ATI questions for EXAM 3

A nurse is caring for a client who surgeon informed him postoperatively that he has a metastasizing malignant neoplasm in the colon. Which of the following statements by the client should the nurse identify as an indication that a client understands this information?

" i have cancer of the colon that has begun to spread."

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching?

"A hepatitis B immunization is given to infants and children." This is given as part of the standard childhood immunizations.

A nurse is providing pre operative teaching to a client who will undergo surgery to create a temporary colostomy.. the client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse make?

A colostomy is from the large intestine, and an ileostomy is from the small inmtine

A nurse is preforming an admission assessment for a client who has colorectal cancer. Which of the following manifestations should the nurse expect to find?

Abdominal cramps Clients who have colorectal cancer are likely to have changes in bowel habits, occult blood in the tool, weight loss, fatigue, and "gas pains" or abdominal cramping.

A nurse is performing a pre operative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods?

Bananas Other cross-receive foods include avocados, kiwi, chestnuts, mangoes, pineapple, and passion fruit.

A nurse in a provider's office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply.)

Regurgitation, nausea, belching, heartburn

A nurse is caring for client who has systemic lupus erythematosus (SLE) and is concerned about skin lesions on her face and neck. The client asks the nurse, "what should i do about theses spots?" Which of the following responses should the nurse give?

"Apply moisturizer after bathing the lesions with warm water."

A nurse is assisting a provider with performing a parade tests on a client. Which of the following actions should the nurse take?

Ask the client to empty his bladder before before the procedure..... to prevent injury to the bladder.

A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of th which of the following foods when the inflammation subsides?

Cabbage and peaches When the acute inflammation has subsided, the client should increase his intake of foods that are high in fiber, such as wheat bran, whole-grain bread, and fresh fruits and vegetables that do no contain seeds.

A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority?

Coughing and deep-breathing exercises

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform? (Select all that apply.)

Empty the bag when it is one-third to one-half full Cut the skin barrier opening a little larger than the ostomy Wash the peristomal skin with mild soap and water Allowing the bag to become too full can cause leakage. The client should cut an opening that is about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. The client should avoid moisturizing soaps because lubricants can affect adhesion of the appliance.

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions?

Increased mucus secretion The nurse should instruct the client that increased mucus secretion is a manifestation of histamine release. Histamine is the neurotransmitter the body produces during an allergic reaction.

A nurse is monitoring the laboratory results of a client who has end-stage liver failure, which of the following results should the nurse expect?

Increased prothrombin time Clients who have end-stage liver failure have an inadequate supply of cutting factors and an increased (i.e. prolonged) prothrombin time.

A nurse is assessing a client who is 12 hr postoperative following an open cholecystectomy. Which of the following findings should the nurse report tot he provider?

Indwelling urinary cather output of 25 ml/hr. The nurse should report a urinary output of <30 ml/hr tot he provider, as this can indicate hypovolemia or renal complication.

A nurse is teaching a client with systemic lupus erythematosus who has a new prescription for prednisone. The nurse should instruct the client to monitor for which of the following adverse effects of this medication?

Infection The nurse should instruct the client to avoid contact with people who are ill and monitor for manifestations of an infection such as a fever or a sore throat. Prednisone can suppress the clients immune response and mask the manifestations of an infection.

A nurse is performing discharge teaching about ostomy care while at home for client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching?

"Empty your ostomy pouch when it becomes half full." The nurse should instruct the client to empty the ostomy when it is one-third to one-half full. This prevents the ostomy from becoming too full of stool and gas and exploding.

A nurse in a provider;s office is teaching a client with a recent diagnosis of rheumatoid arthritis who has a new prescription for naproxen tablets. Which of the following statements buy the client indicates the need to further teaching?

"I can take this medication with aspirin." The nurse should instruct the client to avoid taking this medication with any other NSAIDs such as aspirin because this can increase the risk of bleeding and gastrointestinal ulceration.

A nurse is providing discharge teaching to a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?

"I will need to take methotrexate even if I'm in remission." SLE is an autoimmune disorder characterized by exacerbations and remissions. Methotrexate is on immunosuppressive medication during remission to help prevent exacerbation. The medication is also given when exacerbations occur to reduce the severity of manifestations.

A nurse is providing teaching to a client who is scheduled for a sigmoid color resection with colostomy. Which of the following statements by the client INDICATES a NEED for further teaching?

"I'll have to consume a soft diet after surgery." After surgery, the client quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor.

A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provider?

"Lying quietly in bed helps slow down the activity in your intestines."

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

"Monitor your body temperature and report any elevations promptly." SLE is chronic autoimmune disorder that can affect any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly, as a fever can suggest either an exacerbation or a potentially life-threatening infection.

A nurse is caring for a client who has colitis and reported increased exacerbations due to stress at work. Which of the following responses should the nurse make?

"Perhaps we should review your coping mechanisms and talk about other alternatives."

A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately?

Abdominal pain in the left upper quadrant When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is left upper-quadrant pain, which can indicate an enlarged spleen. An enlarged spleen can rupture, leading to internal hemorrhaging. The nurse should encourage the client to refrain from engaging in strenuous activities until the splenomegaly is resolved.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hr of treatment beginning?

Amylase Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hours following the onset of acute pancreatitis. The amylase level leaks in 20 to 30 hours and returns to the expected reference range within 2 to 3 days.

A nurse in a provider's office is assessing a client who has GERD. When documenting the client;s history, the nurse should expect the client to report symptoms worsen with which of the following actions?

Bending over Gastroesophageal reflux symptoms are most evidence with activists that increase intraabdominal pressure (e.g. bending over, straining, lifting, and lying down).

A nurse is assessing a client who has cholecystitis. Which of he following findings should the nurse expect?

Blumberg's sign. The nurse should expect to find rebound tenderness (blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation.

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect?

Boardlike abdomen The nurse should expect this client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

A nurse is caring for a client who has diverticulitis and a new prescription for low-fiber diet. Which of the following food items should the nurse remove from the client's meal tray?

Coleslaw Coleslaw contains raw cabbage, which is high in fiber. Clients who are following a low-fiber diet should avoid most raw vegetables.

A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The initial approach to treatment likely will involve which of the following procedures?

Colonoscopy

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer?

Corticosteroids Corticosteroids such as prednisone are the treatment of choice for systemic manifestations of SLE because of their rapid anti-inflammatory action.

A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan?

Decrease the client's fat intake The nurse should decrease the client's fat intake to reduce the occurrence of biliary colic.

A nurse is caring for a child who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions?

Destroys old blood cells The nurse should tell the parent that the spleen destroys old blood cells, filters antigens, and stores platelets. A client without a spleen has an increased risk of infection and sepsis due to a reduced immune function.

A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse perform regarding the client's diet?

Determine the client's dietary preferences. The nurse should assess the client's dietary habits before planning to meet dietary needs.

A nurse is teaching a client who has diabetes mellitus about hypoglycemia. Which of the following manifestations should the nurse include? (Select all that apply.)

Diaphoresis, palpitations, shakiness. These are sympathetic nervous system responses to hypoglycemia.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has returned tot he room following physical therapy. The nurse notes the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings?

Diaphoresis. The nurse should recognize that this client has the potential to develop hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A nurse is teaching a group of clients about the functions of the liver and gall bladder. Which of the following should the nurse include in the teaching as the purpose of bile?

Digesting fats Bile is a product of the liver and aids in the ingestion of fats.

A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include?

Eat crackers and yogurt regularly. Crackers, toast, and yogurt can help reduce flatus, which contributes to odor.

A nurse is assessing a client who has bleeding duodenal ulcer. Which of the following findings should the nurse expect?

Emesis with a coffee ground appearance. The nurse should expect a client who has a bleeding duodenal ulcer to have emesis that resembles coffee-grounds or is bright red in color. Hematemesis indicates upper gastrointestinal bleeding, occurring at or above the duodenojejunal junction.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Empty the drainage bag when half-full of urine

A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

Ensure bowel rest.

A nurse is reviewing the laboratory data of a client who reports manifestations suggesting systemic lupus erythematosus (SLE). The nurse should expect an increase in which of the following parameters for a client who SLE?

Erythrocyte sedimentation rate (ESR) Most clients who have n exacerbation of SLE have an increased ESR.

A nurse is teaching a female client with new diagnosis of systemic lupus erythematosus about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching if she identifies which of the following as an exacerbations factor?

Exercise This client needs additional teaching about the importance of exercise to keep her muscles and joints active.

A nurse is providing teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend?

Foods high in fiber Long-term low-fiber eating habits and increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract.

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of laboratory tests to determine the possibility of recent excessive alcohol use?

Gamma-glutamyl transferase (GGT). The GGT laboratory test is specific to the hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client;s affected joints will require which of the following treatments?

Heat paraffin therapy applied to the client's joints Non-pharmacological intervention- relieves the stiffness of client's joint and provides comfort.

A nurse is assessing a client who has complete intestinal obstruction. Which of the following findings should the nurse expect?

Hyperactive bowel sounds above the obstruction. Because the intestinal peristalsis above obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction.

A nurse is teaching a client who tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen through which of the following statements?

I will put a mattress cover on my bed.

A nurse is caring for a client who underwent radiollergosorbent (RAST) testing due to seasonal allergies. The nurse should anticipate an elevation in which of the following immunoglobulin laboratory values?

IgE

A nurse is planning an inservice training session regarding nutrition. Which of the following minerals should the nurse identify as involved in oxygen transportation?

Iron. Iron transport oxygen by means of hemoglobin and myoglobin. It is also a component of enzyme systems.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client?

Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients.

A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (Select all that apply.)

Obtain the clients PT and INR measurements Administer lactulose 30 mL PO 4 times daily Obtains daily weight and abdominal girth measurements Administer a daily multivitamin

A nurse is recommending dietary modifications for client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet?

Oranges and tomatoes Symptoms of GERD worsen following the oral intake of substance that decrease lower esophageal stricture (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint.

A nurse is planning an inservice training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein?

Pepsin Pepsin is an enzyme secreted by the f=gastric mucosa that breaks down protein into polypeptides.

A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infections is the nurse's priority?

Performing hand hygiene before and after contact with the client

A nurse is caring for a client who has a percutaneous endoscopic gastronomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding actions should the nurse take first?

Place the client in the semi-Fowler' s position.

A nurse is caring for a client who had a gastric reaction to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes?

Prevents excessive pressure on sutures lines. The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention.

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory values can indicate arthritis?

Rheumatoid factor An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred?

Rigid abdomen Abdominal tenderness and rigidity indicate a bowel perforation. As fluid escapes into the peritoneal cavity, a reduction in circulating blood volume occurs, lowering blood pressure.

A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching?

Roast chicken and white rice Clients who have ulcerative colitis are restricted to a low-fiber diet, which omits whole grains and raw fruits and vegetables.

A nurse is assessing. Client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction?

Sudden oliguria The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBC's.

A nurse is performing a gastrointestinal assessment of a client who has a liver cirrhosis with abdominal distention. Which of the nurse take to assess for changes in the client's abdominal distention?

Take serial measurements of the abdomen with a tape measure. Measuring the abdomen is the most effective way to assess for a change in abdominal distention because it provides concrete, objective data that can be compared at various points in time to monitor changes.

A nurse us teaching a client with Barrett's esophagus who is scheduled to undergo an esophagogastroduodenoscopy EGD. Which of the following statements should the nurse include in the teaching?

This procedure can determine how well the lower part of your esophagus works.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is for which of the following reasons?

To detect an ulceration in the stomach An EGD is used to visualized the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.

A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform?

Use dedicated equipment for the client. The nurse should use dedicated equipment that is left in the room for a client who has contact-isolation precautions in place.

A nurse is caring for a client who has celiac disease. Which of following foods should the nurse remove from the client's tray?

Wheat toast. Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from he client;s tray.

A nurse is caring for client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet?

White bread and plain yogurt Because of the acute inflammation of diverticulitis, the client should maintain a diet very low in fiber. The client can consume low-fiber foods like white bread, low-fat milk, yogurt with active cultures, poached eggs and canned soft fruit.

A nurse is obtaining a guaiac test from a client. This test is performed to detect which of the following?

blood in stool A guaiac test detects the presence of blood in the stool. It is a commonly used point of care test for fecal occult blood.

A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions?

destroying liver cells that are later replaced with scar tissue. The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the necrotic liver cells.

A nurse is providing teaching to a client who has constipation. Which of the following instructions should the nurse include?

eat yogurt with live cultures. Yogurt with live bacteria cultures provides dietary probiotics that help maintain and promote bowel function.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend?

foods high in fiber (The result of long term low fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High fiber foods help strengthen and maintain active motility of the GI tract.)

A nurse is teaching dietary modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend?

grilled chicken The nurse should identify that a client who has cirrhosis requires protein to compensate for disease-related weight loss. Increasing protein intake form animal or plant sources will also provide the client with more energy.

A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states she does not understand how she will be alright without her gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder?

storing bile The primary function of the gallbladder is to store bile. Because this organ is only for storage, the client's liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum, where it will perform various functions.

A nurse in the emergency department is caring for a client who has bleeding esophageal varies. The nurse should anticipate a prescription for which of the following medications?

vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.