MED SURG HESI
A client recovering from hepatitis A asks the nurse about returning to work. Which is the best response by the nurse? 1 "As soon as you're feeling less tired, you may go back to work." 2 "Unfortunately, few people fully recover from hepatitis in less than six months." 3 "Gradually increase your activities because relapses may occur in those who return to full activity too soon." 4 "You cannot return to work for six months because the virus will still be in your stools, and you still are communicable."
Ans: 3 Relapses are common; they occur after too early ambulation and too much physical activity. Fatigue is a cardinal symptom; if the client tires at rest, a return to work must be delayed. The client does not stay contagious for six months.
What is the normal value of functional residual capacity? Correct1 2.5 L 2 3.5 L 3 4.5 L 4 6.0 L
The normal value of functional residual capacity is 2.5 L. The normal value of inspiratory capacity is 3.5 L. The normal value of vital capacity is 4.5 L.The normal value of total lung capacity is 6.0 L.
The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, specifically to avoid the intake of what? 1 Milk Incorrect2 Cheese 3 Coffee Correct4 Cabbage
Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee should not cause excessive gas problems in moderation. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.
A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? Correct1 Deep breathing techniques 2 Performing productive coughing 3 Turning from side to side frequently 4 Pant breathing while gently closing the eyelid
Deep breathing is an intervention to prevent respiratory complications that does not increase intraocular pressure. Coughing is contraindicated because it increases intraocular pressure. Although turning from side to side is permitted, it is not as effective as deep breathing in preventing respiratory complications. Pant breathing is shallow breathing and will not prevent respiratory complications.
During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response? Correct1 "You seem concerned about your diagnosis." 2 "You are feeling guilty about your smoking." 3 "There have been advances in lung cancer therapy." 4 "Trust your healthcare provider, who is very competent in treating cancer.
The correct response acknowledges the client's concerns and allows them to set the framework for discussion and express self-identified feelings. The client's statement is not specific enough to come to the conclusion that the client feels guilty; this is an assumption by the nurse. Talking about advances in lung cancer therapy or trust for the healthcare provider avoids the client's concerns and cuts off communication.
A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? 1 Tremors 2 Anasarca Incorrect3 Bradypnea Correct4 Tachycardia
The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurologic problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.
A client reports pain four hours after a liver biopsy. The nurse identifies that there is leakage of a large amount of bile on the dressing over the biopsy site. What should the nurse do first? 1 Tell the client to remain flat on the back. 2 Medicate the client for pain as prescribed. 3 Monitor the client's vital signs every 10 minutes. Correct4 Notify the primary healthcare provider immediately.
A small amount of bile-colored spotting is expected, but a large amount is excessive and not expected. The healthcare provider should be notified. The client should be on the right side to compress the liver capsule against the chest wall. Medicating the client treats only the pain and disregards the need for medical evaluation of the complication. Although monitoring vital signs is important, the priority is to notify the healthcare provider.
An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response? 1 "Stay away from preschool and school-aged children." Correct2 "Avoid putting your hands near your nose and mouth." 3 "Wear a sweater under your coat when going outside in cold weather." 4 "Take an aspirin when you think you may be coming down with a cold."
Transmission of microorganisms via the hands is one of the most common ways pathogens are transmitted from one person to another. Avoiding putting hands near the nose and mouth interrupts the chain of infection at the portal of entry phase. Staying away from preschool and school-aged children is unnecessary and could cause social isolation. However, exposure to these children when they have an active infection should be avoided if possible. Precautions can be taken when around children (e.g., washing the hands, avoiding exposure to nasal and oral secretions). Wearing a sweater under the coat when going outside in cold weather will not limit the exposure to pathogenic microorganisms. However, it may make the person more comfortable because older people have less subcutaneous fat and can be more sensitive to cold environmental temperatures. Colds are caused by viruses; an aspirin will not eliminate these microorganisms. In addition, it is not within the role of a nurse to prescribe medications, even if they are over-the-counter medications.
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? 1 Peak expiratory flow rate Incorrect2 Forced vital capacity 3 Forced mid-expiratory flow rate Correct4 Forced expiratory volume/forced vital capacity ratio
Forced expiratory volume/forced vital capacity ratio is useful in differentiating between obstructive and restrictive pulmonary dysfunction. Peak expiratory flow rate aids in monitoring bronchoconstriction in asthma. Forced vital capacity is the amount of air that can be quickly and forcefully exhaled after maximum inspiration. Forced mid-expiratory flow rate is an early indicator of disease of the small airways.
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? 1 Client no longer is infected. 2 Tuberculin skin test is negative. Correct3 Sputum is free of acid-fast bacteria. 4 Client's temperature has returned to normal.
The absence of bacteria in the sputum indicates that the disease can no longer be spread by the airborne route. Treatment is over an extended period; eventually the client may not have an active disease, but still remains infected. Once an individual has been infected, the test will always be positive. The client's temperature returning to normal is not evidence that the disease cannot be transmitted.
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings?
The client is experiencing respiratory acidosis. The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 21 to 28 mEq/L (21 to 28 mmol/L). These results indicate a respiratory etiology. The client's carbon dioxide level is increased (hypercapnia), not decreased. These values are unrelated to hyperkalemia; a serum potassium level of more than 5 mEq/L (5 mmol/L) indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), hemoglobin, and hematocrit are related to anemia.
A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? 1 Ensuring sufficient rest 2 Changing lifestyle routines 3 Breathing clean outdoor air Correct4 Taking medications as prescribed
Tubercle bacilli are particularly resistant to treatment and can remain dormant for long periods. Drugs must be taken consistently, or more drug-resistant forms may recolonize and flourish. Although a balance between activity and rest is desirable, it is not the priority. A change in lifestyle is not necessary. Although clean, fresh air is desirable, it is not the priority.
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished? Correct1 Assess the person's breathing. 2 Offer the person sips of water. 3 Cover the person with a warm blanket. 4 Calculate the extent of the person's burns
A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be initiated. The person should be kept nothing by mouth because extensive burns decrease intestinal peristalsis, and the person may vomit and aspirate. Covering the person with a warm blanket is not done until the assessment for breathing is completed. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility.
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission? Correct1 Monitor the client's vital signs. 2 Increase the client's fluid intake. 3 Improve the client's nutritional status. 4 Determine the client's reasons for drinking
A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.
A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home? 1 Oximetry Correct2 Spirometry 3 Capnography 4 Ventilation-perfusion
A spirometer is a hand-held device that can be used at home. A client blows forcefully and quickly into the device after taking a deep breath. This device is used to diagnose early lung transplant rejections or infections and helps to monitor lung function. Oximetry is used for the intermittent monitoring of arterial or venous oxygen saturation. Capnography helps to assess the level of CO2 in exhaled air; this device graphically displays the amount of partial pressure of CO2. Ventilation-perfusion is used to assess the ventilation and perfusion of the lungs.
After a subtotal gastrectomy, a client has a nasogastric (NG) tube to continuous low suction. Three hours after the surgery, the client complains of nausea and abdominal pain. The client's abdomen appears distended. What should the nurse do first? 1 Instill 30 mL of air into the NG tube 2 Administer the prescribed pain medication 3 Inform the client that abdominal pain is common with NG tubes 4 Notify the surgeon of the absence of bowel sounds
Abdominal distention, nausea, and abdominal pain can be signs of nasogastric tube blockage. Instilling 30 mL of air may reestablish patency. Although opioids usually are prescribed postoperatively, they tend to decrease peristalsis and may increase abdominal distention and nausea. It is not common for NG tubes to cause abdominal pain. There will be no stools for several days. Bowel sounds are not expected for several days after stomach or intestinal surgery. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.
A client is diagnosed with chronic pancreatitis. Which dietary instruction is most important for the nurse to share with the client? 1 Eat a low-fat, low-protein diet 2 Avoid foods high in carbohydrates Correct3 Avoid ingesting alcoholic beverages 4 Eat a bland diet with no snacks in between
Alcohol will cause the most damage. Alcohol increases pancreatic secretions, which cause autodigestion of the pancreas, leading to severe pain. Although the diet should be low in fat, it should be high in protein; also, it should be moderate in carbohydrates. The client should be consuming a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet can be consumed, but snacks high in calories are also recommended.
Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis?
Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? Correct1 The disease process and breathing exercises Incorrect2 How to control or prevent respiratory infections 3 Using aerosol therapy, especially nebulizers 4 Priorities in carrying out everyday activities
Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation. Learning to control or prevent respiratory infections is important, but it should be taught later. Although it is helpful to know about aerosol therapy and nebulizers, knowing how to use aerosol therapy, especially nebulizers, should be taught later. Although it is important to teach the client how to set priorities in carrying out everyday activities, this should be taught later.
Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? Incorrect1 Forced vital capacity 2 Functional residual capacity 3 Forced expiratory volume in 1 second Correct4 Forced expiratory flow over the 25% to 75% volume of the forced vital capacity
Forced expiratory flow over the 25% to 75% volume of the forced vital capacity is the measure that provides a more sensitive index of obstruction in smaller airways. Forced vital capacity indicates respiratory muscle strength and ventilator reserve. Functional residual capacity is normal or decreased in restrictive pulmonary diseases and increased in obstructive pulmonary diseases. Forced expiratory volume in 1 second is reduced in certain obstructive and restrictive disorders.
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? 1 Peak expiratory flow rate 2 Forced vital capacity 3 Forced mid-expiratory flow rate Correct4 Forced expiratory volume/forced vital capacity ratio
Forced expiratory volume/forced vital capacity ratio is useful in differentiating between obstructive and restrictive pulmonary dysfunction. Peak expiratory flow rate aids in monitoring bronchoconstriction in asthma. Forced vital capacity is the amount of air that can be quickly and forcefully exhaled after maximum inspiration. Forced mid-expiratory flow rate is an early indicator of disease of the small airways.
A client with ulcerative colitis has experienced frequent severe exacerbations over the past several years. The client is admitted to the hospital with intense pain, severe diarrhea, and cachexia. Which therapeutic course should the nurse expect the primary healthcare provider to explore with this client? 1 Intensive psychotherapy 2 Continued medical therapy Correct3 Surgical therapy (colectomy) 4 Diet therapy (low-residue, high-protein diet)
If medical management fails, surgical therapy is the next logical choice because it removes the affected intestine. Psychotherapy might improve the client's ability to cope with the disease, but it will not solve the physical problems. Continued medical therapy and diet therapy are classic interventions that probably have been tried during prior exacerbations and have failed.
Which cytokine stimulates the liver to produce fibrinogen and protein C?
Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
A client with early-stage cancer of the esophagus is treated with laser therapy. Which type of food should the nurse instruct the client to select when oral intake is permitted? 1 Cold Correct2 Liquid 3 Low in protein 4 Low in calories
Liquid foods are less irritating to the esophageal mucosa. Cold food is not as "easy" as liquids. High-protein foods are desirable because they promote tissue repair. High-calorie foods are desirable for maintaining weight, promoting anabolism, and preventing negative nitrogen balance.
A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include? 1 Purpose of bronchodilators Correct2 Importance of meticulous oral hygiene Incorrect3 Technique used in pursed-lip breathing 4 Methods used to maintain a dust-free environment
Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection. Bronchodilators will not prevent infection; they dilate the bronchi. Pursed-lip breathing will not prevent infection; it promotes gas exchange in the alveoli and facilitates more effective exhalation. It is impossible to maintain a dust-free environment.
A nurse is caring for a client who just had a gastrectomy. What should the nurse emphasize when teaching the client how to avoid dumping syndrome? 1 Increase activity after eating 2 Drink at least two to three glasses of fluid with each meal Correct3 Eat small meals with low carbohydrate and moderate fat content 4 Sit in a high-Fowler position for 30 minutes after eating
Small meals with low carbohydrate, moderate fat, and high protein are recommended; these are digested more readily and prevent rapid stomach emptying. Rest, not activity, after meals assists in limiting dumping syndrome. Fluid intake with meals should be in moderation. Fluids with meals cause rapid emptying of the food from the stomach into the jejunum before it is adequately subjected to the digestive process; the hyperosmolar mixture causes a fluid shift to the jejunum. A high-Fowler position will not reduce the risk of dumping syndrome.
Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate Correct3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli
The Hering-Breuer reflex prevents overdistention of the lungs. An increase in hydrogen ion concentration will cause an increase in the tidal volume via central chemoreceptors. A decrease in the hydrogen ion concentration will cause a decreased respiratory rate via peripheral chemoreceptors. The Hering-Breuer reflex does not cause a reduction in the number of functional alveoli.
A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? Incorrect1 Cloudy wound drainage 2 Poor gag reflex 3 Decreased urinary output Correct4 Restlessness with dyspnea
The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Decreased urinary output needs to be monitored but does not take priority.
What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. 1 Polyps Correct2 Gag reflex 3 Shotty nodes Correct4 Poor dentition Correct5 Gum retraction
The nurse should place a tongue blade along the side of the client's pharynx behind the tonsil and stimulate the gag reflex. Using a good light source, the nurse should inspect the interior of the mouth for poor dentition and gum retraction. These findings may indicate the presence of a respiratory disorder. Polyps may result from a long-term infection of the oral mucosa. The nurse should observe for the presence of polyps during an inspection of the nose. The presence of small, mobile nontender or shotty nodes is not a sign of the pathologic condition.
The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? 1 Antibiotic 2 Antihistamine Correct3 Bronchodilator 4 Expectorant
Theophylline is a bronchodilator. It relaxes the smooth muscles in the bronchial airway and relieves bronchospasms. This in turn improves air exchange. An antibiotic is used to treat a bacterial infection. An antihistamine blocks the action of histamine. An expectorant is used to loosen mucus in the lungs. An antibiotic, an antihistamine, or an expectorant will not relax the smooth muscles in the bronchial airway for clients experiencing an acute episode.
Which assessment finding is considered the earliest sign of decreased tissue oxygenation? 1 Cyanosis Incorrect2 Cool, clammy skin Correct3 Unexplained restlessness 4 Retraction of interspaces on inspiration
Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.
After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion? Correct1 Wheezing 2 Rhonchi 3 Pleural friction rub 4 Low-pitched crackle
Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is an adventitious breath sound that may indicate bronchospasm. Rhonchi are associated with obstruction by a foreign body. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.
A client is admitted to the surgical unit from the postanesthesia care unit with a Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? Correct1 Use normal saline to irrigate the tube. 2 Employ sterile technique when irrigating the tube. 3 Withdraw the tube quickly when decompression is terminated. 4 Allow the client to have small sips of ice water unless nauseated
Patency of the tube should be maintained to ensure continued suction. Use of normal saline minimizes fluid and electrolyte disturbances during irrigation. The stomach is not considered a sterile body cavity, so medical asepsis is indicated. Care must be taken to avoid traumatizing the mucosa. Ice chips and water represent fluid intake, which must be approved by the healthcare provider; being hypotonic in nature, such intake may lower the level of serum electrolytes.
A client has a suspected peptic ulcer in the duodenum. What should the nurse expect the client to report when describing the pain associated with this disease? 1 An ache radiating to the left side 2 An intermittent colicky flank pain Correct3 A gnawing sensation often caused by H. pylori 4 A generalized abdominal pain intensified by moving
Peptic ulcer pain is usually described as a gnawing sensation and often caused by H. pylori and NSAIDS. An ache radiating to the left side is not specific to duodenal ulcers. An intermittent colicky flank pain may indicate renal colic. A generalized abdominal pain intensified by moving is not specific to duodenal ulcers.
A client with gastroesophageal reflux disease (GERD) should make diet and lifestyle changes. Which instructions should the nurse include in the client's discharge teaching? Select all that apply. Correct1 Encourage to quit smoking Incorrect2 Elevate the foot of the bed Correct3 Avoid caffeine-containing products 4 Eat three large, evenly spaced meals daily Correct5 Avoid lying down for 2 to 3 hours after eating
Smoking cessation should be encouraged. Caffeine should be avoided because it decreases esophageal sphincter pressure, which permits reflux. Advise the client not to lie down for 2 to 3 hours after eating. Coffee and tea contain caffeine, which decreases esophageal sphincter pressure and should be avoided; milk does not have to be eliminated from the diet unless the client has lactose intolerance. The head, not the foot, of the bed should be elevated to prevent nighttime reflux; at night infrequent swallowing and the recumbent position impair esophageal clearance. Three large meals increase the volume pressure in the stomach, which delays gastric emptying; four to six smaller meals are preferred.
Which clinical findings would the nurse expect a client diagnosed with ulcerative colitis to report? Select all that apply. Correct1 Fever Correct2 Diarrhea 3 Gain in weight 4 Spitting up blood Correct5 Abdominal cramps
The inflammatory process can promote a fever and tends to increase peristalsis, causing intestinal spasms and diarrhea. As ulceration occurs, the loss of blood leads to anemia. The client will lose weight (not gain it) because of anorexia and malabsorption. Also, hemoptysis (coughing up blood from the respiratory tract) is not a related sign.
A nurse is teaching a newly admitted client who has acute pancreatitis about dietary restrictions. What should the education include? Correct1 Use of IV fluids 2 Season foods sparingly Incorrect3 Eat small meals frequently 4 Limit coffee to three cups per da
Acute pancreatitis requires an NPO status to allow the pancreas to rest. IV fluids are administered. Spicy, seasoned foods stimulate the pancreas and should be avoided, not just sparingly used. Small, frequent feedings place less demand on the pancreas to release digestive enzymes and are instituted when the acute phase is resolved. Fats stimulate the release of lipase from the pancreas, whether they are saturated or unsaturated fats, and should be avoided. Coffee stimulates pancreatic secretions and should be avoided.
An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A nasogastric tube to suction is in place. What should the nurse expect regarding the client's nasogastric tube drainage during the first 24 hours after surgery? 1 Minimal to no drainage Correct2 Contains some blood and clots 3 Contains large amounts of frank blood 4 Similar to coffee grounds in color and consistency
Containing some blood and clots is an expected response during the first 24 hours after a gastric resection because of oozing of blood and blood coagulation. There will be a moderate amount of drainage, not minimal or no drainage. Green and viscid are normal characteristics of gastric contents, which are unexpected after gastric surgery. Containing large amounts of frank blood indicates hemorrhage, which is unexpected. Coffee ground material results from blood that has been digested by the gastric acid; gastric bleeding with a nasogastric tube in place will be red because gastric acids will not have time to act on the blood.
A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1 Blood glucose Correct2 Serum lipase 3 Serum bilirubin level 4 White blood cell count
Lipase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. An elevated blood glucose level is not indicative of pancreatitis but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. Serum bilirubin level occurs in other disease processes, such as cholecystitis. White blood cell count is not specific to pancreatitis; white blood cells are elevated in other disease processes.
Which disorder would the nurse state is related to the tonsils? 1 Rhinitis 2 Sinusitis Correct3 Pharyngitis 4 Pneumonia
Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis. Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.
A nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. What primary serum blood level should the nurse monitor? 1 Urea 2 Chloride Correct3 Potassium 4 Creatinine
Potassium, a gastrointestinal (GI) constituent, moves quickly through the GI tract of a client with diarrhea and is not absorbed; therefore, serum potassium can become dangerously low and cause cardiac dysrhythmias. Blood urea nitrogen is unaffected by diarrhea; with diarrhea there is a loss of potassium, sodium, and water. Hypochloremia usually is the result of excessive vomiting or gastric decompression. Creatinine reflects muscle and renal function and remains stable unless the client is extremely hemoconcentrated.
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? 1 Infection caused by the excretion of feces 2 Injury caused by exposed intestinal mucosa 3 Altered bowel elimination caused by the ostomy Correct4 Limited water reabsorption caused by removal of intestine
The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications.
Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth? 1 Palpation 2 Inspection 3 Percussion Correct4 Auscultation
The physical assessment maneuvers used for chest examination include inspection, palpation, percussion, and auscultation. During auscultation, the nurse instructs the client to breathe in slowly and a little more deeply than normal through the mouth. The nurse asks the client to breathe deeply while performing palpation. During inspection, the nurse asks the client to sit upright or to have the head of the bed upright. While performing percussion, the nurse helps the client to assume the semi-sitting or supine position.
A client was diagnosed with cancer of the head of the pancreas two months ago. The client is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the client's assessment, the nurse expects the client's stool to be what color? Incorrect1 Green 2 Brown 3 Red-tinged Correct4 Clay-colored
Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum. Green stools may occur with prolonged diarrhea associated with gastrointestinal inflammation. The feces are brown when there is unobstructed bile flow into the duodenum. Inflammation or ulceration of the lower intestinal mucosa results in blood-tinged stools.
A serious train accident occurs in the community. At the scene of the accident, a triage nurse is identifying and labeling victims according to triage acuity principles. With what color tag should the nurse label a client who is experiencing respiratory distress? Correct1 Red 2 Black 3 Green 4 Yellow
A red tag (priority I) indicates a client with respiratory distress, trauma or bleeding, or neurological deficits that need immediate treatment. Victims who are deceased are labeled with a black tag. These individuals are transported to a temporary morgue after clients who have a chance for survival are attended to. A green tag (priority III) indicates a client who needs care that can wait for hours. Although clients with sprains, rashes, and minor pain can wait hours for treatment, they need to be reassessed every 1 to 2 hours to ensure that their condition did not deteriorate. If their condition deteriorates, they should be relabeled according to their level of need. A yellow tag (priority II) indicates injuries that need treatment within 2 hours. Although people who have sustained simple fractures, lacerations, or fevers can wait for treatment for 2 hours, they need to be reassessed every 30 minutes to ensure that their condition did not deteriorate. If their condition deteriorates, they should be relabeled with a red tag (priority I), indicating the need for immediate treatment.
A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? 1 Wound infection 2 Ischemia of the stoma Correct3 Electrolyte imbalances 4 Excoriation of skin around the stoma
An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist, which indicates adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication.
A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? Correct1 "Cover your cough with your forearm." 2 "Dispose of used paper tissues in a paper bag." 3 "Encourage your roommate to get the flu vaccine." 4 "Move out of your apartment until you are over the cold.
Covering the cough with your forearm limits the spread of respiratory droplets that may be inhaled by another. Used paper tissues should be disposed of in a bag impervious to fluids. Although encouraging the roommate to get the flu vaccine may be done, not all pathogenic microorganisms are viruses; many pathogens are bacteria. Moving out of the apartment until the client is over the cold is unrealistic; there are ways to limit the spread of microorganisms (e.g., washing the hands, covering coughing and sneezing, not sharing utensils).
A nurse provides dietary teaching about a low-sodium diet for a client with hypertension. Which nutrient selected by the client indicates a correct understanding about foods that are low in natural sodium? 1 Milk Incorrect2 Meat Correct3 Fruits 4 Vegetables
Fruits contain less natural sodium than do other foods. Milk is higher in natural sodium than is fruit. Meat is higher in natural sodium than is fruit. Vegetables are higher in natural sodium than is fruit.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? 1 Decrease in red cell formation 2 Rupture of emphysematous bullae Correct3 Depression in the respiratory center 4 Excessive drying of the respiratory mucosa
It is believed that clients with COPD should be given low concentrations of oxygen because a decreased oxygen blood level is the stimulus for breathing for these clients. However, the results of a recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen concentrations higher than 2 L/min. More research is needed before this theory is applied clinically. Prolonged hypoxia stimulates erythrocyte production; the goal of therapy is to relieve hypoxia. The pressure, rather than the concentration, at which oxygen is administered increases the risk of rupture of emphysematous bullae. The concentration of oxygen is unrelated to its humidification. To prevent its drying effects on secretions and the mucosa, oxygen should be humidified.
A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. Which conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse? 1 Appropriate, because such clients usually experience painful swallowing for several days Correct2 Appropriate, because early eating or drinking after such a procedure may cause aspiration 3 Inappropriate, because the client is likely to be anxious, and it is easier to remove the water pitcher 4 Inappropriate, because the client is conscious and may be thirsty after not being allowed to drink fluids
Oral intake should not be attempted until return of the gag reflex because the client could aspirate. Although some slight irritation may occur following this test, there are usually no painful sequelae; oral intake would not be withheld because of painful swallowing, although the consistency of food may be changed. The statements that the performance of the graduate nurse is inappropriate because the client may be anxious or thirsty are not correct; additional factors must be considered.
A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer? Correct1 Supplemental oxygen 2 Intravenous morphine 3 Endotracheal intubation Incorrect4 Sublingual nitroglycerin
Oxygen supports vital centers of the body while the cause of the problem is investigated. Although an intravenous morphine may be done eventually if the client is experiencing a myocardial infarction, it is not the initial action and requires a prescription. Endotracheal intubation is not implemented by a nurse. Later, endotracheal intubation may be necessary if the client experiences respiratory failure or obstruction. Although a sublingual nitroglycerin may be done eventually if the client is experiencing angina, it is not an initial action and requires a prescription.
A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Which is the primary nursing concern? 1 Acute pain 2 Risk for injury Correct3 Metabolic alkalosis 4 Ineffective breathing
Prolonged vomiting results in fluid loss and acid (hydrochloric) loss; the client's adaptations reflect dehydration and metabolic alkalosis. Although it is important to address the client's pain, the fluid and electrolyte/acid/base imbalance must be addressed first because this imbalance can be life threatening. Although risk for injury is a potential problem, the priority is the fluid and electrolyte/acid/base problem. The ineffective breathing pattern most likely is caused by the metabolic alkalosis; the fluid and electrolyte/acid/base imbalance is a higher priority and must be addressed first.
When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? 1 Substernal chest pain 2 Episodes of palpitation Correct3 Severe shortness of breath 4 Dizziness when standing u
Severe shortness of breath may indicate a recurrence of the pneumothorax because one lung is unable to meet the oxygen demands of the body. A pneumothorax causes sharp chest pain on the involved side, not substernally. Usually palpitations reflect a cardiac, not a respiratory problem. Dizziness when standing up is not specific to a pneumothorax; this is orthostatic hypotension, which may be related to a variety of medical problems.
Which client would have relatively smaller tidal volumes due to limited chest wall movement? 1 A client with asthma 2 A client with pneumonia Incorrect3 A client with pulmonary fibrosis Correct4 A client with phrenic nerve paralysis
Some respiratory conditions such as phrenic nerve paralysis may limit the diaphragm or chest wall movement and may result in smaller tidal volumes. In this condition, the lungs do not fully inflate, and the gas exchange may be impaired. Exacerbations of asthma may cause expiration to become an active labored process. Pneumonia may result in decreased lung compliance due to an accumulation of fluid in the lungs. As the lung tissue becomes less elastic or distensible, the client with pulmonary fibrosis may have decreased lung compliance.
Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? 1 Cerebral palsy Correct2 Cystic fibrosis 3 Muscular dystrophy 4 Multiple sclerosis
The early symptom of cystic fibrosis is meconium ileus, which is impacted stool in the newborn. Thick mucous secretions, salty sweat, and difficulty gaining weight because of high caloric demands are characteristics of the condition. Cerebral palsy is a motor disorder caused by damage to the brain. Muscular dystrophy is a muscular disorder. Multiple sclerosis is a condition with progressive disintegration of the myelin sheath.
A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. What should the nurse identify is the function of the gallbladder when providing preoperative teaching? Correct1 Stores and concentrates bile 2 Releases bile into the pancreatic duct 3 Connects the common bile duct and the pancreas 4 Controls the flow of fat through the sphincter of Odd
The gallbladder concentrates and stores about 90 mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.
A client had a cholecystectomy and asks whether there will be any dietary restrictions after the client's discharge. The nurse evaluates that the dietary teaching is understood when the client makes what comment to a family member? 1 "I should avoid fatty foods for the rest of my life." 2 "I should not eat those foods that upset me before I had surgery." 3 "I need to eat a high-protein diet for several months, and I should follow a sodium restriction diet." Correct4 "I need to eat smaller amounts of food at a time, and they should contain low to moderate fats."
The response is individual, but ultimately most people can eat anything they want. Eating small, more frequent, and moderate- to low-fat amounts of food allows the readily available bile to mix with the food bolus and prevent gas, bloating, diarrhea, or undigested foods. Fats may have to be gradually reintroduced, but most people tolerate them after this surgery. Foods that caused gastric distress before surgery usually are tolerated after surgery. Increased protein is needed only until healing has occurred. Sodium restriction is not necessary.
A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? My doctor will know what to do." 2 "My family can make the decisions for me." Correct3 "If something happens to me, I do not want CPR." 4 "If I have a heart attack, I do not want any medication
The statement, "If something happens to me, I do not want CPR," specifically states that if cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want cardiorespiratory resuscitation. If a DNR order is signed by the client, cardiopulmonary resuscitation will not be instituted. The response, "My doctor will know what to do," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make healthcare decisions on the client's behalf. The response, "My family can make the decisions for me," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make healthcare decisions on the client's behalf. The response, "If I have a heart attack, I do not want any medication," reflects an advance directive (e.g., living will), wherein the client directs treatment in accordance with personal wishes.
A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? 1 Prepare to intubate the client. Correct2 Increase the oxygen flow rate per facility protocol. 3 Decrease the tension of oxygen in the plasma. 4 Have the arterial blood gases redone to verify accuracy.
This decrease in PaO2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%. The client PaO2 of 65 mm Hg is not severe enough to intubate the client without first increasing flow rate to determine if the client improves. Decreasing the tension of oxygen in the plasma is inappropriate and will compound the problem. The PaO2 is a measure of the pressure (tension) of oxygen in the plasma; this level is decreased in individuals who have perfusion difficulties, such as those with pneumonia. Having the arterial blood gases redone to verify accuracy is negligent and dangerous; a falling PaO2 level is a serious indication of worsening pulmonary status and must be addressed immediately. Drawing another blood sample and waiting for results will take too long.
Six weeks after discharge, a client with a jejunoileal bypass for morbid obesity returns to the outpatient clinic reporting palpitations, abdominal cramps, diarrhea, and dizziness 30 minutes after meals. What complication should the nurse consider that the client is most likely experiencing? 1 Gastric reflux 2 Reflux gastritis Correct3 Dumping syndrome Incorrect4 Abdominal peritonitis
When ingested food rapidly enters the jejunum without having gone through the usual mixing and digestive process, the hypertonic bolus causes rapid movement of extracellular fluid into the bowel; this rapid shift decreases the circulating blood volume. Decreased peripheral vascular resistance, visceral pooling of blood, and reactive hypoglycemia also are implicated. Also, the distended jejunum increases intestinal peristalsis and motility. Backward flow of gastric contents into the esophagus, or gastric reflux, causes heartburn, dysphagia, water brash, acid regurgitation, or belching (eructation). Reflux gastritis is a chronic inflammation of the lining of the stomach caused by reflux of duodenal contents; epigastric pain, nausea, vomiting, and hematemesis are common clinical manifestations. Abdominal peritonitis is an inflammation of the peritoneal membrane; rigidity of abdominal muscles, abdominal pain, low-grade fever, malaise, absent bowel sounds, and shallow respirations are common clinical manifestations.
