in some hip surgeries an epidural catheter for fentanyl epidural analgesia is given what is your nursing priority care in such a case
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Nursing Elites

ATI RN

Nutrition ATI Test

1. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

2. When conducting assessments for malnutrition, which risk factors should the nurse consider? (SATA)

Correct answer: D

Rationale: When assessing for malnutrition, nurses should consider multiple risk factors. Dental problems and depression can impact a person's ability to eat and maintain proper nutrition. The ability to read and write may not directly relate to malnutrition risk. The correct answer is 'All of the above' because dental problems and depression are indeed risk factors, along with other factors like the inability to prepare meals and the loss of a spouse.

3. For individuals with lactose intolerance, which of the following foods should be avoided?

Correct answer: B

Rationale: Individuals with lactose intolerance lack the enzyme lactase needed to break down lactose. Milk contains lactose, a sugar found in dairy products, and should be avoided by individuals with lactose intolerance. Choices A, C, and D are not sources of lactose and are generally well-tolerated by individuals with lactose intolerance.

4. Which organ absorbs water and vitamin K and may be affected by ulcerative colitis?

Correct answer: C

Rationale: The large intestine is the organ that is primarily responsible for the absorption of water and vitamin K in the human body. A disease like ulcerative colitis can disrupt these functions by causing inflammation and ulcers in the lining of the large intestine, leading to digestive issues. The stomach (Choice A) primarily functions to break down and digest food, not to absorb water and vitamins. The pancreas (Choice B) secretes enzymes to aid in digestion and hormones to regulate blood sugar, but does not absorb water and vitamins. The small intestine (Choice D) is primarily responsible for absorbing nutrients from digested food, but not specifically water and vitamin K. Therefore, these other choices are incorrect.

5. During the later stages of chronic kidney disease, what is the recommended protein intake in grams per kilogram of body weight per day?

Correct answer: A

Rationale: In the later stages of chronic kidney disease, the recommended protein intake is typically restricted to 0.6 to 0.75 grams per kilogram of body weight per day. This lower protein intake helps reduce the workload on the kidneys, as excessive protein can be challenging for the kidneys to process. Choice B (1.2 to 1.55) is incorrect as it suggests a higher protein intake, which is not recommended for individuals with advanced kidney disease. Choices C (1.0 to 1.2) and D (0.8 to 1.0) also advocate for protein intakes higher than what is typically advised for individuals in later stages of chronic kidney disease.

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