Adult Health: Complex Exam 3; 2022/2023 with Complete Solutions

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Adult Health: Complex Exam 3; 2022/2023 with Complete Solutions ___ is used when the patient is unable to take in nutritional support orally; administration of nutritionally balanced and liquified fo ... ods {{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 More]

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