NCAF Exam 3
The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? Low-fiber diet Skin protection Antibiotic administration Intravenous glucocorticoids
Skin protection
The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? "Are you taking Vitamin C or B? "Do you have any allergy to sulfa drugs?" "Can you swallow pills pretty easily?" "Do you have insurance to cover this drug?"
"Do you have any allergy to sulfa drugs?"
A nurse cares for a middle-age female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, "What can I do to help prevent these infections?" How would the nurse respond? "Test your urine daily for the presence of ketone bodies and proteins." "Use tampons rather than sanitary napkins during your menstrual period." "Drink more water and empty your bladder more frequently during the day." "Keep your hemoglobin A1C under 9% by keeping your blood sugar controlled."
"Drink more water and empty your bladder more frequently during the day."
The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? "Drink plenty of fluids to prevent dehydration." "You should only drink 1 L of fluids daily." "Increase your protein intake by drinking more milk." "Sips of cola or tea may help to relieve your nausea."
"Drink plenty of fluids to prevent dehydration."
A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client's history? "Have you been taking any aspirin, ibuprofen, or naproxen recently?" "Do you have anyone in your family with renal failure?" "Have you had a diet that is low in protein recently?" "Has a relative had a kidney transplant lately?"
"Have you been taking any aspirin, ibuprofen, or naproxen recently?"
The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed? "I will probably lose weight by cutting out potato chips." "I will cut out bacon with my eggs every morning." "My cooking style will change by not adding salt." "I am thrilled that I can continue to eat fast food."
"I am thrilled that I can continue to eat fast food."
A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? "I don't know. I wish I had an answer for you, but I don't." "It's important to keep a positive attitude for your family right now." "Scientists have not determined why cancer develops in certain people." "I think that this is a trial so you can become a better person because of it."
"I don't know. I wish I had an answer for you, but I don't."
After teaching a client with acromegaly who is scheduled for an open transsphenoidal hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "I will no longer need to limit my fluid intake after surgery." "I am glad no visible incision will result from this surgery." "I hope I can go back to wearing size 8 shoes instead of size 12." "I will wear slip-on shoes after surgery to limit bending over."
"I hope I can go back to wearing size 8 shoes instead of size 12."
After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? "I will take a laxative every night before going to bed." "I must increase my intake of dietary fiber and fluids." "I shall only use salt when I am cooking my own food." "I'll eat white bread to minimize gastrointestinal gas."
"I must increase my intake of dietary fiber and fluids."
The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? "I should leave the drainage bag above the level of my abdomen." "I could flush the tubing with normal saline if the flow stops." "I should take a stool softener every morning to avoid constipation." "My diet should have low fiber in it to prevent any irritation."
"I should take a stool softener every morning to avoid constipation."
After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the diet therapy for this condition? "I must decrease my intake of fat." "I will increase my intake of protein." "A decreased intake of carbohydrates will be required." "An increased intake of vitamin C is necessary."
"I will increase my intake of protein."
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "I'll ride my bike or take a long walk at least three times a week." "I must try to include at least 25 g of fiber in my diet every day." "I will take a laxative nightly at bedtime to avoid becoming constipated." "I should use my legs rather than my back muscles when I lift heavy objects."
"I will take a laxative nightly at bedtime to avoid becoming constipated."
After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "I will avoid large crowds and people who are sick." "I will take this medication with my breakfast each morning." "Nausea and vomiting are common side effects of this drug." "I should wash my hands after I play with my dog."
"I will take this medication with my breakfast each morning."
A nurse is reviewing care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) with assistive personnel. What statement by the AP indicates understanding of this client's care? "I will weigh the client carefully before breakfast and compare with yesterday's weight." "I will encourage plenty of fluids to promote urination and prevent dehydration." "I will teach the client not to select high-sodium or salty foods on the menu." "I will assess the client's mucous membranes and skin for signs of dehydration."
"I will weigh the client carefully before breakfast and compare with yesterday's weight."
The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? "I won't let anyone use my dishes or glasses." "I'll wash my hands with antibacterial soap." "I'll keep my bathroom extra clean." "I'll cook all the meals for my family."
"I'll cook all the meals for my family."
After teaching a client who is recovering from an endoscopic transsphenoidal hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? "I will wear dark glasses to prevent sun exposure." "I'll keep food on upper shelves so I do not have to bend over." "I must wash the incision with saline and redress it daily." "I should cough and deep breathe every 2 hours while I am awake."
"I'll keep food on upper shelves so I do not have to bend over."
After teaching a client with hypertension secondary to renal disease, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? "I can prevent more damage to my kidneys by managing my blood pressure." "If I have increased urination at night, I need to drink less fluid during the day." "I need to see the registered dietitian to discuss limiting my protein intake." "It is important that I take my antihypertensive medications as directed."
"If I have increased urination at night, I need to drink less fluid during the day."
A nurse cares for a young client with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How would the nurse respond? "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." "Let's talk to the ostomy nurse about options for ostomy supplies and dress styles." "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."
"Let's talk to the ostomy nurse about options for ostomy supplies and dress styles."
A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? "Cap the catheter drain at night to prevent leakage and skin damage." "Position the drainage bag lower than the catheter insertion site." "Irrigate the catheter with an ounce of saline every night." "Pierce a hole in the top of the drainage bag to get rid of odors."
"Position the drainage bag lower than the catheter insertion site."
The nurse is caring for a client with acromegaly who is starting bromocriptine. What health teaching by the nurse about drug therapy will the nurse include? "Take this drug on an empty stomach first thing in the morning." "You will be starting on a high dose of the drug to ensure it will work." "You might experience an increase in blood pressure in about a week." "Seek medical attention immediately if you have chest pain and dizziness."
"Seek medical attention immediately if you have chest pain and dizziness."
A nurse cares for a client who has pyelonephritis. The client states, "I am embarrassed to talk about my symptoms." How would the nurse respond? "I am a professional. Your symptoms will be kept in confidence." "I understand. Elimination is a private topic and shouldn't be discussed." "Take your time. It is okay to use words that are familiar to you." "You seem anxious. Would you like a nurse of the same gender to care for you?"
"Take your time. It is okay to use words that are familiar to you."
The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? Consuming too much fruit Consuming fried or pickled foods Consuming dairy products Consuming raw seafood
Consuming raw seafood
A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How would the nurse respond? "Your friends will be happy that you are alive." "Tell me more about your concerns." "A therapist can help you resolve your concerns." "With time you will accept your new body."
"Tell me more about your concerns."
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? "The capsules can be opened and the powder sprinkled on applesauce if needed." "I will wipe my lips carefully after I drink the enzyme preparation." "The best time to take the enzymes is immediately after I have a meal or a snack." "I will not mix the enzyme powder with food or liquids that contain protein."
"The best time to take the enzymes is immediately after I have a meal or a snack."
A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How would the nurse respond? "I will ask your doctor to order a mental health consult for you." "You feel this way because of your hormone levels." "Can I bring you information about support groups?" "I will close the door to your room and restrict visitors."
"You feel this way because of your hormone levels."
A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? "You will have to wear an appliance for your permanent ileostomy." "You should be able to have better bowel continence after healing occurs." "You will have a large abdominal incision that will require irrigation." "This procedure can be performed under general or regional anesthesia."
"You should be able to have better bowel continence after healing occurs."
A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test? "You'll have to drink a contrast medium right before the test." "You'll need to do a bowel prep the nursing before the test." "You'll be able to drink liquids up until the test begins." "You'll have a large camera close to you during the test."
"You'll have a large camera close to you during the test."
The nurse is caring for a client who has chronic pyelonephritis. What assessment finding would the nurse expect? Fever Flank pain Hypertension Nausea and vomiting
Hypertension
The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client's 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours? 380 mL 500 mL 620 mL 750 mL
620 mL
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone? A 36-year-old female who has used oral contraceptives for 5 years A 42-year-old male who experienced head trauma 3 years ago A 55-year-old female with a severe allergy to shellfish and iodine A 64-year-old male with adult-onset diabetes mellitus
A 42-year-old male who experienced head trauma 3 years ago
The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding? Client with a blood pressure of 158/90 mm Hg Client with Kussmaul respirations Client with skin itching from head to toe Client with halitosis and stomatitis
Client with Kussmaul respirations
The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? Palpating the access site for a bruit or thrill Using the right arm for a blood pressure reading Administering intravenous fluids through the AV fistula Checking distal pulses in the left arm
Administering intravenous fluids through the AV fistula
A 70-kg adult client with chronic kidney disease (CKD) is on a 40-g protein diet. The patient has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would be of most concern to the nurse? Albumin level of 2.5 g/dL (3.63 mcmol/L) Phosphorus level of 5 mg/dL (1.62 mmol/L) Sodium level of 135 mEq/L (135 mmol/L) Potassium level of 5.5 mEq/L (5.5 mmol/L)
Albumin level of 2.5 g/dL (3.63 mcmol/L)
The nurse is admitting a client who has acute glomerulonephritis caused by beta streptococcus. What drug therapy would the nurse expect to be prescribed for this client? Antihypertensives Antilipidemics Antidepressants Antibiotics
Antibiotics
A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. What action would the nurse take? Position the client to lay on the surgical incision. Measure the specific gravity of the client's urine. Administer intravenous pain medications. Assess the rate and quality of the client's pulse.
Assess the rate and quality of the client's pulse.
After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching? Roasted chicken with rice pilaf and a cup of coffee with cream Spaghetti with meat sauce, a fresh fruit cup, and hot tea Garden salad with a cup of bean soup and a glass of low-fat milk Baked fish with steamed carrots and a glass of apple juice
Baked fish with steamed carrots and a glass of apple juice
A client is started on continuous venovenous hemofiltration (CVVH). Which finding would require immediate action by the nurse? Potassium level of 5.5 mEq/L (5.5 mmol/L) Sodium level of 138 mEq/L (138 mmol/L) Blood pressure of 76/58 mm Hg Pulse rate of 88 beats/min
Blood pressure of 76/58 mm Hg
A client with chronic kidney disease (CKD) has an elevated serum phosphorus level. What drug would the nurse anticipate to be prescribed for this client? Calcium acetate Doxycyline Magnesium sulfate Lisinopril
Calcium acetate
The nurse is caring for a client with adrenal insufficiency. What priority physical assessment would the nurse perform? Respiratory assessment Skin assessment Neurologic assessment Cardiac assessment
Cardiac assessment
A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? Temperature of 100.1° F (37.8° C) Positive Murphy sign Clay-colored stools Upper abdominal pain after eating
Clay-colored stools
A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse's priority action? Calculate the mean arterial pressure (MAP). Ask for insertion of a pulmonary artery catheter. Take the client's pulse. Decrease the rate of the IV infusion.
Decrease the rate of the IV infusion.
The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient's recent history? Pyelonephritis Dehydration Bladder cancer Kidney stones
Dehydration
The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). For what common complication will the nurse monitor? Hypertension Bradycardia Dehydration Pulmonary embolus
Dehydration
A client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? Discuss what the treatment regimen means to the client. Refer the client to a mental health nurse practitioner. Reschedule the appointments to another date and time. Discuss the option of peritoneal dialysis.
Discuss what the treatment regimen means to the client.
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? Drainage from a fistula Diminished bowel sounds Pain at the incision site Nasogastric (NG) tube drainage
Drainage from a fistula
A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient's care? Edema and pain Cardiac and respiratory status Electrolyte and fluid imbalance Mental health status
Electrolyte and fluid imbalance
The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? Decreased potassium level Increased sodium level Elevated leukocyte count Decreased thrombocyte count
Elevated leukocyte count
A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? Urinary tract infection Chronic kidney disease Heart failure Fluid and electrolyte imbalances
Fluid and electrolyte imbalances
A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate? Give the client a bottle of water immediately. Start an intravenous line for fluids. Teach the patient to drink 2 to 3 L of water daily. Perform an electrocardiogram.
Give the client a bottle of water immediately.
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? Inspection of oral mucosa Recent dietary intake Heart rate and rhythm Percussion of abdomen
Heart rate and rhythm
The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which laboratory test value would the nurse monitor to determine this drug's effectiveness? Potassium Sodium Renin Hemoglobin
Hemoglobin
The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? Positive Murphy sign with rebound tenderness to palpitation Dull, hypoactive bowel sounds in the lower abdominal quadrants High-pitched, rushing bowel sounds in the right lower quadrant Reports of abdominal cramping that is worse at night
High-pitched, rushing bowel sounds in the right lower quadrant
The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/minRespirations = 28 breaths/minBlood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? Electrolyte imbalance Pleural effusion Internal bleeding Pancreatic pseudocyst
Internal bleeding
The nurse is caring for a client who has acromegaly. What physical change would the nurse expect to observe? Large hands and face Thin, dry skin Short height Truncal obesity
Large hands and face
A client is placed on fluid restriction because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? Decreased calcium levels Increased phosphorus levels No adventitious sounds in the lungs Increased edema in the legs
No adventitious sounds in the lungs
A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? Warm the dialysate solution in a microwave before instillation. Obtain a sample of the effluent and send to the laboratory. Flush the tubing with normal saline to maintain patency of the catheter. Check the peritoneal catheter for kinking and curling.
Obtain a sample of the effluent and send to the laboratory.
A client is taking furosemide 40 mg/day for management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best? Obtain daily weights of the client. Auscultate heart and breath sounds. Palpate the client's abdomen. Assess the client's diet history.
Obtain daily weights of the client.
The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider? Pale and bluish stoma Liquid stool Ostomy pouch intact Blood-tinged output
Pale and bluish stoma
A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding would alert the nurse to immediately contact the primary health care provider? Flank pain Periorbital edema Bloody and cloudy urine Enlarged abdomen
Periorbital edema
A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse? Place the client on a cardiac monitor immediately. Teach the client to limit high-potassium foods. Continue to monitor the client's intake and output. Ask to have the laboratory redraw the blood specimen.
Place the client on a cardiac monitor immediately.
The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? Clamp the nasogastric tube. Place the patient in semi-Fowler position. Assess vital signs once every shift. Provide oral rehydration.
Place the patient in semi-Fowler position.
The nurse is preparing to give tolvaptan for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). For which potentially life-threatening adverse effect would the nurse monitor? Increased intracranial pressure Myocardial infarction Rapid-onset hypernatremia Bowel perforation
Rapid-onset hypernatremia
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L (114 mmol/L). What nursing action would be appropriate? Consult with the dietitian about increased dietary sodium. Restrict the client's fluid intake to 600 mL/day. Handle the client gently by using turn sheets for repositioning. Instruct assistive personnel to measure intake and output.
Restrict the client's fluid intake to 600 mL/day.
After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? Lasagna, tossed salad with Italian dressing, and low-fat milk Grilled cheese sandwich, tomato soup, and coffee with cream Cream of potato soup, Caesar salad with chicken, and a diet cola Roasted chicken breast, baked potato with chives, and orange juice
Roasted chicken breast, baked potato with chives, and orange juice
A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? Serum potassium of 2.6 mEq/L (2.6 mmol/L) Client ate 20% of breakfast meal White blood cell count of 8200/mm3 (8.2 109/L) Client's weight decreased by 3 lb (1.4 kg)
Serum potassium of 2.6 mEq/L (2.6 mmol/L)
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? Nausea and vomiting Severe boring abdominal pain Jaundice and itching Elevated temperature
Severe boring abdominal pain
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? Severe, steady right lower quadrant pain Abdominal pain associated with nausea and vomiting Marked peristalsis and hyperactive bowel sounds Abdominal pain that increases with knee flexion
Severe, steady right lower quadrant pain
A client with diabetes mellitus type 2 has been well controlled with metformin. The client is scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time? Teach the client about the purpose of the MRI. Assess the client's blood urea nitrogen and creatinine. Tell the client to withhold metformin for 24 hours before the MRI. Ask the client if he or she is taking antibiotics.
Tell the client to withhold metformin for 24 hours before the MRI.
A nurse evaluates a client with acute glomerulonephritis (GN). Which assessment finding would the nurse recognize as a positive response to the prescribed treatment? The client lost 11 lb (5 kg) in the past 10 days. The client's urine specific gravity is 1.048. No blood is observed in the client's urine. The client's blood pressure is 152/88 mm Hg.
The client lost 11 lb (5 kg) in the past 10 days.
A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy? The need to check the client's urinary specific gravity. The need to take blood pressure at least twice a day. The need to monitor blood glucose every day. The need to weigh every day and report weight gain.
The need to weigh every day and report weight gain.
A nurse plans care for a client with a growth hormone deficiency. Which action would the nurse include in this client's plan of care? Avoid intramuscular medications. Place the client in protective isolation. Use a lift sheet to reposition the patient. Assist the client to dangle before rising.
Use a lift sheet to reposition the patient.
