/dumping syndrome
- aspiration pneumonia
Assess residuals every ___-___ {{Ans- 4-6 hours
6 nursing actions to treat complications of enteral tube feedings
{{Ans-
- stop feeding
- suction airway while patient is laying on side
- provide oxygen
- watch for increase in temp. (infection)
- auscultate breath sounds
- chest x-ray
___ is intravenous administration of amino acids, with carbohydrates, fats, electrolytes, vitamins, minerals; must be administered through a central vein or PICC lines
{{Ans- parenteral tube feedings (TPN)
TPN is usually given IV as a ___ {{Ans- sterile solution
TPN is always administered via ___ {{Ans- infusion pump
A mixture of TPN contains ___, ___, ___, ___, ___, ___
{{Ans-
- amino acids
- dextrose
- added electrolytes
- minerals
- vitamins
- fat emulsions can be added although as usually given separately
4 nursing interventions for clients on TPN
{{Ans-
- maintain sterility of solution and infusion site
- monitor BUN levels in patients with impaired kidney functions or liver disease
- monitor blood & urine glucose levels every 6 hours until insulin production adjusts to the increased glucose infusions
- supplemental insulin may be needed
6 complications from TPN
{{Ans-
- hyperglycemia
- hypoglycemia
- vitamin deficiencies
- air embolism
- infection
- fluid imbalance
3 nursing actions to treat TPN-caused metabolism complications (hyperglycemia, hypoglycemia, vitamin deficiencies)
{{Ans-
- draw daily labs and get results before a new TPN is made
- replace fluid deficits with another intravenous site
- monitor for hyperglycemia
3 nursing actions to treat air embolism caused by TPN
{{Ans-
- monitor for signs/symptoms of air embolus
- clamp catheter and lay on left side in Trendelenburg to trap air
- administer oxygen
4 nursing actions to treat infection caused by TPN
{{Ans-
- monitor insertion site for signs/symptoms of infection
- change central line dressing as per protocols (every 48-72 hours)
- monitor for infection
- no other meds are given in same line as TPN !!!!
TPN is ___, which can place clients at risk for fluid shifts causing increased risk of fluid volume excess {{Ans- hyperosmotic
3 nursing actions to treat fluid imbalance caused by TPN
{{Ans-
- assess lung sounds for crackles & monitor for respiratory distress
- monitor daily weight, I&O
- always run TPN on a pump
Increase ___ to reduce diarrhea caused by enteral feedings or TPN {{Ans- fiber
TPN is only compatible with ___ {{Ans- normal saline
___ is inflammation of the appendix walls {{Ans- appendicitis
5 clinical manifestations of appendicitis
{{Ans-
- RLQ pain
- dull pain around umbilicus
- loss of appetite
- possible nausea/vomiting
- temperature of 99-102 degrees
2 diagnostics for appendicitis
{{Ans-
- CT scan
- rebound tenderness
If a patient with appendicitis has relieved pain then ___ {{Ans- appendix has ruptured
If the appendix has not ruptured, ___ and ___
{{Ans-
- maintain airway
- assess
If the appendix has ruptured, ___ {{Ans- nasogastric decompression
3 infections of appendicitis
{{Ans-
- ruptured appendix
- infection (peritonitis, sepsis)
- pain
If a patient with appendicitis gets peritonitis, ___ must be performed
{{Ans- complete washout of the abdominal cavity
Do NOT administer ___ or ___ or ___ to appendicitis patients
{{Ans-
- enema
- laxative
- opioids
Administer ___ for acetaminophen overdose {{Ans- n-Acetylcystine
Clients with drug-induced hepatitis should avoid ___ and ___
{{Ans-
- herbals
- OTC medications
Drug-induced hepatitis can be caused by ___, ___, ___
{{Ans-
- acetaminophen
- statins
- alcohol
3 clinical manifestations of acute hepatic failure
{{Ans-
- sleepy
- poor appetite
- pooping problems
5 labs for acute hepatic failure
{{Ans-
- elevated bilirubin
- elevated PTT
- elevated AST, ALT, Ammonia
3 diagnostics for acute hepatic failure
{{Ans-
- labs (bili, PTT, AST, ALT, ammonia)
- CT
- MRI
5 nursing actions to treat acute hepatic failure
{{Ans-
- monitor respiratory status
- skin integrity and nutritional status
- fluid balance and neurological status
- assess GI status and pain
- manage & reduce ammonia for hepatic encephalopathy (if applicable)
___ is used to treat hepatic encephalopathy {{Ans- lactulose
Lactulose will cause ___ {{Ans- diarrhea
6 complications of acute hepatic failure
{{Ans-
- hepatic encephalopathy
- portal hypertension
- liver failure
- cerebral edema
- sepsis
- hypoglycemia
___ occurs when ammonia levels are so high they are toxic to the brain {{Ans- hepatic encephalopathy
5 manifestations of hepatic encephalopathy
{{Ans-
- ascites
- sodium & water retention
- jaundice
- coagulation abnormalities
- confusion [Show Less]