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The nurse identifies which diet best meets the nutritional needs of the pt newly Dx with cirrhosis ? a. high in fat and low in fiber b. high in protein and low in sodium c. high in calcium and low in fat d. high in iron and low in sodium

b. high in protein and low in sodium

The pt comes back form an overseas trip reporting multiple, watery bowel movements. The HCP prescribes loperamide. It is most important for the nurse to follow up on which pt statement ? a. I feel dizzy and my mouth feels like cotton b. I should change by diet as well as take the med c. my temp is 101.2F d. I find it hard to keep by eyes open

c. my temp is 101.2F

The nurse in the outpatient clinic instructs a pt taking lansoprazole for the first time. The nurse determines further teaching is required if the pt makes which statement ? a. I should take the med on a full stomach b. the capsules are not to be crushed or chewed c. I can take this med with antacids d. I can open the capsule and sprinkle the contents on soft food, such as applesauce, and swallow immediately

a. I should take the med on a full stomach

The nurse cares for a pt after a traditional cholecystectomy. The nurse contacts the HCP if which observation is made ? a. 800mL bloody drainage the 1st day post-op b. the pt frequently reports abdominal pain during the first 24 hours c. NG tube connected to intermittent suction the first day post-op d. temp elevation to 100F the evening of surgery

a. 800mL bloody drainage the 1st day post-op

The nurse provides care for a pt after a total gastrectomy. The nurse is most concerned if which observation is made ? a. The NG tube is attached to low continuous suctioning b. The pt urine output during the previous 8hr was 500mL c. The pt asks for oral pain medication d. The pt performs coughing and deep breathing every 2 hr and is appropriately using the incentive spirometer

a. The NG tube is attached to low continuous suctioning

The LPN reports to the nurse that a pt surgical wound has burst and abdominal contents are protruding. Which action does the nurse take first ? a. assess the pt wound b. call the HCP c. cover the wound with sterile saline soaked gauze d. place the pt on NPO status

a. assess the pt wound

The neighbor of the nurse comes running to the nurse's house saying, "I just found my 2 year old in the kitchen surrounded by several bottles of cleaning solutions and the bottles are all open!" Which action by the nurse is best? a. call the poison control b. ask the child if the child drank anything c. give the child ipecac syrup with 2 glasses of water d. give the child a mixture of milk and burned toast

a. call the poison control

The pt tells the nurse she has always had a heavy menstrual flow and needs extra iron. The nurse recommends the pt eat which food ? a. chicken livers b. pork c. hamburger d. tofu

a. chicken livers

The clinic nurse monitors a pt recovering from hepatitis A. The nurse understands that hepatitis A is transmitted through which role ? a. fecal-oral b. droplet c. airborne d. contact

a. fecal-oral

A toddler pt accidentally drinks some drain cleaner and is brought to the ED. Which piece of equipment is most essential for the nurse when caring for this pt ? a. intubation tray b. EKG machine c. dialysis machine d. gastric lavage tube

a. intubation tray

The nurse understands that phentermine is prescribed most for which pt ? a. obese b. dying c. experiencing anorexia d. abusing alcohol

a. obese

Immediately following a liver biopsy, the nurse places the pt in which position ? a. on the right side b. on the left side c. prone d. supine

a. on the right side

The nurse identifies folic acid is prescribed for which conditions ? Select all that apply a. pregnancy b. alcoholism c. parkinson's disease d. liver disease e. type 1 diabetes f. pernicious anemia

a. pregnancy b. alcoholism d. liver disease

The nurse provides care for a pt admitted with a Dx of acute pancreatitis. The nurse administers morphine sulfate IV for reports of pain. Which pt behavior indicates to the nurse the med is effective ? a. pt sleeps for 1 hr b. pt frequently changes positions in bed c. pt states there is less nausea d. pt does not report thirst

a. pt sleeps for 1 hr

After an open cholecystectomy, a pt is returned to the unit with a NG tube connected to low intermittent suction, a T-tube in place, and a Penrose drain. What is the purpose of the Penrose drain ? a. removes accumulated bile and blood from the surgical site b. permits irrigation of the peritoneum c. provides access for antibiotic infusion d. creates a route for alimentation

a. removes accumulated bile and blood from the surgical site

The nurse teaches a pt how to perform a routine dressing change for a surgical incision using a clean technique. the pt performs a return demonstration. Which action by the pt shows an understanding of the procedure ? a. washes hands before changing the dressing b. utilizes a splash guard and mask c. dons sterile gloves before each dressing change d. keeps the dressing moist so it will not adhere to the wound

a. washes hands before changing the dressing

The nurse recognizes which child pt is at greatest risk for poisoning ? a. 5 month old b. 2 year old c. 5 year old d. 7 year old

b. 2 year old

The nurse instructs a client receiving lovastatin for treatment of hypercholesterolemia. The nurse determines further teaching is necessary if the cleint makes which statement ? a. I dont expect to see the full effect from taking if for another 2-4 weeks b. I always take it on an empty stomach, so it can get right to work c. I will have to have my blood drawn for testing to see if my liver is doing okay d. I will contact my HCP if I have any unexplained muscle pain

b. I always take it on an empty stomach, so it can get right to work

The nurse in the same day surgery prepares a client for discharge after conventional herniorrhaphy. The nurse should intervene if the client makes which statement? a. I should not strain when having a bowel movement b. I should cough and deep breathe every two hours. c. I can walk up and down the stairs as soon as I get home d. I should call the health care provider if I have an elevated temperature.

b. I should cough and deep breathe every two hours.

The nurse provides care for a pt in the outpatient clinic. The nurse obtains a Hx on a pt reporting diarrhea. It is most important for the nurse to follow up on which pt statement ? a. I eat a lot of processed foods b. I've been taking cephalexin for the last week c. I eat small meals 4-6 times per day d. I prefer to eat my food cold

b. I've been taking cephalexin for the last week

Which med does the nurse have available for the tx of acetaminophen overdose ? a. vitamin K b. acetylcysteine c. aspirin d. naloxone

b. acetylcysteine

After inserting a needle into the ventrogluteal muscle to inject vitamin K, which action does the nurse take next ? a. instructs the pt to contract the muscle b. administers the vitamin K slowly c. spreads the skin with the thumb and index finger d. pulls back the needle while injecting slowly

b. administers the vitamin K slowly

The nurse on the surgical unit provides care for a client with a new colostomy. How should the nurse expect the stoma to appear immediately after surgery ? a. bluish and dry b. beefy-red and moist c. grey and small d. dark red

b. beefy-red and moist

An older pt says, "I have recently developed constipation." It is most important for the nurse to take which action ? a. encourage the pt to eat more grains an fruits b. determine the frequency and characteristics of the bowel movements c. instruct the pt to increase fluid intake d. teach the pt about the importance of exercise

b. determine the frequency and characteristics of the bowel movements

The nurse instructs a pt how to take psyllium. Which instruction is most important for the nurse to include ? a. take psyllium immediately after you have a loose BM b. mix psyllium with water, milk, or fruit juice and take at about the same time each day c. stir the psyllium in a fluid and let it stand for 2 min to form a thicker solution d. allow the psyllium to dissolve under your tongue for the best absorption

b. mix psyllium with water, milk, or fruit juice and take at about the same time each day

The nurse instructs a pt how to increase folic acid in the diet. The nurse determines teaching is effective if the pt makes which statement ? a. I like oatmeal for breakfast b. my favorite lunch is a spinach salad c. I will eat more grapes, apples, and bananas each day d. I will eat more chicken

b. my favorite lunch is a spinach salad

The nurse monitors a pt recovering from hepatitis B. The nurse understands this pt has developed which type of immunity to hepatitis B ? a. artificial active acquired immunity b. natural active acquired immunity c. innate immunity d. artificial passive acquired immunity

b. natural active acquired immunity

The nurse understands which is the principal reason for the use of enzyme inhibitors (acetazolamide) in a client with pancreatitis ? a. pancreatic enzymes are irritating to the liver b. pancreatic enzymes escape into interstitial tissue c. pancreatic enzymes are missing and must be replaced d. pancreatic enzymes are inactivated and must be enhanced

b. pancreatic enzymes escape into interstitial tissue

The nurse cares for a pt receiving famotidine. The pt reports resuming smoking and experiencing gastric pain about 1 hr after meals. Which response by the nurse is best ? a. smoking decreases stomach acid production, so you will not digest foods as easily b. smoking interferes with the meds effectiveness, and you are no longer receiving the full anti-ulcer effect c. nicotine can increase feelings of anxiety and restlessness, which the med lowers d. if you smoke too much, you will become dizzy

b. smoking interferes with the meds effectiveness, and you are no longer receiving the full anti-ulcer effect

When assessing the abdomen, the nurse places a pt in which position ? a. sitting with a pillow at the back b. supine or with knees flexed c. side lateral d. sims

b. supine or with knees flexed

The nurse understands the primary reason for maintaining a constant rate of infusion with parenteral nutrition is to prevent which complication ? a. risk of fluid overload b. unstable blood glucose level c. potential clotting of the catheter d. electrolyte imbalance

b. unstable blood glucose level

The nurse in the outpatient clinic counsels the pt with a Dx fo cholecystitis. The nurse determines teaching is successful if the pt makes which statement ? a. I really like a lot of cream in my oats b. we eat a lot of broiled fish and chicken c. I can't wait to eat the chocolates my children gave me d. my favorite dish is broccoli with cheese sauce

b. we eat a lot of broiled fish and chicken

The nurse assesses a pt in the outpatient clinic with a Dx of ulcerative colitis. While obtaining the pt Hx, the nurse expects the pt to make which statement ? a. I feel a constant sharp pain in my lower abdomen b. I feel an intermittent gnawing pain in my middle abdomen c. I feel an intermittent cramping pain in my lower abdomen d. I feel a burning pain in my upper esophagus after I eat

c. I feel an intermittent cramping pain in my lower abdomen

The nurse provides care for a client with a sigmoid colostomy. The nurse instructs the client about how to care for the stoma. The nurse knows that teaching is successful if the client makes which statement ? a. I will drape the area and wash the stoma with hexachlorophene soap b. I will clean the stoma vigorously with alcohol wipes and pat dry c. I will clean around the stoma with soap and water and pat dry d. I will drape the area and cleanse the stoma with povidone iodine

c. I will clean around the stoma with soap and water and pat dry

The nurse instructs a pt about the bowel preparation required prior to a sigmoidoscopy. The nurse identifies teaching is successful if the pt makes which statement ? a. I can eat a regular diet prior to the test b. I will be asleep when this test is performed c. I will have an enema the morning of the test d. I will have nasogastric suction decompression

c. I will have an enema the morning of the test

A liver scan is prescribed for a client prior to surgery. Which description best describes this procedure ? a. the client will ingest a small amount of radioactive material and venipuncture will be performed to monitor blood levels b. the client will stand in front of a large machine that takes an x-ray pictures of the liver c. The client will be asked to lie still while a scanning probe is passed back and forth over the body. d. the clients skin will be lubricated with oil and ultrasound pictures will be taken

c. The client will be asked to lie still while a scanning probe is passed back and forth over the body.

The nurse provides care for a pt admitted with the Dx of small bowel obstruction, and has severe abdominal distension. Which finding best describes the reason for the distension ? a. increased gastric acid pH levels b. vagal nerve stimulation c. accumulation of fluid in intestine d. decreased perfusion of intestine

c. accumulation of fluid in intestine

The home health nurse visits a pt with a Dx of ulcerative colitis. the pt reports perineal irritation due to frequest stools. Which suggestion by the nurse is best ? a. apply a heat lamp to the perineal area three times per day b. use protective plastic bed pads c. clean the perineal area with soap and water after each bowel movement d. increase roughage in the diet to prevent the frequent stools

c. clean the perineal area with soap and water after each bowel movement

The nurse examines the abdomen of an adult pt who reports being in good health on the intake questionnaire. Which assessment does the nurse anticipate ? a. high-pitched sounds heard in the upper right quadrant b. no bowel sounds during five minutes of auscultation c. gurgles in all quadrants during a minute of auscultation d. hypoactive bowel sounds heard in the lower quadrants

c. gurgles in all quadrants during a minute of auscultation

The nurse provides care for a pt after an appendectomy. The day after surgery, the pt has severe abdominal pain, a temp of 101F, and a rigid abdomen. The nurse suspects the pt is experiencing which complication ? a. anesthesia intolerance b. atelectasis and pneumonia c. infection of the peritoneal sac d. bladder distension

c. infection of the peritoneal sac

The nurse gives discharge instructions to a family of a pt Dx with hepatic encephalopathy. The nurse determines further teaching is necessary if the family makes which statement ? a. we should contact the hcp if our parent is restless at night b. our parent may have some tremors in their hands c. our parent should eat meat at every meal d. lactulose may cause bloating and cramps

c. our parent should eat meat at every meal

The nurse provides care for a client after a traditional open cholecystectomy. It is most important for the nurse to position the client in which position ? a. side-lying with bed flat b. supine c. semi-fowler d. lying flat with knees elevated

c. semi-fowler

The nurse cares for the client immediately after removal of a cataract in the left eye. the HCP orders prochlorperazine to be administered after the surgery. The nurse understands it is important to administer the medication for which reason ? a. to decrease the pain felt because of the sutures b. to help the client sleep better c. to prevent pressure on the suture line d. to help dissolve the sutures

c. to prevent pressure on the suture line

The nurse prepares a client for a sigmoidoscopy. The nurse recognizes a need to intervene if the pt makes which statement ? a. I tool my bp med with a sip of water this morning b. I haven't eaten any fruits or veggies since the day before yesterday c. I had good results from the tap water enema this morning d. I hope this is easier than the barium enema I had two days ago

d. I hope this is easier than the barium enema I had two days ago

The nurse prepares a pt for a sigmoidoscopy. The nurse recognizes a need to intervene if the pt makes which statement ? a. I took my bp med with a sip of water this morning b. I haven't eaten any fruits or veggies since the day before yesterday c. I had good results from the tap water enema this morning d. I hope this is easier than the barium enema I had two days ago

d. I hope this is easier than the barium enema I had two days ago

The nurse cares for a pt with a Dx of ulcerative colitis. When reviewing the pt record, the nurse expects to find which lab value ? a. rbc 4 million/mm b. platelet count 75,000/mm c. Hgb 18.2 g/dL d. WBC 15,000

d. WBC 15,000

The nurse provides care for a pt Dx with alcoholic cirrhosis. The pt is at high risk to develop which complication ? a. Hepatitis B b. pancreatic cancer c. weight gain d. epistaxis

d. epistaxis

The nurse records the vital signs and checks the IV and operative sites for a client who has just returned to the medical-surgical unit following abdominal surgery. Which additional action is essential before the nurse leaves the clients room. a. update the clients partner on the clients condition b. dim the room lights so the client can rest c. administer mouth care d. raise the side rails on the bed.

d. raise the side rails on the bed.

A pt is given hepatitis B immune globulin (HBIg) after having unprotected sexual contact with a person Dx with hepatitis B. The nurse explains to the pt that the med is given for which purpose ? a. prevent other sexually transmitted infections b. stimulate the immune system to develop antibodies to hepatitis c. prevent the pt from contracting hepatitis d. temporarily increase the pt resistance to hepatitis

d. temporarily increase the pt resistance to hepatitis

The home health care nurse evaluates a pt ability to use aseptic technique when changing the dressing on an abdominal wound. Which pt action demonstrates the best understanding of correct technique ? a. pt uses bare hands to remove the old dressing b. the pt utilizes warm tap water to cleanse the wound c. the pt applies antibiotic ointment with an ungloved finger d. the pt uses hand sanitizer before putting on gloves.

d. the pt uses hand sanitizer before putting on gloves.

The nurse provides care for a pt who is 5'7" tall, weighs 300lbs, and is recuperating from an exploratory laparotomy. The pt cooperates with coughing and deep breathing exercises and ambulates a distance of 25ft in the hallway. For which post-op complication should the nurse most vigilantly assess the pt ? a. pneumonia b. fat emboli c. pulmonary emboli d. wound dehiscence

d. wound dehiscence


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