Med-Surg Exam 2

What is asterixis? What is it an indication of?

-irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread -indicats hepatic encephalopathy

A client with ulcerative colitis is to take sulfasalazine (Azulfidine). Which of the following instructions should the nurse provide for the client about taking this medication at home? (Select all that apply.) 1. Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. 3. Stop taking the medication if the urine turns orange-yellow. 4. Avoid activities that require alertness. 5. If dose is missed, skip and continue with the next dose.

1. Drink enough fluids to maintain a urine output of at least 1,200- 1,500 mL per day. 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. 4. Avoid activities that require alertness.

The client without HIV is positive on a tuberculin skin test with an induration larger than _____ mm.

10 mm

What is the normal ammonia level?

10 to 80 mcg/dL

What is the normal platelet count?

150,000 to 400,000

Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following? 1. Decreased renal function. 2. Inadequate pain relief. 3. Extension of the obstruction. 4. Inadequate fluid replacement.

4. Inadequate fluid replacement.

The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than _____ mm.

5 mm

What is the normal white blood cell count?

5,000 to 10,000

What is the normal clotting time?

8 to 15 minutes

A client uses a metered-dose inhaler (MDI) to aid in management of asthma. Which action indicates to the nurse that the client needs further instruction regarding its use? (Select all that apply.) a. Activation of the MDI is not coordinated with inspiration b. The client inspires rapidly when using the MDI c. The client holds his breath for 3 seconds after inhaling with the MDI d. The client shakes the MDI after use e. The client performs puffs in rapid succession

All of the above.

The nurse is conducting a community presenation of the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? (Select all that apply) a. Fatigue b. Unexplained weight loss with adequate nutritional intake c. Rectal bleeding d. Bowel changes e. Positiive fecal occult blood testing

All of the above.

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

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

A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? a. "I eat at least 3 large meals each day." b. "I eat while lying in a semirecumbent position." c. "I have eliminated taking liquids with my meals." d. "I eat a high-protein, low- to moderate-carbohydrate diet."

a. "I eat at least 3 large meals each day."

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? a. "I need to limit my intake of dietary fiber." b. "I need to drink plenty, at least 8 to 10 cups daily." c. "I need to eat regular meals and chew my food well." d. "I will take the prescribed medications because they will regulate my bowel patterns."

a. "I need to limit my intake of dietary fiber."

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) a. "I plan to eat small, frequent meals." b. "I will eat easy-to-digest foods with limited spice" c. "I will use skim milk when cooking" d. "I plan to drink regular cola" e. "I will limit alcohol intake to two drinks per day"

a. "I plan to eat small, frequent meals." b. "I will eat easy-to-digest foods with limited spice" c. "I will use skim milk when cooking"

The nurse has provided teaching for an adult client about screening for a colon cancer. Which statement by the client indicates that education was effective? a. "I should have an annual fecal occult blood test." b. "I should have an annual colonoscopy when I become 60." c. "I will have a colonoscopy before the fecal occult blood test." d. "I will not need to have further fecal occult blood tests after a colonoscopy."

a. "I should have an annual fecal occult blood test."

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? a. "I should increase the fiber in my diet." b. "I will need to avoid caffeinated beverages." c. "I'm going to learn some stress reduction techniques." d. "I can have exacerbations and remissions with Crohn's disease."

a. "I should increase the fiber in my diet."

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? a. "I should wash my hands after blowing my nose to prevent spreading the virus." b. "I need to avoid drinking fluids if I develop symptoms." c. "I need a flu shot every 2 years because of the different flu strains." d. "I should cover my mouth with my hand when I sneeze."

a. "I should wash my hands after blowing my nose to prevent spreading the virus."

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? a. "I will discard used tissues in a plastic bag." b. "I need to wash my hands at least 4 times a day." c. "I will brush my teeth and rinse my mouth once a day." d. "I will turn my head to the side if I need to cough or sneeze."

a. "I will discard used tissues in a plastic bag."

A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? a. "I will plan to limit fiber in my diet." b. "I will restrict fluid intake during meals." c. "I will switch to black tea instead of drinking coffee." d. "I will try to eat three moderate to large meals a day."

a. "I will plan to limit fiber in my diet."

The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which of the following statements would indicate that the client has understood the instructions? a. "I'll avoid lying down after a meal" b. "I can still enjoy my potato chips and cola at bedtime" c. "I wish I didn't have to give up swimming" d. "If I wear a girdle, I'll have more support for my stomach"

a. "I'll avoid lying down after a meal"

The nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which statement made by the client indicates a need for further instruction regarding home care measures? a. "It is all right to use a straight razor to shave under my arms." b. "I must be sure to use thick potholders when I am cooking." c. "I must be sure not to have blood pressures taken or blood drawn from my right arm." d. "I should inform all of my other health care providers that I have had this surgical procedure."

a. "It is all right to use a straight razor to shave under my arms."

The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? a. "It will cause diaphoresis and diarrhea." b. "I have to monitor for hiccups and diarrhea." c. "It will be associated with constipation and fever." d. "I have to monitor for fatigue and abdominal pain."

a. "It will cause diaphoresis and diarrhea."

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? a. "There are portable oxygen delivery systems that you can take with you." b. "When you go out, you can remove the oxygen and then reapply it when you get home." c. "You probably will not be able to go out as much as you used to." d. "Home health services will come to you so you will not need to get out."

a. "There are portable oxygen delivery systems that you can take with you."

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply) a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation

a. A client who has a BMI of 30 c. A client who has a fractured femur e. A client who has chronic atrial fibrillation

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors is most likely of greatest significance in causing an exacerbation of ulcerative colitis? a. A demanding and stressful job b. Changing to a modified vegetarian diet c. Beginning a weight-training program d. Walking 2 miles (3.2 km) every day

a. A demanding and stressful job

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? (Select all that apply.) a. Activities should be resumed gradually. b. Avoid contact with other individuals, except family members, for at least 6 months. c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. f. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

a. Activities should be resumed gradually. c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? (Select all that apply.) a. Administer stool softeners as prescribed. b. Instruct the client to limit fluid intake to avoid urinary retention. c. Encourage a high-fiber diet to promote bowel movements without straining. d. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. e. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.

a. Administer stool softeners as prescribed. c. Encourage a high-fiber diet to promote bowel movements without straining. d. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.

A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. Advise the client to keep a food diary b. Encourage the client to brush teeth before and after meals c. Assess the laboratory report of ferritin d. Eat nutrient-dense foods last at meal time e. Encourage the client to limit drinking fluids during meals

a. Advise the client to keep a food diary b. Encourage the client to brush teeth before and after meals c. Assess the laboratory report of ferritin e. Encourage the client to limit drinking fluids during meals

A 79 yo is admitted to the hospital with a dx of bacterial PNA. While obtaining the client's health history, the nurse learns that the client has osteoarthritis, follows a vegetarian diet, and is very concerned with cleanliness. Which of the following would MOST likely be a predisposing factor for PNA? a. Age b. Osteoarthritis c. Vegetarian diet d. Daily bathing

a. Age

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? a. Age younger than 50 years b. History of colorectal polyps c. Family history of colorectal cancer d. Chronic inflammatory bowel disease

a. Age younger than 50 years

A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The nurse should anticipate prescriptions for which of the following medications? (Select all that apply.) a. Antacids b. Histamine2 receptor antagonists c. Opioid analgesics d. Fiber laxatives e. Proton pump inhibitors

a. Antacids b. Histamine2 receptor antagonists e. Proton pump inhibitors

A nurse is planning care for a client who has a platelet count of 10,000/mm3. Which of the following interventions should the nurse include in the plan of care? a. Apply prolonged pressure to puncture site after blood sampling b. Administer epoetin alfa as prescribed c. Place the client in a private room d. Have the client use an oral topical anesthetic before meals

a. Apply prolonged pressure to puncture site after blood sampling

The nurse is providing follow-up care to a client with tuberculosis who does not regularly take the prescribed medication. Which nursing action would be MOST appropriate for this client? a. Ask the client's spouse to supervise the daily administration of the medications b. Visit the client weekly to verify compliance with taking the medication c. Notify the physician of the client's noncompliance and request a different prescription d. Remind the client that TB can be fatal if not treated promptly

a. Ask the client's spouse to supervise the daily administration of the medications

A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written the following prescriptions: for the client to be up ad lib, have narcotics for pain, and have a NG tube inserted if needed, and for IV RInger's lactate and hyperalimentation fluids. The nurse should do the following in order of priority from FIRST to LAST: a. Assist with ambulation to promote peristalsis b. Insert a NG tube c. Administer IV Ringer's lactate d. Start an infusion of hyperalimentation fluids

a. Assist with ambulation to promote peristalsis c. Administer IV Ringer's lactate b. Insert a NG tube d. Start an infusion of hyperalimentation fluids

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

a. Avoid contact sports. b. Wash hands frequently. d. Avoid crowded places such as shopping malls. f. Avoid people who have received live attenuated vaccines.

A nurse is completing discharge teaching with a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching? a. Avoid foods that trigger exacerbation b. Consume 15 to 20 g of fiber daily c. Plan three moderate to large meals per day d. Limit fluid intake to 1 L each day

a. Avoid foods that trigger exacerbation

Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply: a. Bran cereal b. Broccoli c. Tomato juice d. Navy beans e. Cheese

a. Bran cereal b. Broccoli d. Navy beans

A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices can trigger cholecystitis? a. Brownie with nuts b. Bowl of mixed fruit c. Grilled turkey d. Baked potato

a. Brownie with nuts

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) a. Client who has dysphagia b. Client who has AIDS c. Client who was vaccinated for pneumococcus and influenza 6 months ago d. Client who is postoperative and has received local anesthesia e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis

a. Client who has dysphagia b. Client who has AIDS e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? (Select all that apply.) a. Coffee b. Chocolate c. Peppermint d. Nonfat milk e. Fried chicken f. Scrambled eggs

a. Coffee b. Chocolate c. Peppermint e. Fried chicken

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? a. Contact the health care provider (HCP). b. Document the finding in the client's record. c. Call the employee health service department. d. Call the radiology department for a chest radiographic study to be done.

a. Contact the health care provider (HCP).

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? (Select all that apply.) a. Cough b. Dyspnea c. Weight gain d. High-grade fever e. Chills and night sweats

a. Cough b. Dyspnea e. Chills and night sweats

After a subtotal gastrectomy, the NG tube drainage will be what color for about 12 to 24 hours after the surgery? a. Dark brown b. Bile green c. Bright red d. Cloudy white

a. Dark brown

Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? a. Decreased diarrhea b. Decreased cramping c. Improved intestinal tone d. Elimination of peristalsis

a. Decreased diarrhea

When developing a discharge plan to manage the care of a client with COPD, the nurse should advise the client to expect to: a. Develop respiratory infections easily b. Maintain current status c. Require less supplemental oxygen d. Show permanent improvement

a. Develop respiratory infections easily

A nurse is planning care for a client who has a small bowel obstruction and a NG tube in place. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. Document the NG drainage with the client's output. b. Irrigate the NG tube every 8 hr c. Assess bowel sounds d. Provide oral hygiene every 2 hr e. Monitor NG tube for placement

a. Document the NG drainage with the client's output. c. Assess bowel sounds d. Provide oral hygiene every 2 hr e. Monitor NG tube for placement

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? (Select all that apply.) a. Dry air b. Clean air c. Exercise d. Rest and sleep e. An upper respiratory infection (URI) f. Nonsteroidal antiinflammatory drugs (NSAIDs)

a. Dry air c. Exercise e. An upper respiratory infection (URI) f. Nonsteroidal antiinflammatory drugs (NSAIDs)

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respirations

a. Dyspnea

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risk for complications? (Select all that apply.) a. Dyspnea b. Localized bloody drainage on the dressing c. Fever d. Hypotension e. Report of pain at the puncture site

a. Dyspnea c. Fever d. Hypotension

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? (Select all that apply.) a. Dyspnea b. Headache c. Night sweats d. A bloody, productive cough e. A cough with the expectoration of mucoid sputum

a. Dyspnea c. Night sweats d. A bloody, productive cough e. A cough with the expectoration of mucoid sputum

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? (Select all that apply.) a. Dyspnea at rest b. Clubbed fingers c. Muscle retractions d. Decreased respiratory rate e. Increased body temperature f. Prolonged expiratory breathing phase

a. Dyspnea at rest b. Clubbed fingers c. Muscle retractions f. Prolonged expiratory breathing phase

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? a. Elevated on a pillow b. Level with the right atrium c. Dependent to the right atrium d. Elevated above shoulder level

a. Elevated on a pillow

A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis? (Select all that apply) a. Emesis greater than 500 mL with a fecal odor b. Report of spasmodic abdominal pain c. High-pitched bowel sounds d. Abdomen flat with rebound tenderness to palpation e. Laboratory findings indicating metabolic acidosis

a. Emesis greater than 500 mL with a fecal odor b. Report of spasmodic abdominal pain c. High-pitched bowel sounds

Which factor is most commonly associated with the development of pancreatitis? (Select all that apply.) a. EtOH abuse b. hypercalcemia c. hyperlipidemia d. pancreatic duct obstruction

a. EtOH abuse d. pancreatic duct obstruction

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care? (Select all that apply.) a. Evaluate intake and output b. Monitor laboratory reports of electrolytes c. Provide three large meals a day d. Administer ibuprofen for pain e. Observe stool characteristics

a. Evaluate intake and output b. Monitor laboratory reports of electrolytes e. Observe stool characteristics

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? a. Fatigue b. Pale urine c. Weight gain d. Spider angiomas

a. Fatigue

The nurse is doing volunteer work in a homeless shelter. The nurse should monitor the individuals for which initial signs and symptoms of tuberculosis? (Select all that apply.) a. Fatigue b. Lethargy c. Chest pain d. Morning cough e. Low-grade fever f. Labored breathing

a. Fatigue b. Lethargy d. Morning cough e. Low-grade fever

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? (Select all that apply.) a. Fever b. Positive Cullen's sign c. Complaints of indigestion d. Palpable mass in the left upper quadrant e. Pain in the upper right quadrant after a fatty meal f. Vague lower right quadrant abdominal discomfort

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

A clinic nurse notes that large numbers of clients present with flulike symptoms. Which recommendations should the nurse include in the plan of care for these clients? (Select all that apply.) a. Get plenty of rest. b. Increase intake of liquids. c. Take antipyretics for fever. d. Get a flu shot immediately. e. Eat fruits and vegetables high in vitamin C.

a. Get plenty of rest. b. Increase intake of liquids. c. Take antipyretics for fever. e. Eat fruits and vegetables high in vitamin C.

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which of th following symptoms? a. Heartburn b. Jaundice c. Anorexia d. Stomatitis

a. Heartburn

A nurse is caring for a client wo is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? a. Hip arthroplasty 2 weeks ago b. Elevated sedimentation rate c. Incident of exercise-induced asthma 1 week ago d. Elevated platelet count

a. Hip arthroplasty 2 weeks ago

A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) a. Hypokalemia b. Tachycardia c. Fluid retention d. Nausea e. Black, tarry stools

a. Hypokalemia c. Fluid retention e. Black, tarry stools

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? a. Inability to pass flatus b. Loss of anal sphincter control c. Severe, constant pain with rapid onset d. Firm, nontender mass palpable at the lower right costal margin

a. Inability to pass flatus

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? a. Inability to pass flatus b. Loss of anal sphincter control c. Severe, constant pain with rapid onset d. Firm, nontender mass palpable at the lower right costal margin

a. Inability to pass flatus

The physician prescribes metoclopramide hydrochloride for the client with a hiatal hernia. This drug is used in hiatal hernia therapy to accomplish which of the following objectives? a. Increase tone of the esophageal sphincter b. Neutralize gastric secretions c. Delay gastric emptying d. Reduce secretion of digestive juices

a. Increase tone of the esophageal sphincter

Which of the following physical assessment finding are normal for a client with advanced COPD? a. Increased anteroposterior chest diameter b. Underdeveloped neck muscles c. Collapsed neck veins d. increased chest excursions with respiration

a. Increased anteroposterior chest diameter

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which of the following after the procedure is completed? a. Laxative b. Anticholinergic c. Antacid d. Demulcent

a. Laxative

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? a. Lying recumbent following meals b. Consuming small, frequent, bland meals c. Taking H2-receptor antagonist medication d. Raising the head of the bed on 6-inch (15 cm) blocks

a. Lying recumbent following meals

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (Select all that apply.) a. Maintain NPO (nothing by mouth) status. b. Encourage coughing and deep breathing. c. Give small, frequent high-calorie feedings. d. Maintain the client in a supine and flat position. e. Give hydromorphone intravenously as prescribed for pain. f. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

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

Which of the following is a priority goal for the client with COPD? a. Maintaining functional ability b. Minimizing chest pain c. Increasing CO2 levels in the blood d. Treating infectious agents

a. Maintaining functional ability

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? a. Malaise b. Dark stools c. Weight gain d. Left upper quadrant discomfort

a. Malaise

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

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

The client with COPD is taking theophylline. The nurse should instruct the client to report which of the following sign of theophylline toxicity? (Select all that apply.) a. Nausea b. Vomiting c. Seizures d. Insomnia e. Vision changes

a. Nausea b. Vomiting c. Seizures d. Insomnia

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? a. Notify the health care provider (HCP). b. Administer the prescribed pain medication. c. Call and ask the operating room team to perform surgery as soon as possible. d. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

a. Notify the health care provider (HCP).

After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be MOST important for the nurse to include information about which of the following in the client's teaching plan? a. Nutritional intake b. Management of alopecia c. Exercise and activity levels d. Access to community resources

a. Nutritional intake

A client with a peptic ulcer reports epigastric pain that frequently causes the client to wake up during the night. The nurse should instruct the client to do which activities? (Select all that apply.) a. Obtain adequate rest to reduce stimulation b. Eat small, frequent meals throughout the day c. Take all medications on time as prescribed d. Sit up for 1 hour when awakened at night e. Stay away from crowded areas

a. Obtain adequate rest to reduce stimulation b. Eat small, frequent meals throughout the day c. Take all medications on time as prescribed d. Sit up for 1 hour when awakened at night

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? a. Obtain baseline vital signs and oxygen saturation b. Obtain a sputum culture c. Obtain a complete history from the client d. Provide a pneumococcal vaccine

a. Obtain baseline vital signs and oxygen saturation

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in he client's room? (Select all that apply.) a. Oxygen equipment b. Inventive spirometer c. Pulse oximeter d. Sterile dressing e. Suture removal kit

a. Oxygen equipment c. Pulse oximeter d. Sterile dressing

A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum

a. Persistent cough c. Fatigue d. Night sweats e. Purulent sputum

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure which of the following actions should the nurse take? a. Position the client in an upright position, leaning over the bedside table. b. Explain the procedure. c. Obtain ABGs. d. Administer benzocaine spray.

a. Position the client in an upright position, leaning over the bedside table.

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? a. Positive b. Negative c. Inconclusive d. Need for repeat testing

a. Positive

A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client the nurse should do which of the following? (Select all that apply.) a. Precuss the abdomen to note resonance and tympany b. Percuss the liver to note lack of dullness c. Monitor the VS for fever, tachypnea, and bradycardia d. Assess presence of polyphagia and polydipsia e. Auscultate bowel sounds to note frequency

a. Precuss the abdomen to note resonance and tympany b. Percuss the liver to note lack of dullness e. Auscultate bowel sounds to note frequency

The nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which of the following? (Select all that apply.) a. Projectile vomiting b. Significant abdominal distention c. Copious diarrhea d. Rapid onset of dehydration e. Increased bowel sounds

a. Projectile vomiting d. Rapid onset of dehydration e. Increased bowel sounds

The nurse is caring for a client who just had an upper GI endocsopy. The client's VS must be taken every 30 minutes after the procedure. The nurse assigns unlicensed nursing personnel (UAP) to take the VS. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 F (38.8 C). What should the nurse do in response to this reported assessment data? a. Promptly assess the client for potential perforation b. Tell the assistant to change thermometers and retake the temperature c. Plan to give the client acetaminophen (Tylenol) to lower the temperature d. Ask the UAP to bathe the client with tepid water

a. Promptly assess the client for potential perforation

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet? a. Protein b. Calories c. Minerals d. Carbohydrates

a. Protein

Which of the following are significant to gather from a client who has been diagnosed with PNA? (Select ALL that apply.) a. Quality of breath sounds b. Presence of bowel sounds c. Occurrence of chest pain d. Amount of peripheral edema e. Color of nail beds

a. Quality of breath sounds c. Occurrence of chest pain e. Color of nail beds

The clinic nurse is performing an abdominal assessment on a client and preparing to auscultate bowel sounds. The nurse should place the stethoscope in which quadrant first? Click on the image to indicate your answer. a. RUQ b. LUQ c. RLQ d. LLQ

a. RUQ

A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? a. Remove fluids from the meal tray. b. Give the client 2 large meals per day. c. Ask the client to sit up for 1 hour after eating. d. Provide concentrated, high-carbohydrate foods.

a. Remove fluids from the meal tray.

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (Select all that apply.) a. Rigid abdomen b. Tachycardia c. Elevated blood pressure d. Circumoral cyanosis e. Rebound tenderness

a. Rigid abdomen b. Tachycardia e. Rebound tenderness

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse include? (Select all that apply.) a. Sit upright in the bed or in a chair. b. Inhale as deeply and quickly as possible. c. Hold the device in a downward position. d. Place the mouthpiece in your mouth and seal your lips tightly around it. e. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

a. Sit upright in the bed or in a chair. d. Place the mouthpiece in your mouth and seal your lips tightly around it. e. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? (Select all that apply.) a. Sitting up and leaning on a table b. Standing and leaning against a wall c. Lying supine with the feet elevated d. Sitting up with the elbows resting on knees e. Lying on the back in a low Fowler's position

a. Sitting up and leaning on a table b. Standing and leaning against a wall d. Sitting up with the elbows resting on knees

The community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cervical cancer. Which are risk factors for cervical cancer? (Select all that apply.) a. Smoking b. Multiple sex partners c. Human papillomavirus infection d. Annual gynecological examinations e. First intercourse before 17 years of age

a. Smoking b. Multiple sex partners c. Human papillomavirus infection e. First intercourse before 17 years of age

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal cramping and pain

a. Sweating and pallor

The client is scheduled to have an upper GI tract series of x-rays. Following the x-rays, the nurse should instruct the client to: a. Take a laxative b. Follow a clear liquid diet c. Administer an enema d. Take an antiemetic

a. Take a laxative

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. Take the medication 1 hr before a meal b. Limit NSAIDs when taking this medication c. Expect skin flushing when taking this medication d. Increase fiber intake when taking this medication e. Chew the medication thoroughly before swallowing

a. Take the medication 1 hr before a meal b. Limit NSAIDs when taking this medication

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following indicates that the client is using the MDI correctly? (Select all that apply.) a. The inhaler is held upright b. The head is tilted down while inhaling the medicine c. The client waits 5 minutes between puffs d. The client rinses the mouth with water following administration e. The client lies supine for 15 minutes following administration

a. The inhaler is held upright d. The client rinses the mouth with water following administration

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? a. This is a normal, expected event. b. The client is experiencing early signs of ischemic bowel. c. The client should not have the nasogastric tube removed. d. This indicates inadequate preoperative bowel preparation.

a. This is a normal, expected event.

Which of the following symptoms is common in clients with active TB? a. Weight loss b. Increased appetite c. Dyspnea on exertion d. Mental status changes

a. Weight loss

The nurse is admitting a client who has pancreatic cancer and is presenting with jaundice due to obstruction of the common bile duct. Which of the following needs is an important part of the nursing care plan? a. adequate nutrition b. self-image c. skin integrity d. urinary elimination

a. adequate nutrition

Which laboratory test is used to diagnose pancreatitis? a. amylase & lipase b. hemoglobin level c. blood glucose level d. WBC count

a. amylase & lipase

A female client had a laparoscopic cholecystectomy this morning. She is now complaining of right shoulder pain. The nurse would explain to the client this symptom is a. common following this procedure b. expected after general anesthesia c. unusual and will be reported to the surgeon d. indicative of the need to use the incentive spirometer

a. common following this procedure

Peritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular space into the peritoneal cavity. If this occurs, the nurse would evaluate for: a. decreased serum albumin b. abdominal pain c. oliguria d. peritonitis

a. decreased serum albumin

Which of the following medications would the nurse question for a client with acute pancreatitis? a. furosemide (lasix) 20 mg IVP b. Imipenem (primaxin) 500 mg IV c. morphine sulfate 2mg IVP d. famotidine (Pepcid) 20 mg IVP

a. furosemide (lasix) 20 mg IVP

A patient is receiving morphine sulfate during hospitalization for the pain he is experiencing with pancreatitis. In terms of providing safe patient care, which of the following meds would be most important for the nurse to have available? a. naloxone (narcan) b. disulfiram (antabuse) c. dolophine (methadone) d. epinephrine (adrenaline)

a. naloxone (narcan)

When the patient with acute pancreatitis c/o abdominal pain, the nurse can suggest which position to best decrease tension or pressure on the abdomen? a. side-lying with HOB 45 degrees b. prone decubitus c. supine with knees extended d. modified Trendelenberg

a. side-lying with HOB 45 degrees

The client asks the nurse is surgery is needed to correct a hiatal hernia. Which reply by the nurse would be MOST accurate? a. "Surgery is usually required, although medical treatment is attempted first." b. "Hiatal hernia symptoms can usually be successfully manged with diet modifications" c. "Surgery is not performed for this type of hernia" d. "A minor surgical procedure to reduce the size of the diaphagmatic opening will probably be planned"

b. "Hiatal hernia symptoms can usually be successfully manged with diet modifications"

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? a. "I have had unprotected sex with multiple partners." b. "I ate shellfish about 2 weeks ago at a local restaurant." c. "I was an intravenous drug abuser in the past and shared needles." d. "I had a blood transfusion 30 years ago after major abdominal surgery."

b. "I ate shellfish about 2 weeks ago at a local restaurant."

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

b. "I examine myself every 2 months."

The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? a. "I walk 1 to 2 miles every day." b. "I need to decrease fiber in my diet." c. "I have a bowel movement every other day." d. "I drink 6 to 8 glasses of water every day."

b. "I need to decrease fiber in my diet."

The nurse is teaching the postgastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching? a. "I need to lie down after eating." b. "I need to drink liquids with meals." c. "I need to avoid concentrated sweets." d. "I need to eat small meals 6 times daily."

b. "I need to drink liquids with meals."

The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) indicate(s) that the client has understood the nurse's instructions? (Select all that apply.) a. "I will need to dispose of my old clothing when I return home" b. "I should always cover my mouth and nose when sneezing" c. "It is important that I isolate myself from family when possible" d. "I should use paper tissues to cough in and dispose of them promptly" e. "I can use regular plates and utensils whenever I eat"

b. "I should always cover my mouth and nose when sneezing" d. "I should use paper tissues to cough in and dispose of them promptly" e. "I can use regular plates and utensils whenever I eat"

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the followng statements by the client should indicate an immediate conern for the nurse? a. "I am allergic to morphine" b. "I take antacids several times a day" c. "I had a blood clot in m leg several years ago" d. "It hurts to take a deep breath"

b. "I take antacids several times a day"

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? a. "This medication can decrease my immune response." b. "I take this medication to prevent asthma attacks." c. "I need to take this medication with food." d. "This medication has a slow onset to treat my symptoms."

b. "I take this medication to prevent asthma attacks."

A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.) a. "I can substitute one medication for another if I run out because they all fight infection." b. "I will wash my hands each time I cough." c. "I will wear a mask when I am in a public area." d. "I am glad I don't have to have any more sputum specimens."

b. "I will wash my hands each time I cough." c. "I will wear a mask when I am in a public area."

A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching? a. "I can take my medications with soda." b. "Peppermint tear will increase my indigestion." c. "Wearing an abdominal binder will limit my symptoms." d. "I will drink hot chocolate at bedtime to help me sleep." e. "I can lift weights as a way to exercise."

b. "Peppermint tear will increase my indigestion."

The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. In which order should the nurse explain the steps to the client? a. "Breathe in normally through your nose for two counts (while counting to yourself, one, two)" b. "Relax your neck and shoulder muscles" c. "Pucker your lips as if you were going to whistle" d. "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four"

b. "Relax your neck and shoulder muscles" a. "Breathe in normally through your nose for two counts (while counting to yourself, one, two)" c. "Pucker your lips as if you were going to whistle" d. "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four"

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse should tell the client: a. "Ulcerative colitis can be cured by the use of steroids." b. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." c. "Long-term use of steroids will prolong periods of remission." d. "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

b. "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding."

A charge nurse is teaching a group of unit nurses about a client who has chronic gastritis and is scheduled for a selective vagotomy. Which of the following statements by a unit nurse indicates understanding of the purpose of the procedure? a. "The client will have an increased duodenal gastric emptying." b. "The client will have a reduction of gastric acid secretions" c. "The client will have an increase of gastric mucus secretion" d. "The client will have an increased secretion of hydrogen/potassium ATPase enzymes"

b. "The client will have a reduction of gastric acid secretions"

The nurse cares for a client with cholecystitis. The client says to the nurse, "I don't understand why my right shoulder hurts when the gallbladder is not by my shoulder!" Which of the following responses by the nurse is BEST? a. "Sometimes small pieces of the gallstones break off and travel to other parts of the body" b. "There is an invisible connection between the gall bladder and the right shoulder" c. "The gallbladder is on the right side of the body and so is that shoulder" d. "Your shoulder became tense because you were guarding against the gallbladder pain"

b. "There is an invisible connection between the gall bladder and the right shoulder"

A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? a. "The scop will be passed through your rectum" b. "You might have shoulder pain after surgery." c. "You will have a Jackson-Pratt drain in place after surgery" d. "You should limit how often you walk for 1 to 2 weeks"

b. "You might have shoulder pain after surgery."

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. "You will need to continue to take the multimedication regimen for 4 months." b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." c. "You will need to remain hospitalized for treatment." d. "You will need to wear a mask at all times."

b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."

A client is having a diagnostic workup for colorectal cancer. Which factors in the client's history place the client at increased risk for this type of cancer? (Select all that apply.) a. A high-fiber diet b. A diet high in fats c. Minimal alcohol intake d. A diet high in carbohydrates e. A history of inflammatory bowel disease f. A maternal grandfather who had a history of heart disease

b. A diet high in fats d. A diet high in carbohydrates e. A history of inflammatory bowel disease

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? (Select all that apply.) a. A low arterial PCo2 level b. A hyperinflated chest noted on the chest x-ray c. Decreased oxygen saturation with mild exercise d. A widened diaphragm noted on the chest x-ray e. Pulmonary function tests that demonstrate increased vital capacity

b. A hyperinflated chest noted on the chest x-ray c. Decreased oxygen saturation with mild exercise

A client newly admitted with TB is being admitted with the prescription for "isolation precautions for TB". The nurse should assign the client to which type of room? a. A room at the end of the hall b. A private room to implement airborne precautions c. A room near the nurses' station to ensure privacy d. A room with windows to allow sunlight

b. A private room to implement airborne precautions

The client with an intestional obstruction continues to have acute pain even though the NG tube is patent and draining. Which action by the nurse would be MOST appropriate? a. Reassure the client that the NG tube is functioning b. Assess the client for a rigid abdomen c. Administer an opioid as prescribed d. Reposition the client on the left side

b. Assess the client for a rigid abdomen

A man comes to the ED c/o N & V, and severe RUQ pain. His temp is 101.3 F and an abdominal x-ray reveals an enlarged gallbladder. He is given a diagnosis of acute cholecystitis and is scheduled for surgery. After administering an analgesic to the client, the nurse recognizes that which of the following actions is a priority? a. Assessing the client's need for dietary teaching. b. Assessing the client's fluid and electrolyte status. c. Examining the client's health history for allergies to antibiotics d. Determining whether the client has signed consent for surgery.

b. Assessing the client's fluid and electrolyte status.

An elderly client admitted with pneumonia (PNA) and dementia has attempted several times to pull out the IV and Foley catheter. The nurse obtains an order for bilateral soft wrist restraints. Which nursing action is MOST appropriate? a. Perform circulation checks to bilateral upper extremities each shift b. Attach the ties of the restrains to the bedframe c. Reevaluate the need for restraints and document weekly d. Ensure the restraint order has been signed by the physician within 72 hours

b. Attach the ties of the restrains to the bedframe

A 27-year-old client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask her whether the breast lumps seem to become more prominent or troublesome at which time? a. After menses b. Before menses c. During menses d. At any time, regardless of the menstrual cycle

b. Before menses

Which of the following factors would most likely contribute to the development of a client's hiatal hernia? a. Having a sedentary desk job b. Being 5 feet, 3 inchest tall and weighing 190 lb (86.2 kg) c. Using laxatives frequently d. Being 40 years old

b. Being 5 feet, 3 inchest tall and weighing 190 lb (86.2 kg)

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

b. Brown gravy

Which are risk factors for chronic obstructive pulmonary disease (COPD)? (Select all that apply.) a. Purified air b. Cigarette smoking c. Genetic risk factor d. Environmental factors e. Eating plenty of fruits and vegetables f. Alpha-1 antitrypsin (AAT) deficiency

b. Cigarette smoking c. Genetic risk factor d. Environmental factors f. Alpha-1 antitrypsin (AAT) deficiency

A nurse is providing discharge teaching to a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. Take baths rather than showers b. Clamp T-tube for 1 hr before and after meals c. Keep the drainage system above the level of the abdomen d. Expect to have the T-tube removed 3 days postop e. Report brown-green drainage to the provider

b. Clamp T-tube for 1 hr before and after meals c. Keep the drainage system above the level of the abdomen

The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which of the following? (Select all that apply.) a. Dry, flushed skin b. Decreased urine output c. Tachycardia d. Widening pulse pressure e. Rapid respirations f. Thirst

b. Decreased urine output c. Tachycardia e. Rapid respirations f. Thirst

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing GERD? a. Limit caffeine intake to two cups of coffee per day b. Do not lie down for 2 hours after eating c. Follow a low-protein diet d. Take meds with mild to decrease irritation

b. Do not lie down for 2 hours after eating

A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? a. Decrease intake of calorie-dense foods b. Drink canned protein supplements c. Increase intake of high fiber foods d. Take a bulk-forming laxative daily

b. Drink canned protein supplements

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

b. Early menarche d. Family history of breast cancer e. High-dose radiation exposure to chest f. Previous cancer of the breast, uterus, or ovaries

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? a. Placing cool compresses on the affected arm b. Elevating the affected arm on a pillow above heart level c. Avoiding arm exercises in the immediate postoperative period d. Maintaining an intravenous site below the antecubital area on the affected side

b. Elevating the affected arm on a pillow above heart level

Which of the following lifestyle modifications should the nurse encourage the client with a hiatal hernia to include in activities of daily living? a. Daily aerobic exercise b. Eliminating smoking and alcohol use c. Balancing activity and rest d. Avoiding high-stress situations

b. Eliminating smoking and alcohol use

For the client with stomatitis resulting from chemotherapy, the care plan should include which intervention? a. Inspect the mouth every week for fungus. b. Encourage foods with neutral or cool temperatures. c. Give the client spicy foods to stimulate the sense of taste. d. Perform frequent oral hygiene using a commercial alcohol-based mouthwash.

b. Encourage foods with neutral or cool temperatures.

A nurse is assessing a client who has a history of asthma. Which of th following factors should the nurse identify as a risk for asthma? a. Gender b. Environmental allergies c. Alcohol use d. Race

b. Environmental allergies

A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory tests should the nurse expect to be elevated? (Select all that apply.) a. Hematocrit b. Erythrocyte sedimentation rate c. WBC d. Folic acid e. Albumin

b. Erythrocyte sedimentation rate c. WBC

A nurse is teaching about pernicious anemia with a client who has chronic gastritis. Which of the following information should the nurse include in the teaching? a. Pernicious anemia is caused when the cells producing gastric acid are damaged. b. Expect a monthly injection of vitamin B12 c. Plan to take vitamin K supplements d. Pernicious anemia is caused by an increased production of intrinsic factor

b. Expect a monthly injection of vitamin B12

Which of the following would be an expected outcome for a client with PUD? The client will: a. Demonstrate appropriate use of analgesics to control pain b. Explain the rationale for eliminating alcohol from the diet c. Verbalize the importance of monitoring hemoglobin and hematicrit every 3 months d. Eliminate engaging in contact sports

b. Explain the rationale for eliminating alcohol from the diet

A client has had a positive reaction to the Mantoux test. The nurse interprets this reaction to mean that the client has a. Active TB b. Had contact with Mycobacterium tuberculosis c. Developed a resistance to tubercule bacilli d. Developed passive immunity to TB

b. Had contact with Mycobacterium tuberculosis

A client with COPD is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer O2 as prescribed. Which of the following statements is true concerning oxygen administration to a client with COPD? a. High oxygen concentrations will cause coughing and dyspnea b. High oxygen concentrations may inhibit the hypoxic stimulus to breathe c. Increased oxygen use will cause the client to become dependent on the oxygen d. Increased oxygen is contraindicated in clients who are using bronchodilators

b. High oxygen concentrations may inhibit the hypoxic stimulus to breathe

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? a. Select foods high in fat. b. Increase intake of fluids, including juices. c. Eat a good supper when anorexia is not as severe. d. Eat less often, preferably only 3 large meals daily.

b. Increase intake of fluids, including juices.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? a. Increase to 3 L/min and titrate until the SpO2 is 95%. b. Increase to 3 L/min and titrate until the SpO2 is 88%. c. Place the client on a nonrebreather mask on 100% FiO2. d. Maintain at 2 L/min and call respiratory therapy for a breathing treatment.

b. Increase to 3 L/min and titrate until the SpO2 is 88%.

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? a. Absence of saliva b. Loss of tooth enamel c. Sweet taste in mouth d. Absence of eructation

b. Loss of tooth enamel

A client who has been diagnosed with TB has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? (Select all that apply.) a. Having eye examinations every 6 months b. Maintaining follow-up monitoring of liver enzymes c. Decreasing protein intake in the diet d. Avoiding alcohol intake e. The urine may have an orange color

b. Maintaining follow-up monitoring of liver enzymes d. Avoiding alcohol intake e. The urine may have an orange color

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? a. Encourage foods that are high in protein. b. Monitor for fluid and electrolyte imbalance. c. Explain that high-fat diets usually are better tolerated. d. Explain that most daily calories need to be consumed in the evening hours.

b. Monitor for fluid and electrolyte imbalance.

A client with PUD reports being nauseated most of the day and now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? (Select all that apply.) a. Administering an antacid hourly until nausea subsides b. Monitoring the client's VS c. Notifying the physician of the client's symptoms d. Initiating oxygen therapy e. Reassessing the client in an hour

b. Monitoring the client's VS c. Notifying the physician of the client's symptoms

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result? a. Positive b. Negative c. Uncertain d. Borderline

b. Negative

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take? a. Instruct the client to chew the medication before swallowing b. Offer a glass of water following medication administration c. Administer the medication 30 min before meals d. Sprinkle the contents on peanut butter

b. Offer a glass of water following medication administration

The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 mm3 (2 × 109/L), the platelet count is 150,000 mm3 (150 × 109/L), the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL (12 mcmol/L). Which nursing action would be appropriate? a. Place the client on bleeding precautions. b. Place the client on neutropenic precautions. c. Remove the rectal thermometer from the client's room. d. Instruct the dietary department to eliminate all proteins from the client's diet.

b. Place the client on neutropenic precautions.

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect to find? (Select all that apply) a. Bradypnea b. Pleural friction rub c. Hypertension d. Petechiae e. Tachycardia

b. Pleural friction rub d. Petechiae e. Tachycardia

A client who had an appendectomy for a perforated appendix returns from surgery with a drain insered into the incisional site. The purpose of the drain is to: a. Provide access for wound irrigation b. Promote drainage of wound exudates c. Minimize development of scar tissue d. Decrease postoperative discomfort

b. Promote drainage of wound exudates

Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease? a. Encouraging regular ambulation b. Promoting bowel rest c. Maintain current weight d. Decreasing episodes of rectal bleeding

b. Promoting bowel rest

A client with Chron's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following FIRST? a. Encourage the client to drink at least 1,000 mL/day b. Provide parenteral rehydration therapy prescribed by the physician c. Turn and reposition every 2 hours d. Monitor vital signs every shift

b. Provide parenteral rehydration therapy prescribed by the physician

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? a. Stoma is beefy red and shiny b. Purple discoloration of the stoma c. Skin excoriation around the stoma d. Semi-formed stool noted in the ostomy pouch

b. Purple discoloration of the stoma

A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? (Select all that apply) a. Encourage a high-fiber diet b. Remove plants from the room c. Have the client wear a mask when leaving the room d. Have client-specific equipment remain in the room e. Eliminate raw foods from the client's diet

b. Remove plants from the room c. Have the client wear a mask when leaving the room d. Have client-specific equipment remain in the room e. Eliminate raw foods from the client's diet

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 mm3 (200 × 109/L). The nurse should prepare to implement which action based on this finding? a. Remove the fresh flowers from the client's room. b. Remove the rectal thermometer from the client's room. c. Instruct family members to wear a mask when entering the client's room. d. Call the dietary department to report that the client will be on a low-bacteria diet.

b. Remove the rectal thermometer from the client's room.

The nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low and places the client on neutropenic precautions. Which interventions are components of these types of precautions? (Select all that apply.) a. Allowing only fresh fruits in the client's room b. Removing fresh-cut flowers from the client's room c. Encouraging the client to eat any types of fresh vegetables d. Instructing family members on the proper technique for hand washing e. Instructing family members to wear a mask when entering the client's room

b. Removing fresh-cut flowers from the client's room d. Instructing family members on the proper technique for hand washing e. Instructing family members to wear a mask when entering the client's room

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mmHg, HCO3 22 mmHg. The nurse sould recognize that the client is experiencing which of the following acid-base imbalances? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

b. Respiratory alkalosis

A client with bacterial PNA is to be started on IV antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? a. Urinalysis b. Sputum culture c. Chest radiograph d. RBC count

b. Sputum culture

A client diagnosed with asthma has been prescribed fluticasone (Flovent) one puff every 12 hours per inhaler. Place in correct order the statements the nurse would use when teaching the client how to properly use the inhaler with a spacer. a. Hold your breath for at least 10 seconds, then breathe in and out slowly b. Take off the cap and shake the inhaler c. Rinse your mouth d. Breathe out all of your air. Hold the mouth-piece of your inhaler and spacer between your teeth with your lips closed around it e. Press down on the inhaler once and breathe in slowly f. Attach the spacer

b. Take off the cap and shake the inhaler f. Attach the spacer d. Breathe out all of your air. Hold the mouth-piece of your inhaler and spacer between your teeth with your lips closed around it e. Press down on the inhaler once and breathe in slowly a. Hold your breath for at least 10 seconds, then breathe in and out slowly c. Rinse your mouth

Which nursing interventions are appropriate in caring for a client with emphysema? (Select all that apply.) a. Reduce fluid intake to less than 1500 mL/day. b. Teach diaphragmatic and pursed-lip breathing. c. Encourage alternating activity with rest periods. d. Teach the client techniques of chest physiotherapy. e. Keep the client in a supine position as much as possible.

b. Teach diaphragmatic and pursed-lip breathing. c. Encourage alternating activity with rest periods. d. Teach the client techniques of chest physiotherapy.

The client with TB is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the HIGHEST priority? a. Offering the client emotional support b. Teaching the client about the disease and its treatment c. Coordinating various agency services d. Assessing the client's environment for sanitation

b. Teaching the client about the disease and its treatment

Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? a. RR of 25 to 30 bpm b. The ability to perform ADLs c. A maximum loss of 5 to 10 lb. (2.27 to 4.53 kg) of body weight d. Chest pain that is minimized by splinting the rib cage

b. The ability to perform ADLs

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? a. The client breathes in through the mouth. b. The client breathes out slowly through the mouth. c. The client avoids using the abdominal muscles to breathe out. d. The client puffs out the cheeks when breathing out through the mouth.

b. The client breathes out slowly through the mouth.

The nurse is caring for a client who has had a gastrocopy. Which of the following may indicate that the client is devloping a complication r/t the procedure? (Select all that apply.) a. The client has a sore throat b. The client has a temperature of 100 F (37.8 C) c. The client appears drowsy following the procedure d. The client has epigastric pain e. The client experiences hematemesis

b. The client has a temperature of 100 F (37.8 C) d. The client has epigastric pain e. The client experiences hematemesis

A nurse is assessing an older adult client in an extended care facility. The nurse should recognize which of the following findings is a manifestation of an obstruction of the large intestine due to a fecal impaction? a. The client reports he had a bowel movement yesterday b. The client is having small, frequent liquid stools c. The client is flatulent d. The client indicates he vomited once this morning

b. The client is having small, frequent liquid stools

A client has been diagnosed with adenocarcinoma of the stomach and is schedule to undergo a subtotal gastrectomy (Billroth II procedure). During preop teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is MOST accurate? a. The procedure will result in enlargement of the pyloric sphincter b. The procedure will result in anastomosis of the gastric stump to the jejunum c. The procedure will result in removal of the duodenum d. The procedure will result in repositioning of the vagus nerve

b. The procedure will result in anastomosis of the gastric stump to the jejunum

The nurse assesses the client's stoma during the initial postoperatvie period. Which of the following observations should be reported immediately to the physician? a. The stoma is slightly edematous b. The stoma is dark red to purple c. The stoma oozes a small amount of blood d. The stoma does not expel stool

b. The stoma is dark red to purple

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client? a. This is expected and will last for at least 1 year. b. This is expected, and the client should gradually increase activity as tolerated. c. This is an unexpected finding with TB, but it should resolve within 1 month or so. d. This is a short-lived problem that should be gone within 1 week after beginning medication therapy.

b. This is expected, and the client should gradually increase activity as tolerated.

The community health nurse is preparing an educational session for a group of women and will be discussing the primary prevention strategies and treatment measures for breast cancer. What information should the nurse include in the educational session? a. Older women are more likely to get mammograms. b. Treatment decisions are based on a woman's overall health. c. Women younger than age 65 are more likely to get breast cancer. d. A woman's age is the main factor used to decide which screening methods to use.

b. Treatment decisions are based on a woman's overall health.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? a. Sitting position b. Tripod position c. Supine position d. High Fowler's position

b. Tripod position

A nurse is completing an admission assessment for a client who has a small bowel obstruction. Which of the following findigns should the nurse report to the provider? (Select all that apply) a. Emesis prior to insertion of the NG tube b. Urine specific gravity 1.040 c. Hematocrit 60% d. Serum potassium 3.0 mEq/L e. WBC 10,000/uL

b. Urine specific gravity 1.040 c. Hematocrit 60% d. Serum potassium 3.0 mEq/L

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar

b. Venturi mask

A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? (Select all that apply.) a. Administer the cefazolin b. Verify the medication prescription as written by the physician c. Contact the pharmacy and speak to a pharmacist d. Request that cephalexin be sent promptly e. Return the cefazolin to the pharmacy

b. Verify the medication prescription as written by the physician c. Contact the pharmacy and speak to a pharmacist d. Request that cephalexin be sent promptly e. Return the cefazolin to the pharmacy

The nurse is caring for a client who had a subtotal gastrectomy. The nurse should assess the client for which signs and symptoms of dumping syndrome? a. Diarrhea, chills, and hiccups b. Weakness, diaphoresis, and diarrhea c. Fever, constipation, and rectal bleeding d. Abdominal pain, elevated temperature, and weakness

b. Weakness, diaphoresis, and diarrhea

The nurse is developing a plan of care for a client with Chron's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? (Select all that apply.) a. Monitor vital signs once a shift b. Weighing the client daily c. Change the central venous line dressing daily d. Monitoring the IV infusion rate hourly e. Taping all IV tubing connections securely

b. Weighing the client daily d. Monitoring the IV infusion rate hourly e. Taping all IV tubing connections securely

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) a. SaO2 95% b. Wheezing c. Retraction of sternal muscles d. Pink mucous membranes e. Premature ventricular complexes (PVCs)

b. Wheezing c. Retraction of sternal muscles e. Premature ventricular complexes (PVCs)

Which test is commonly used to diagnose cholecystitis? a. abdominal CT scan b. abdominal ultrasound c. barium swallow d. endoscopy

b. abdominal ultrasound

Which factor should be the main focus of nursing management for a client hospitalized for acute cholecystitis? a. administration of antibiotics b. assessment for complications c. preparation for lithotripsy d. preparation for surgery

b. assessment for complications

Which action of pancreatic enzymes can cause pancreatic damage? a. utilization by the intestine b. autodigestion of the pancreas c. reflux into the pancreas d. clogging of the pancreatic duct

b. autodigestion of the pancreas

Following incisional cholecystectomy, the nurse will monitor the patient's T-tube for: a. gastric secretions b. bile drainage c. mucoid drainage d. exocrine secretions

b. bile drainage

Because ____________may occur with pancreatitis, the nurse must observe for the S&S of ________ which may include jerking, irritability, muscular twitching, numbness or tingling around the lips and in the fingers. a. hypercalcemia, tetany b. hypocalemia, tetany c. hypomagnesia, tetany d. hypocalcemia, akinesia

b. hypocalemia, tetany

A client with acute pancreatitis has a blood pressure of 83/40, HR 128 bpm, RR 28/min, and Grey Turner's sign. What action should the nurse perform FIRST? a. assess urine output b. place an IV line c. position on the left side d. insert an NG tube

b. place an IV line

The nurse administers morphine sulfate as ordered to a patient c/o severe pain during an acute episode or pancreatitis. Which of the following assessment findings would indicate morphine toxicity? a. blurred vision b. pupils are pinpoint c. pupils are unequal d. pupils are dilated

b. pupils are pinpoint

The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is PRIMARILY responsible for making it difficult to manage shock in pancreatitis? a. severity of intestinal hemorrhage b. vasodilating effects of kinin peptides c. tendency toward heart failure d. frequent incidence of acute tubular necrosis

b. vasodilating effects of kinin peptides

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which of the following statements, if made by the client to the nurse, indicates that further teaching is necessary? a. "I do not have to restrict my physical activity" b. "I should take pancrelipase (viokase) before meals" c. "I am not at risk for developing diabetes" d. "I am not allowed to drink any alcoholic beverages"

c. "I am not at risk for developing diabetes"

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? a. "This medication can increase my blood sugar levels." b. "This medication can decrease my immune response." c. "I can have an increase in my heart rate while taking this medication." d. "I can have mouth sores while taking this medication."

c. "I can have an increase in my heart rate while taking this medication."

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? a. "I plan to eat 4 to 6 small meals a day." b. "I should sleep in the right side-lying position." c. "I plan to have a snack 1 hour before going to bed." d. "I will stop having a glass of wine each evening with dinner."

c. "I plan to have a snack 1 hour before going to bed."

After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? (Select all that apply.) a. "With careful attention to my diet, my diverticulosis can be cured." b. "Using a cathartic laxative weekly is okay to control bowel movements." c. "I should follow a diet that's high in fiber." d. "It is important for me to drink at least 2,000 mL of fluid every day." e. "I should exercise regularly."

c. "I should follow a diet that's high in fiber." d. "It is important for me to drink at least 2,000 mL of fluid every day." e. "I should exercise regularly."

A nurse is teaching a female adult client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of teaching? a. "I will need to have a mammogram every 2 years beginning at age 45." b. "I should have a colonoscopy every 15 years beginning at age 60." c. "I will need to have an annual breast examination every year after 40." d. "I should have a fecal occult test done every 3 years."

c. "I will need to have an annual breast examination every year after 40."

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? a. "I will decrease my fluid intake while taking this medication." b. "I will expect to have black, tarry stools." c. "I will take my medication with meals." d. "I will monitor for weight loss while on this medication."

c. "I will take my medication with meals."

A nurse is teaching a client who has a new prescription for famotidine. Which of the following statements by the client indicates understanding of the teaching? a. "The medicine coats the lining of my stomach" b. "The medication should stop the pain right away" c. "I will take my pill 1 hr before meals" d. "I will monitor for bleeding from my nose"

c. "I will take my pill 1 hr before meals"

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? a. "I should avoid blowing my nose." b. "I may need a platelet transfusion if my platelet count is too low." c. "I'm going to take aspirin for my headache as soon as I get home." d. "I will count the number of pads and tampons I use when menstruating."

c. "I'm going to take aspirin for my headache as soon as I get home."

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching? a. "Take the medication 2hr after eating" b. "Discontinue this medication if your skin turns yellow-orange" c. "Notify the provider if you experience a sore throat" d. "Expect your stools to turn black"

c. "Notify the provider if you experience a sore throat"

A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? a. "Your nausea will lessen with each course of chemotherapy." b. "Hot food is better tolerated due to the aroma." c. "Try eating several small meals throughout the day" d. "Increase your intake of red meat as tolerated"

c. "Try eating several small meals throughout the day"

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. "Your urine can turn a dark orange." b. "Watch for a change in the sclera of your eyes." c. "Watch for any changes in vision." d. "Take vitamin B6 daily."

c. "Watch for any changes in vision."

Following a laproscopic cholecystectomy, the client c/o abdominal pain and bloating. Which of the following responses by the nurse is BEST? a. "Increase your intake of fresh fruits and vegetables" b. "I'll give you the prescribed pain medication" c. "Why don't you take a walk in the hallway" d. "You may need an indwelling catheter"

c. "Why don't you take a walk in the hallway"

A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. "You might notice yellowing of your skin." b. "You might experience pain in your joints." c. "You might notice tingling of your hands." d. "You might experience a loss of appetite."

c. "You might notice tingling of your hands."

In general health screening, the nurse should recognize which patient as at greatest risk for development of gallbladder disease? a. 32 yo man on corticosteroid therapy b. 18 yo woman with anorexia nervosa c. 60 yo woman on estrogen replacement therapy d. 40 yo man with alcoholism

c. 60 yo woman on estrogen replacement therapy

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? a. A 25-year-old woman with diabetic ketoacidosis b. A 65-year-old man out of bed 1 day after prostate resection c. A 73-year-old woman who has just had pinning of a hip fracture d. A 38-year-old man with pulmonary contusion sustained in an automobile crash

c. A 73-year-old woman who has just had pinning of a hip fracture

The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? a. A pale color b. A purple color c. A brick-red color d. A large amount of red drainage

c. A brick-red color

The nurse has been assigned to provide care for four patients. In what order should the nurse assess these patients? a. A client awaiting surgery for a hiatal hernia repair at 1100. b. A client wih suspected gastric cancer who is on NPO status for tests. c. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain. d. A client who is requesting pain medication 2 days after repair of a fractured jaw.

c. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain. d. A client who is requesting pain medication 2 days after repair of a fractured jaw. b. A client wih suspected gastric cancer who is on NPO status for tests. a. A client awaiting surgery for a hiatal hernia repair at 1100.

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse should determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? a. An uninsured man who is homeless b. A newly immigrated woman from Korea c. A man who is an inspector for the U.S. Postal Service d. An older woman admitted from a long-term care facility

c. A man who is an inspector for the U.S. Postal Service

The nurse should instruct the client with an ileostomy to report which of the following immediately? a. Passage of liquid stool form the stoma b. Occasional presence of undigested food in the effluent c. Absence of drainage from the ileostomy for 6 or more hours d. Temperature of 99.8 F (37.7 C)

c. Absence of drainage from the ileostomy for 6 or more hours

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? a. Do not exceed 1 L/min. b. Do not exceed 2 L/min. c. Adjust the oxygen depending on SpO2. d. Adjust the oxygen depending on respiratory rate.

c. Adjust the oxygen depending on SpO2.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 101.2 F (38.4 C), and blood pressure 100/54 mmHg. Which of the following nursing actions is the priority? a. Notify the provider b. Administer heparin via IV infusion c. Administer oxygen therapy d. Obtain a spiral CT scan

c. Administer oxygen therapy

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the client should eat which of the following? a. Bland foods b. High-protein foods c. Any foods that are tolerated d. A glass of milk with each meal

c. Any foods that are tolerated

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? a. Dorsiflex the client's foot. b. Measure the abdominal girth. c. Ask the client to extend the arms. d. Instruct the client to lean forward.

c. Ask the client to extend the arms.

Which of the following nursing interventions would MOST likely promote self-care behaviors in the client with hiatal hernia? a. Introduce the client to other people who are successfully managing their care b. Include the client's daughter in the teaching so she can help implement the plan c. Ask the client to identify other situations in which the client changed health care habits d. Provide reassurance that the client will be able to implement all aspects of the plan successfully

c. Ask the client to identify other situations in which the client changed health care habits

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action? a. Place the client in supine position. b. Apply an ice collar around the client's neck. c. Assist the client to a sitting position with the head tilted forward. d. Instruct the client to swallow the blood until the bleeding can be controlled.

c. Assist the client to a sitting position with the head tilted forward.

A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? a. Before meals. b. With meals. c. At bedtime. d. When pain occurs.

c. At bedtime.

The nurse is caring for a client with cancer of the prostate who has undergone a prostatectomy. Which action should the nurse include in discharge instructions? a. Avoid driving the car for a few days. b. Restrict fluid intake to prevent incontinence. c. Avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks. d. Notify the health care provider if small blood clots are noticed during urination.

c. Avoid lifting objects heavier than 20 lb (9 kg) for at least 6 weeks.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum

c. Bronchospasm

Which interventions are the most appropriate for a client who is experiencing thrombocytopenia? (Select all that apply.) a. Use a straight-edge razor for shaving. b. Obtain a rectal temperature every 8 hours. c. Check secretions for frank or occult blood. d. Give vitamin K by the intramuscular route. e. Encourage fluid intake to avoid constipation. f. Provide oral sponges or a soft toothbrush for oral care.

c. Check secretions for frank or occult blood. e. Encourage fluid intake to avoid constipation. f. Provide oral sponges or a soft toothbrush for oral care.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken

c. Chest pain that occurs suddenly

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply.) a. Client reports pain relieved by eating b. Client states that pain often occurs at night c. Client reports a sensation of bloating d. Client states that pain occurs 30 min to 1 hr after a meal e. Client experiences pain upon palpation of the epigastric region

c. Client reports a sensation of bloating d. Client states that pain occurs 30 min to 1 hr after a meal e. Client experiences pain upon palpation of the epigastric region

A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority? a. Client reports difficulty sleeping b. The client's urine is positive for glucose c. Client reports having an elevated body temperature d. Client reports gaining 4lb in the last 6 months

c. Client reports having an elevated body temperature

The client has been taking magnesium hydroxide (milk of magnesia) to control hiatal hernia symptoms. The nurse should assess the client for which of the following conditions most commonly associated with the ongoing use of magnesium-based antacids? a. Anorexia b. Weight gain c. Diarrhea d. Constiptation

c. Diarrhea

A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? a. Serum amylase 80 units/L b. WBC 9,000/mm3 c. Direct bilirubin 2.1 mg/dL d. Alkaline phosphatase 25 units/L

c. Direct bilirubin 2.1 mg/dL

Which of the following lab findings are expected when the client has diverticulitis? a. Elevated RBC count b. Decreased platelet count c. Elevated WBC count d. Elevated serum blood urea nitrogen (BUN) concentration

c. Elevated WBC count

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? a. Restricting fluids b. Placing a pillow under the knees c. Encouraging active range-of-motion exercises d. Applying a heating pad to the lower extremities

c. Encouraging active range-of-motion exercises

The nurse reads that a client's tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation? a. Systemic tuberculosis b. Pulmonary tuberculosis c. Exposure to tuberculosis d. No evidence of tuberculosis

c. Exposure to tuberculosis

A client with PNA has a temperature of 102.6 F (39.2 C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? a. Position changes every 4 hours b. Nasotracheal suctioning to clear secretions c. Frequent linen changes d. Frequent offering of a bedpan

c. Frequent linen changes

A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? a. Promote bronchodilation b. Act as an expectorant c. Have an anti-inflammatory effect d. Prevent development of respiratory infections

c. Have an anti-inflammatory effect

A client who has been diagnosed with GERD has heartburn. To decrease the heartburn, the nurse should instrut the client to ELIMINATE which of the following items from the diet? a. Lean beef b. Air-popped popcorn c. Hot chocolate d. Raw vegetables

c. Hot chocolate

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? a. Increased oxygen saturation with ambulation b. A widened diaphragm documented by chest x-ray c. Hyperinflation of lungs documented by chest x-ray d. A shortened expiratory phase of the respiratory cycle

c. Hyperinflation of lungs documented by chest x-ray

A client has had an exaceration of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which of the following complications? a. Heart failure b. Deep vein thombosis c. Hypokalemia d. Hypocalcemia

c. Hypokalemia

A client who has a history of Chron's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: a. Hyperalbuminemia b. Thrombocytopenia c. Hypokalemia d. Hypercalcemia

c. Hypokalemia

A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign? a. Tap lightly at the costovertebral margin on the client's back b. Palpate the right lower quadrant c. Inspect the skin around the umbilicus d. Auscultate the area below the scapula

c. Inspect the skin around the umbilicus

The nurse is caring for a client who has asthma. The nurse should conduct a focused assessment to detect which of the following? a. increased forced expiratory volume b. Normal breath sounds c. Inspiratory and expiratory wheezing d. Morning headaches

c. Inspiratory and expiratory wheezing

Which of the following mental status changes may occur when a client with PNA is first experiencing hypoxia? a. Coma b. Apathy c. Irritability d. Depression

c. Irritability

Since the diagnosis of stomach cancer, the client has been having trouble sleeping and is frequently preoccupied with thoughts about how life will change. The client says, "I wish my life could stay the same." Based on this information, the nurse should understand that the client: a. Is having difficulty coping b. Has a sleep disorder c. Is grieving d. Is anxious

c. Is grieving

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for which of the following? a. Suppression of the client's respiratory infection b. Decrease in bronchial secretions c. Less difficulty breathing d. Thinning of tenacious, purulent sputum

c. Less difficulty breathing

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? a. Ambulate following a meal. b. Eat high-carbohydrate foods. c. Limit the fluids taken with meals. d. Sit in a high Fowler's position during meals.

c. Limit the fluids taken with meals.

Following a gastrectomy, the nurse should position the client in which of the following positions? a. Prone b. Supine c. Low Fowler's d. Right or left Sims

c. Low Fowler's

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? a. Sitting up and leaning on a table b. Standing and leaning against a wall c. Lying on the back in a low Fowler's position d. Sitting up with the elbows resting on the knees

c. Lying on the back in a low Fowler's position

The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? a. Maintain a high-carbohydrate diet. b. Increase fluid intake, particularly at mealtime. c. Maintain a low Fowler's position while eating. d. Ambulate for at least 30 minutes following each meal.

c. Maintain a low Fowler's position while eating.

Immediately after having surgery to create an ileostomy, which goal has the HIGHEST priority? a. Providing relief from constipation b. Assisting the client with self-care activities c. Maintaining fluid and electrolyte balance d. Minimizing odor formation

c. Maintaining fluid and electrolyte balance

A client with PNA is experiencing pleuritic chest pain. The nurse should assess the client for: a. A mild but constant acing in the chest b. Severe midsternal pain c. Moderate pain that worsens on inspiration d. Muscle spasm pain the accompanies coughing

c. Moderate pain that worsens on inspiration

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? a. Aids in exhalation b. Moves up and inward c. Moves downward and out d. Makes the thoracic cage smaller

c. Moves downward and out

A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? a. Use a glycerin-soaked swab to clean the client's teeth b. Encourage increased intake of citrus fruit juices c. Obtain a culture of the lesions d. Provide an alcohol-based mouthwash for oral hygiene

c. Obtain a culture of the lesions

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

c. Pain relieved by food intake

The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer? a. Weight loss b. Nausea and vomiting c. Pain that is relieved by food intake d. Pain that radiates down the right arm

c. Pain that is relieved by food intake

A client has an NG tube inserted at the time of abdominal perineal resection with permanent colostomy for colon cancer. This tube will most likelt be removed when the client demonstrates: a. Absence of nausea and vomiting b. Passage of mucus from the rectum c. Passage of flatus and feces from the colostomy d. Absence of stomach drainage for 24 hours

c. Passage of flatus and feces from the colostomy

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? a. Roast pork b. Cheese omelet c. Pasta with sauce d. Tuna fish sandwich

c. Pasta with sauce

The nurse teaches a client with COPD to assess for signs and symptoms of right-sided heart failure. Which of the following S&S should be included in the teaching plan? a. Clubbing of nail beds b. Hypertension c. Peripheral edema d. Increased appetite

c. Peripheral edema

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: a. Contact the surgeon to request an order for a narcotic for the pain. b. Maintain the client in a recumbent position. c. Place the client on nothing-by-mouth (NPO) status. d. Apply heat to the abdomen in the area of the pain.

c. Place the client on nothing-by-mouth (NPO) status.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? a. Cyanosis b. Hyperinflated chest c. Rapid, shallow respirations d. Coarse crackles auscultated bilaterally

c. Rapid, shallow respirations

What should the nurse teach a client about how to avoid the dumping syndrome? (Select all that apply.) a. Consume three regularly spaced meals per day b. Eat a diet wit high-carbohydrate foods with each meal c. Reduce fluids with meals, but take them between meals d. Obtain adequate amounts of protein and fat in each meal e. Eat in a relaxing environment

c. Reduce fluids with meals, but take them between meals d. Obtain adequate amounts of protein and fat in each meal e. Eat in a relaxing environment

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following lab values? a. Serum sodium b. Serum potassium c. Serum creatinine d. Serum calcium

c. Serum creatinine

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? a. Chest x-ray b. Bronchoscopy c. Sputum culture d. Tuberculin skin test

c. Sputum culture

A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? a. Take quick breaths upon inhalation. b. Place your hand over your stomach. c. Take a deep breath in though your nose. d. Puff your cheeks upon exhalation.

c. Take a deep breath in though your nose.

A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the proceudre would indicate the development of a potential complication? a. The client has a sore throat b. The client displays signs of sedation c. The client experiences a sudden increase in temperature d. The client demonstrates a lack of appetite

c. The client experiences a sudden increase in temperature

A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the MOST likely cause of the client's constipation? a. The client has not been including enough fiber in the diet b. The client needs to increase the daily exercise c. The client is experiencing an adverse effect of aluminum hydroxide d. The client has devloped a gastrointestional obstruction

c. The client is experiencing an adverse effect of aluminum hydroxide

The nurse is supervising care of a client receiving total parenteral nutrition (TPN) through a single-lumen central venous access device. The nurse would be most concerned if which of the following was observed? a. The RN hangs a new bag of TPN daily b. A mask is placed on the client when changing the clients' dressing c. The client's dressing is changed daily using sterile technique d. The client is weighed two to three times per week.

c. The client's dressing is changed daily using sterile technique

A client who has ulcerative colitis has persistent diarrhea, and has lost 12 lb (5.4 kg) since the exacerbation of the disease. Which of the following will be most effective in helping the client meet nutritional needs? a. Continuous enteral feedings b. Following a high-calorie, high-protein diet c. Total parenteral nutrition (TPN) d. Eating six small meals a day

c. Total parenteral nutrition (TPN)

A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained, and a peripheral IV has been inserted. Which of the following prescriptions from a health care provider should the nurse question? a. infuse a 500 mL NS bolus b. calcium gluconate 90 mg in 100 mL NS c. Total parenteral nutrition (TPN) at 72 mL/hr d. placement of a Foley catheter

c. Total parenteral nutrition (TPN) at 72 mL/hr

The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. The nurse should teach the client to put the pillow in which location for self-examination of the right breast? a. Under the left scapula b. Under the left shoulder c. Under the right shoulder d. Under the small of the back

c. Under the right shoulder

When obtaining a nursing history from a client with a suspected gastric ulcer, which S&S should the nurse assess? (Select all that apply.) a. Epigastric pain at night b. Relief of epigastric pain after eating c. Vomiting d. Weight loss e. Melena

c. Vomiting d. Weight loss e. Melena

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. Which of the following information should the nurse include in the teaching? a. Take the medication with food b. Monitor for diarrhea c. Wait 1 hr before taking other oral medications d. Maintain a low-fiber diet

c. Wait 1 hr before taking other oral medications

The nurse is caring for a client five hours after a pancreatectomy for cancer of the pancreas. On assessment, the nurse notes that there is minimal drainage from the NG tube. It is most important for the nurse to take which of the following actions? a. notify the physician b. monitor vital signs q 15" c. check the tubing for kinks d. replace the NG tube

c. check the tubing for kinks

When admitting a client to the hospital with suspected acute pancreatitis, which electrolyte disorder would be expected? a. hypoglycemia b. hypernatremia c. hypocalcemia d. hyperkalemia

c. hypocalcemia

The nurse recognizes which of the following as goals for treatment of the patient with acute pancreatitis? a. manage pain and increase pancreatic secretions b. hydrate aggressively to decrease serum calcium levels c. increase fluid volume and decrease pancreatic enzymes d. administer steroids to decrease pancreatic inflammation

c. increase fluid volume and decrease pancreatic enzymes

A 36 yo client is scheduled for a cholecystectomy this morning. Preop meds have been administered. While completing the preop checklist, the nurse discovers the client has not signed the consent for surgery. What should the nurse do next? a. send the client to surgery b. have the client sign the consent form now c. inform the physician d. have a family member sign the consent

c. inform the physician

For a client with the diagnosis of acute pancreatitis, the nurse would plan for which important component of care? a. testing for Homan's sign b. measuring the abdominal girth c. performing a finger stick for blood glucose d. straining the urine

c. performing a finger stick for blood glucose

A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be MOST appropriate? a. "It has been 4 days since your surgery, and you will soon be discharged. You have to learn to care for your colostomy before you leave the hospital." b. "I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it." c. "I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness." d. "I can see that you are upset. Would you like to share your concerns with me?"

d. "I can see that you are upset. Would you like to share your concerns with me?"

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? a. "I need to avoid alcohol and sedative medications." b. "I have to cut down on the percentage of carbohydrates in my diet." c. "Besides smoking, I can't be around second- or thirdhand smoke." d. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."

d. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."

The nurse has provided instructions to a client receiving external radiation therapy. Which client statement would indicate a need for further instruction regarding self-care related to the radiation therapy? a. "I need to eat a high-protein diet." b. "I need to avoid exposure to sunlight." c. "I need to wash my skin with a mild soap and pat dry." d. "I need to apply pressure on the irritated area by wearing snug clothing to prevent bleeding."

d. "I need to apply pressure on the irritated area by wearing snug clothing to prevent bleeding."

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? a. "I need to continue medication therapy for 1 month." b. "I can't shop at the mall for the next 6 months." c. "I can return to work if a sputum culture comes back negative." d. "I should not be contagious after 2 to 3 weeks of medication therapy."

d. "I should not be contagious after 2 to 3 weeks of medication therapy."

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

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

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. "I will place the adapter on my finger to read my blood oxygen saturation level." b. "I will lie on my back with my knees bent." c. "I will rest my hand over my abdomen to create resistance." d. "I will take in a deep breath and hold it before exhaling."

d. "I will take in a deep breath and hold it before exhaling."

A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? a. "I should take my antacid before I take my other meds." b. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid" c. "My antacid will be most effective if I take it whenever I experience stomach pains" d. "It is best for me to take my antacid 1 to 3 hours after meals."

d. "It is best for me to take my antacid 1 to 3 hours after meals."

A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which of the following responses by the nurse is MOST appropriate? a. "Eating six meals a day is time-consuming, isn't it?" b. "You will have to eat six small meals a day for the rest of your life." c. "You will be able to tolerate three meals a day before you are discharged." d. "Most clients can resume their normal meal patterns in about 6 to 12 months."

d. "Most clients can resume their normal meal patterns in about 6 to 12 months."

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? a. "The pain doesn't usually come right after I eat." b. "The pain gets so bad that it wakes me up at night." c. "The pain that I get is located on the right side of my chest." d. "My pain comes shortly after I eat, maybe a half-hour or so later."

d. "My pain comes shortly after I eat, maybe a half-hour or so later."

The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in how long? a. 6 to 12 hours b. 12 to 24 hours c. 24 to 28 hours d. 48 to 72 hours

d. 48 to 72 hours

A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication should the nurse look for during the client's postprocedure assessment? a. Bradycardia b. Nausea and vomiting c. Numbness in the legs d. A rigid, boardlike abdomen

d. A rigid, boardlike abdomen

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, boardlike abdomen

d. A rigid, boardlike abdomen

When instructing clients on how to decrease the risk of COPD, the nurse should emphasize which of the following? a. Participate regularly in aerobic exercises b. Maintain a high-protein diet c. Avoid exposure to people with known respiratory infections d. Abstain from cigarette smoking

d. Abstain from cigarette smoking

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. Which of the following indicates that the client has attaiend the goal? The client has: a. Regained weight loss b. Resumed normal dietary intake of three meals a day c. Controlled nausea and vomiting through regular use of antiemetics d. Achieved optimal nutritional status through oral or parenteral feedings

d. Achieved optimal nutritional status through oral or parenteral feedings

A 34 yo female with a history of asthma is admitted to the ED. The nurse notes that the client is dyspneic, with a RR of 35 breaths per minute, nasal flaring, and use of accessory muscles. Auscultation of lung fields reveals greatly diminished breath sounds. Based on those finding, which action should the nurse take to initiate care of the client? a. Initiate oxygen therapy as prescribed and reassess the client in 10 minutes b. Draw blood for an ABG c. Encourage the client to relax and breathe slowly through the mouth d. Administer bronchodilators as prescribed

d. Administer bronchodilators as prescribed

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 100 F (37.8 C), respiraions 30/min, blood pressure 130/7, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. a. Perform a sputum culture b. Administer an antipyretic medication to promote client comfort c. Administer antibiotics d. Administer oxygen therapy

d. Administer oxygen therapy a. Perform a sputum culture c. Administer antibiotics b. Administer an antipyretic medication to promote client comfort

The client with GERD has a chronic cough. This symptom may be indicidative of which of the following? a. Development of laryngeal cancer b. Irritation of the esophagus c. Esophageal scar tissue formation d. Aspiration of gastric contents

d. Aspiration of gastric contents

A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessor muscles when breathing. Which of the following classes of medications should the nurse expect to administer? a. Antibiotic b. Beta-blocker c. Antiviral d. Beta2 agonist

d. Beta2 agonist

Which of the following is an expected outcome for an adult client with well-controlled asthma? a. Chest x-ray demonstrates minimal hyperinflation b. Temperature remains lower than 100 F (37.8 C) c. Venous blood sample for red bloods cells demonstrates increased count d. Breath sounds are clear

d. Breath sounds are clear

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? a. Blood-tinged sputum b. Dry, nonproductive cough c. Sore throat d. Bronchospasms

d. Bronchospasms

A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? a. Remove the dressing and leave the incision open to air b. Remove the drain if wound drainage is minimal c. Gently irrigate the drain to remove exudate d. Clean the area around the drain moving away from the drain

d. Clean the area around the drain moving away from the drain

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infections. Which of the following findings would be expected? a. Normal breath sounds b. Prolonged inspiration c. Normal chest movement d. Coarse crackles and rhonchi

d. Coarse crackles and rhonchi

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note? a. High fever b. Flushed skin c. Complaints of weight gain d. Complaints of night sweats

d. Complaints of night sweats

To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following? a. Sit upright for 30 minutes after meals. b. Drink liquids with meals, avoiding caffeine. c. Avoid milk and other dairy products. d. Decrease the carbohydrate content of meals.

d. Decrease the carbohydrate content of meals.

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? a. Hypercalcemia b. Hypernatremia c. Frothy, fatty stools d. Decreased hemoglobin

d. Decreased hemoglobin

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? a. Pain in the right upper quadrant radiating to right shoulder b. Report of pain being worse when sitting upright c. Pain relieved with defecation d. Epigastric pain radiating to the left shoulder

d. Epigastric pain radiating to the left shoulder

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? a. Folate deficiency b. Malabsorption of fat c. Intestinal obstruction d. Fluid and electrolyte imbalance

d. Fluid and electrolyte imbalance

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply.) a. Diarrhea b. Black, tarry stools c. Hyperactive bowel sounds d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. Left upper quadrant pain with radiation to the back

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

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to report? a. History of cholelithiasis b. Elevated serum amylase level c. Decrease in bowel sounds upon auscultation d. Hand spasms present when blood pressure is checked

d. Hand spasms present when blood pressure is checked

Penicillin (PCN) has been prescribed for a client admitted to the hospital for a treatment of PNA. Prior to administering the first dose of PCN, the nurse should ask the client: a. Do you have a history of seizures? b. Do you have any cardiac history? c. Do you have any recent infection? d. Have you had a previous allergy to PCN?

d. Have you had a previous allergy to PCN?

Which of the following is a potential riskf actor for the development of colon cancer? a. Chronic constipation b. Long-term use of laxatives c. History of smoking d. History of inflammatory bowel disease

d. History of inflammatory bowel disease

A client with a peptic ulcer has been instructed to avoid intense physicial activity and stress. Which strategy should the client incorporate in the home care plan? a. Conduct physical activity in the morning in order to be able to rest in the afternoon b. Have the family agree to perform the necessary yard work at home c. Give up jogging and substitute a less demanding hobby d. Incorporate periods of physical and mental rest in the daily schedule

d. Incorporate periods of physical and mental rest in the daily schedule

A nurse is teaching a client who as a new diagnosis of dumping syndrome following gastric surgery. Which of the following information should the nurse include in the teaching? a. Eat three moderate-sized meals a day b. Drink at least one glass of water with each meal c. Eat a bedtime snack that contains a milk product d. Increase protein in the diet

d. Increase protein in the diet

A client with peptic ulcer disease (PUD) is taking rantidine (Zantac). What is the expected outcome of this drug? a. Heal the ulcer b. Protect the ulcer surface from acids c. Reduce acid concentration d. Limit gastric acid secretions

d. Limit gastric acid secretions

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning? a. Sitting up and leaning on a table b. Standing and leaning against a wall c. Sitting up with elbows resting on knees d. Lying on the back in a low Fowler's position

d. Lying on the back in a low Fowler's position

The nurse is providing care to a client who has undergone modified right mastectomy for the treatment of breast cancer. Which activity should the nurse incorporate into the plan of care? a. Keep suction drains fully inflated to provide adequate suction. b. Perform venipunctures and blood pressures on the operative side only. c. Inform the client that drains will be removed on the second postoperative day. d. Maintain head of the bed elevation at 30 degrees with the right arm elevated on a pillow.

d. Maintain head of the bed elevation at 30 degrees with the right arm elevated on a pillow.

A client is admitted to the hospital after vomiting bright red blood an is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. The nurse should do which of the following first? a. Administer pain medication as prescribed b. Raise the head of the bed c. Prepare to insert a NG tube d. Notify the physician

d. Notify the physician

A client with a well-managed ileostomy has a sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. The nurse should: a. Tell the client to take an antiemetic b. Encourage the client to increase fluid intake to 3L/day to replace fluid lost through vomiting c. Instruct the client to take 30mL of milk of magnesia (MOM) to stimulate bowel movement d. Notify the physician

d. Notify the physician

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? a. Percussion of posterior lobes of lungs b. Auscultation of trachea c. Inspection of the conjunctiva d. Palpation of the orbital areas

d. Palpation of the orbital areas

A client with acute appendicitis develops a fever, tachycardia and hypotension. Based on these findings, the nurse should further assess the client for which of the following complications? a. Deficient fluid volume b. Intestinal obstruction c. Bowel ischemia d. Peritonitis

d. Peritonitis

The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? a. High-fiber, low-fat diet b. Age older than 30 years c. Distant relative with colorectal cancer d. Personal history of ulcerative colitis or gastrointestinal polyps

d. Personal history of ulcerative colitis or gastrointestinal polyps

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination.

d. Promote carbon dioxide elimination.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which intervention as the best strategy to assist the client in coping with the illness? a. Allow the client to deal with the disease in an individual fashion. b. Ask family members whether they wish a psychiatric consultation. c. Encourage the client to visit with the pastoral care department's chaplain. d. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

d. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should: a. Encourage the client to increase fluid intake b. Advise the client should avoid iron-rich foods c. Place the client on contact precautions d. Report the finding to the health care provider

d. Report the finding to the health care provider

The nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position? a. Prone b. Supine c. Left side d. Right side

d. Right side

The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time? a. 1 or 2 days b. 1 to 2 weeks c. Almost 1 week d. Several weeks to months

d. Several weeks to months

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a. Sitting up in bed b. Side-lying in bed c. Sitting in a recliner chair d. Sitting up and leaning on an overbed table

d. Sitting up and leaning on an overbed table

The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? a. Recently retired from a job b. Significant other has a gastric ulcer c. Occasionally drinks 1 cup of coffee in the morning d. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis

d. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis

Which of the following indicates that the client with COPD who has been discharged to home understands the plan of care? a. The client promises to do pursed-lip breathing b. The client states actions to reduce pain c. The client will use oxygen via a nasal cannula at 5L/min d. The client agrees to call the physician if dyspnea on exertion increases

d. The client agrees to call the physician if dyspnea on exertion increases

A nurse is reviewing a new prescription for ursodiol with a client who has cholelithiasis. Which of the following information should the nurse include in the teaching? a. This medication is used to decrease acute biliary pain b. This medication requires thyroid function monitoring every 6 months c. This medication is not recommended for clients who have diabetes mellitus d. This medication dissolves gallstones gradually over a period of up to 2 years

d. This medication dissolves gallstones gradually over a period of up to 2 years

Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? a. To promote oxygen intake b. To strengthen the diaphragm c. To strengthen the intercostal muscles d. To promote carbon dioxide elimination

d. To promote carbon dioxide elimination

A client receiving chemotherapy is experiencing mucositis. The nurse should advise the client to use which item as the best substance to rinse the mouth? a. Alcohol-based mouthwash b. Hydrogen peroxide mixture c. Lemon-flavored mouthwash d. Weak salt and bicarbonate mouth rinse

d. Weak salt and bicarbonate mouth rinse

In alcohol-related pancreatitis, which intervention may be most effective to reduce the exacerbation of pain? a. lying in a supine position b. eating a low-fat diet c. administer an NSAID d. abstaining from EtOH

d. abstaining from EtOH

A client with pancreatitis may exhibit Cullen's sign on physical examination. Which symptom best describes Cullen's sign? a. jaundiced sclera b. pain that occurs with movement c. bluish discoloration of the left flank area d. bluish discoloration of the periumbilical area

d. bluish discoloration of the periumbilical area

The cyanosis that accompanies bacterial PNA is PRIMARILY caused by which of the following? a. Decreased cardiac output b. Pleural effusion c. Inadequate peripheral circulation d. decreased oxygenation of the blood

d. decreased oxygenation of the blood

Which of the following diets would be MOST appropriate for a client with COPD? a. low-fat, low-cholesterol diet b. Bland, soft diet c. low-sodium diet d. high-calorie, high-protein diet

d. high-calorie, high-protein diet

A client with a h/o cholecystitis is now being admitted to the hospital for possible surgical intervention. The orders include NPO, IV therapy, and bedrest. In addition to assessing for nausea, vomiting and anorexia, the nurse should observe for pain a. in the right lower quadrant b. after ingesting food c. radiating to the left shoulder d. in the epigastrum and right upper quadrant

d. in the epigastrum and right upper quadrant

When counseling a client in the ways to prevent cholecystitis, which guideline is most important? a. eat a low-protein diet b. eat a low-fat, low-cholesterol diet c. limit exercise to 10min a day d. keep weight proportional to height

d. keep weight proportional to height

Which factor should be the initial focus of nursing management in a client with acute pancreatitis? a. dietary management b. prevention of skin breakdown c. management of hypoglycemia d. pain control

d. pain control

The nurse should monitor the client with acute pancreatitis for which of the following complications? a. heart failure b. duodenal ulcer c. cirrhosis d. pneumonia

d. pneumonia

The assessment finding that should be reported immediately should it develop in the client with acute pancreatitis is: a. nausea and vomiting b. decreased bowel sounds c. abdominal pain d. shortness of breath

d. shortness of breath