Final Review Test #9-FINAL
The nurse is reviewing the results of a Hemoccult test with the client. Which question, asked by the nurse, is important to screen for the potential of a false-positive result. Select all that apply.
"Are you prescribed regular strength aspirin daily?" "When was the last time that you included red meat in your diet?" "Can you tell me the amount of alcohol that you drink on an average week?" When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test results. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.
A patient with cirrhosis is complaining to the nurse of itching. The client asks the nurse if the itching is because he has been taking warm baths. What is the best response by the nurse?
"The itching is caused by the accumulation of bile salts." Skin may itch (pruritus) from accumulated bile salts related to the diseased liver. It is not related to the baths or a psychological response from the illness. Medication side effect may cause itching, but the most likely cause is the accumulation of bile salts.
A male client, age 32 years, was recently married, and he and his wife would like to have children. The client is scheduled to have a total colectomy and is concerned with being able to have children. What is the best answer given by the nurse related to the client's concern?
"You may want to consider collection and storing of sperm for later use if you are planning to have children." Young male clients may wish to collect and store sperm for later use if they plan to have children. Sexual dysfunction in men after a total colectomy is unusual but sometimes occurs. If such dysfunction persists after a colectomy, operative and nonoperative options are available to facilitation erection.
You are admitting a client with an acoustic neuroma to your unit. What would you include during the assessment of this client?
(neuroma is a tumor) --test for facial sensation
Following cataract removal, discharge instructions will be provided to the client. Which of the following instructions is most important?
-- avoid things that can increase intraocular pressure
A client diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?
-- hypertension
The nurse is obtaining subjective data from a client with difficulty hearing. In order to assist the client in hearing the nurse's voice, which adjustments are made? Select all that apply.
-- speak in a clear voice -- clearly articulate -- slowly -- lower tone -- face client when speaking
You are caring for a client with open-angle glaucoma. You know that this disease causes which of the following? Select all that apply
--drainage system to much drainage -- degeneration of the optic nerve -- edema of the cornea -- atrophy in the peripheral areas
The nurse is working in the triage section of a walk-in clinic. which triad of common symptoms, when placed together, indicate Meniere's disease?
--hearing loss tinnitus vertigo
The nurse is caring for an 8-year old and anticipates that the client has otitis externa from symptoms stated on the history. Which symptoms, from the history and physical examination, would confirm the diagnosis?
--place ear plugs in the ear before swimming
A nursing student is presenting a report on Meniere's disease to other members of the class. What symptoms would the student list?
--vertigo tinnitus hearing loss
A client is receiving brinzolamide (azopt) and timolol maleate (Timoptic) eye drops. When introducing the client on the administration of the eye drops, the nurse plans to tell the client to:
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A client, diagnosed with a cataract, comes into the clinic. What assessment should the nurse observe in this client?
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A clients diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that of the following is the common client complaint associated with a disorder involving the inner ear?
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A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. The nurse tells the client:
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A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurse looks at the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate?
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A nurse is assigned to care for a client following a cataract extraction. The nurse plans to position the client:
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A nurse is assigned to care for a client with a detached retina. Which finding would the nurse expect to be documented in the client's record?
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A nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction would the nurse suggest to include in the plan of care?
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A nurse is assisting the physician with an ear irrigation on an assigned client. The nurse would plan to:
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A nurse is reviewing the record of a client with mastioditis. The nurse would expect to which of the following documented regarding the results of the otoscopic examination?
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An LVN is assigned to care for a client with glaucoma. the LVN reviews the client's medication record and would notify the RN if which medication was noted on the client's record?
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Betaxolol hydrochloride (betoptic) eye drops have been prescribed for the client with glaucoma. Which action is appropriate related to monitoring for the side effects of this medication?
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During the early portoperative stage, the cataract extraction client complains of nausea and severe eye pain over the operative site. the nurse takes which action?
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THe nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan?
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The nurse is establishing a visual tet using the Snellen chart for a client experiencing visual changes. At Which distance should the nurse instruct the client to stand?
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The nurse is obtaining a history from a client complaining of ear pain and dizziness. Which assessment finding is the best evidence that the client has a perforated eardrum?
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The nurse is obtaining a history on a client stating the inability to read the newspaper and even seeing detail when looking at an image. Which assessment test would add additional data for a diagnosis?
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The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to administer the drops. Select all that apply
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The nurse notes that the physician has documented a diagnosis of presbycusis on the client's chart. the nurse understands that this condition is accurately described as:
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To minimize the systemic effects that eye drops can produce, the nurse plans to instruct the client to:
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When caring for a client with a foreign object removed from the eye, the nurse is most correct to assess the eye protective functions of which structures? Select all that apply.
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Which nursing suggestion would be most helpful to the client with recurrent otitis externa?
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A client scheduled for a total colectomy has been taking the immunosuppressive agent, azathioprine (Imuran). When should the client be told to discontinue the medication to prevent negative effects on tissue healing?
1 month before surgery Immunosuppressive agents such as azathioprine, 6-mercaptopurine, and cyclosporine should be discontinued 3 to 4 weeks before surgery to prevent negative effects on tissue healing. Aspirin-containing compounds are discontinued at least 1 week before surgery to decrease the risk of bleeding.
The nurse is checking the residual content for a client who is receiving intermittent feedings. Which residual content, if obtained, would lead the nurse to delay the feeding?
120 mL Feedings typically are delayed if the residual content measures more than 100 mL for intermittent feedings or 10% to 20% of the hourly amount of a continuous feeding. Thus, a residual content of 120 mL would require the nurse to delay the feeding.
A nurse is employed as a gastroenterologist's office nurse. When assessing the client, which objective data would provide useful information for diagnosis?
22-lb weight loss in 2 months Clients with an ileostomy should avoid enteric-coated products and some modified-release drugs, such as slow-release beads and layered tablets. These products may pass through without being absorbed. The client may take liquid and chewable tablets because they will go through the breakdown process in the stomach.
The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty?
6 hours Response Feedback: Step 1:2 × 8 oz = 16 oz Step 2:1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Abdominal distention The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.
The nurse is assisting the physician with a procedure to remove ascitic fluid from a client with cirrhosis. What procedure does the nurse ensure the client understands will be performed?
Abdominal paracentesis Abdominal paracentesis may be performed to remove ascitic fluid. Abdominal fluid is rapidly removed by careful introduction of a needle through the abdominal wall, allowing the fluid to drain. Fluid is removed from the lung via a thoracentesis. Fluid cannot be removed with an abdominal CT scan, but it can assist with placement of the needle. Fluid cannot be removed via an upper endoscopy.
What potentially life-threatening complication can the client have if corticosteroids are abruptly withdrawn or the client has significant stress due to the impending surgical procedure?
Adrenal crisis Adrenal crisis is potentially life threatening and can result from the abrupt withdrawal of corticosteroids or significant stress after the client has been treated with corticosteroids. Cushing's disease is a disease when there are increased levels of cortisol released. Myxedema coma is a result of dangerously decreased levels of thyroid hormone, and thyroid storm is a dangerously increased level of thyroid hormone.
The nurse is caring for a young woman who is struggling with weight loss issues, without apparent physical cause. Which is the most likely nursing assessment for this nutritional disorder in which normal body weight is not maintained?
Anorexia nervosa Anorexia nervosa is a nutritional disorder that is characterized by a refusal to maintain normal body weight in the absence of physical cause. Anorexia nervosa is considered a psychiatric disorder in a relentless pursuit of thinness. Bulimia is an eating disorder in which voracious appetite is followed by purging and is most likely found in normal to overweight individuals. Kwashiorkor is a severe protein deficiency associated with lack of protein in the diet. Crohn's disease can result in nutritional deficiencies but has apparent physiological cause.
The nurse is evaluating the medication list of a client with acute gastritis. Which medication would create the most concern?
Anti-arthritis medication (Advil) Advil is an NSAID and is contraindicated with peptic ulcer disease or gastric irritation. Digoxin and Lasix have little effects on gastric secretions. Benadryl decreases presence of histamine aggravating hypersecretion in the stomach.
The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?
At the umbilicus Measurement of abdominal girth is done at the widest point, which is usually the umbilicus. The right upper quadrant, lower border of the liver, or just below the last rib would be inappropriate sites for abdominal girth measurement.
A client is being discharged from the outpatient care center after having an inguinal hernia reduced nonsurgically. What can the nurse instruct the client to do to decrease the incidence of recurrence? Select all that apply.
Avoid heavy lifting and strenuous exercise. How to wear a truss. Avoid constipation. The nurse educates the client about ways to avoid constipation, control a cough, and perform proper body mechanics—how to wear and care for skin under a truss. Analgesics are not required for the prevention of a hernia. The client should bend at the knees not at the waist.
At morning report, the nurse learns the assigned client is blind. Which question should the nurse ask the client upon initial assessment?
Can you perceive light and motion
When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important?
Checking if the mucous membranes are dry Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.
Which of the following instructions should the nurse include in the teaching plan of a client who has undergone colostomy?
Chew food well. The nurse should instruct a client who has undergone colostomy to chew food properly. This helps decrease gas that results chiefly from swallowing air rather than from digestion. The client need not limit or avoid traveling or outdoor activities. If traveling by air, the nurse should instruct the client to take ostomy supplies in carry-on luggage to prevent their loss if luggage is misdirected or lost. If the client requires firm tight support, he or she should find a stoma shield to help prevent irritation or undue pressure on the stoma.
A client comes to the clinic and informs the nurse that he is there to see the physician for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with?
Cholelithiasis Initially, with cholelithiasis clients experience belching, nausea, and RUQ discomfort, with pain or cramps after high-fat meal. Symptoms become acute when a stone blocks bile flow from the gallbladder. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain called biliary colic. The symptoms do not correlate with hepatitis.
A client with cirrhosis is complaining of severe pruritus related to the accumulation of bile salts. What can be prescribed for the client to relieve the itching?
Cholestyramine (Questran) Cholestyramine (Questran) may be prescribed to bind bile salts and relieve pruritus. Kanamycin (Kantrex) is prescribed to reduce the bacterial count in the intestine. Lactulose (Cephulac) is used to decrease the amount of ammonia level in the blood. Cyclosporine (Sandimmune) is used to prevent rejection of a transplanted organ.
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?
Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
A client is having the first stage of an ileoanal anastomosis. What should the nurse inform the client they will experience?
Continuous discharge of mucus from the anus After the first stage of surgery, clients experience an almost continuous discharge of mucus from the anus and a frequent discharge of fecal material from the ileostomy. Initially, clients cannot control the frequent watery discharge.
An eight-grade boy tells the school nurse that the eye doctor told him he had astigmatism and that meant his eyeball wasn't shaped right. The boy says he went home and looked in the mirror and both eyes looked just alike. What is the school nurse's best response?
Cornea of the eye is shaped differently
A client is scheduled to have a total colectomy due to a colon mass and is also taking prednisone for asthma. The physician has instructed the client to taper down on the prednisone and discontinue. What negative outcome does the nurse know may occur if the client does not adhere to the instructions?
Delayed or altered tissue healing Whenever possible, prednisone should be tapered and discontinued before surgery to avoid negative effects of the drug on tissue healing. The client will have liquid stools after the ileostomy through the pouch because the stool is not formed. Hypertension and increase in blood loss do not necessarily correlate with the corticosteroid use.
A nurse is assessing a client for a fracture to the bony orbit. What would the nurse document if her assessment for fracture was positive?
Diplopia (double vision)
The nurse is caring for a patient who has had diarrhea for 3 days. What major problems associated with severe or prolonged diarrhea should the nurse monitor for when caring for this patient? Select all that apply.
Electrolyte imbalances Vitamin deficiencies Dehydration Three major problems associated with severe or prolonged diarrhea include dehydration, electrolyte imbalances, and vitamin deficiencies.
A client at a long-term care facility informs the nurse that he is having cramping when trying to have a bowel movement, and all that is coming out is liquid. When the nurse reviews the client's last bowel movement history, it is determined that the client has not had a bowel movement in 7 days. What does the nurse understand is most likely occurring with this client?
Encopresis Sometimes, if a client has been constipated for a long time, the client may begin passing liquid stool around an obstructive stool mass called encopresis, a phenomenon sometimes misinterpreted as diarrhea. The liquid stool results from dry stool stimulating nerve endings in the lower colon and rectum, which increases peristalsis. Scybala is hard, rocklike stool. The nurse cannot make a judgment about the correctness of the last bowel movement if it is not documented. Encopresis will mimic diarrhea, but there is an obstructive mass above where the liquid stool is leaking around.
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?
Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.
The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
Esophagogastroduodenoscopy The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EGD). The other options are lower gastrointestinal studies typically requiring a bowel preparation.
A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?
Give high-protein, semiliquid foods A major goal for a client with esophageal cancer is adequate or improved nutrition and eventually stable weight. Because he has difficulty in swallowing, the nurse should ensure that the client receives soft foods or high-calorie, high-protein, semiliquid foods to get improved nutrition. Providing oral liquids alone will not provide improved nutrition. Using a straw leads to bloating and should be avoided. Providing liquid supplements are used in between meals, not as meals. Encouraging small, frequent meals will give improved nutrition to a client who does not have any difficulty in swallowing.
The nurse would instruct a client who has an appendectomy to avoid which of the following?
Heavy lifting It is essential for clients who have undergone appendectomy to avoid heavy lifting or unusual exertion for several months to minimize the risk of postoperative complications. However, the client need not avoid sunlight because there is no risk of photosensitivity. It is not essential for the client to avoid dairy products or purine-rich foods because these food products have no implications on the client's recovery.
A client had an open cholecystectomy with a T-tube insertion, and the nurse is measuring the bile drainage every 8 hours. When should the nurse notify the physician?
If more than 500 mL of bile drainage is present in 24 hours. The nurse measures bile drainage every 8 hours or according to agency policy. If more than 500 mL of bile drains within 24 hours or if drainage is significantly reduced, the nurse notifies the physician.
A client, who is recovering from bariatric surgery, is returning from the postanesthesia care unit. Which nursing assessment is of greatest concern in the immediate postoperative period for this client?
Impaired Gas Exchange Extremely obese clients are at greater risk for complications related to anesthesia and surgery. Obstructive sleep apnea and impaired breathing can be a problem requiring continuous or positive airway pressure devices. Self-care deficit and impaired mobility are real problems that need to be addressed but less significant than airway issues. Diarrhea due to dumping syndrome is not an immediate post-op issue.
A client is complaining of problems with constipation. What dietary suggestion can the nurse inform the client may help facilitate the passage of stool?
Increase dietary fiber. Constipation may result from insufficient dietary fiber and water. A diet low in fiber predisposes people to constipation because the stools produced are small in volume and dry. Increasing the carbohydrate, fat, and protein content will not facilitate the passage of stool.
Which of the following symptoms would indicate that a client with chronic pancreatitis has developed secondary diabetes?
Increased appetite and thirst When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.
Which of the following interventions would be most appropriate for a client with a hiatal hernia and nursing diagnosis of Acute Pain related to reflux of gastric secretions?
Inform the client to remain upright for at least 2 hours after meals. Because the client is showing signs of pain related to the pressure and the reflux of gastric secretions, it is essential to inform him or her to remain upright for at least 2 hours after meals because an upright position helps prevent reflux. Encouraging the client to eat frequent, small, well-balanced meals; to avoid alcohol and tobacco products; and to eat slowly and chew foods thoroughly would be appropriate for a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements.
When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first?
Inspection When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and, lastly, palpation.
A client who is recovering from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which of the following measures will help ease the client's discomfort?
Keeping the head of the bed elevated. It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.
The nurse is administering medications to a patient that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?
Lactulose (Cephulac) Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
The nurse is discussing care of the client's ileostomy and is instructing the client to avoid certain medications that may pass through without being absorbed. What medications should the nurse instruct the client to avoid? Select all that apply.
Layered tablets Enteric-coated products Slow-release beads Clients with an ileostomy should avoid enteric-coated products and some modified-release drugs, such as slow-release beads and layered tablets. These products may pass through without being absorbed. The client may take liquid and chewable tablets because they will go through the breakdown process in the stomach.
The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?
Liver function studies The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.
After teaching a group of students about irritable bowel syndrome and antidiarrheal agents, the instructor determines that the teaching was effective when the students identify which of the following as an example of an opiate-related antidiarrheal agent?
Loperamide (Imodium) Loperamide (Imodium) and diphenoxylate with atropine sulfate (Lomotil) are examples of opiate-related antidiarrheal agents. Bismuth subsalicylate (Pepto-Bismol) and kaolin and pectin (Kaopectate) are examples of absorbent antidiarrheal agents. Bisacodyl (Dulcolax) is a chemical stimulant laxative.
When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?
Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. Measuring the abdominal girth is the most accurate method of determining an increase or decrease in abdominal distention. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis. The nurse would report to the physician about abdominal enlargement along with other parameters of the assessment.
Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?
Measure pH of aspirates Measuring pH of aspirates is recommended method to confirm placement. Although radiographic confirmation is the most reliable method, this is usually reserved for initial placement or uncertainty of placement. X-rays would not be performed prior to each medication administration, not realistic. Auscultation technique and placing end of tube in water should not be used in determining location.
The client is having a Weber test. During the Weber test, where should the tuning fork be placed?
Middle of the clients skull or forehead
Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow?
Monitoring the stool passage and its color Monitoring stool passage and its color will ensure that the client remains barium free following a barium swallow test. The white or clay color of the stool would indicate barium retention. The stool should be placed in a special preservative if the client undergoes a stool analysis. Observing the color and volume of urine will not ensure that the client is barium free because barium is not eliminated through urine but through stool.
Which intervention would be most appropriate for a client who has undergone colostomy surgery?
Monitoring the volume of gastric secretions. The nurse should monitor the volume of suctioned gastric secretions in a client who has undergone colostomy surgery. The nurse should monitor vital signs once every 4 hours and take temperature by any route other than rectal. The nurse should also ensure that the client's fluid intake is adequate and not minimized.
A client comes to the clinic complaining of not having a bowel movement in several days, abdominal cramping, and nausea. When the nurse puts the client on the stretcher, he vomits a large amount of fecal material. What should the first action by the nurse be?
Notify the physician. The physician should be notified immediately to examine the client because the client is exhibiting signs of an intestinal obstruction. Starting the IV and inserting a nasogastric tube would be interventions that the physician will order after seeing the client. The nurse does not insert intestinal tubes.
A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has?
Obstructive jaundice Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.
The nurse is obtaining data from an older adult client who is being seen in the clinic for a checkup. The client informs the nurse that he is taking a daily dose of Epsom salts to have a daily bowel movement. What priority intervention should the nurse anticipate doing to detect the changes that can occur from prolonged use?
Obtaining an ECG Magnesium products may cause ECG changes with prolonged use. The nurse should perform an ECG and compare it to the last one performed. A CBC would not establish a specific problem for the overuse of magnesium products, nor would listening to bowel sounds. Administering an oil retention enema would not be indicated at this time because the patient is not complaining of constipation and may overstimulate peristalsis.
A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding?
Octreotide (Sandostatin) Acute hemorrhage from esophageal varices is life threatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide (Sandostatin) is started as soon as possible. Sandostatin is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin (Pitressin) or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
One part of the intestine telescopes into another portion of the intestine. In intussusception of the bowel, one part of the intestine telescopes into another portion of the intestine. When the bowel twists and turns itself and obstructs the intestinal lumen, this is known as a volvulus. A hernia is when the bowel protrudes through a weakened area in the abdominal wall. An adhesion is a loop of intestine that adheres to an area that is healing slowly after surgery.
The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)
Percussion Inspection Auscultation Palpation The nurse is correct to assess the abdomen in a specific order to be able to judge the undisturbed status of the abdominal region. Begin with inspection of the abdomen using the nurse's assessment skills. Next, auscultate the abdomen before percussing and finally palpating.
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?
Peritonitis Lack of bowel motility typically accompanies peritonitis. The abdomen feels rigid and boardlike as it distends with gas and intestinal contents. Bowel sounds typically are absent. The diagnosis of acute appendicitis correlates with the symptoms of rupture of the appendix and peritonitis. A paralytic ileus and gas alone do not produce these symptoms.
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
Permit the client to drink only clear liquids After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.
The nurse is administering furosemide (Lasix) to promote urinary excretion of excess fluids for a client with cirrhosis. When administering Lasix to this client, what should the nurse closely monitor?
Potassium level Diuretics such as furosemide (Lasix) must be administered with caution because long-term use can cause sodium depletion. The other levels do not relate to the administration of furosemide (Lasix).
A client with a history of peptic ulcer disease is admitted for hematemesis associated with gastric bleeding. Which is the most appropriate action of the nurse?
Prepare for nasogastric irrigations. Hemorrhage with peptic ulcer disease is initially handled through cold saline lavage via nasogastric tube. Increasing the IV rate is not a nursing measure. Administering oxygen is not indicated unless the client is experiencing respiratory difficulties. While having hematemesis, the head of the bed would remain elevated to avoid risk for aspiration.
A nurse is preparing to administer the prescribed vitamin B12 to a client who has had most of his ileum removed. The nurse understands that this is necessary for which reason?
Prevents deficiencies Parenteral injections or intranasal administrations (Nascobal) of vitamin B12 are used to prevent deficiencies in clients who have had most or all of the ileum removed because this area is responsible for B12 absorption. Vitamin B12 does not prevent thrombosis or constipation or aid digestion.
A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely?
Prochlorperazine (Compazine) Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Ondansetron blocks receptors for 5 HT3, affecting the neural pathways involved in nausea and vomiting. Hydroxyzine and promethazine are antihistamines that block H1 receptors, resulting in a decrease in stimulation of the CTZ and vomiting.
The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?
Prothrombin time (PT) The client must have coagulation studies before the procedure such as a PT or PTT because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.
The client receiving radiotherapy complains of increased fatigue. The nurse understands that the most significant reason for this symptom is related to which factor?
Radiation suppresses red blood cell production. Radiation treatment can suppress blood cell production, leading to low RBC, WBC, and platelet counts. Anemia can result in fatigue and lack of energy. With a low WBC count, infection is a concern but specific to fatigue. Advancing cancers can cause fatigue but not as significant during active treatment.
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
Rectal bleeding Internal hemorrhoids cause bleeding but are less likely to cause pain, unless they protrude through the anus. External hemorrhoids may cause few symptoms, or they can produce pain, itching, and soreness of the anal area.
A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?
Reduce fluid accumulation and venous pressure. Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.
The nurse is assessing a client for fecal impaction, and when inserting a lubricated, gloved finger, the stool feels like small rocks. What does the nurse document this finding as?
Scybala When a practitioner inserts a gloved and lubricated finger in the rectum, the stool may feel like small rocks, a condition referred to as scybala. The client may have hard stool or be impacted but the correct terminology to be documented is scybala. A fecal obstruction is not always able to be determined on digital examination and will require an x-ray.
A client with complaints of nausea and vomiting has been ordered a nasogastric tube insertion. Which action should the nurse take first once the NG tube is inserted?
Secure the NG tube and assess drainage. Immediately after insertion, the tube should be secured to the client's nose to prevent dislodgement or accidental removal. The nurse is also assessing the amount and consistency of drainage. Sending the client to x-ray for verification of placement may be protocol for some institutions but would be done after the tube is secure. Instilling water may be a routine adopted to maintain patency of the tube but is not the first action.
The nurse is assessing the stool consistency of a client with an ascending colostomy. Which of the following would the nurse expect to find?
Semiliquid The consistency of fecal material ranges from semiliquid to formed depending on the area from which the colostomy is formed. With an ascending colostomy, stool would be semiliquid. An ileostomy would produce liquid stool; a transverse colostomy would produce soft stool; a sigmoid colostomy would produce formed stool.
The wound care nurse suspects a nutritional problem with a client who presents with weight loss, poor appetite, and delayed healing. Which of the following laboratory findings would be most indicative of a nutritional problem?
Serum albumin level 2 g/dL Serum albumin level is a helpful lab value for assessing nutritional status of a client. Normal serum albumin levels 3.5 to 5 g/dL are not reflected in this client and would indicate a low protein level. Arterial blood pH is normal between 3.45 and 4.35. Hemoglobin levels of 11 to 17 g/dL are within normal levels. BUN level of 34 mg/dL is elevated and indicative of kidney problems but not specific to nutritional problems.
The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis?
Severe midabdominal to upper abdominal pain radiating to both sides and to the back The most common complaint of clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back. The other answers are not pain that is usually associated with acute pancreatitis.
The nurse is providing care to a client who has had a percutaneous liver biopsy. The nurse would monitor the client for which of the following?
Signs and symptoms of bleeding A major complication after a liver biopsy is bleeding, so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.
The nurse is instructing a nursing student when a new client comes to the eye clinic. The client explains that he thinks he has a corneal abrasion. The nurse should explain what to the student nurse?
Slit lam
A client is recently diagnosed with Crohn's disease and is beginning treatment. What first-line treatment does the nurse expect that the client will be placed on to decrease the inflammatory response?
Sulfasalazine (Azulfidine) Considered first-line treatment for inflammatory bowel disease, 5-ASA drugs contain salicylate, which is bonded to a carrying agent that allows the drug to be absorbed in the intestine. These drugs work by decreasing the inflammatory response. MTX or Imuran are used when failure to maintain remission necessitates the use of an immune-modulating agent. Cipro is used as an effective adjunct to treat the disease.
The nurse is reviewing laboratory work that is consistent with a client being positive for hepatitis and in the incubation phase of the illness. What should the nurse be concerned with at this stage of the illness?
The client is infectious. In the incubation phase, the virus replicates within the liver, and the client is asymptomatic. Late in this phase, the virus can be found in blood, bile, and stools. At this point, the client is considered infectious.
A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason?
The client's natural bowel function may become sluggish.
The nurse is assessing a client of color for jaundice. In which location would the nurse assess for discoloration? Select all that apply.
The hard palate The sclera The gums The conjunctiva In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
A client informs the nurse that he is taking a stimulant laxative in order to be able to have a bowel movement daily. What should the nurse inform the client about the taking a stimulant laxative?
They can be habit forming and will require increasing doses to be effective. The nurse should discourage self-treatment with daily or frequent enemas or laxatives. Chronic use of such products causes natural bowel function to be sluggish. In addition, laxatives continuing stimulants can be habit forming, requiring continued use in increasing doses. Although the nurse should encourage the client to have adequate fluid intake, laxative use should not be encouraged. The laxative may interact with other medications the client is taking and may cause a decrease in absorption. A fiber supplement may be taken alone but should not be taken with a stimulant laxative.
The nurse would expect to observe which of the following when assessing a client with cholelithiasis?
Urine that appears dark brown When a client is being assessed for cholelithiasis, the urine appears dark brown, whereas the stools may be light colored. Bowel sounds are present because cholelithiasis does not cause lack of bowel motility. The stool does not contain blood or mucus.
In a client receiving radiation therapy to the head, prevention of infection of the teeth and gums is important. Which is the primary nursing care measure that should be taken?
Use of topical antiseptic mouthwash Good oral hygiene should include gentle tooth brushing and use of oral antiseptic mouthwash to maintain integrity and avoid infections of teeth and gums. Blood transfusions may become necessary if WBC production is compromised but not specific to oral hygiene. Dental cleanings monthly will not prevent infection. Lead shields are not specific for preventing infection.
A female client with chronic hepatitis B has been prescribed recombinant interferon alfa-2b (Intron A, Roferon-A) in combination with ribavirin (Rebetol). Which of the following instructions should a nurse provide this client?
Use strict birth control methods A female client who has been prescribed recombinant interferon alpha-2b in combination with ribavirin should be instructed to use strict birth control methods. This is because ribavirin may cause birth defects. It is not essential for the client to avoid calcium-rich foods or hot baths or soaks. The client needs to maintain physical rest during therapy.
A client has undergone a total gastrectomy for refractory ulcers. The nurse would explain the need for lifelong treatment with which of the following?
Vitamin B12 replacement If a total gastrectomy (removal of the stomach) is performed, the client receives vitamin B12 injections or intranasal vitamin B12 for life because, without the stomach, the intrinsic factor necessary for absorption of vitamin B12 no longer is produced. However, B12 therapy usually is not necessary for 1 or 2 years after surgery because the body uses very small amounts of this vitamin and body reserves usually are sufficient for several years. Combination antibiotic therapy is used to treat ulcers due to H. pylori. Subcutaneous insulin and antiemetics are not typically used.
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?
Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.
A client is prescribed a magnesium and aluminum hydroxide antacid to treat gastroesophageal reflux disease (GERD). The nurse cautions this client to do which of the following?
Watch for possible antacid-related diarrhea. Antacids containing magnesium and aluminum hydroxides tend to cause diarrhea in some clients. In such cases, switching to an aluminum-only antacid or calcium-containing antacid may be helpful. Antacids may be given two to four times per day or as frequently as every 1 to 2 hours. They are not administered within 1 hour of histamine2-receptor antagonists or other oral medications because they may decrease absorption of the other drug. Sore throat and fever are adverse effects associated with histamine2-receptor antagonists, not antacids, which need to be reported.
While cleaning gutters, a client reports getting debris in the eyes. On inspection, no obvious foreign object is noted. Which of the following diagnostic evaluation techniques would be most beneficial for this client?
administer the flourenstine dye
The nurse is caring for a client with recurrent ear infections. The nurse assesses the client for further infectious processes traveling deeper into the tissue and becoming more lethal. Which infection, originated in the ear, is of most concern?
bacterial meningitis
The nurse is caring for a client experiencing hearing loss. the nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate?
conductive hearing loss
Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication?
constricts the pupil (makes it little)
The nurse is caring for a client being treated for Meniere's disease. Which medication is monitored closely due to its addictive properties?
diazepam (Valium)
The nurse is caring for a client who just returned from a trip requiring an airline flight. The client commented on how his ears hurt upon descent. The nurse is correct in stating which site as being the pressure equalizer in the ear?
eustachian
A client is diagnosed with blepharitis. What symptoms should a nurse monitor in this client?
eyelids
The nurse is caring for a client who underwent surgery for a retinal detachment. The surgery included the injection of an air bubble to promote contact between the retina and choroids. What position should the nurse keep the client in?
face down
Which assessment finding would contraindicate the use of atropine in a client scheduled for general anesthesia?
gluacoma
A client has undergone enucleation. What complication of enucleation should be addressed by the nurse?
hemorrhage
A client is diagnosed with uveitis. Which assessment finding is most important in determining likelihood of recurrence?
if the client aspendilitis
Which of the following teaching items would be a priority in maintaining normal pressure range in the eye?
increase fiber
The nurse is completing a corneal light reflex test using a penlight. Which result would indicate a normal test result?
light is the same spot in each eye
The nurse is assisting the client in planning care during exacerbations of Meniere's disease. Which diet would the nurse identify as appropriate at this time?
low sodium
A client has exhibited repeated return of hordeolum (sty). which assessment finding is most important in determining care for this client?
mascara
A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear?
mineral oil small forceps
The client has been diagnosed with objective vertigo. Which symptom would the nurse relate to the tentative diagnosis?
sensation of things moving
The nurse is obtaining a history from a client who indicates hearing loss due to drug toxicity. Which type of hearing loss is noted?
sensory nuero
What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?
serous
A nurse is doing preoperative and postoperative teaching with a client who is undergoing cataract surgery. What is an important teaching point the nurse should teach the client about?
soft food avoid strenuous activity do not bend stoop or do other exercise that increase IOP Do not immerse the eyes in water Do not engage in any activity that could cause dust or other particles to lodge in the eye
The nurse is evaluating the client while taking the color vision test. Which response would the nurse anticipate when caring for a client with normal color vision?
the number that is within it
During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?
tinitus
A client splashes bleach into the right eye and requires irrigation of the eye. Which nursing action is most important to prevent extension of chemical irritation?
turn head with right side lower than the left
The nurse is instilling an antibiotic solution into the ear of an adult with otitis media. Which nursing action is most correct to ensure that the medication travels down the ear canal?
up and back
AS client is diagnosed with keratitis. What advice should the nurse give this client?
wear dark glasses
