DNI MS 1: Exam 6

A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? - Alcohol intake of 1 to 2 drinks per week - Family history of H. pylori infection - Former smoker still using nicotine patches - Willingness to adhere to drug therapy

- Willingness to adhere to drug therapy Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the clients willingness and ability to follow the regimen. The other assessment findings are not as critical.: Applying/Application REF: 1127

A patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse - periodically aspirates and tests gastric pH. - monitors arterial blood gas values on a daily basis. - checks each stool for the presence of occult blood. - measures the amount of residual stomach contents hourly.

- periodically aspirates and tests gastric pH. The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube (Links to an external site.). Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation? - "It empties the stomach of fluids and gas." - "It prevents spasms at the sphincter of Oddi." - "It prevents air from forming in the small intestine and large intestine." - "It removes bile from the gallbladder."

- "It empties the stomach of fluids and gas." An NG tube is inserted into the patient's stomach to drain fluid and gas.

Doctor orders Zithromax for a child that weighs 82 lbs. The safe dose range for this medication is 10-12 mg/kg/day. What is the maximum safe daily dose for this child? - 984 mg/dose - 447.3 mg/day - 347 mg/dose - 586.8 mg/dose

- 447.3 mg/day

A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist? - Client who has poor oral hygiene practices - Client who smokes and drinks daily - Client who tans for an upcoming vacation - Client who occasionally uses illicit drugs

- Client who smokes and drinks daily Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol. Illicit drugs are not related to oral cancers.

A patient with a body mass index (BMI) of 17 kg/m2 and a low albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? - Restlessness - Hypertension - Pitting edema - Food allergies

- Pitting edema Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.

When a patient has a history of a total gastrectomy, the nurse will monitor for clinical manifestations of - constipation. - dehydration. - elevated total cholesterol. - cobalamin (vitamin B12) deficiency.

- cobalamin (vitamin B12) deficiency. The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

A client admitted for evaluation of gastroesophageal reflux disease (GERD) begins to complain of severe heartburn in the chest that radiates to the jaw. The client asks for the nitroglycerin (NTG) tablets brought in from home. The nurse realizes that the clinical manifestations demonstrated by the client are - classic manifestations of a myocardial infarction, and the physician should be paged immediately. - greatly influenced by fear related to the location of the pain, and the use of NTG should be discouraged. - indications that a thorough pain assessment should be done to determine the etiology of the pain, and the NTG should be given at once. - specifically associated with GERD and not myocardial infarction, but the NTG should be allowed if the client wants to use it.

- indications that a thorough pain assessment should be done to determine the etiology of the pain, and the NTG should be given at once. Responses to pain-relieving measures (e.g., NTG) help to differentiate between esophagitis and problems of cardiac origin (e.g., angina pectoris). If the nitroglycerin does relieve the pain, the physician should be notified because the patient indeed may be having a cardiac event.

The MD orders your patient to start an IV Heparin drip at 16 units/kg/hr and to administer a loading bolus dose of 60 units/kg IV before initiation of the drip. You're supplied with a Heparin bag that reads 12,500 units/250 mL. The patient weighs 198 lbs. What is the flow rate you will set the IV pump at (mL/hr)? - 69.6 mL/hr - 12.5 mL/hr - 43.6 mL/hr - 28.8 mL/hr

- 28.8 mL/hr

The doctor's order says: Vancomycin 2,000 mcg IV. The instructions on the vial of Vancomycin says to reconstitute with sterile water for a concentration of 2mg/ml then to dilute each 2 mg in 75 ml of sterile Normal Sale. How many milliliters should you use to administer the ordered dose?* - 90 ml/dose - 150 ml/dose - 75 ml/dose - 10 ml/dose

- 75 ml/dose

The nurse receives change-of-shift report about the following four patients. Which patient will the nurse assess first? - A patient who has malnutrition associated with 4+ generalized pitting edema - A patient whose parenteral nutrition has 10 mL of solution left in the infusion bag - A patient whose gastrostomy tube is plugged after crushed medications were given through the tube - A patient who is receiving continuous enteral feedings and has new-onset crackles throughout the lungs

- A patient who is receiving continuous enteral feedings and has new-onset crackles throughout the lungs The patient data suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients also should be assessed as quickly as possible, but the data about them do not suggest any immediately life-threatening complications.

A patient with a nasogastric tube to low intermittent suction after surgery begins to vomit bright red blood. Which action should the nurse take first? - Administer oxygen. - Irrigate the nasogastric tube. - Increase the intravenous rate. - Turn the patient onto his or her side.

- Turn the patient onto his or her side. Protection of the airway during vomiting is a priority to prevent aspiration. Those at risk of aspiration are persons who are unconscious, older, and experiencing gag reflex impairments. Place these types of persons on their side when they begin to vomit. This allows the gastric contents to be expelled from the mouth rather than pooling at the back of the throat and being aspirated. A. The patient does not necessarily need oxygen at this time. B. The patient could aspirate while the nurse is irrigating the nasogastric tube. C. There is no reason to increase the patients intravenous infusion at this time.

Recently a client has been diagnosed with achalasia and is bothered greatly by the substernal pain. The nurse should encourage the client to - begin a reducing diet. - eat foods with a dry consistency. - sleep with the head of the bed elevated. - take aspirin before going to sleep.

- sleep with the head of the bed elevated. To prevent nocturnal reflux of food, the client should sleep with the head of the bed elevated.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? - Its a good thing I love orange and cherry gelatin. - My spouse will be here to drive me home. - I should refrigerate the GoLYTELY before use. - I will buy a case of Gatorade before the prep.

- Its a good thing I love orange and cherry gelatin. The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.

Vasopressin (Pitressin) 0.2 units/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 20 units/50 mL normal saline. How many mL/min will the nurse infuse? ____________________ - 0.3 - 1.2 - 0.5 - 0.9

- 0.5 There are 0.4 units/1 mL. An infusion of 0.5 mL/min will result in the patient receiving 0.2 mL/min as prescribed.

Your patient has a Heparin drip running at 29 mL/hr. The Heparin bag reads 10,000 units/ 100 mL. How many units per hour is the patient receiving? - 2,900 units/hr - 1,590 units/hr - 3,352 units/hr - 1,980 units/hr

- 2,900 units/hr

After receiving change-of-shift report, which patient should the nurse assess first? - A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena - A patient who is crying after receiving a diagnosis of esophageal cancer - A patient with esophageal varices who has a blood pressure of 96/54 mm Hg - A patient with nausea who has a dose of metoclopramide (Reglan) scheduled

- A patient with esophageal varices who has a blood pressure of 96/54 mm Hg The patients history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

Parenteral nutrition (PN) containing amino acids and dextrose was ordered and hung 24 hours ago for a malnourished patient. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take? - Ask the health care provider to clarify the written PN order. - Add a new container of PN using the current tubing and filter. - Hang a new container of PN and change the IV tubing and filter. - Infuse the remaining 50 mL and then hang a new container of PN.

- Add a new container of PN using the current tubing and filter. All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.

A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? - Agree on a postoperative communication method. - Explain that staff will answer the call light promptly. - Give the client a Magic Slate to write on postoperatively. - Reassure the client that you will take care of all of his or her needs.

- Agree on a postoperative communication method. Before surgery that interrupts the clients ability to communicate, the nurse, client, and family (if possible) agree upon a method of communication in the postoperative period. The client may or may not prefer a slate and may not be able to communicate in writing. Reassuring the client and telling him or her you will take care of all of his or her needs does not help the client be an active participant in care. Ensuring that the staff will answer the call light promptly will not guarantee this will occur.

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) - Alcohol - Caffeine - Corticosteroids - Fruit juice - Nonsteroidal anti-inflammatory drugs (NSAIDs)

- Alcohol - Caffeine - Corticosteroids - Nonsteroidal anti-inflammatory drugs (NSAIDs) Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.

A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) - Ask a second nurse to double-check the blood. - Prime the IV tubing with normal saline. - Prime the IV tubing with dextrose in water. - Take and record a set of vital signs. - Teach the client about reaction manifestations.

- Ask a second nurse to double-check the blood. - Prime the IV tubing with normal saline. - Take and record a set of vital signs. - Teach the client about reaction manifestations. Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.

An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best? - Ask the family why they feel this way. - Assess family concerns and fears. - Refuse to go along with the family's wishes. - Tell the family that such secrets cannot be kept.

- Assess family concerns and fears. The nurse should use open-ended questions and statements to fully assess the family's concerns and fears. Asking why questions often puts people on the defensive and is considered a barrier to therapeutic communication. Refusing to follow the family's wishes or keep their confidence will not help move this family from their position and will set up an adversarial relationship.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? - Assess the 24-hour fluid balance. - Assess the clients oral cavity. - Prepare to hang a normal saline bolus. - Turn up the infusion rate of the TPN.

- Assess the 24-hour fluid balance. This client has clinical indicators of dehydration, so the nurse calculates the clients 24-hour intake, output, and fluid balance. This information is then reported to the provider. The clients oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The clients dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didn't know it would be this hard to live like this. What response by the nurse is best? - Assess the clients coping and support systems. - Inform the client that things will get easier. - Re-educate the client on needed dietary changes. - Tell the client lifestyle changes are always hard.

- Assess the clients coping and support systems. The nurse should assess this clients coping styles and support systems in order to provide holistic care. The other options do not address the clients distress.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? - Allow the client cool liquids only. - Assess the clients gag reflex. - Remind the client to remain NPO. - Tell the client to wait 4 hours.

- Assess the clients gag reflex. The local anesthetic used during this procedure will depress the clients gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the clients readiness for them.

Which of these nursing actions should the RN working in the emergency department delegate to nursing assistive personnel who help with the care of a patient who has been admitted with nausea and vomiting? - Auscultate the bowel sounds. - Assess for signs of dehydration. - Ask the patient what precipitated the nausea. - Assist the patient with oral care after vomiting.

- Assist the patient with oral care after vomiting. Oral care is included in nursing assistive personnel education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

The nurse is watching a new graduate nurse perform auscultation of a patients abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? - We need to determine the areas of tenderness before using percussion and palpation. - Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation. - Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination. - Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.

- Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation. Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

When the nurse is assessing an alert and independent older patient in the clinic for malnutrition risk, the most appropriate initial question is, - How do you get to the grocery store to buy your food? - Do you have any difficulty in preparing or eating food? - Can you tell me the foods that you have eaten over the past 24 hours? - Are you taking any medications that alter your taste or tolerance of foods?

- Can you tell me the foods that you have eaten over the past 24 hours? This question is the most open-ended and will provide the best overall information about the patients daily intake and risk for poor nutrition. The other questions may be asked, depending on the patients response to the first question.

An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? - Changes in your liver cause drugs to be metabolized differently. - Perhaps you don't need as high a dose of the drug as before. - Stomach muscles atrophy with age and you digest more slowly. - Your body probably cant tolerate as much medication anymore.

- Changes in your liver cause drugs to be metabolized differently. Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs possibly to toxic levels. The other options do not accurately explain this age-related change.

A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? - Auscultate lung sounds after each feeding. - Check tube placement before each feeding. - Check tube placement every 8 hours. - Weigh the client daily on the same scale.

- Check tube placement before each feeding. For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met.

A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? - Albumin: 3.5 g/dL - Cholesterol: 142 mg/dL - Hemoglobin: 9.8 mg/dL - Prealbumin: 28 mg/dL

- Cholesterol: 142 mg/dL A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? - Client having a radial neck dissection tomorrow who is asking questions - Client who had a tracheostomy 4 hours ago and needs frequent suctioning - Client who is 1 day postoperative for an oral tumor resection who is reporting pain - Client waiting for discharge instructions after a small tumor resection

- Client who had a tracheostomy 4 hours ago and needs frequent suctioning The client who needs frequent suctioning should be seen first to ensure that his or her airway is patent. The client waiting for pain medication should be seen next. The nurse may need to call the surgeon to see the client who is asking questions. The client waiting for discharge instructions can be seen last.

A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? - Client who underwent diverticula removal with a pulse of 106/min - Client who had esophageal dilation and is attempting first postprocedure oral intake - Client who had an esophagectomy with a respiratory rate of 32/min - Client who underwent hernia repair, reporting incisional pain of 7/10

- Client who had an esophagectomy with a respiratory rate of 32/min The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for.

For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)? - Client taking antacids - Client taking antibiotics - Client who is pregnant - Client over 65 years of age

- Client who is pregnant Misoprostol can cause abortion, so pregnant women should not take this drug. The other clients have no contraindications to taking misoprostol.

A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? - Client with a blood glucose level of 138 mg/dL - Client with foul-smelling diarrhea - Client with a potassium level of 2.6 mEq/L - Client with a sodium level of 138 mEq/L

- Client with a potassium level of 2.6 mEq/L The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross-contamination.

A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? - Client with congestive heart failure - Older client with dementia - Client who has multiorgan failure - Client who is post gastric resection

- Client with congestive heart failure Clients receiving PPN typically get large amounts of fluid volume, making the client with heart failure a poor candidate. The other candidates are appropriate for this type of nutritional support.

The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Vital Signs Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Physician Orders Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 - Administer the prescribed pain medication. - Consult the surgeon about a different antibiotic. - Consult the surgeon about increased IV fluids. - Have respiratory therapy reduce the respiratory rate.

- Consult the surgeon about increased IV fluids. This clients vital signs, cardiac output, dry skin, and urine output indicate hypovolemia or possible hypotension resulting from pressure placed on the posterior heart during surgery. The client needs more fluids, so the nurse should consult with the surgeon about increasing the fluid intake. The client may be restless as a result of the hypotension and may not need pain medication at this time. There is no reason to request a different antibiotic. The respiratory rate does not need to be adjusted.

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: - Increased salivation. - Increased liver size. - Increased esophageal emptying. - Decreased gastric acid secretion.

- Decreased gastric acid secretion. Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? - Assess the clients readiness to make lifestyle changes. - Ensure adequate staff when moving the client. - Leave side rails down to prevent pressure ulcers. - Reinforce the need to be sensitive to the client.

- Ensure adequate staff when moving the client. Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the clients willingness to make lifestyle changes. Leaving the side rails down may present a safety hazard. The staff should be sensitive to this clients situation, but safety takes priority.

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? - Assess the clients pain. - Check the surgical incision. - Ensure an adequate airway. - Program the morphine pump.

- Ensure an adequate airway. All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management.

A 62-year-old patient who has been diagnosed with esophageal cancer tells the nurse, I know that my chances are not very good, but I do not feel ready to die yet. Which response by the nurse is most appropriate? - You may have quite a few years still left to live. - Thinking about dying will only make you feel worse. - Having this new diagnosis must be very hard for you. - It is important that you be realistic about your prognosis.

- Having this new diagnosis must be very hard for you. This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response You may have quite a few years still left to live is misleading. The response beginning, Thinking about dying indicates that the nurse is not open to discussing the patients fears of dying. And the response beginning, It is important that you be realistic, discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

The nurse is teaching a patient about gastric surgery and dumping syndrome. Which statement indicates that the patient understands dumping syndrome? - I need to eat small frequent meals. - I should drink lots of fluids with meals. - I need to sit up for 2 hours after each meal. - I can expect the symptoms to begin 2 hours after eating.

- I need to eat small frequent meals. Treatment for dumping syndrome includes teaching the patient to eat small, frequent meals that are high in protein and fat and low in carbohydrates, especially refined sugars. B. The patient should be taught to avoid fluids 1 hour before meals, with meals, or for 2 hours after meals to prevent rapid gastric emptying. C. It is best for the patient to lie down after meals to delay gastric emptying. D. The symptoms occur 5 to 30 minutes after eating.

The nurse notes that the peripheral parenteral nutrition (PN) bag has only 20 mL left and a new PN bag has not yet arrived from the pharmacy. Which intervention is the priority? - Monitor the patients capillary blood glucose until a new PN bag is hung - Flush the peripheral line with saline and wait until the new PN bag is available - Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy - Decrease the rate of the current PN infusion to 10 mL/hr until the new bag arrives

- Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurses scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not the priority.

The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first? - Infuse normal saline at 250 mL/hr. - Administer IV ondansetron (Zofran). - Provide oral care with moistened swabs. - Insert a 16-gauge nasogastric (NG) tube.

- Infuse normal saline at 250 mL/hr. Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? - Albumin: 2.1 g/dL - Hematocrit: 28% - Hemoglobin: 8.1 mg/dL - International normalized ratio (INR): 4.2

- International normalized ratio (INR): 4.2 An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.

Doctor orders Digoxin 0.92 mg daily for a child that weighs 16 lbs. The safe dosage for this medication is 8-12 mcg/kg/day. Is this a safe dosage for this child? - Yes, this is a safe dose. - No, this is not a safe dose. A safe dose is 0.06-0.09 mg/day. - No, this is not a safe dose. A safe dose is 1-2 mg/day. - No, this is not a safe dose. A safe dose is 0.25-0.5 mg/day. - No, this is not a safe dose. A safe dose is 0.06-0.09 mg/day.

- No, this is not a safe dose. A safe dose is 0.06-0.09 mg/day.

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the clients abdomen is tense and rigid. What action takes priority? - Administer the prescribed pain medication. - Notify the health care provider immediately. - Percuss all four abdominal quadrants. - Take and document a set of vital signs.

- Notify the health care provider immediately. This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? - Auscultate for bowel sounds. - Notify the provider immediately. - Order an abdominal flat-plate x-ray. - Palpate the mass and measure its size.

- Notify the provider immediately. This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurses priority action is to notify the provider.

A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? - Irrigate the NG tube. - Obtain the vital signs. - Listen for bowel sounds. - Give the ordered antacid.

- Obtain the vital signs. The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken.

All of the following nursing actions are included in the plan of care for a patient who is malnourished. Which action is appropriate for the nurse to delegate to nursing assistive personnel (NAP)? - Assist the patient to choose high nutrition items from the menu. - Monitor the patient for skin breakdown over the bony prominences. - Offer the patient the prescribed nutritional supplement between meals. - Assess the patients strength while ambulating the patient in the room.

- Offer the patient the prescribed nutritional supplement between meals.

Which action by nursing assistive personnel (NAP) when caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the RN intervene? - Offering the patient a glass of water - Positioning the patient on the right side - Checking the vital signs every 30 minutes - Swabbing the patients mouth with cold water

- Offering the patient a glass of water Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the NAP are appropriate.

A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? - Assessing blood glucose as directed - Changing the IV dressing each day - Checking the TPN with another nurse - Performing appropriate hand hygiene

- Performing appropriate hand hygiene Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse.

Which of these nursing actions included in the plan of care for a patient who is receiving intermittent tube feedings through a percutaneous endoscopic gastrostomy (PEG) tube may be delegated to an LPN/LVN? - Providing skin care to the area around the tube site - Assessing the patients nutritional status at least weekly - Determining the need for the addition of water to the feedings - Teaching the patient and family how to administer tube feedings

- Providing skin care to the area around the tube site LPN/LVN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require RN-level education and scope of practice.

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? - Economic ability to join a gym - Food allergies and intolerance - Psychosocial influences on weight - Reasons for wanting to lose weight

- Psychosocial influences on weight While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the clients psychosocial status as the priority.

A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? - Assist the client back to bed. - Notify the provider immediately. - Put on a pair of gloves. - Take a set of vital signs.

- Put on a pair of gloves. All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids.

A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first? - Notify the surgeon. - Put on a pair of gloves. - Reinsert the NG tube. - Take a set of vital signs.

- Put on a pair of gloves. To avoid exposure to blood and body fluids, the nurse first puts on a pair of gloves. Taking vital signs and notifying the surgeon are also appropriate, but the nurse must protect himself or herself first. The surgeon will reinsert the NG tube either at the bedside or in surgery if the client needs to go back to the operating room.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? - Ask the client to call back if this happens again today. - Instruct the client to go to the emergency department. - Remind the client that a small amount of bleeding is possible. - Tell the client to come in to the clinic this afternoon.

- Remind the client that a small amount of bleeding is possible. After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

Which action should the nurse take first in order to improve calorie and protein intake for a patient who eats only about 50% of each meal because of feeling too tired to eat much. - Teach the patient about the importance of good nutrition. - Serve multiple small feedings of high-calorie, high-protein foods. - Obtain an order for enteral feedings of liquid nutritional supplements. - Consult with the health care provider about providing parenteral nutrition (PN).

- Serve multiple small feedings of high-calorie, high-protein foods. Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patients ability to take in more nutrients. Teaching the patient may be appropriate, but will not address the patients inability to eat more because of fatigue. Tube feedings or PN may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake should be attempted first.

A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? - Administer ibuprofen (Motrin). - Call the Rapid Response Team. - Start a large-bore IV with normal saline. - Tell the client to remain lying down.

- Start a large-bore IV with normal saline. This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients record because I just have to know how much she weighs! What action by the clients nurse is most appropriate? - Make an anonymous report to the charge nurse. - State that is a violation of client confidentiality. - Tell the nurse Dont look; Ill tell you her weight. - Walk away and ignore the other nurses behavior

- State that is a violation of client confidentiality. Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern.

A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse perform first? - Checking the level of consciousness - Measuring the quantity of any emesis - Auscultating the chest for breath sounds - Taking the blood pressure (BP) and pulse

- Taking the blood pressure (BP) and pulse The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.

Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately? - The patient is experiencing intermittent waves of nausea. - The patient has absent breath sounds throughout the left lung. - The patient has decreased bowel sounds in all four quadrants. - The patient complains of 6/10 (0 to 10 scale) abdominal pain.

- The patient has absent breath sounds throughout the left lung. Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patients respiratory status. The patients decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? - The patient has taken only sips of water. - The patient is lethargic and difficult to arouse. - The patients chart indicates a recent resection of the small intestine. - The patient has been vomiting several times a day for the last 4 days.

- The patient is lethargic and difficult to arouse. A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration.

During change-of-shift report, the nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? - The patient has a permanent pacemaker to prevent bradycardia. - The patient is worried about discomfort during the examination. - The patient has had an allergic reaction to shellfish and iodine in the past. - The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

- The patient refused to drink the ordered polyethylene glycol (GoLYTELY). If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patients anxiety about discomfort.

A patient who requires daily use of a nonsteroidal anti-inflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about - substitution of acetaminophen (Tylenol) for the NSAID. - use of enteric-coated NSAIDs to reduce gastric irritation. - reasons for using corticosteroids to treat the rheumatoid arthritis. - the benefits of misoprostol (Cytotec) in protecting the gastrointestinal (GI) mucosa.

- the benefits of misoprostol (Cytotec) in protecting the gastrointestinal (GI) mucosa. Misoprostol, a prostaglandin analog, reduces acid secretion and incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patients rheumatoid arthritis.

A patient with acute gastrointestinal (GI) bleeding is receiving normal saline IV at a rate of 500 mL/hr. Which assessment finding obtained by the nurse is most important to communicate immediately to the health care provider? - The patients blood pressure (BP) has increased to 142/94 mm Hg. - The nasogastric (NG) suction is returning coffee-ground material. - The patients lungs have crackles audible to the midline. - The bowel sounds are very hyperactive in all four quadrants.

- The patients lungs have crackles audible to the midline. The patients lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

The nurse is performing an admission assessment on a 20-year-old college student who is being admitted for electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? - The patients knuckles are macerated. - The patient uses laxatives on a daily basis. - The patient has a history of weight fluctuations. - The patients serum potassium level is 2.9 mEq/L.

- The patients serum potassium level is 2.9 mEq/L. The low serum potassium level may cause life-threatening cardiac dysrhythmias and potassium supplementation is needed rapidly. The other information also will be reported because it suggests that bulimia may be the etiology of the patients electrolyte disturbances, but it does not suggest imminent life-threatening complications.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patients peptic ulcer. The nurse will teach the patient to take - antacids 30 minutes before the sucralfate. - sucralfate at bedtime and antacids before meals. - antacids after eating and sucralfate 30 minutes before eating. - sucralfate and antacids together 30 minutes before each meal.

- antacids after eating and sucralfate 30 minutes before eating. Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

A client has returned from an extensive excision of a malignant oral tumor. On assessment, the nurse finds the client sitting in a high-Fowler position and complaining of jaw pain. The patient is dusky in color, but vital signs are within normal limits. The priority action by the nurse at this time is to - assess oxygenation status by checking pulse oximetry and lung sounds. - call the physician and anticipate an order for an electrocardiogram (ECG). - have the client rate the pain and then administer the ordered pain medication. - remove the oral packing to assess the surgical incision.

- assess oxygenation status by checking pulse oximetry and lung sounds. After surgical excision of an oral tumor, clients may appear dusky because of venous congestion. The nurse needs to quickly ascertain if the dusky color is related to insufficient oxygenation by assessing lung sounds and pulse oximetry. Once normal oxygenation status is confirmed, the nurse can do a more detailed pain assessment and give pain medication.

The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will - prevent aspiration of gastric contents. - inhibit the development of stress ulcers. - lower the chance for H. pylori infection. - decrease the risk for nausea and vomiting.

- inhibit the development of stress ulcers. Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to - lie down for about 30 minutes after eating. - choose foods that are high in carbohydrates. - increase the amount of fluid intake with meals. - drink sugared fluids or eat candy after each meal.

- lie down for about 30 minutes after eating. The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

After 6 hours of parenteral nutrition (PN) infusion, the nurse checks a patients capillary blood glucose level and finds it to be 120 mg/dL. The most appropriate action by the nurse is to - obtain a venous blood glucose specimen - slow the infusion rate of the PN infusion. - recheck the capillary blood glucose in 4 hours. - notify the health care provider of the glucose level.

- recheck the capillary blood glucose in 4 hours. Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, notification of the health care provider is not necessary. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurses scope of practice and will decrease the patients nutritional intake.

A client who has begun receiving TPN with lipids develops shaking chills, shortness of breath, and chest pain. The priority action by the nurse is to immediately - call the physician. - obtain a 12-lead ECG. - stop the infusion. - take a set of vitals.

- stop the infusion. Although rare, allergic reactions to intravenous lipid preparations have been reported and usually present within 30 minutes. Clinical manifestations of reactions can include fever, shaking chills, shortness of breath, chest pain, or back pain. When this occurs, the nurse must first stop the infusion before doing anything else.