him 3

What information will the nurse provide to a client who is scheduled for extracorporeal shock wave lithotripsy?

- Your urine will be strained after the procedure - Be sure to finish all of your antibiotics - Remember to drink at least 3 liters of fluid a day to promote urine flow

After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?

"An orange color in my urine should not alarm me." Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing

The client passes a urinary stone that laboratory analysis indicates is composed of calcium oxalate. Based on this analysis, which instruction does the nurse specifically include for dietary prevention of the problem?

"Avoid dark green leafy vegetables such as spinach." Rationale: Calcium oxalate stones form more easily in the presence of oxalate. Sources of oxalate include spinach, black tea, and rhubarb. Avoiding these sources of oxalate may reduce the number of stones formed.

A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this client's teaching?

"Buy slacks with elastic waistbands that are easy to pull down." Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void.

A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider?

"Can we discontinue the indwelling catheter?" An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter.

A nurse assesses a client who presents with renal calculi. Which question should the nurse ask?

"Do any of your family members have this problem?" There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones.

A male client being treated for bladder cancer has a live virus compound instilled into his bladder as a treatment. What instruction does the nurse provide for postprocedure home care?

"Do not share your toilet with family members for the next 24 hours." The toilet should not be shared for 24 hours following this procedure because others using the toilet could be infected with the live virus that was instilled into the client. If only one toilet is available in the household, teach the client to flush the toilet after use and to follow this by adding 1 cup of undiluted bleach to the bowl water.

A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this client's risk factors?

"Do you smoke cigarettes?" Smoking is known to be a factor that greatly increases the risk of bladder cancer.

A nurse cares for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How should the nurse respond?

"I can teach you strategies to help control your incontinence." The nurse should accept and acknowledge the client's concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the client's concerns with the use of pads or stating statistics about the occurrence of incontinence.

The nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences. Which client statement shows a correct understanding of what the nurse has taught?

"I should be drinking at least 1.5 to 2.5 liters of fluids every day." To reduce the number of UTIs, clients should be drinking a minimum of 1.5 to 2.5 liters of fluid (mostly water) each day.

The nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective?

"I should drink 2½ liters of fluid every day." Drinking 2½ liters of fluid a day flushes out the urinary system and helps reduce the risk for cystitis.

After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching?

"I should drink at least 3 liters of fluid every day." Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake.

The nurse is questioning a female client with a urinary tract infection (UTI) about her antibiotic drug regimen. Which statement by the client indicates a need for further instruction?

"I take my medication only when I have symptoms." Clients with UTIs must complete all prescribed antibiotic therapy, even when symptoms of infection are absent.

A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the health care provider before the ESWL procedure begins?

"I take over-the-counter naproxen (Aleve) twice a day for joint pain." Because a high risk for bleeding during ESWL has been noted, clients should not take nonsteroidal anti-inflammatory drugs before this procedure; the ESWL will have to be rescheduled for this client.

A client diagnosed with stress incontinence is started on propantheline (Pro-Banthine). What interventions does the nurse suggest to alleviate the side effects of this anticholinergic drug?

- Encourage increased fluids - Increase fiber intake - Use hard candy for dry mouth

The nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates a correct understanding of these procedures?

"I will have to drain my pouch with a catheter." For the client with a neobladder and a Kock pouch, urine is collected in a pouch and is drained with the use of a catheter.

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?

"I will limit my total intake of fluids." Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

The nurse is teaching the importance of a low purine diet to a client admitted with urolithiasis consisting of uric acid. Which statement by the client indicates that teaching was effective?

"I will no longer be able to have red wine with my dinner." Nutrition therapy depends on the type of stone formed. When stones consist of uric acid (urate), the client should decrease intake of purine sources such as organ meats, poultry, fish, gravies, red wines, and sardines. Reduction of urinary purine content may help prevent these stones from forming.

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How should the nurse respond?

"Low estrogen levels can make the tissue more susceptible to infection." Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection.

A nurse provides phone triage to a pregnant client. The client states, "I am experiencing a burning pain when I urinate." How should the nurse respond?

"Make an appointment with your provider to have your infection treated." Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated.

A client who was previously diagnosed with a urinary tract infection (UTI) and started on antibiotics returns to the clinic 3 days later with the same symptoms. When asked about the previous UTI and medication regimen, the client states, "I only took the first dose because after that, I felt better." How does the nurse respond?

"Not completing your medication can lead to return of your infection." Not completing the drug regimen can lead to recurrence of an infection and bacterial drug resistance. Needing to be re-treated does not mean that the client will have a prolonged treatment regimen. Some treatment modalities are given over a 3-day period. Given this client's history, larger doses for a shorter time span may be a wise plan.

An older adult woman confides to the nurse, "I am so embarrassed about buying adult diapers for myself." How does the nurse respond?

"That is tough. What do you think might help?" Stating that the situation is tough acknowledges the client's concerns, and asking the client to think about what might help assists the client to think of methods to solve her problem.

A 53-year-old postmenopausal woman reports "leaking urine" when she laughs, and is diagnosed with stress incontinence. What does the nurse tell the client about how certain drugs may be able to help with her stress incontinence?

"They may be used to improve urethral resistance." Bladder pressure is greater than urethral resistance; drugs may be used to improve urethral resistance.

A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this client's teaching?

"Try to consciously hold your urine until the scheduled toileting time." The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this client's teaching?

"Use a second form of birth control while on this medication." The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?

"What medications are you taking?" Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the client is taking an anticholinergic medication

The nurse is educating a female client about hygiene measures to reduce her risk for urinary tract infection. What does the nurse instruct the client to do?

"Wipe from front to back." Wiping front to back keeps organisms in the stool from coming close to the urethra, which increases the risk for infection.

A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, "I am anxious about having an ileal conduit. What is it like to have this drainage tube?" How should the nurse respond?

"Would you like to speak with someone who has an ileal conduit?" The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Discussing the procedure candidly with someone who has undergone the same procedure will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge.

The nurse is teaching a client about pelvic muscle exercises. What information does the nurse include?

"You know that you are exercising correct muscles if you can stop urine flow in midstream." When the client can start and stop the urine stream, the pelvic muscles are being used. Pelvic muscle exercises can be performed anywhere and should be performed more often than 5 minutes twice daily. Noticeable results take several weeks.

The health care provider requests phenazopyridine (Pyridium) for a client with cystitis. What does the nurse tell the client about the drug?

"Your urine will turn red or orange while on the drug." Phenazopyridine will turn the client's urine red or orange. Clients should be warned about this effect of the drug because it will be alarming to them if they are not informed, and care should be taken because it will stain undergarments.

A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this client's discharge teaching? (Select all that apply.)

- "Finish the prescribed antibiotic even if you are feeling better." - "Drink at least 3 liters of fluid each day." - "The bruising on your back may take several weeks to resolve." The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve.

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.)

- "How much water do you drink every day?" - "Do you take estrogen replacement therapy?" -. "Are you on steroids or other immune-suppressing drugs?" Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis.

A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this client's dietary teaching? (Select all that apply.)

- "Limit your intake of food high in animal protein." - "Read food labels to help minimize your sodium intake." - "Reduce your intake of milk and other dairy products." Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium.

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)

- "Stress incontinence occurs due to weak pelvic floor muscles." - "Urge incontinence occurs due to abnormal bladder contractions." Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle.

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching? (Select all that apply.)

- "Wash your hands before and after self-catheterization." - "Use lubricant on the tip of the catheter before insertion." - "Maintain a specific schedule for catheterization." The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours.

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.)

- "When you start and stop your urine stream, you are using your pelvic muscles." - "Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10." - "Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them." The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them.

Which clients with long-term urinary problems does the nurse refer to community resources and support groups?

- A 32-year-old with a cystectomy - A 44-year-old with a Kock pouch - A 78-year-old with urinary incontinence

A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.)

- Assess the medical history and current medical problems. - Obtain a current list of medications. Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list.

A client with a urinary tract infection is prescribed trimethoprim/sulfamethoxazole (Bactrim). What information does the nurse provide to this client about taking this drug?

- Be certain to wear sunscreen and protective clothing - Drink at least 3 liters of fluids every day - Take this drug with 8 ounces of water - You will need to take all of this drug to get the benefits

An older adult client diagnosed with stress incontinence is prescribed the medication oxybutynin (Ditropan). Which side effects does the nurse tell the client to expect?

- Dry mouth - Increased intraocular pressure - Constipation

The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation?

- Dysuria - Frequency - Nocturia - Urgency

Which interventions are helpful in preventing bladder cancer?

- Showering after working with or around chemicals - Stopping the use of tobacco - Wearing gloves and a mask when working around chemicals and fumes

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.)

- Stress incontinence - Urine loss with physical exertion - Urge incontinence - Large amount of urine with each occurrence -. Overflow incontinence - Constant dribbling of urine Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine.

Which clients with an indwelling urinary catheter does the nurse reassess to determine whether the catheterization needs to be continued or can be discontinued?

- Three-day postoperative client - Client in the stepdown unit - Incontinent older adult in long-term care

The nurse in the urology clinic is providing teaching for a female client with cystitis. Which instructions does the nurse include in the teaching plan?

- Try to take in 64 ounces of fluid each day. - Be sure to complete the full course of antibiotics - If urine remains cloudy, call the clinic

A client wants to lose 1.5 pounds a week. After reviewing a diet history, the nurse determines the client typically eats 2450 calories a day. What should the client's calorie goal be to achieve this weight loss? (Record your answer using a whole number.) __ calories/day

1700 calories/day

A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) _____ mL

280 mL

A client weighs 228 pounds (103.6 kg) and is 5'3" (160 cm) tall. What is this client's body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.) _____

40.4

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter?

56-year-old woman who is admitted with a vaginal-rectal fistula and diabetes Rationale: This client has a wound that can be irritated by urine and whose urinary tract could become infected by the draining fistula (her diabetes increases her overall risk for infection).

The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first?

A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure. The client who has been receiving morphine sulfate may be oversedated and may not be aware of any discomfort caused by bladder distention.

Which client does the nurse manager on the medical unit assign to an experienced LPN/LVN?

A 55-year-old with incontinence who has intermittent catheterization prescribed Insertion of catheters is within the education and legal scope of practice for LPN/LVNs.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis?

A 58-year-old female who is not taking estrogen replacement Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?

A 58-year-old postmenopausal client who is not taking estrogen therapy - Electrical stimulation Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation.

A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?

A 78-year-old female who is confused For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times.

The nurse is caring for a client with a hiatal hernia who had an open fundoplication yesterday. Which task does the nurse delegate to unlicensed assistive personnel (UAP)? A. Using a pillow to support the incision when the client coughs B. Adjusting the position of the nasogastric (NG) tube C. Assessing the level of postoperative pain using a 0-to-10 scale D. Giving the client sips of water once bowel sounds are heard

A-Assisting a client to cough is a task within the education and skill level of UAP. NG tube maintenance, pain assessment, and assessment of bowel sounds require more knowledge of the potential complications associated with this surgical procedure, and are actions best performed by licensed nursing staff.

When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks.

ANS: A, B, C, E NO SALTY FOOD!

1. An emergency department nurse cares for a client who is severely dehydrated and is prescribed 3 L of intravenous fluid over 6 hours. At what rate (mL/hr) should the nurse set the intravenous pump to infuse the fluids? (Record your answer using a whole number.) ____ mL/hr

ANS: 500 mL/hr Because IV pumps deliver in units of milliliters per hour, the pump would have to be set at 500 mL/hr to deliver 3 L (3000 mL) over 6 hours. 6x = 3000 x = 500

The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia

ANS: A, B, C, E Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| medications| adverse effects MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron. DIF: Applying/Application REF: 1146 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapi

After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss. DIF: Applying/Application REF: 1147 KEY: Herniation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity. DIF: Applying/Application REF: 1156 KEY: Ostomy care| support| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used. DIF: Applying/Application REF: 1154 KEY: Ostomy care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time. DIF: Applying/Application REF: 1151 KEY: Ostomy care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the clients dietary habits. b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. Hold the clients metformin (Glucophage). d. Contact the health care provider immediately.

ANS: A An elevated BUN/creatinine ratio is often indicative of dehydration, urinary obstruction, catabolism, or a high-protein diet. The nurse should inquire about the clients dietary habits. Kidney damage related to NSAID use most likely would manifest with elevations in both BUN and creatinine, but no change in the ratio. The nurse should obtain more assessment data before holding any medications or contacting the provider.

12. A nurse reviews the allergy list of a client who is scheduled for an intravenous urography. Which client allergy should alert the nurse to urgently contact the health care provider? a. Seafood b. Penicillin c. Bee stings d. Red food dye

ANS: A Clients with seafood allergies often have severe allergic reactions to the standard dyes used during intravenous urography. The other allergies have no impact on the clients safety during an intravenous urography.

5. A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.

ANS: A Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

13. A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the clients capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.

ANS: A Metformin can cause lactic acidosis and renal impairment as the result of an interaction with the dye. This drug must be discontinued for 48 hours before the procedure and not started again after the procedure until urine output is well established. The clients health care provider needs to provide alternative therapy for the client until the metformin can be resumed. Keeping the client NPO, checking the clients blood glucose, and administering intravenous fluids should be part of the clients plan of care, but are not the priority, as the examination should not occur while the client is still taking metformin.

5. A nurse contacts the health care provider after reviewing a clients laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

ANS: A Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This clients creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate.

8. A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

ANS: A Shock leads to decreased renal perfusion. An elevated BUN accompanies this condition. The creatinine should be normal because no kidney damage occurred. A low BUN signifies overhydration, malnutrition, or liver damage. A low BUN/creatinine ratio indicates fluid volume excess or acute renal tubular acidosis.

18. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAPs performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female clients and male icon for all male clients b. Telling the client, This test measures the amount of urine in your bladder. c. Applying ultrasound gel to the scanning head and removing it when finished d. Taking at least two readings using the aiming icon to place the scanning head

ANS: A The UAP should use the female icon for women who have not had a hysterectomy. This allows the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. The UAP should explain the procedure to the client, apply gel to the scanning head and clean it after use, and take at least two readings.

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.

ANS: A The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.

An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A "Changes in your liver cause drugs to be metabolized differently." Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I should refrigerate the GoLYTELY before use." d. "I will buy a case of Gatorade before the prep."

ANS: A "It's a good thing I love orange and cherry gelatin." The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.

A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.

ANS: A Ask the client about shellfish allergies. PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.

To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A Left lateral After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia

ANS: A, B, C, D In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

ANS: A, B, C, E Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care. DIF: Applying/Application REF: 1148 KEY: Herniation| postoperative care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing. DIF: Remembering/Knowledge REF: 1166 KEY: Bowel care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

5. A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Take your blood pressure every morning. b. Weigh yourself at the same time each day. c. Adjust your diet to prevent diarrhea. d. Contact your provider if you have visual disturbances. e. Assess your urine for renal stones.

ANS: A, B, D A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or complications of PKD; therefore, teaching related to these concepts would be inappropriate.

2. A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness

ANS: A, B, D Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

MULTIPLE RESPONSE 1. A nurse reviews a clients laboratory results. Which results from the clients urinalysis should the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive

ANS: A, B, D The pH, specific gravity, and glucose are all within normal ranges. The other values are abnormal.

A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.

ANS: A, B, D, E Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli

ANS: A, D Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.

ANS: A, B, E After gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse should provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition.

4. A nurse prepares a client for a percutaneous kidney biopsy. Which actions should the nurse take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the clients urine. e. Administer antihypertensive medications.

ANS: A, B, E Prior to a percutaneous kidney biopsy, the client should be NPO for 4 to 6 hours. Coagulation studies should be completed to prevent bleeding after the biopsy. Blood pressure medications should be administered to prevent hypertension before and after the procedure. There is no need to keep the client on bedrest or assess for blood in the clients urine prior to the procedure; these interventions should be implemented after a percutaneous kidney biopsy.

A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

ANS: A, B, E When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed.

5. A nurse plans care for an older adult client. Which interventions should the nurse include in this clients plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the unlicensed assistive personnel (UAP). e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.

ANS: A, B, E, F The nurse should ensure that the client receives adequate fluid intake and has adequate lighting to ambulate safely to the bathroom at night, encourage the client to use the toilet every 2 hours, provide thorough perineal care after each voiding, and assess for urinary retention and urinary tract infections. The nurse should not delegate any teaching to the UAP, including bladder training instructions. The UAP may participate in bladder training activities, including encouraging and assisting the client to the bathroom at specific times.

The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years

ANS: A, C The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

ANS: A, C, D, E FAM NO SNACKS!

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating

ANS: A, D The nurse should monitor urine output and contact the provider if urine output decreases or becomes absent. The nurse should also assess for blood in the clients urine. The urine may be pink-tinged, but gross bleeding or blood clots should not be present. If bleeding is present, the nurse should urgently contact the provider. Tolerating oral fluids is a positive outcome and does not need intervention. Metformin would be a concern if the client received dye; no dye is used in a cystoscopy procedure. The client may experience a burning sensation when urinating after this procedure; this would not require a call to the provider.

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction. DIF: Applying/Application REF: 1159 KEY: Drain MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy. DIF: Applying/Application REF: 1165 KEY: Postoperative nursing| urinary retention MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How should the nurse respond? a. "This drug is still in the research phase and is not available for public use yet." b. "Unfortunately, lubiprostone is approved only for use in women." c. "Lubiprostone works well. I will recommend this prescription to your provider." d. "This drug should not be used with bulk-forming laxatives."

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men. DIF: Applying/Application REF: 1146 KEY: Irritable bowel| medications MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. DIF: Applying/Application REF: 1162 KEY: Gastrointestinal trauma| hemorrhage MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation. DIF: Applying/Application REF: 1165 KEY: Postoperative care| syncope MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

10. A nurse cares for a client who has elevated levels of antidiuretic hormone (ADH). Which disorder should the nurse identify as a trigger for the release of this hormone? a. Pneumonia b. Dehydration c. Renal failure d. Edema

ANS: B ADH increases tubular permeability to water, leading to absorption of more water into the capillaries. ADH is triggered by a rising extracellular fluid osmolarity, as occurs in dehydration. Pneumonia, renal failure, and edema would not trigger the release of ADH.

12. A nurse provides health screening for a community health center with a large population of African-American clients. Which priority assessment should the nurse include when working with this population? a. Measure height and weight. b. Assess blood pressure. c. Observe for any signs of abuse. d. Ask about medications.

ANS: B All interventions are important for the visiting nurse to accomplish. However, African Americans have a high rate of hypertension leading to end-stage renal disease. Each encounter that the nurse has with an African-American client provides a chance to detect hypertension and treat it. If the client is already on antihypertensive medication, assessing blood pressure monitors therapy.

An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.

ANS: B All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole.

A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs

ANS: B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.

3. After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take a laxative every night before going to bed. b. I must increase my intake of dietary fiber and fluids. c. I shall only use salt when I am cooking my own food. d. Ill eat white bread to minimize gastrointestinal gas.

ANS: B Clients with PKD often have constipation, which can be managed with increased fiber, exercise, and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count and would not be included in a high-fiber diet.

8. An emergency department nurse assesses a client with kidney trauma and notes that the clients abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products

ANS: B Clients with blood at the urinary meatus should not have a urinary catheter inserted via the urethra before additional diagnostic studies are done. The urethra could be torn. The nurse should question the provider about the need for a catheter; if one is needed, the provider can insert a suprapubic catheter. The nurse should monitor the clients vital signs closely, send blood for type and crossmatch in case the client needs blood products, and administer intravenous fluids.

6. After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. I must decrease my intake of fat. b. I will increase my intake of protein. c. A decreased intake of carbohydrates will be required. d. An increased intake of vitamin C is necessary.

ANS: B In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

11. A nurse reviews a female clients laboratory results. Which results from the clients urinalysis should the nurse recognize as abnormal? a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color

ANS: B Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings for a female clients urinalysis.

For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)? a. Client taking antacids b. Client taking antibiotics c. Client who is pregnant d. Client over 65 years of age

ANS: C Misoprostol can cause abortion, so pregnant women should not take this drug. The other clients have no contraindications to taking misoprostol.

1. A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen

ANS: B Periorbital edema would not be a finding related to PKD and should be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.

A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.

ANS: B Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.

2. A nurse reviews the health history of a client with an oversecretion of renin. Which disorder should the nurse correlate with this assessment finding? a. Alzheimers disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis

ANS: B Renin is secreted when special cells in the distal convoluted tubule, called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension. Renin has no impact on Alzheimers disease, diabetes mellitus, or viral hepatitis.

13. After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will take this medication with food and plenty of water. b. I shall keep my appointment at the infusion center each week. c. Ill limit my intake of green leafy vegetables while on this medication. d. I must not take this medication if I have an infection or am feeling ill.

ANS: B Temsirolimus is administered as a weekly intravenous infusion. This medication blocks protein that is needed for cell division and therefore inhibits cell cycle progression. This medication is not taken orally, and clients do not need to follow a specific diet.

9. After teaching a client with hypertension secondary to renal disease, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I can prevent more damage to my kidneys by managing my blood pressure. b. If I have increased urination at night, I need to drink less fluid during the day. c. I need to see the registered dietitian to discuss limiting my protein intake. d. It is important that I take my antihypertensive medications as directed.

ANS: B The client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions. These clients should be assessed thoroughly for potential dehydration. Increased nocturnal voiding can be decreased by consuming fluids earlier in the day. Blood pressure control is needed to slow the progression of renal dysfunction. When dietary protein is restricted, refer the client to the registered dietitian as needed.

A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. "Do you have family or friends for support?" b. "I'd like to know what you are feeling now." c. "Well, we knew this would probably happen." d. "Would you like me to refer you to hospice?"

ANS: B The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and "yes-or-no" questions are not therapeutic. Stating that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.

An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best? a. Ask the family why they feel this way. b. Assess family concerns and fears. c. Refuse to go along with the family's wishes. d. Tell the family that such secrets cannot be kept.

ANS: B The nurse should use open-ended questions and statements to fully assess the family's concerns and fears. Asking "why" questions often puts people on the defensive and is considered a barrier to therapeutic communication. Refusing to follow the family's wishes or keep their confidence will not help move this family from their position and will set up an adversarial relationship.

A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best? a. "Slippery elm has no benefit for this problem." b. "Slippery elm is often used for this disorder." c. "There is no evidence that this will work." d. "You should not take any herbal remedies."

ANS: B There are several complementary and alternative medicine regimens that are used for gastritis and peptic ulcer disease. Most have been tested on animals but not humans. Slippery elm is a common supplement used for this disorder.

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.

ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.

9. A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take? a. Evaluate the clients intake and output for the past 24 hours. b. Document the finding in the chart and continue to monitor. c. Obtain a specimen for a urine culture and sensitivity. d. Encourage the client to drink more fluids, especially water.

ANS: B This specific gravity is within the normal range for urine. There is no need to evaluate the clients intake and output, obtain a urine specimen, or increase fluid intake.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B Assess the client's gag reflex. The local anesthetic used during this procedure will depress the client's gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.

A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture

ANS: B Enzyme-linked immunosorbent Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.

The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food

ANS: B Liquefied food ready for digestion Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Liver Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size.

ANS: B Notify the provider immediately. This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider.

After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I must avoid dairy products to reduce gas and odor in the pouch."

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the client's skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the client's skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. DIF: Applying/Application REF: 1154 KEY: Colorectal cancer| postoperative care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

2. A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems? (Select all that apply.) a. A 24-year-old pregnant woman prescribed prenatal vitamins b. A 32-year-old bodybuilder taking synthetic creatine supplements c. A 56-year-old who is taking metformin for diabetes mellitus d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain e. A 75-year-old with chronic obstructive pulmonary disease (COPD) who is prescribed an albuterol nebulizer

ANS: B, C, D Many medications can affect kidney function. Clients who take synthetic creatine supplements, metformin, and high-dose or long-term NSAIDs are at risk for kidney dysfunction. Prenatal vitamins and albuterol nebulizers do not place these clients at risk.

A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

ANS: B, C, E LIQUID FLUSH FLUSH

MULTIPLE RESPONSE 1. A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea

ANS: B, C, E Clients with PKD experience abdominal distention that manifests as flank pain and increased abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with PKD often experience constipation, but would not report nocturia or dysuria.

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

ANS: B, D, E Take Healthy People to BED

4. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site

ANS: B, D, E After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider. DIF: Understanding/Comprehension REF: 1151 KEY: Colorectal cancer| assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| postoperative nursing| bowel care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others. DIF: Applying/Application REF: 1157 KEY: Colorectal cancer| ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| intestinal obstruction MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate? a. Assess the client for iodine or shellfish allergies. b. Educate the client on the side effects of sedation. c. Inform the client a second scan may be needed. d. Teach the client about bowel preparation for the scan.

ANS: C A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.

A nurse answers a client's call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? a. Assist the client back to bed. b. Notify the provider immediately. c. Put on a pair of gloves. d. Take a set of vital signs.

ANS: C All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids.

15. A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10. Which action should the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the pulse rate and blood pressure. d. Examine the color of the clients urine.

ANS: C An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal hemorrhage. A change in vital signs can indicate that hemorrhage is occurring. Before other actions, the nurse must assess the clients hemodynamic status.

14. A nurse cares for a client who has pyelonephritis. The client states, I am embarrassed to talk about my symptoms. How should the nurse respond? a. I am a professional. Your symptoms will be kept in confidence. b. I understand. Elimination is a private topic and shouldnt be discussed. c. Take your time. It is okay to use words that are familiar to you. d. You seem anxious. Would you like a nurse of the same gender to care for you?

ANS: C Clients may be uncomfortable discussing issues related to elimination and the genitourinary area. The nurse should encourage the client to use language that is familiar to the client. The nurse should not make promises that cannot be kept, like keeping the clients symptoms confidential. The nurse must assess the client and cannot take the time to stop the discussion or find another nurse to complete the assessment.

4. A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond? a. Test your urine daily for the presence of ketone bodies and proteins. b. Use tampons rather than sanitary napkins during your menstrual period. c. Drink more water and empty your bladder more frequently during the day. d. Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled.

ANS: C Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the clients sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. Testing urine and using tampons will not help prevent pyelonephritis. A hemoglobin A1c of 9% is too high.

14. A nurse teaches a client who is recovering from a urography. Which instruction should the nurse include in this clients discharge teaching? a. Avoid direct contact with your urine for 24 hours until the radioisotope clears. b. You may have some dribbling of urine for several weeks after this procedure. c. Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster. d. Your skin may become slightly yellow from the dye used in this procedure.

ANS: C Dyes used in urography are potentially nephrotoxic. A large fluid intake will help the client eliminate the dye rapidly. Dyes used in urography are not radioactive, the client should not experience any dribbling of urine, and the dye should not change the color of the clients skin.

4. A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, Is my anemia related to the renal insufficiency? How should the nurse respond? a. Red blood cells produce erythropoietin, which increases blood flow to the kidneys. b. Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density. c. Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow. d. Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.

ANS: C Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia and renal insufficiency are not manifestations of vitamin D deficiency. The kidneys do not play a role in the transportation of red blood cells or any other cells in the blood.

16. A nurse obtains a sterile urine specimen from a clients Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next? a. Clamp another section of the tube to create a fixed sample section for retrieval. b. Insert a syringe into the injection port and aspirate the quantity of urine required. c. Clean the injection port cap of the drainage tubing with povidone-iodine solution. d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

ANS: C It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination before injection of the syringe. The urine sample should be collected directly from the catheter; therefore, a second clamp to create a sample section would not be appropriate. Every sample from the catheter is usable; there is the need to discard the first sample.

A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. "Aspirin must be avoided." b. "Do not worry about black stools." c. "Report diarrhea to your provider." d. "Take 1 hour before meals."

ANS: C Maalox can cause hypermagnesemia, which causes diarrhea, so the client should be taught to report this to the provider. Aspirin is avoided with bismuth sulfate (Pepto-Bismol). Black stools can be caused by Pepto-Bismol. Maalox should be taken after meals.

The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor

ANS: C Sucralfate is a mucosal barrier fortifier (protector). It is not a gastric acid inhibitor, a histamine receptor blocker, or a proton pump inhibitor.

A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.

ANS: C This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C Provide physical stimulation. For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.

ANS: C Remind the client that a small amount of bleeding is possible. After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting

ANS: C, D Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.

3. A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

ANS: C, D The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the client's mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

ANS: C, D, E UAP RES!

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac. DIF: Applying/Application REF: 1146 KEY: Herniation MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression. DIF: Applying/Application REF: 1157 KEY: Intestinal obstruction| pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful. DIF: Applying/Application REF: 1162 KEY: GI trauma| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| health screening MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2

ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.

2. A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond? a. No genetic link is known, so your children are not at increased risk. b. Your sons will develop this disease because it has a sex-linked gene. c. Only if both you and your spouse are carriers of this disease. d. Each of your children has a 50% risk of having ADPKD.

ANS: D Children whose parent has the autosomal dominant form of PKD have a 50% chance of inheriting the gene that causes the disease. ADPKD is transmitted as an autosomal dominant trait and therefore is not gender specific. Both parents do not need to have this disorder.

1. A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this clients teaching? a. Since you only have one kidney, a salt and fluid restriction is required. b. Your therapy will include hemodialysis while you recover. c. Medication will be prescribed to control your high blood pressure. d. You need to avoid participating in contact sports like football.

ANS: D Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.

1. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client. b. Contact the provider and recommend a 24-hour urine test. c. Review the clients recent dietary selections. d. Perform a capillary artery glucose assessment.

ANS: D Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the clients dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

7. A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the clients creatinine level. d. Increase the clients fluid intake.

ANS: D Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the clients fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

3. A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take? a. Contact the provider and recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Obtain a suction device and implement seizure precautions. d. Encourage the client to drink more fluids.

ANS: D Normal urine osmolality ranges from 300 to 900 mOsm/L. This clients urine is more concentrated, indicating dehydration. The nurse should encourage the client to drink more water. Dehydration can be associated with elevated serum sodium levels. Although a low-sodium diet may be appropriate for this client, this diet change will not have a significant impact on urine osmolality. A diuretic would increase urine output and decrease urine osmolality further. Low serum sodium levels, not elevated serum levels, place the client at risk for seizure activity. These options would further contribute to the clients dehydration or elevate the osmolality.

10. A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the clients record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the clients abdomen and vital signs.

ANS: D The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the clients abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

7. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take? a. Position the client to lay on the surgical incision. b. Measure the specific gravity of the clients urine. c. Administer intravenous pain medications. d. Assess the rate and quality of the clients pulse.

ANS: D The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

17. A nurse cares for a client who is having trouble voiding. The client states, I cannot urinate in public places. How should the nurse respond? a. I will turn on the faucet in the bathroom to help stimulate your urination. b. I can recommend a prescription for a diuretic to improve your urine output. c. Ill move you to a room with a private bathroom to increase your comfort. d. I will close the curtain to provide you with as much privacy as possible.

ANS: D The nurse should provide privacy to clients who may be uncomfortable or have issues related to elimination or the urogenital area. Turning on the faucet and administering a diuretic will not address the clients concern. Although moving the client to a private room with a private bathroom would be nice, this is not realistic. The nurse needs to provide as much privacy as possible within the clients current room.

A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy

ANS: D Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical.

A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.

ANS: D Palpate the RUQ last. If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the client's stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample.

ANS: D Put on gloves prior to collecting the sample. To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.

A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first?

Administer morphine sulfate 4 mg IV. Morphine administered intravenously will decrease the pain and the associated sympathetic nervous system reactions of nausea and hypotension.

A nurse cares for a client who has kidney stones from secondary hyperoxaluria. Which medication should the nurse anticipate administering?

Allopurinol (Zyloprim) Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim).

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer?

An 86-year-old male with a 50-pack-year cigarette smoking history The greatest risk factor for bladder cancer is a long history of tobacco use.

A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. Which action should the nurse take?

Apply an ice pack to the site. The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising.

After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP's understanding. Which action indicates the UAP needs additional teaching?

Changing the client's incontinence brief when wet Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

The nurse is working with the dietitian to plan a menu for a client who has persistent difficulty swallowing. What is a suitable breakfast selection for this client? A. Scrambled eggs and toast B. Oatmeal and orange juice C. Puréed fruit and English muffin D. Cream of wheat and applesauce

D-Both cream of wheat and applesauce are foods of semi-solid consistency and are appropriate for this client. The client who is having difficulty swallowing should be given semi-solid foods and thickened liquids. Toast would not be appropriate, and orange juice would have to be thickened before it is given to this client. An English muffin would be inappropriate for this client because it is not a semi-solid food.

The nurse is reviewing orders for a client with possible esophageal trauma after a car crash. Which request does the nurse implement first? A. Give total parenteral nutrition (TPN) through a central venous catheter. B. Administer cefazolin (Kefzol) 1 g intravenously. C. Obtain a computed tomography (CT) scan of the chest and abdomen. D. Keep the client nothing by mouth (NPO) for possible surgery.

D-Clients with possible esophageal tears should be NPO until diagnostic testing is completed, because leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing. TPN is prescribed to provide calories and protein for wound healing; although this is important, it is not a priority for the nurse to implement first. Antibiotics may be requested to prevent possible infection, but this is not the priority. A CT of the chest and abdomen will be needed, but is not the nurse's initial action.

A client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea? A. Ensure that the client takes adequate amounts of fluids with meals. B. Advance the diet to solid food and encourage eating as much as possible at meals. C. Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal. D. Encourage the client to take fluids between meals rather than with meals.

D-Diarrhea is believed to be the result of vagotomy syndrome and can be managed by taking fluids between meals rather than with meals. For this client, fluids with meals can lead to the development of diarrhea immediately after eating. The client may not be physically ready to advance to a solid diet. The client should eat six to eight small meals daily. Magnesium hydroxide is a magnesium-based antacid that can cause diarrhea.

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a client's hiatal hernia. Which change does the nurse recommend to this client? A. Eat only two or three meals daily. B. Sleep flat in a left side-lying position. C. Drink tea instead of coffee. D. Avoid working while bent over the computer.

D-The client should avoid working while bent over because this position presses on the diaphragm, causing discomfort. The client with a hiatal hernia should eat four to six meals a day. The head of the client's bed should be elevated approximately 6 inches. Both tea and coffee should be eliminated from this client's diet because of the caffeine content.

What does the nurse teach a client to do to decrease the risk for urinary tract infection (UTI)?

Drink about 3 liters of fluid daily. Drinking about 3 liters of fluid daily, if another medical problem does not require fluid restriction, helps prevent dehydration and UTIs.

A cognitively impaired client has urge incontinence. Which method for achieving continence does the nurse include in the client's care plan?

Habit training Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis.

The nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a need for further clarification?

I will use a new, sterile catheter each time I do the procedure." Catheters are cleaned and reused. With proper handwashing and cleaning of the catheter, no increase in bacterial complications has been shown.

A client in the community health clinic is prescribed trimethoprim/sulfamethoxazole for cystitis. She reports that she developed hives to "something called Septra." What is the nurse's best action?

Notify the prescriber immediately. Rationale: Septra is a brand name for TMP-SMX, a sulfa-based antibiotic with multiple brand names. The provider needs the allergy information in order to substitute another effective antibiotic.

A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a "shift to the left" in a client's white blood cell count. Which action should the nurse take?

Notify the provider and start an intravenous line for parenteral antibiotics. An increase in band cells creates a "shift to the left." A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics.

A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first?

Obtain urine sample for culture and sensitivity. Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow?

Overflow incontinence The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended.

Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients?

Periodically re-evaluating the need for indwelling catheters Studies have shown that re-evaluating the need for indwelling catheters in clients is the most effective way to prevent UTIs in the hospital setting.

Which nursing activity illustrates proper aseptic technique during catheter care?

Positioning the collection bag below the height of the bladder Urine collection bags must be kept below the level of the bladder at all times. Elevating the collection bag above the bladder causes reflux of pathogens from the bag into the urinary tract.

The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker require the nurse to intervene? (Select all that apply.) A. Checking tube placement every 12 hours B. Keeping the bed flat C. Placing the client upright when taking sips of water D. Providing mouth care every 8 hours E. Securing the tube

a,b,d-The nasogastric tube should be checked every 4 to 8 hours. The head of the bed should be elevated at least 30 degrees. Oral hygiene should be provided every 2 to 4 hours. The client should be placed upright when taking sips or small amounts of water to prevent choking and to allow observation of the client for dysphagia. The tube should be secured to prevent dislodgment.

A client who is 6 months pregnant comes to the prenatal clinic with a suspected urinary tract infection (UTI). What action does the nurse take with this client?

Refers the client to the clinic nurse practitioner for immediate follow-up Pregnant women with UTIs require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis. This in turn can cause preterm labor with adverse effects for the fetus. It is unsafe for the client to be sent home without analysis of the symptoms that she has. Her problem needs to be investigated without delay.

A 65-year old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer?

Smoking Rationale: Many compounds in tobacco enter the bloodstream and affect other organs, such as the bladder. Concentrated urine is associated with kidney stones and UTIs.

The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea? A. Loperamide (Imodium) B. Mesalamine (Pentasa) C. Minocycline (Minocin) D. Pantoprazole (Protonix)

a-Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery. It can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide. Mesalamine is used to treat clients with mild to moderate ulcerative colitis. Minocycline is an antibiotic used for treatment of infection. Pantoprazole is used to treat gastroesophageal reflux disease.

The certified Wound, Ostomy, and Continence Nurse or enterostomal therapist teaches a client who has had a cystectomy about which care principles for the client's post-discharge activities?

Stoma and pouch care The enterostomal therapist demonstrates external pouch application, local skin care, pouch care, methods of adhesion, and drainage mechanisms.

Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise?

Stress Pelvic floor (Kegel) exercise therapy for women with stress incontinence strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence.

The nurse is caring for clients on a renal/kidney medical-surgical unit. Which drug, requested by the health care provider for a client with a urinary tract infection (UTI), does the nurse question?

Tegretol Drug alerts state that confusion is frequent (sound alike and look alike) between the drugs Tequin (gatifloxacin) and Tegretol (carbamazepine).

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider?

The ileostomy stoma is pale and cyanotic in appearance. A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis.

A 32-year-old female with a urinary tract infection (UTI) reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100° F. Which drug does the health care provider prescribe?

Trimethoprim/sulfamethoxazole (Bactrim) Guidelines indicate that a 3-day course of trimethoprim/sulfamethoxazole is effective in treating uncomplicated, community-acquired UTI in women. Drugs from the same class as nitrofurantoin reduce bacteria in the urinary tract by inhibiting bacterial reproduction (bacteriostatic action). This client needs a drug that will kill bacteria.

A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this client's plan of care to assist with elimination?

Use the Valsalva maneuver. In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding.

A client is referred to a home health agency after being hospitalized with overflow incontinence and a urinary tract infection. Which nursing action can the home health RN delegate to the home health aide (unlicensed assistive personnel [UAP])?

Using a bladder scanner (with training) to check residual bladder volume after the client voids Use of a bladder scanner is noninvasive and can be accomplished by a home health aide (UAP) who has been trained and evaluated in this skill.

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a client diagnosed with esophageal cancer. Which instruction to the client is the highest priority? A. Place food at the back of the mouth as you eat. B. Do not be overly concerned with tongue or lip movements. C. Before swallowing, tilt the head back to straighten the esophagus. D. Do not attempt to reach food particles that are on the lips or around the mouth.

a-Placing food at the back of the mouth when eating will help the client avoid aspirating. Both tongue movements and sealing of the lips should be monitored in this client. The client's head should be tilted forward in the chin-tuck position. The client should be able to reach food particles on her or his lips and around the mouth with the tongue.

A client has been diagnosed with mild gastroesophageal reflux disease and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this client? A. "Avoid caffeine-containing foods and beverages." B. "Eat three meals each day and avoid snacking between meals." C. "Peppermint lozenges help to reduce stomach upset." D. "Sleep on your left side with a pillow between your knees."

a-Teach the client to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn, such as peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Remind the client to eat four to six small meals each day rather than three large ones. Peppermint decreases LES pressure and increases the risk of symptoms. Clients should be taught to elevate the head by 6 to 12 inches for sleep to prevent nighttime reflux.

A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. "Increase the fiber and water in your diet." b. "Reduce fat to less than 30% each day." c. "Report dry mouth and decreased sweating." d. "Lorcaserin may cause loose stools for a few days."

a. "Increase the fiber and water in your diet."

A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the client's formula. c. Dilute the client's formula. d. Slow the rate of infusion.

a. Administer free-water boluses.

A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

a. Ask the client if the weight loss was intentional.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.

a. Assess the 24-hour fluid balance.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What response by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.

a. Assess the client's coping and support systems.

A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection

a. Client with congestive heart failure

The nurse is caring for a client with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the client about porfimer sodium? (Select all that apply.) A. Avoid sunlight for 2 weeks. B. Cover all exposed body areas. C. Follow a clear liquid diet for 3 to 5 days after the procedure. D. Monitor for hypertension. E. Tissue particles may be found in the sputum.

b,c,e-Porfimer sodium causes photosensitivity, and sunglasses and protective clothing covering all exposed body areas are essential. A clear liquid diet should be followed for 3 to 5 days after the procedure and then should be advanced to full liquids as tolerated. The client should be warned that tissue particles may be released from the tumor site and may be present in the sputum. Sunlight should be avoided for 1 to 3 months. Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium.

The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? (Select all that apply.) A. Blood-tinged sputum B. Dyspepsia C. Excessive salivation D. Flatulence E. Regurgitation

b,d,e-Dyspepsia, also known as heartburn, is one of the main symptoms of GERD. Flatulence is common after eating, as well as regurgitation (backward flow into the throat) of food and fluids. Blood-tinged sputum and excessive salivation are not symptoms of GERD.

A client with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? A. "Consume carbonated beverages if you experience stomach upset." B. "Remain on a soft diet for about a week and avoid raw fruits and vegetables." C. "You may resume running and weight lifting if you wish." D. "You may stop taking your anti-reflux medications after 1 week."

b-After LNF, clients should be taught to remain on a soft diet for 1 week. Carbonated beverages should be avoided. Clients may walk, but should avoid heavy lifting. Anti-reflux medications should be taken for 1 month after the procedure.

A client who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? A. "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." B. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed." C. "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." D. "You need to talk to your doctor about your concerns. The doctor may recommend that you join a support group for cancer survivors."

b-Suggesting that the client invite people over for a meal provides psychosocial support to the client and assists the client in finding a solution to the problem. Telling the client not to worry about it or to call the provider is evasive and unhelpful; it is used to placate the client and does not address the client's concerns. The client should use problem-solving and coping skills before resorting to the use of medication.

A client has been diagnosed with terminal esophageal cancer. The client is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? A. "Haven't you received adequate pain management in the hospital?" B. "Would you like me to get a nurse from hospice to come talk with you?" C. "Do you want me to call the hospital chaplain to explain hospice to you?" D. "Talk to your health care provider about hospice services."

b-The best way to alleviate the client's concerns would be to have a hospice nurse talk with the client and answer any questions. Suggesting that the client has had adequate pain management sounds defensive. Referring the client to the chaplain or the health care provider is evasive and attempts to shift responsibility away from the nurse.

A client in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? A. Teach the client about antacid effects and side effects. B. Ask the client about medications and dietary intake. C. Suggest that the client sleep with the head elevated 6 inches. D. Tell the client to avoid drinking alcohol late in the evening.

b-The nurse's initial action should be further assessment of the client's risk factors for gastroesophageal reflux disease. Before suggesting interventions or beginning client teaching, the nurse must elicit more information about the client's symptoms. The nurse needs additional data before telling the client to avoid drinking alcohol late in the evening.

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

b. Beginning venous thromboembolism prophylaxis

A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale.

b. Check tube placement before each feeding.

A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL

b. Cholesterol: 142 mg/dL A cholesterol level below 160 mg/dL is a possible indicator of malnutrition

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client's readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.

b. Ensure adequate staff when moving the client.

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating "quiet time" so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse

b. Ensuring siderails are not causing excess pressure

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client's record because "I just have to know how much she weighs!" What action by the client's nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State "That is a violation of client confidentiality." c. Tell the nurse "Don't look; I'll tell you her weight." d. Walk away and ignore the other nurse's behavior.

b. State "That is a violation of client confidentiality."

Which of these assigned clients does the nurse assess first after receiving the change-of-shift report? A. Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography (CT) scan in 30 minutes B. Adult with gastroesophageal reflux disease (GERD) who is describing epigastric pain at a level of 6 (0-to-10 pain scale) C. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube D. Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as-needed (PRN) basis

c-The presence of blood in NG drainage is an unexpected finding 2 days after esophagogastrectomy and requires immediate investigation. The young adult scheduled for a CT scan, the adult with GERD, and the older adult with an ileus are all stable and do not require the nurse's immediate attention.

The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease who has been prescribed esomeprazole (Nexium) once daily. The client reports that the drug doesn't completely control the symptoms. The nurse contacts the provider to discuss which intervention? A. Adding a second proton pump inhibitor medication B. Increasing the dose of esomeprazole C. nging to a twice-daily dosing regimen D. Switching to omeprazole (Prilosec)

c-The proton pump inhibitors are usually effective when given once daily, but can be given twice daily if symptoms are not well controlled. Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight

c. Psychosocial influences on weight

A client with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? A. Teaching family members how to determine whether the client is obtaining adequate nutrition B. Assessing lung sounds for possible aspiration when the client is swallowing clear liquids C. Reminding the client to use the chin-tuck technique each time the client attempts to swallow D. Instructing family members about symptoms that may indicate a need to call the provider

c-The role of a home health aide when caring for a client with swallowing difficulty includes reinforcement of previously taught swallowing techniques. Client teaching and providing instructions to family members are not within the scope of practice of a home health aide and should be done by the nurse. Likewise, assessment is part of the nursing process and should be done by a nurse.

A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L

c. Client with a potassium level of 2.6 mEq/L

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

c. Ensure an adequate airway.

A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.

c. Fill out and file a variance report.

A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the client's gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.

c. Hold the feeding until the nausea subsides.

A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition

c. Specific lack of protein

A client is being discharged after a minimally invasive esophagectomy. Which teaching point does the nurse consider to be of the highest priority during the predischarge teaching session? A. Instruct the client to eat three meals daily. B. Emphasize the importance of lying down after meals. C. Encourage the client to ask his or her health care provider for antidepressant medication. D. Report the presence of fever and a swollen, painful neck incision.

d-Wound management and prevention of infection are major concerns because the client who has had an esophagectomy typically has multiple drains and incisions. The client should eat six to eight small meals daily, and should sit up after meals to encourage satisfactory swallowing. The client's coping skills should be assessed, as well as his or her level of anxiety and/or depression, before antidepressant medication is prescribed.

A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. "All weight-loss drugs can cause suicidal ideation." b. "No drugs are currently available for weight loss." c. "Only over-the-counter medications are available." d. "There are three drugs currently approved for this."

d. "There are three drugs currently approved for this."

A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene

d. Performing appropriate hand hygiene

A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this client's height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers.

d. Use knee-height calipers.