Exam 4

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A. bradycardia B. numbness in the legs C. nausea and vomiting D. A rigid, board-like abdomen

A rigid, board-like abdomen

The nurse is reviewing a med rec of a patient who has cirrhosis, which of these should the nurse be concerned about? (Select all that Apply) A. acetaminophen B. broad spectrum antibiotics C. anticoagulants D. beta blockers

A. acetaminophen B. broad spectrum antibiotics

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that Apply) A. obtain a capillary blood glucose four times daily B. administer prescribed medications through a secondary port on the TPN IV tubing C. Monitor vital signs three times during the 12 hour shift D. change the TPN IV tubing every 24 hour E. Ensure a daily aPTT is obtained

A. obtain a capillary blood glucose four times daily C. Monitor vital signs three times during the 12 hour shift D. change the TPN IV tubing every 24 hour

On assessment of a client with GERD, which statement requires nursing intervention? A. "I quit smoking several years ago." B. "Sometimes I wake up gasping for air in the middle of the night." C. "My family likes to eat small meals every 3 to 4 hours throughout the day." D. "When I buy meat, I ask for the leanest cut that is available."

"Sometimes I wake up gasping for air in the middle of the night."

The nurse has just administered lactuloses who came in with encephalopathy. Which of these shows that the intervention has been effective?

A. The patient has had frequent bowel movements in order to decrease levels of ammonia in the blood

The patient's assessment reveals yellowish coloration of skin and sclerae. Which laboratory values does the nurse anticipate? A. Increased urine bilirubin, decreased direct bilirubin B. Increased direct bilirubin, increased indirect bilirubin C. Decreased direct bilirubin, increased indirect bilirubin D. Increased direct bilirubin, decreased indirect bilirubin

Increased direct bilirubin, increased indirect bilirubin

The nurse is assessing the stoma site of a patient who is 24 hours post-op colostomy. Which of the following findings should the nurse expect? A. Dark red to purplish color of the stoma B. Mucous and serosanguineous drainage from the stoma site C. Sanguineous drainage and clots in the stoma bag D. Liquid fecal drainage in the stoma bag

Mucous and serosanguineous drainage from the stoma site

The nurse is educating a client on how to take prescribed pancreatic enzymes. Which statement by the client indicates that the teaching has been effective? A. "I will sprinkle my enzymes on my pork-chop" B. "I can add the enzymes to my sweet tea during a meal" C. "I will take my enzymes when I feel full" D. "I can take my enzymes before breakfast"

"I can add the enzymes to my sweet tea during a meal"

A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum" B. "You might have shoulder pain after surgery" C. "You will have a Jackson-Pratt drain in place after surgery" D. "You should limit how often you walk for 1-2 weeks"

"You might have shoulder pain after surgery"

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (Select all that Apply) A. "I plan to eat small, frequent meals" B. "I will eat easy to digest foods with limited spice" C. "I will use skim milk when cooking" D. "I plan to drink regular cola" E. "I will limit alcohol intake to two drinks per day"

A. "I plan to eat small, frequent meals" B. "I will eat easy to digest foods with limited spice" C. "I will use skim milk when cooking"

When a patient is diagnosed with peritonitis which intervention is priority? A. Administer fluids B. Administer antibiotics C. Take blood cultures D. Insert NG tube

Administer fluids

A client is experiencing pain from appendicitis. Which of these should the nurse implement as a priority intervention? A. Encourage fluid intake to help flush the infection out B. Ambulate the client as tolerated to promote peristalsis C. Assist the client into the supine position D. Administer prescribed pain medication as ordered

Administer prescribed pain medication as ordered

A nurse is caring for a client with a laparoscopic appendectomy. The patient is complaining of shoulder pain. What action should the nurse provide after surgery?

Ambulate patient to help patient pass gas

A client who is 2 days post a partial bowel resection calls the nurse and reports, "something ripped in my belly when I coughed." Upon assessing the patient, the nurse discovers protrusion of the intestines through the stitches. What action should the nurse take first? A. Apply a wet sterile dressing to the incision B. Place the patient in a supine position C. Call the rapid response team D. Teach the client to brace the abdomen when coughing

Apply a wet sterile dressing to the incision

A nurse is admitting a client who has a GI bleed. Which of the following actions should the nurse take first? A. Check for a gag reflex B. Assess orthostatic blood pressure C. Administer pain medication D. Explain the procedure for an upper GI series

Assess orthostatic blood pressure

A nurse is caring for a client who has Total parenteral nutrition infusing a radical colon resection for Ulcerative Colitis. The nurse notes a sudden onset of dyspnea, anxiety and hypoxia with the client complaining of chest pain. Which of these actions should the nurse take? (Select all that Apply) A. obtain the client's blood glucose B. Notify the provider C. Clamp the central line catheter D. Administer a bronchodilator if ordered and inform the provider immediately E. Place the client in left lateral Trendelenburg position

B. Notify the provider C. Clamp the central line catheter E. Place the client in left lateral Trendelenburg position

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that Apply) A. Take the medication 1 hour before a meal B. Limit NSAIDs when taking this medication C. Expect skin flushing when taking this medication D. Increase fiber intake when taking this medication E. Chew the medication thoroughly before swallowing.

C. Expect skin flushing when taking this medication D. Increase fiber intake when taking this medication E. Chew the medication thoroughly before swallowing.

When administering a new GI medication to an older patient, the nurse anticipates what? A. A higher-than-normal dose may be needed B. Close monitoring is needed because toxic levels may develop C. Older adults always require a lower-than-normal dose than younger patients D. Nausea and vomiting may develop rapidly and are common side effects in older adults

Close monitoring is needed because toxic levels may develop

Which teaching will the nurse provide when discharging a client with chronic pancreatitis? A. Weight reduction and daily exercise regimen B. Constipation precautions, including daily laxative use C. Dietary adjustments to include avoiding high-fat food, caffeine, and alcohol D. Relaxation techniques and stress management

Dietary adjustments to include avoiding high-fat food, caffeine, and alcohol

The nurse closely monitors the client with acute pancreatitis for which life-threatening complication? A. Jaundice B. Type I diabetes mellitus C. Abdominal pain D. Disseminated intravascular coagulation (DIC)

Disseminated intravascular coagulation (DIC)

The physician has prescribed a clear liquid diet to be advanced as tolerated for a client who developed a paralytic ileus following acute pancreatitis. Which of the following is the best assessments parameter the nurse should use before initiating a diet? A. Ensure the client has passed flatus or moved his bowel B. Assess the client for bowel sounds C. Assess the client for swallowing difficulty D. Assess for nausea and vomiting

Ensure the client has passed flatus or moved his bowel

A nurse is teaching a client who has just had an acute episode of cholecystitis about dietary changes that might help prevent further attacks. The nurse should teach the client about avoid eating A. Fried eggs B. Whole wheat bread C. Baked potatoes D. Steamed rice

Fried eggs

The nurse is preparing the morning 0900 meds for a client with GERD. The patient has Maalox, Protonix, and Norvasc ordered. What interventions would be appropriately related to the meds? A. Hold the antacids. They should not be given until 2100 B. Give the antacids first, followed by the other oral meds to prevent irritation C. All meds need to be given on time at 0900 as ordered D. Give the antacids at 1-2 hours after giving the oral meds

Give the antacids at 1-2 hours after giving the oral meds

Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? A. I do not like the taste of spicy foods B. I got dentures four years ago C. I experience occasional constipation D. I take ibuprofen three times daily for arthritis

I take ibuprofen three times daily for arthritis

Which does the nurse recognize as the primary reason for a higher incidence of liver cancer in the United States? A. Incidence of hepatitis C B. Incidence of HIV infection C. Incidence of illicit drug use D. Incidence of hepatitis A

Incidence of hepatitis C

The nurse is caring for a client who is jaundiced and reports pruritus. Which intervention will the nurse include in the plan of care? A. Monitor the client's vital signs and intake and output B. Instruct the client to scratch with knuckles instead of nails C. Assist the client with a hot bath and apply moisturizer D. Encourage the client to eat a high protein, high-cholesterol diet

Instruct the client to scratch with knuckles instead of nails

What is the priority nursing intervention in the management of a patient with decompensated cirrhosis? A. Limiting protein intake B. Managing nausea and vomiting C. Monitoring fluid intake and output D. Elevating the head of bed >30 degrees

Managing nausea and vomiting

The nurse is replacing the ileostomy for a client who had a bowel resection 2 days ago. Which action by the nurse would be appropriate for the nurse to perform? A. The nurse cleanse the ileostomy with an alcohol pad B. Cut the pouch whole 3 inches bigger than stoma C. Applies bag loosely to the client D. Pat ileostomy skin dry with a towel

Pat ileostomy skin dry with a towel

A nurse notices that a client with cholecystitis suddenly has an onset of tachycardia, pallor, and diaphoresis. Which of the following actions should the nurse take first? A. Initiate oxygen therapy via nasal cannula B. Place the client's head of the bed flat C. Insert an NG tube as ordered immediately D. Lower the room temperature and get the client ice chips

Place the client's head of the bed flat

A nurse cares for a client who has cirrhosis of the liver. Which actions should the nurse take to decrease the presence of ascites? A. Increased oral fluid intake B. Weigh the client daily C. Provide a low-sodium diet D. Monitor intake and output

Provide a low-sodium diet

In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? A. Heart rate of 105 beats/min B. Serum glucose of 136 mg/dL C. Blood pressure of 102/76 mm Hg D. Respiratory rate of 28 breaths/min

Respiratory rate of 28 breaths/min

Which assessment finding requires immediate nursing intervention in a patient with severe ascites? A. Confusion B. Temperature 38.2º C C. Tachycardia, rate 110 beats/min D. Shallow respirations, rate 32 breaths/min

Shallow respirations, rate 32 breaths/min

A nurse is caring for a client who received midazolam hydrochoride (Versed) during an esophagogastroduodenoscopy (EGD). The client's respiratory rate is 10 breaths/min. Which of the following actions should the nurse take first? A. Stimulate the client with a chest rub B. Call the Rapid Response Team C. Ventilate with a bag-valve mask D. Administer Romazicon (flumazenil)

Stimulate the client with a chest rub

In evaluating a client who was admitted with nausea/vomiting and diarrhea, which of these should the nurse identify as a successful resolution of fluid volume deficit? A. The client's current serum sodium level is 145mEq B. There is an absence of postural hypotension and tachycardia C. The client has increased appetite and denies nausea D. The client lost only 2 pounds within the past 48 hours

There is an absence of postural hypotension and tachycardia

The nurse is caring for a client with a bleeding duodenal ulcer who was admitted to the hospital after vomiting bright, red blood. Which condition does the nurse anticipate when the client develops a sudden, sharp pain in the mid-epigastric region and a rigid, board-like abdomen? A. Pancreatitis B. Ulcer perforation C. Small bowel obstruction D. Development of additional ulcers

Ulcer perforation

When taking a history of a client diagnosed with a duodenal peptic ulcer disease, which assessment finding would the nurse expect? A. Waking at night with abdominal pain B. Severe weight gain C. Severe diarrhea after eating D. Abdominal pain shortly after eating

Waking at night with abdominal pain

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-Tube has drained 750mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? A. clamp the T-Tube B. irrigate the T-Tube C. document the findings D. notify the healthcare provider

document the findings

A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? A. generalized cyanosis B. hyperactive bowel sounds C. grey blue discoloration of the skin around the umbilicus D. wheezing in the lower lung fields

grey blue discoloration of the skin around the umbilicus

The nurse is reviewing medications for a client who is diagnosed with Acute Peptic ulcer diseases related to a recent history of gastritis. Which of these medications should the nurse clarify with the provider? A. ibuprofen 500mg PO daily B. protonix 40mg PO BID C. Lisinopril 12.5mg PO daily D. Metronidazole (Flagyl) 500mg PO BID

ibuprofen 500mg PO daily

Which of the following interventions should the nurse include in the care plan of a client being admitted with an acute exacerbation of ulcerative colitis? A. maintain a clear liquid diet B. maintain strict intake and output C. prepare to adminster a laxative D. Encourage increased oral fluid intake

maintain strict intake and output

A nurse is reviewing risk factos with a client who has cholecystitis. The nurse should identify that which of the following as a risk factor for cholecystitis? A. obesity B. rapid weight gain C. decreased blood triglyceride level D. male gender

obesity

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? A. instruct the client o chew the medication before swallowing B. offer a glass of water following medication administration C. adminster the medication 30 minutes before meals D. sprinkle the contents on peanut butter

offer a glass of water following medication administration

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? A. absence of saliva B. painful swallowing C. sweet taste in mouth D. absence of eructation

painful swallowing

The nurse is replacing the ileostomy bag for a patient who had a bowel resection 2 days ago? Which action is appropriate for the nurse to preform A. washes the stoma with alcohol pads B. measures and cuts the stoma bag 3 inches around C. applies the illeostomy to the body loosely D. pat the skin dry with a towel before putting the bag in place

pat the skin dry with a towel before putting the bag in place

You are discharging a patient diagnosed with GERD, which patient statement indicates need for further teaching? A. "I will eat 3 small meals and 3 snacks a day" B. "I will not quit smoking" C. "I will lose desired weight, if overweight" D. "I will stop drinking coffee"

"I will not quit smoking"

A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? A. "I will plan to limit fiber in my diet" B. "I will restrict fluid intake during meals" C. "I will switch to black tea instead of drinking coffee" D. "I will try to eat cold foods rather than warm when my stomach feels upset"

"I will plan to limit fiber in my diet"

A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori (H. pylori). Which of the following statements by the client indicates understanding of the teaching? A. "I will continue my prescription for corticosteroids" B. "I will schedule a CT scan to monitor improvement" C. "I will take a combination of medications for treatment" D. "I will have my throat swabbed to recheck for this bacteria"

"I will take a combination of medications for treatment"

A nurse is teaching a client who has a new prescription for famotidine. Which of the following statements by the client indicates understanding of the teaching? A. "The medicine coats the lining of my stomach" B. "The medication should stop the pain right away" C. "I will take my pill at bedtime" D. "I will monitor for bleeding from my nose"

"I will take my pill at bedtime"

Which patient is more likely to develop gallstones? A. 45-year-old caucasian female with a family history of gallstones B. 55-year-old african-american male with a history of diabetes mellitus C. 62-year-old hispanic/latina female with a history of irritable bowel syndrome D. 60-year-old obese, american-indian female with a history of diabetes mellitus

60-year-old obese, american-indian female with a history of diabetes mellitus

The nurse is caring for four clients. Which is at the highest risk for Hepatitis B infection? A. 24-year old with abdominal pain who just returned from Central America B. 40-year old who is two days postpartum and is breastfeeding C. 65-year old who reports using street drugs when ten years ago when homeless D. 81-year old who donated own blood prior to a surgical procedure

65-year old who reports using street drugs when ten years ago when homeless

The nurse will include what postoperative teaching when caring for the client who is preparing to undergo endoscopic cholecystectomy? Select all that apply. A. "You'll have a small, midline abdominal incision." B. "You can't eat or drink for a few days after the procedure." C. "You won't be able to return to regular activity for several weeks." D. "Generally the pain associated with this procedure is minimal." E. "This procedure has a low incidence of infection." F. "The hospital stay after this procedure is typically 3 to 4 days."

A. "You'll have a small, midline abdominal incision." D. "Generally the pain associated with this procedure is minimal." E. "This procedure has a low incidence of infection."

The nurse is performing medication reconciliation for a newly admitted client. The nurse recognizes which drugs contribute to signs and symptoms of gastritis? Select all that apply. A. Aspirin, taken once daily to prevent cardiac concerns B. Naproxen, taken once daily for joint pain associated with arthritis C. Amoxicillin, taken over a 10-day period for an acute sinus infection D. Bacitracin ointment (over the counter), applied to minor scrapes on arms and legs E. Prednisone, tapered over a 14-day period to decrease inflammation associated with an acute sinus infection

A. Aspirin, taken once daily to prevent cardiac concerns B. Naproxen, taken once daily for joint pain associated with arthritis E. Prednisone, tapered over a 14-day period to decrease inflammation associated with an acute sinus infection

A 59-year-old patient with a history of alcohol abuse spanning 15 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis today. Which assessment finding alerts the nurse that the paracentesis has been successful? A. Decrease in post-procedure weight B. No residual obtained during procedure C. Substantial decrease in blood pressure D. Immediate sensation of a need to urinate

A. Decrease in post-procedure weight

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea that have lasted a week. For which complications will the nurse assess? Select all that apply. A. Dehydration B. Hypokalemia C. Skin breakdown D. Deep vein thrombus E. Hyperkalemia

A. Dehydration B. Hypokalemia C. Skin breakdown

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (Select all that Apply) A. Maintain NPO status B. Encourage coughing and deep breathing C. give small, frequent high calorie feedings D. maintain the client in a supine and flat position E. give hydromorphone intravenously as prescribed for pain F. maintain intravenous fluids at 10mL/hour to keep the vein open

A. Maintain NPO status B. Encourage coughing and deep breathing E. give hydromorphone intravenously as prescribed for pain

A nurse is planning care for a client admitted with a diagnosis of diverticulitis. Which of these interventions should the nurse include in the care plan? (Select all that apply) A. Teach the patient to avoid activities that increase intra-abdominal pressure B. Initiate client education on low fiber diet when resuming diet C. Avoid palpation with abdominal assessments D. Administer antibiotics as ordered E. Check the client's stool for occult (frank) bleeding

A. Teach the patient to avoid activities that increase intra-abdominal pressure B. Initiate client education on low fiber diet when resuming diet D. Administer antibiotics as ordered E. Check the client's stool for occult (frank) bleeding

When caring for a patient who has just had an upper GI endoscopy, the nurse assesses that the client has developed a temperature of 101.8° F (38.8° C). What is the appropriate nursing intervention? A. Promptly assess the client for potential perforation. B. Ask the nursing assistant to bathe the client with tepid water. C. Administer acetaminophen (Tylenol) to lower the temperature. D. Delegate to an unlicensed assistive personnel (UAP) to retake the temperature.

A. Promptly assess the client for potential perforation.

A nurse is caring for an older client who reports to the emergency room with poor appetite with occasional nausea and vomiting for the past two weeks. Which of these should the nurse suspect when reviewing the client's admission labs? (select all that apply) A. Serum potassium (K) 3.0 mEq/L B. Calcium (Ca) 11 mg/dL C. Serum magnesium (Mg) 3.0 mEq/L D. Serum sodium (Na) 150mEq/L

A. Serum potassium (K) 3.0 mEq/L D. Serum sodium (Na) 150mEq/L

A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The nurse should expect prescriptions for which of the following medications? (Select all that Apply) A. antacids B. histamine 2 receptor antagonists C. opioid analgesics D. fiber laxatives E. proton pump inhibitors

A. antacids B. histamine 2 receptor antagonists E. proton pump inhibitors

The nurse is planning to teach a client with gastro-esophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? (Select all that Apply) A. coffee B. chocolate C. peppermint D. nonfat milk E. fried chicken F. scrambled eggs

A. coffee B. chocolate C. peppermint E. fried chicken

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that Apply) A. diuretic B. beta blocking agent C. opioid analgesic D. lactulose E. sedative

A. diuretic B. beta blocking agent D. lactulose

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care? (Select all that Apply) A. evaluate intake and output B. monitor laboratory reports of electrolytes C. provide three large meals a day D. administer ibuprofen for pain E. observe stool characteristics

A. evaluate intake and output B. monitor laboratory reports of electrolytes E. observe stool characteristics

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? (Select all that Apply) A. fever B. positive Cullen's sign C. complaints of indigestion D. palpable mass in the left upper quadrant E. pain in the upper right quadrant after a fatty meal F. vague lower right quadrant abdominal discomfort

A. fever C. complaints of indigestion E. pain in the upper right quadrant after a fatty meal

A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that Apply) A. limit physical activity B. avoid alcohol C. take acetaminophen for comfort D. wear a mask when in public places E. eat small frequent meals

A. limit physical activity B. avoid alcohol E. eat small frequent meals

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (Select all that Apply) A. rigid abdomen B. tachycardia C. elevated blood pressure D. circumoral cyanosis E. rebound tenderness

A. rigid abdomen B. tachycardia E. rebound tenderness

A nurse is caring for a client with Crohn's disease who has a heavily draining ileostomy. Which of the following interventions should the nurse implement to maintain skin integrity? A. Provide the client with a low fiber diet B. Apply skin barrier protectant around the stoma C. Change pouch as soon as it is full D. Administer antibiotics as prescribed

Apply skin barrier protectant around the stoma

A nurse is admitting a client who has a GI bleed. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure B. Explain the procedure for an upper GI series C. Administer pain medication D. Check for a gag reflex

Assess orthostatic blood pressure

A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse? A. Assess the client's airway B. Allow the client to sleep C. Prepare to administer an antidote to the sedative. D. Evaluate preprocedure laboratory findings

Assess the client's airway

The nurse is caring for a client who is being discharged after acute cholecystitis. What client response demonstrates effective teaching? (Select all that Apply) A. "I can have broccoli, beans and cabbage in my diet." B. "I will avoid eating pizza." C. "I need to increase my protein intake" D. "I will eat a large breakfast and small dinner"

B. "I will avoid eating pizza." C. "I need to increase my protein intake"

The community nurse is talking with four clients who have reported digestive concerns. Which client does the nurse recognize as most likely to experience gallstone production? Select all that apply. A. 23-year-old Caucasian vegetarian who is a dancer B. 35-year-old American Indian who works in construction C. 48-year-old Canadian who manages a fast-food restaurant D. 59-year-old Asian American who is an investment banker E. 64-year-old Mexican American who resides with grandchildren

B. 35-year-old American Indian who works in construction E. 64-year-old Mexican American who resides with grandchildren

When a complete assessment of this patient is performed, what other signs and symptoms does the nurse expect? (Select all that apply.) A. Muscle twitching B. Dry skin with rash C. Personality changes D. Peripheral dependent edema E. Ecchymosis, spider angiomas

B. Dry skin with rash D. Peripheral dependent edema E. Ecchymosis, spider angiomas

A client who recently had laparoscopic surgery to treat a ruptured appendix has developed subsequent peritonitis. The client currently has two Jackson Pratt drains placed in the abdomen. Which finding(s) would the nurse report immediately to the surgeon? Select all that apply. A. Serosanguineous drainage B. Fever C. Cloudy drainage D. Painful abdominal distention E. Pain level 3 on a scale of 1 to 10

B. Fever C. Cloudy drainage D. Painful abdominal distention

The nurse is caring for a client who has had paracentesis performed. Which nursing intervention is appropriate? Select all that apply. A. Keep head of bed flat B. Measure, describe, and record drainage C. Ambulate 30 minutes postprocedure D. Weigh client E. Label fluid container and send for laboratory analysis

B. Measure, describe, and record drainage D. Weigh client E. Label fluid container and send for laboratory analysis

A nurse is planning care for a client who has gastric ulcer disease. Which of the following conditions should be of least concern to the nurse? The client: A. Develops hematemesis B. Exhibits signs of dehydration C. Manifests melena D. Complains of dyspepsia

Complains of dyspepsia

The nurse is caring for a client who has just been prescribed a glucocorticoid to treat an exacerbation of ulcerative colitis. What teaching will the nurse provide? A. Decrease the drug dose during the next exacerbation. B. Report fever to health care provider immediately. C. Determine if the client's insurance covers payment for this medication. D. This drug will act as an antidiarrheal.

B. Report fever to health care provider immediately.

A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that Apply) A. anorexia B. changes in orientation C. asterixis D. ascites E. fetor hepaticus

B. changes in orientation C. asterixis E. fetor hepaticus

A nurse is providing discharge teaching to a client who is postoperative following laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? (Select all that Apply) A. take baths rather than showers B. resume a diet of choice C. cleanse the puncture site using mild soap and water D. remove adhesive strips from the puncture site using mild soap and water E. Report nausea and vomiting to the surgeon

B. resume a diet of choice C. cleanse the puncture site using mild soap and water E. Report nausea and vomiting to the surgeon

The patient tells the nurse that once he is discharged to home, he has no intention to stop drinking alcohol. What is the appropriate nursing response? A. "Why do you continue to drink?" B. "It's your choice to drink or not to drink." C. "Does it frighten you to consider quitting?" D. "If you continue to drink, you are going to die."

C. "Does it frighten you to consider quitting?"

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply) A. diarrhea B. black, tarry stools C. hyperactive bowel sounds D. gray-blue color at the flank E. abdominal guarding and tenderness F. left upper quadrant pain with radiation to the back

D. gray-blue color at the flank E. abdominal guarding and tenderness F. left upper quadrant pain with radiation to the back

An older patient diagnosed with bacterial gastroenteritis resorts abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

Dehydration

A nurse is admitting a client who has been diagnosed with pancreatitis. The provider has prescribed for the NG tube with intermediate/low suction. Which of the interventions should the nurse take? A. Delegate the unlicensed assistive personnel to set up suction equipment B. Make sure suction equipment is working prior to the arrival of the client C. Place the crash cart close to clients room D. Clarify the order with the health care provider

Make sure suction equipment is working prior to the arrival of the client

The patient has been NPO but is not tolerating food. What education will the nurse provide regarding nutrition? A. Small and frequent meals are best B. Use of alcohol and caffeine should be consumed in moderation C. Expect to experience nauseas and vomiting as you begin to consume foods D. Low-carbohydrate, high-protein, and high-fat foods should be consumed

Small and frequent meals are best

A client reports ongoing episodes of heartburn. The nurse educates the client on prevention and control of reflux by recommending dietary elimination of which food item? A. Lean steak B. Carrot sticks C. Chocolate candy D. Air-popped popcorn

chocolate candy

A patient with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark frothy urine. Which laboratory analysis is a priority in the nurse's assessment of this patient? A. Lipase level B. Total bilirubin C. Liver function tests D. White blood cell count

Total bilirubin

A client has undergone esophgogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? A.monitoring the temperature B. monitoring complaints of heartburn C. giving warm gargles for a sore throat D. assess for the return of the gag reflex

assess for the return of the gag reflex

A nurse is admitting a client who has a GI bleed. Which of the following actions should the nurse take first? A. assess orthostatic blood pressure B. explain the procedure for an upper GI series C. administer pain medication D. check for a gag reflex

assess orthostatic blood pressure

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 550mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? A. document the findings as normal B. clamp the T-tube C. Notify the health care provider D. Irrigate the T-tube with saline

document the findings as normal

A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. decrease intake of calorie dense foods B. drink canned protein supplements C. increase intake of high giber foods D. eat high reside foods

drink canned protein supplements

A nurse is admitting a patient who has a bowel obstruction resulting from pancreatitis. The provider has prescribed that the client has a NG tube applied to intermittent low suction. Which of these interventions are the appropriate for the nurse? A. delegate to the UAP to set up the suction equipment B. ensure that the suction equipment is working appropriately prior to arrival to the client C. Place a crash cart close to the client's room D. Clarify the order with the health care provider

ensure that the suction equipment is working appropriately prior to arrival to the client

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. pain in the right upper quadrant radiating to right shoulder B. report of pain being worse when sitting upright C. pain relieved with defection D. epigastric pain radiating to the left shoulder

epigastric pain radiating to the left shoulder

The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the client to avoid? A. Popcorn B. Oatmeal C. Bran D. Lettuce

popcorn

A nurse on a medical surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. initiate contact precautions B. weigh the client weekly C. measure abdominal girth at the base of the ribcage D. provide a high calorie, high carbohydrate diet

provide a high calorie, high carbohydrate diet

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. Which of the following information should the nurse include in the teaching? A. take the medication with food B. monitor for diarrhea C. wait 1 hour before taking other oral medications D. maintain a low fiber diet

wait 1 hour before taking other oral medications