Final Study

A client with ulcerative colitis (UC) reports abdominal pain, 10 bloody stools per day, and decreased appetite. The client states, "What's the point of taking medication? It doesn't help anyway." Which nursing diagnoses (NDs) are appropriate to include in the client's plan of care? Select all that apply. 1) Acute pain 2) Altered nutritional status 3) Hopelessness 4) Noncompliance 5) Risk for deficient fluid volume

1) Acute pain 2) Altered nutritional status 3) Hopelessness 5) Risk for deficient fluid volume

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? (Select all that apply.) 1) "Avoid foods that may cause epigastric distress such as spicy or acidic foods" 2) "It is best if you refrain from consuming alcohol products" 3) "Report black tarry stools to your health care provider immediately" 4) "Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days" 5) "You may take over-the-counter drugs such as aspirin if you have mild epigastric pain"

1,2,3,4

The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? Select all that apply. 1. Administer high-dose chemotherapy. 2. Teach the client about autologous transfusions. 3. Have the family members HLA typed. 4. Monitor the complete blood cell count daily. 5. Provide central line care per protocol.

1,3,4,5

2. The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1. Fever and infections. 2. Nausea and vomiting. 3. Excessive energy and high platelet counts. 4. Cervical lymph node enlargement and positive acid-fast bacillus.

1. Fever and infections. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce white blood cells of the number and maturity needed to fight infection.

50. The nurse is reviewing a plan of care for a client with cancer of the cervix who is undergoing treatment with a cesium (radiation) implant. Which nursing interventions are most appropriate for this client? (SATA) 1. Maintain the client on bed rest. 2. Place the client on a low-fiber diet. 3. Keep the head of the bed flat at all times. 4. Restrict visitors to visiting for 60 minutes per day. 5. Stand at the entrance of the room to communicate with the client when possible.

1. Maintain the client on bed rest. 2. Place the client on a low-fiber diet. 5. Stand at the entrance of the room to communicate with the client when possible.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis? 1) "My pain is a burning sensation in my upper abdomen" 2) "My pain is an 8 out of 10 and on my left side below my belly button" 3) "My pain is excruciating in my lower abdomen above my right hip" 4) "My pain is intermittent in my abdomen and right shoulder"

3) "My pain is excruciating in my lower abdomen above my right hip"

61. Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? (SATA). 1. Use a straight-edge razor for shaving. 2. Obtain a rectal temperature every 8 hours. 3. Check secretions for frank or occult blood. 4. Give vitamin K by the intramuscular route. 5. Encourage fluid intake to avoid constipation. 6. Provide oral sponges or a soft toothbrush for oral care.

3. Check secretions for frank or occult blood. 5. Encourage fluid intake to avoid constipation. 6. Provide oral sponges or a soft toothbrush for oral care.

20. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm

3. Pain relieved by food intake

76. The nurse is caring for a client with prostate cancer who is being treated with a hormone therapy. What should the nurse monitor for in order to evaluate the effect of this treatment? 1. An increase in testosterone levels 2. An increase in prostaglandin levels 3. An increase the amount of circulating androgens 4. A decline in the amount of circulating androgens

4. A decline in the amount of circulating androgens

25. Which assessment data support to the nurse the client's diagnosis of gastric ulcer? 1. Presence of blood in the client's stool for the past month. 2. Reports of a burning sensation moving like a wave. 3. Sharp pain in the upper abdomen after eating a heavy meal. 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

4. Complaints of epigastric pain 30 to 60 minutes after ingesting food.

66. The oncology nurse specialist provides an educational session for nursing staff regarding the characteristics of Hodgkin's disease. The nurse determines that further teaching is needed if a nursing staff member states that which is a characteristic of the disease? 1. Reed-Sternberg cells are present. 2. The lymph nodes, spleen, and liver are involved. 3. The prognosis depends on the stage of the disease. 4. The disease occurs most often in those older than 75 years of age.

4. The disease occurs most often in those older than 75 years of age.

The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering? A. Nifedipine to a client with Raynaud's disease with a blood pressure of 78/60 B. Propranolol to a client with arterial hypertension C. Vitamin K to a client with an International Normal Ratio (INR) of 3.2 D. Enalapril to a client with a sodium level of 138 mEq/L

A. Nifedipine to a client with Raynaud's disease with a blood pressure of 78/60

49. The nurse is doing preoperative teaching with a client newly diagnosed with a stage I cervical cancer. Which statement by the client indicates that education was effective? 1. "I have carcinoma that is just in the cervix." 2. "My carcinoma has extended to the pelvis and the vagina." 3. "I have carcinoma that has extended beyond the cervix but has not extended to the pelvic wall." 4. "My carcinoma has extended beyond the true pelvis and has involved the bladder or rectal mucosa."

Answer: 1. "I have carcinoma that is just in the cervix."

56. The nurse has provided instructions to a client regarding testicular self-examination (TSE). Which client statement indicates the need for further teaching regarding TSE? 1. "I know to report any small lumps." 2. "I examine myself every 2 months." 3. "I examine myself after I take a warm shower." 4. "I feel a hard and cord-like thing in back and going up."

Answer: 2. "I examine myself every 2 months." Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding (option 4) is normal. After a warm bath or shower, the scrotum is relaxed, making it easier to perform TSE.

The nurse is caring for a client with leukemia. In assessing the client for signs of leukemia, the nurse determines that what should be monitored? 1. Platelet count 2. Bone marrow biopsy 3. White blood cell count 4. Complete blood cell count

Answer: 2. Bone marrow biopsy

44. The nurse is preparing to care for a client with a diagnosis of metastatic cancer. The nurse notes documentation in the client's chart that the client is experiencing cachexia. Which should the nurse expect to note on assessment of the client? 1. Elevated blood pressure and ascites 2. Sunken eyes and a hollow cheek appearance 3. Periorbital edema and swelling around the ears 4. Generalized edema and the presence of weight gain

Answer: 2. Sunken eyes and a hollow cheek appearance Rationale: Cachexia accompanies chronic wasting diseases and conditions such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes; hollow cheeks; and an exhausted, defeated expression. Options 1, 3, and 4 are not characteristic of a cachectic appearance.

84. The nurse is caring for a client undergoing external radiation. The client has developed a dry desquamation of the skin in the treatment area, and the nurse is teaching about management of the skin reaction. Which comment made by the client suggests understanding of the instructions? 1. "I don't need to stay out of the sun or put on sunscreen." 2. "I can use ice packs to relieve itching in the treatment area." 3. "When bathing I will use lukewarm water on the affected area." 4. "I can lubricate the irritated area with an ointment like bacitracin."

Answer: 3. "When bathing I will use lukewarm water on the affected area."

87. A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply. 1. Avoid contact sports. 2. Wash hands frequently. 3. Increase intake of fresh fruits and vegetables. 4. Avoid crowded places such as shopping malls. 5. Treat a sore throat with over-the-counter products. 6. Avoid people who have received live attenuated vaccines.

Answers: 1. Avoid contact sports. 2. Wash hands frequently. 4. Avoid crowded places such as shopping malls. 6. Avoid people who have received live attenuated vaccines.

42. The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? (SATA) 1. Fever 2. Weight loss 3. Night sweats 4. Visual changes 5. Enlarged, painless lymph nodes

Answers: 1. Fever 2. Weight loss 3. Night sweats 5. Enlarged, painless lymph nodes

88. A client with laryngeal cancer has undergone laryngectomy and is now receiving external radiation therapy to the head and neck. The nurse should monitor the client for which side and adverse effects of external radiation? Select all that apply. 1. Cystitis 2. Stomatitis 3. Dysgeusia 4. Leukopenia 5. Xerostomia 6. Thrombocytopenia

Answers: 2. Stomatitis 3. Dysgeusia 5. Xerostomia

Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? A. The client will pace his activities to conserve energy B. The client demonstrates the correct way to pursed-lip breathe C. The client will drink at least 2,500 mL of water daily D. The client lists three (3) signs/symptoms to report to the HCP E. The client will be able to ambulate 100 feet with dyspnea

B. The client demonstrates the correct way to pursed-lip breathe

The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? A. Light yellow coloring of the client's skin and eyes B. The client's blood pressure reading is 184/88 mm Hg. C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and leaking IV fluid

B. The client's blood pressure reading is 184/88 mm Hg.

The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client with insulin shock. The nurse should administer which medication? A. Dilute the Dextrose in one liter of 0.9% Normal Saline Solution B. Mix the Dextrose in a 40 ml piggyback for a total volume of 100 ml C. Push the undiluted Dextrose slowly through the currently infusing IV D. Ask the pharmacist to add the Dextrose to a TPN solution

C. Push the undiluted Dextrose slowly through the currently infusing IV

The nurse is caring for a client diagnosed with flail chest who has had a chest tube. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? A. Notify the HCP that the lungs have re-expanded B. Increase the amount of wall suction C. Check for any leaks in the tubing or around the chest tube D. Auscultate the client's posterior breath sounds and check the tubing for kinks or clots E. Prepare to remove the client's chest tubes

D. Auscultate the client's posterior breath sounds and check the tubing for kinks or clots

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis and is checking the client's activated partial thromboplastin time (aPTT) every 6 hours. The client's aPTT is 25 seconds. The nurse anticipates that which action is needed? A. Decreasing the rate of heparin infusion B. Discontinuing the heparin infusion and preparing protamine sulfate C. Leaving the rate of heparin infusion as is D. Increasing the rate of the heparin infusion

D. Increasing the rate of the heparin infusion

the nurse administer levothyroxine to a client with hypothyroidism, which data indicates that the drug is effective? 1. Increase in T3 & t4 2. Decrease in HR 3. Increase in TSH 4. Decrease in urine output 5. Decrease in periorbital edema a. 1,5 b. 1,2,3,4,5 c. 1,2,3,5 d. 2,3,4 e. 1,2,3

a. 1,5 increase in T3 and T4 / Decrease in periorbital edema

7. A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision by using a pillow to support. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

b. Demonstrate how to splint the incision by using a pillow to support.

the nurse prepares to administer 3 uinits of regular insulin and 20 units of NPH insulin and 20 units of NPH insulin subcutaneously to a client with a blood gluvose level of 250 mg/dl. Which procedure is correct? a. avoid combining the two insulins because incompatibility could cause and adverse reaction b.using only one syringe, add the regular insulin into the syringe, then add the NPH insulin c. administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick. d. using one syringe, first insert air into the regular vial and then insert air into the NPH vial.

b. using only one syringe, add the regular insulin into the syringe, then add the NPH insulin

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? a. Call the health care provide b. Call the pharmacy for further instructions c. Hang a solution of 10% dextrose in water d. Hang a solution of 5% dextrose in 0.9% sodium chloride

c. Hang a solution of 10% dextrose in water