FINAL AH Questions

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? "Does the pain in your stomach radiate to your back?" "Does the pain in your lower abdomen radiate to your hip?" "Does the pain in your lower abdomen radiate to your groin?" "Does the pain in your stomach radiate to your lower middle abdomen?"

"Does the pain in your stomach radiate to your back?"

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? "Lactulose should be taken every day to prevent constipation." "It is not safe to take acetaminophen up to four times a day for pain." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."

"Herbs and other spices should be used to season my foods instead of salt." Rationale:A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver.

The nurse is reviewing self-care for a patient with cirrhosis. Which statement indicates the patient needs further teaching? "A scrotal support may be more comfortable when I have scrotal edema." "I need to take good care of my belly and ankle skin where it is swollen." "I can use pillows to support my head to help me breathe when I am in bed." "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."

"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Rationale:If the patient with cirrhosis develops a fast or irregular heart rate, it may be indicative of hypokalemia and would be reported to the health care provider because this is not normal for cirrhosis.

The most effective method of administering a chemotherapy agent that is a vesicant is to a. give it orally. b. give it intraarterially. c. use a central venous access device. d. use the smallest gauge needle through a peripheral line.

c. use a central venous access device.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? "I will handle the area gently." 2"I will wear loose-fitting clothing." 3"I will avoid the use of deodorants." 4"I will limit sun exposure to 1 hour daily.

4"I will limit sun exposure to 1 hour daily.

When providing discharge teaching for a patient after a laparoscopic cholecystectomy, what information would the nurse include? Do not return to work or normal activities for 3 weeks. A low-fat diet may be better tolerated for several weeks. Bile-colored drainage will probably drain from the incision. Keep the bandages on and the puncture site dry until it heals.

A low-fat diet may be better tolerated for several weeks.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding would the nurse interpret as a sign or symptom of portal hypertension? Flat neck veins Abdominal distention Hemoglobin of 14.2 g/dL (142 mmol/L) Platelet count of 600,000 mm3 (600 × 109/L)

Abdominal distention

A patient with cholelithiasis is being prepared for surgery. Which assessment finding is a contraindication for a cholecystectomy? Low-grade fever of 100°F and dehydration Abscess in the right upper quadrant of the abdomen Multiple obstructions in the cystic and common bile duct Activated partial thromboplastin time (aPTT) of 54 seconds

Activated partial thromboplastin time (aPTT) of 54 seconds Rationale:An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration.

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful? Fresh fruit Brown gravy Fresh vegetables Poultry without skin

Brown gravy

The community health nurse is creating a poster for an educational session for a group of community members and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer would the nurse list on the poster? Select all that apply. Multiparity Early menarche Early menopause Family history of breast cancer High-dose radiation exposure to chest Previous cancer of the breast, uterus, or ovaries

Early menopause Family history of breast cancer High-dose radiation exposure to chest Previous cancer of the breast, uterus, or ovarie

The nurse is caring for a hospitalized client with pancreatitis. Which findings would the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. Elevated lipase level Elevated trypsin level Elevated amylase leve

Elevated amylase leve Elevated lipase level

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. ​​ Fever Positive Cullen's sign Complaints of indigestion Palpable mass in the left upper quadrant Pain in the upper right quadrant after a fatty meal Vague lower right quadrant abdominal discomfor

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal

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. Diarrhea Black, tarry stools Hyperactive bowel sounds Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back

Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority in planning care? Prevent all oral intake. Control abdominal pain. Provide enteral feedings. Avoid dietary cholesterol.

Control abdominal pain. Rationale:Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels

Decreased ammonia levels rationale:Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. An additional finding may be an improvement in level of consciousness.

When planning care for a patient with cirrhosis, which clinical problem is the highest priority?

Ineffective breathing pattern Rationale:Although all these clinical problems are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting is diagnosed with acute pancreatitis. Which intervention would the nurse include in the plan of care? Immediately start enteral feeding to prevent malnutrition. Insert an NG and maintain NPO status to allow pancreas to rest. Initiate early prophylactic antibiotic therapy to prevent infection. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

Insert an NG and maintain NPO status to allow pancreas to rest. Rationale:Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions would be included in the care plan for this client? Select all that apply. Monitor daily weight. Measure abdominal girth. Monitor respiratory status. Place the client in a supine position. Assist the client with care as needed.

Monitor daily weight. Measure abdominal girth. Monitor respiratory status. Assist the client with care as needed.

The nurse is caring for a patient with acute pancreatitis from gallstones. Which clinical manifestations would the nurse expect? (Select all that apply.) Hematochezia Nausea and vomiting Hyperactive bowel sounds Left upper abdominal pain Ascites and peripheral edema Temperature 99.3°F (37.4°C)

Nausea and vomiting Left upper abdominal pain Temperature 99.3°F (37.4°C)

A patient admitted with diabetes, malnutrition, osteomyelitis, and chronic alcohol use has a serum amylase level of 480 U/L and a serum lipase level of 610 U/L. Which diagnosis does the nurse expect? Starvation Pancreatitis Systemic sepsis Diabetic ketoacidosis

Pancreatitis Rationale:The patient with chronic alcohol use could develop pancreatitis as a complication, which would increase the serum amylase (normal, 30 to 122 U/L) and serum lipase (normal, 31 to 186 U/L) levels as shown.

During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action would the nurse take first? a. Schedule a sigmoidoscopy to provide baseline data. b. Obtain more information about the patient's relatives. c. Teach the patient about the need for a colonoscopy at age 50. d. Teach the patient how to do home testing for fecal occult blood.

b. Obtain more information about the patient's relatives.

the nurse is assessing a client with cirrhosis for signs and symptoms of low albumin. Which sign or symptom would the nurse expect to note? Weight loss Peripheral edema Capillary refill of 5 seconds Bleeding from previous puncture sites

Peripheral edema

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.) Hepatocytes are unable to convert ammonia to urea. Osmoreceptors in the hypothalamus stimulate thirst. An enlarged spleen removes blood cells from the circulation. Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

he nurse is caring for a client diagnosed with pancreatitis. The nurse is reviewing the client's morning laboratory results. Which laboratory result would require a need for follow-u Serum calcium 7.0 mg/dL (1.83 mmol/L) Serum calcium 9.7 mg/dL (2.54 mmol/L)hypoklcemia Serum magnesium 1.9 mEq/L (0.78 mmol/L) Serum magnesium 2.3 mEq/L (0.95 mmol/L)

Serum calcium 9.7 mg/dL (2.54 mmol/L)hypoklcemia

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) Provide a high-protein, low-carbohydrate diet. Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. Apply gentle pressure for the shortest possible time after venipuncture. Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal anti-inflammatory (NSAIDs).

Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal anti-inflammatory (NSAIDs). Rationale:Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse would apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.

A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider would the nurse implement first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Ask the patient about home insulin doses. d. Start an insulin infusion at 0.1 units/kg/hr.

a. Place the patient on a cardiac monitor.

The nurse is reviewing the pathophysiology of cirrhosis and the associated diagnostic laboratory studies. Which laboratory trend(s) is associated with cirrhosis? Select all that apply. ​​ Hyperkalemia Thrombocytosis Thrombocytopenia Increased ammonia level Decreased serum albumin

Thrombocytopenia Increased ammonia level Decreased serum albumin

A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action would the nurse take? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about direct-acting antiviral treatment. d. Explain that the infection will resolve over a few months.

a. Schedule the patient for HCV genotype testing.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily

a. The patient is alert and oriented The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy.

A patient who recently started chemotherapy has uncontrollable nausea, diarrhea, muscle cramps, and dizziness. Which complication of cancer is this most likely caused by? a. Tumor lysis syndrome b. Third space syndrome c. Spinal cord compression d. Superior vena cava syndrome

a. Tumor lysis syndrome

Surgery is used in cancer care to (select all that apply) a. diagnose cancer. b. cure or control cancer. c. provide supportive care. d. prevent spread of cancer. e. assist with rehabilitation after treatment.

a. diagnose cancer. b. cure or control cancer. c. provide supportive care. d. prevent spread of cancer. e. assist with rehabilitation after treatment.

Which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

b. Phosphate level

Which patient statement would indicate to the nurse that teaching after a laparoscopic cholecystectomy was effective? a. "I can take a shower and walk around the house tomorrow." b. "I need to limit my activities and not return to work for 4 weeks." c. "I can expect yellowish drainage from the incision for a few days." d. "I will follow a low-fat diet for life because I do not have a gallbladder.

a. "I can take a shower and walk around the house tomorrow." After a laparoscopic cholecystectomy, patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate? a. "The cancer involves only the cervix." b. "The cancer cells look like normal cells." c."Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

a. "The cancer involves only the cervix."

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margi

a. Asterixis and lethargy The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy.

The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6 AM glucose is 230 mg/dL. Which action would the nurse teach the patient to take? a. Check the glucose during the night. b. Avoid snacking right before bedtime. c. Increase the rapid-acting insulin dose. d. Administer a larger dose of long-acting insulin

a. Check the glucose during the night.

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin d. Potassium

a. Lipase Lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective

Which assessment finding would the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses

b. Rapid, deep respirations Patients with metabolic acidosis caused by AKI may have Kussmaul respirations to eliminate carbon dioxide.

A woman has recently been diagnosed with early-stage uterine cancer. What can you do to promote effective coping strategies? (select all that apply) a. maintain the patient's hope. b. connect the patient to a support group. c. help the patient in setting realistic goals d. discuss replacement childcare for the patient's children. e. when patient begins to discuss her fears, change the topic to something uplifting.

a. maintain the patient's hope. b. connect the patient to a support group. c. help the patient in setting realistic goals

Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)? a. "I should weigh myself daily and report sudden weight loss or gain." b. "I need to shop for foods low in sodium and avoid adding salt to food." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

b. "I need to shop for foods low in sodium and avoid adding salt to food." Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

Which risk factor would the nurse specifically ask about when a patient is being admitted with acute pancreatitis? a. Diabetes b. Alcohol use c. High-protein diet d. Cigarette smoking

b. Alcohol Alcohol use is one of the most common risk factors for pancreatitis in the United States.

Which result is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? a. Bilirubin levels b. Ammonia levels c. Potassium levels d. Prothrombin tim

b. Ammonia levels The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well.

Which action would the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver

b. Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy

Which topic is most important for the nurse to include in teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose b. Avoiding all alcohol use c. Maintaining good nutrition d. Using vitamin B supplements

b. Avoiding all alcohol use

Which food choice would the nurse suggest for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad b. Baked chicken c. Creamed broccoli d. Toasted wheat bread

b. Baked chicken

The nurse teaches a patient who has liver cancer about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Lime sherbet b. Blueberry yogurt c. Fresh strawberries d. Cream cheese bage

b. Blueberry yogurt

What features of cancer cells distinguish them from normal cells? (select all that apply) a. Cancer cells proliferate faster. b. Cancer cells lack contact inhibition. c. Cancer cells regain a fetal appearance and function. d. Cancer cells return to a previous undifferentiated state. e. Proliferation occurs when there is a need for more cells.

b. Cancer cells lack contact inhibition. c. Cancer cells regain a fetal appearance and function. d. Cancer cells return to a previous undifferentiated state.

During routine hemodialysis, a patient reports nausea and dizziness. Which action would the nurse take first? a. Slow down the rate of dialysis. b. Check the blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

b. Check the blood pressure (BP).

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information would the nurse teach the patient about the expected outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Decreasing the tumor size will improve the effects of other therapy. c. Relieving the pressure in the stomach will promote optimal nutrition. d. Tumor growth will be controlled by removing all the cancerous tissue

b. Decreasing the tumor size will improve the effects of other therapy.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention would the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's hom

b. Establish time to take a short walk almost every day.

The nurse is planning care for a patient with acute severe pancreatitis. Which outcome would the nurse identify as the highest priority? a. Achieving fluid and electrolyte balance b. Maintaining normal respiratory function c. Expressing satisfaction with pain control d. Developing no ongoing pancreatic disease

b. Maintaining normal respiratory function Respiratory failure can occur as a complication of acute pancreatitis and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Which scheduling would the nurse teach a patient with chronic pancreatitis to use for the prescribed pancrelipase (Viokase)? a. Bedtime b. Mealtime c. When needed for pain d. When feeling nauseated

b. Mealtime Pancreatic enzymes are used to help with digestion of nutrients and would be taken with every meal

Which topic would the nurse plan to teach the patient diagnosed with acute hepatitis B? a. Administering a-interferon b. Measures for improving appetite c. Side effects of nucleotide analogs d. Ways to increase activity and exercise

b. Measures for improving appetite

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

b. Monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway.

After an arteriovenous graft is inserted in a patient's right forearm, the patient reports pain and coldness in the right fingers. Which action would the nurse take? a. Remind the patient to take a daily low-dose aspirin tablet. b. Report the patient's symptoms to the health care provider. c. Elevate the patient's arm on pillows above the heart level. d. Teach the patient about normal arteriovenous graft function

b. Report the patient's symptoms to the health care provide

An IV vesicant chemotherapeutic agent is prescribed for a patient. Which action is would the nurse plan to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the medication through a small-bore catheter. d. Hold the medication until a central venous line is available.

b. Stop the infusion if swelling is observed at the site.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by assistive personnel (AP), if observed by the nurse, would require an intervention? a. The AP flushes the toilet once after emptying the patient's bedpan. b. The AP stands by the patient's bed for 30 minutes talking with the patient. c. The AP places the patient's bedding in the laundry container in the hallway. d. The AP gives the patient an alcohol-containing mouthwash to use for oral care

b. The AP stands by the patient's bed for 30 minutes talking with the patient.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching? a. The patient requests a vegetarian diet. b. The patient ambulates around the hospital. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

b. The patient ambulates around the hospital.

The nurse is caring for a patient with colon cancer. Which information indicates a need for specific patient teaching before the patient begins external radiation therapy to the abdomen? a. The patient has a history of dental caries. b. The patient swims several days each week. c. The patient snacks frequently during the day. d. The patient showers each day with mild soap.

b. The patient swims several days each week.

Which information from a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 30 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.

b. The patient used IV drugs about 30 years ago.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient reports right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's abdominal skin has multiple spider-shaped blood vessels.

b. The patient's hands flap back and forth when the arms are extended. Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment.

Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient reports chronic heartburn. d. The patient has increased pain after eating.

b. The patient's stools are tan colored. Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, and would be reported but do not require urgent intervention.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient was effective when the patient's later blood specimen reveals the presence of a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM

b. anti-HBs. rationale:The presence of surface antibody to hepatitis B (anti-HBs) is a marker of a positive response to the vaccine or previous illness with hepatitis B. The other laboratory values indicate current infection with hepatitis B

Principles of radiation treatment include (select all that apply) a. brachytherapy is delivered by an external beam. b. doses of radiation are expressed in units called gray or centigray. c. low energy beam radiation is ineffective on superficial skin lesions. d. the total dose for a radiation treatment is divided into daily fractions. e. radiosensitivity is the unresponsiveness of cells to the radiation treatment.

b. doses of radiation are expressed in units called gray or centigray. d. the total dose for a radiation treatment is divided into daily fractions.

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. "I can use ice packs to relieve itching." b. "I will scrub the area with warm water." c. "I can apply aloe vera gel after I bathe." d. "I will expose my skin to a sun lamp each day."

c. "I can apply aloe vera gel after I bathe."

The nurse, who is teaching a patient how to manage chemotherapy-induced diarrhea, determines that teaching is successful when the patient states a. "I will only drink two glasses of liquid a day." b. "I should eat more fresh fruits and vegetables." c. "I will decrease fried and fatty foods in my diet." d. "Increasing the fiber in my diet will bulk up my stools."

c. "I will decrease fried and fatty foods in my diet."

During change-of-shift report, the nurse learns about the following four patients. Which patient would the nurse assess first? a. A patient who has compensated cirrhosis and reports anorexia b. A patient with chronic pancreatitis who has gnawing abdominal pain c. A patient with cirrhosis and ascites who has a temperature of 102F (38.8C) d. A patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain

c. A patient with cirrhosis and ascites who has a temperature of 102F (38.8C)

A patient with metastatic colon cancer has severe vomiting after each administration of chemotherapy. Which action would the nurse take? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

c. Administer prescribed antiemetics 1 hour before the treatments.

A patient has inadequate nutrition due to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Apply prescribed anesthetic gel to oral lesions before meals. d. Teach the patient about the importance of nutritional intake

c. Apply prescribed anesthetic gel to oral lesions before meals.

How would the nurse prepare a patient with ascites for paracentesis? a. Place the patient on NPO status. b. Assist the patient to lie flat in bed. c. Ask the patient to empty the bladder. d. Position the patient on the right side

c. Ask the patient to empty the bladder.

Which action would the nurse in the emergency department take first for a patient who arrives vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position.

c. Check blood pressure and heart rate. The nurse's first action would be to determine the patient's hemodynamic status by assessing vital signs.

When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action would the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the health record. d. Notify the health care provider immediately.

c. Check the calcium level in the health record. The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider would be notified after the nurse checks the patient's calcium level

External-beam radiation is planned for a patient with cervical cancer. What instructions would the nurse give the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after each bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

c. Clean the perianal area carefully after each bowel movement.

A patient on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action in the agency dysrhythmia protocol would the nurse take first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's blood pressure and discomfort level.

c. Give supplemental O2 at 2 to 3 L/min via nasal cannula.

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse would monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia

c. Hematuria

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding

c. Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered.

A patient who has cirrhosis and esophageal varices is being treated with propranolol. Which finding is the best indicator to the nurse that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 130/80 mm Hg. c. Stools test negative for occult blood

c. Stools test negative for occult blood Because the purpose of b-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools

Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8F (38.2C) d. No bowel movement for 4 days

c. Temperature 100.8F (38.2C)

Which response by the nurse best explains the purpose of propranolol for a patient who was admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite

c. The medication will prevent irritation of the enlarged veins. Esophageal varices are dilated submucosal veins. Patients with varices who are at risk for bleeding often receive a nonselective -blocker (nadolol, propranolol) to reduce bleeding risk. -Blockers decrease high portal pressure, which decreases the risk for rupture

A patient had an incisional cholecystectomy 6 hours ago. Which action would the nurse identify as the highest priority for the patient to accomplish? a. Perform leg exercises hourly while awake. b. Ambulate the evening of the operative day. c. Turn, cough, and deep breathe every 2 hours. d. Choose preferred low-fat foods from the menu.

c. Turn, cough, and deep breathe every 2 hours. Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing.

To prevent fever and shivering during an infusion of rituximab (Rituxan), the nurse should premedicate the patient with a. aspirin. b. diazepam. c. acetaminophen. d. sodium bicarbonate.

c. acetaminophen.

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate? a. benign tumors do not cause damage to other tissues b. benign tumors are likely to recur in the same location c. malignant tumors may spread to other tissues or organs d. malignant cells reproduce more rapidly than normal cells

c. malignant tumors may spread to other tissues or organs

The immune system monitors and regulates proliferation of cancer cells through (select all that apply) a. suppressing cytotoxic T cells. b. deactivating natural killer cells. c. producing antibodies that bind to tumor cells. d. surveillance of cells with tumor-associated antigens. e. sensitizing natural killer cells before they lyse tumor cells.

c. producing antibodies that bind to tumor cells. d. surveillance of cells with tumor-associated antigens.

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will indicate whether the cancer has spread to other organs." d. "The biopsy will help guide the treatment choices for my enlarged prostate."

d. "The biopsy will help guide the treatment choices for my enlarged prostate."

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient would the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone du

d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone du

A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased

d. Abdominal pain is decreased NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status has been effective. Electrolyte levels may be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this to occur to determine whether treatment was effective.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action would the nurse take? a. Withhold both drugs. b. Administer both drugs. c. Administer the furosemide. d. Administer the spironolactone

d. Administer the spironolactone Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider

A patient has cirrhosis and 4+ pitting edema. Which focused data would the nurse assess? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

d. Albumin level The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edem

A young adult contracts hepatitis from contaminated food. Which result would the nurse expect serologic testing to reveal during the acute (icteric) phase of the patient's illness? a. Antibody to hepatitis D (anti-HDV) b. Hepatitis B surface antigen (HBsAg) c. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG) d. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)

d. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM) Rationale:Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

A patient smokes 2 packs of cigarettes/day. Which action by the nurse could help the patient reduce the risk of lung cancer? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Teach the patient about annual chest x-rays for lung cancer screening d. Discuss dangers associated with cigarettes during each patient encounter

d. Discuss dangers associated with cigarettes during each patient encounter

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varicE

d. Fewer episodes of bleeding varicE TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy

Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

d. Palpable abdominal mass A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

d. Place the patient on a pressure-relief mattress. The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

Which prescribed medication would the nurse expect will have the most rapid effect on a patient admitted to the emergency department in thyroid storm? a. Iodine b. Methimazole c. Propylthiouracil d. Propranolol (Inderal)

d. Propranolol (Inderal) -Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. T

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions would the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution

d. Rinse the mouth before and after each meal and at bedtime with a saline solution

A patient receiving treatment for cancer is having problems maintaining their weight. What is the best option that the nurse can do for the patient? a. Counsel them to eat foods low in fiber. b. Recommend high-fat foods that are spicy. c. Contact the provider about a feeding tube. d. Suggest adding nutrition supplements with meals.

d. Suggest adding nutrition supplements with meals.

A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 × 103/μL, hemoglobin of 10.8 g/dL, and a platelet count of 99 × 103/μL. Based on the CBC results, which are the most serious clinical findings? a. Anorexia and nausea b. Headache, mucositis, and constipation c. Fatigue and skin redness at site of radiation d. Temperature of 101.9°F, fatigue, and shortness of breath

d. Temperature of 101.9°F, fatigue, and shortness of breath

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a weight gain of 9 pounds. b. The patient reports some dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L

d. The patient has a serum sodium level of 118 mEq/L A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action

A characteristic of the promotion stage of cancer development is a. tumor cells detach from the primary tumor. b. tumor cells are trapped in a sentinel lymph node. c. genetic mutations of cells initially occur in this stage. d. cellular alterations that occur in this stage are reversible.

d. cellular alterations that occur in this stage are reversible.

The nurse is caring for a female who had surgery 1 day ago to remove a breast mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to a. review the importance of advanced directives. b. provide reassurance that everything will be fine. c. discuss healthy stress relief and coping practices. d. let her communicate about the meaning of this experience.

d. let her communicate about the meaning of this experience.

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. maintain NPO (nothing by mouth) status. Encourage coughing and deep breathing. Give small, frequent high-calorie feedings. Maintain the client in a supine and flat position. Give hydromorphone intravenously as prescribed for pain. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

maintain NPO (nothing by mouth) status. Encourage coughing and deep breathing. Give hydromorphone intravenously as prescribed for pain.