Older Adults Exam 4

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? "I will eat foods high in potassium while taking spironolactone (Aldactone)." "It is safe to take acetaminophen up to four times a day for pain." "Herbs should be used to season my foods instead of salt." "Lactulose should be taken every day to prevent constipation."

"Herbs should be used to season my foods instead of salt."

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective? "I will have to drink water instead of caffeinated drinks." "I should have a glass of low-fat milk at bedtime." "I should keep something in my stomach all the time to neutralize the excess acids." "I will have to eliminate all spicy foods from my diet."

"I will have to drink water instead of caffeinated drinks."

Adam is discharge on quadruple therapy of a PPI, bismuth, metronidazole, and tetracycline. Ten days after his discharge from the hospital, Adam is readmitted with a suspected perforation of the ulcer. Select the assessment findings that indicate a perforation. Select all that apply. A.Decreased bowel sounds B.Grunting, shallow respiration C.Rigid, board-like abdomen D.Shoulder pain E.Sudden, severe upper abdominal pain

A.Decreased bowel sounds B.Grunting, shallow respiration C.Rigid, board-like abdomen D.Shoulder pain E.Sudden, severe upper abdominal pain

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to be documented in the EHR? A.Diarrhea B.Chronic constipation C.Constipation alternating with diarrhea D.Stool constantly oozing from the rectum

A.Diarrhea

The nurse is facilitating a support group for clients diagnosed with Crohn's disease. Which information is most important for the nurse to discuss with the clients? A.Discuss coping skills to assist with adaptation to lifestyle modifications. B.Teach about drug administration, dosages, and scheduled times. C.Teach dietary changes necessary to control symptoms. D.Explain the care of the ileostomy and necessary equipment.

A.Discuss coping skills to assist with adaptation to lifestyle modifications.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? A.Malaise B.Dark stools C.Weight gain D.Left upper quadrant discomfort

A.Malaise

In the client with cirrhosis, which lab values does the nurse anticipate will be increased from the normal value? (select all that apply) A.Total serum bilirubin B.AST/ALT C.Serum albumin D.APTT/PT/INR E.Sodium and potassium

A.Total serum bilirubin B.AST/ALT D.APTT/PT/INR

The nurse is teaching a client with a peptic ulcer about discharge instructions. The client asks the nurse which type of analgesic he may take. Which of the following responses by the nurse would be most accurate? Aspirin Ibuprofen Naproxen Acetaminophen

Acetaminophen

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective ? A."I will take my lipid-lowering medication at the same time each night." B."I may experience some discomfort if I eat a high-fat meal in the next few weeks." C."I need someone to stay wit me for about a week after surgery." "I should not splint my incision when I deep breathe and cough."

B."I may experience some discomfort if I eat a high-fat meal in the next few weeks."

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective ? A."I will take my lipid-lowering medication at the same time each night." B."I may experience some discomfort if I eat a high-fat meal in the next few weeks." C."I need someone to stay wit me for about a week after surgery." D."I should not splint my incision when I deep breathe and cough."

B."I may experience some discomfort if I eat a high-fat meal in the next few weeks."

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What is the nurse's priority? A.Prevent all oral intake. B.Control abdominal pain. C.Provide enteral feedings. D.Avoid dietary cholesterol.

B.Control abdominal pain.

The nurse is caring for a client with gastroesophageal reflux disease (GERD). When assessing the client's current medications, which finding would be of concern? A.Omeprazole once daily B.Diazepam prn C.Milk of magnesia prn D.Metoclopramide once daily

B.Diazepam prn

During the nursing assessment, the client's wife asks the nurse if its true only alcoholics get cirrhosis. Which nursing response best promotes accurate and effective communication? A.List the reasons only alcoholics get cirrhosis. B.Explain there are several types of cirrhosis. C.Illustrate how alcoholics will eventually develop cirrhosis. D.Define the difference between social drinkers and alcoholics.

B.Explain there are several types of cirrhosis.

The nurse practices Universal Precautions to be protected from which bloodborne types of hepatitis viruses? (Select all that apply.) A.Hepatitis A B.Hepatitis B C.Hepatitis C D.Hepatitis D E.Hepatitis E

B.Hepatitis B C.Hepatitis C D.Hepatitis D

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? A.Immediately start enteral feeding to prevent malnutrition. B.Insert an NG and maintain NPO status to allow pancreas to rest. C.Initiate early prophylactic antibiotic therapy to prevent infection. D.Administer acetaminophen (Tylenol) every 4 hours for pain relief.

B.Insert an NG and maintain NPO status to allow pancreas to rest.

Management of ascites is focused on sodium restriction, diuretic therapy, and fluid removal. Which action should the nurse take while monitoring the client's fluid volume status? A.Instruct the client to perform self-catherization B.Measure abdominal girth daily C.Administer prn anti-emetics before meals D.Encourage the client to eat frequent high-protein snacks

B.Measure abdominal girth daily

A patient admitted with diabetes, malnutrition, osteomyelitis, and chronic alcohol use has an elevated serum amylase level of 480 U/L and an elevated serum lipase level of 610 U/L. Which diagnosis does the nurse expect? A.Starvation B.Pancreatitis C.Systemic sepsis D.Diabetic ketoacidosis

B.Pancreatitis

A client is hospitalized with dehydration and dysphagia. Which task would not be appropriate to delegate to a licensed practical nurse? • A.Administer a subcutaneous injection B.Perform initial swallow screen C.Assist the CNA with ambulating client D.Record vital signs on the electronic health record

B.Perform initial swallow screen

A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and cramping abdominal pain associated with the diarrhea. The physician orders the patient to be NPO on admission. The nurse recognizes that this order is most important to: prevent nausea and vomiting. decrease abdominal distention. promote bowel rest and healing. allow for diagnostic testing to be completed.

promote bowel rest and healing.

Which assessment data best indicates the client recovering from an open cholecystectomy may require pain medication? A.Pulse is 65 beats per minute B.Shallow respirations C.Hypoactive bowel sounds Use of a pillow to splint when coughing

B.Shallow respirations

Which type of precautions should the nurse implement to prevent hepatitis B exposure? A.Airborne B.Standard C.Droplet D.Exposure

B.Standard

You are caring for the patient on post-op day 2. Bowel sound are hypoactive, abdomen is distended and tender to light palpation, patient denies passing flatus and reports spasms of abdominal pain. What intervention is most appropriate? A.Administer morphine sulfate IV per the prn order B.Report findings to the surgeon C.Assist the patient to ambulate in the hall D.Advise the patient this is expected due to NPO status.

C.Assist the patient to ambulate in the hall

A client with irritable bowel syndrome has instructions to take psyllium 2 rounded teaspoons full twice a day for constipation. What is most important for the nurse to include in the teaching plan? A.Urine may be discolored. B.Stop taking the laxative once a bowel movement occurs. C.Each dose should be taken with a full glass of water or juice. D.Daily use may inhibit the absorption of some fat-soluble vitamins.

C.Each dose should be taken with a full glass of water or juice.

After several contacts with his HCP for LLQ pain, initially labeled constipation, a 33 y/o male is admitted with a diagnosis of acute diverticulitis. What assessment findings do you think would indicate the need for hospitalization rather than outpatient treatment? A.LLQ pain B.Need for antibiotics C.Elevated WBC and guarding D.Decreased appetite and constipation

C.Elevated WBC and guarding

Early one morning the client tells the nurse his bowel movement is black and tarry. The nurse notifies the healthcare provider. Which new order does the nurse question? A.Perform hemoccult testing on stools x 3 B.Call lab to draw a CBC C.Encourage coughing and deep breathing every hour D.Administer propranolol (Inderal) 20 mg PO BID

C.Encourage coughing and deep breathing every hour

With a confirmed diagnosis of cirrhosis, which assessment finding warrants immediate intervention? A.Increased girth B.Scleral jaundice C.Hematemesis D.Pruritis

C.Hematemesis

The nurse is caring for a client diagnoses with ulcerative colitis. Which symptom(s) support this diagnosis? A.Increased thirst and appetite B.Elevated hemoglobin C.Multiple bloody liquid stools D.Exacerbations unrelated to stress

C.Multiple bloody liquid stools

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 symptom(s)? 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

A 42-yr-old nurse has been diagnosed with PUD(peptic ulcer disease). The medication regimen includes misoprostol, a cytoprotective agent. The nurse understands that this medication exerts its therapeutic effect by: A.Neutralizing excess gastric acid B.Inhibiting HCl production C.Supporting mucous production D.Increasing gastric emptying time

C.Supporting mucous production

The nurse is caring for a 42-year-old female whose stool is positive for blood per the hemoccult results from the lab. What assessment question is most important for the nurse to ask next? A.Have you recently noticed any changes in your bowel pattern? B.When was your last bowel movement? C.When was your last period? D.Have you been experiencing abdominal pain?

C.When was your last period?

You are caring for a patient post exploratory laparotomy who has refused pain medications since returning from post-anesthesia recovery and now reports pain rated 7/10. Blood pressure is 84/44; heart rate is 112; O2 sat is 97%. The patient demonstrates abdominal guarding and shallow respirations. What problem should be addressed first? Pain Breathing Circulation

Circulation

The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which person should the nurse refer for an immunoglobulin (IG) injection? A.A friend who delivers meals to the patient and family each week. B.A relative with a history of hepatitis A who visits the patient daily. C.A child living in the home who received the hepatitis A vaccine 3 months ago. D.A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient.

D.A caregiver with no history of hepatitis A antibodies who lives in the same household with the patient.

The client has undergone esophagogastroduodenoscopy. The nurse placed highest priority on which item as part of the client's care plan? A.Monitoring temperature B.Monitoring complaints of heartburn C.Giving warm gargles for sore throat D.Assessing for return of the gag reflex

D.Assessing for return of the gag reflex

Later that morning, the client calls for the nurse and reports he feels dizzy and is vomiting bright red blood. When the nurse arrives, he is standing in the middle of the room. He is pale and his skin feels cool and clammy. What intervention is a priority for the nurse? A.Take and record the client's blood pressure B.Go to the med cart to obtain an anti-emetic C.Call the lab to draw a STAT CBC D.Assist the client to bed and position them side lying

D.Assist the client to bed and position them side lying

A 46-yr-old client has been experiencing frequent episodes of "heart burn" and regurgitation of sour-tasting fluid, especially after a large meal. The client is diagnosed with a hiatal hernia. The nurse knows that the client understands her treatment regimen when she states she will: A.Elevate her legs when she is sleeping. B.Increase her roughage in her diet C.Drink more fluids with her meals. D.Avoid caffeine, alcohol, and chocolate.

D.Avoid caffeine, alcohol, and chocolate.

The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client? Tell the client to measure the amount of stool. Recommend the client come to the clinic immediately. Explain the client should follow the BRAT diet. Discuss the taking an OTC histamine-2 blocker

Explain the client should follow the BRAT diet.

Which of the following would be the priority focus of nursing care for a client with peritonitis? Fluid and electrolyte balance. Gastric irritation Pain management Psychosocial issues

Fluid and electrolyte balance.

A patient with advanced cirrhosis now has hepatic encephalopathy. The nurse writes the nursing diagnosis of "Disturbed thought process related to ___________________." Altered blood clotting Fluid volume excess Ascites formation Increased serum ammonia levels

Increased serum ammonia levels

Which of the following laboratory results is most commonly used to diagnose acute pancreatitis? Decreased serum glucose Increased serum amylase Increased serum calcium Decreased aspartate transaminase (AST)

Increased serum amylase

A patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. Which intervention should the nurse include in the patient's plan of care? Administer acetaminophen (Tylenol) every 4 hours for pain relief. Insert an NG and maintain NPO status to allow pancreas to rest. Immediately start enteral feeding to prevent malnutrition. Initiate early prophylactic antibiotic therapy to prevent infection.

Insert an NG and maintain NPO status to allow pancreas to rest.

Which finding would the nurse most expect when assessing a patient with diverticulosis? Rectal bleeding Right lower quadrant cramping pain Low grade temperature No symptoms

No symptoms

The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain through suppression of pancreatic secretions is the use of a. antibiotics. b. NPO status. c. antispasmodics. d. proton pump inhibitors.

b. NPO status.

Which assessment data best indicates the client recovering from an open cholecystectomy may require pain medication? a.Pulse is 65 beats per minute b.Shallow respirations c.Hypoactive bowel sounds d.Use of a pillow to splint when coughing

b.Shallow respirations

Adam's bleeding is controlled with treatment. His lowest H&H, occurring 24 hours after admission, is 11.5 g/dl (115 g/L) and 32%. Two days after admission his NG tube is removed, and oral intake is started. In reviewing Adam's diet with him, you evaluate that he understands the dietary recommendations for PUD when he says: A."I can eat and drink most foods and fluids that don't cause me distress." B."I should substitute coffee and tea for alcohol at my social business functions." C."I must eat bland foods at least six times a day to promote healing of my ulcer." D."I should eliminate all milk and milk products because they stimulate gastric acid production."

A."I can eat and drink most foods and fluids that don't cause me distress."

A client is admitted with a diagnosis of hepatic encephalopathy. The nurse's assessment documentation would most likely include which of the following? A.Altered mental status B.Proficient concentration C.Increased energy D.Talkativeness

A.Altered mental status

Which intervention is most important when preventing the transmission of hepatitis A? A.Careful hand washing B.Standard precautions C.Effective sewage disposal D.Good personal hygiene

A.Careful hand washing

A self-help group of clients with irritable bowel syndrome have invited a nurse to present a program on nutrition. Which substance should the nurse teach the clients to minimize in the diet to decrease gastrointestinal (GI) irritability? A.Cola drinks B.Gelatin C.Fiber D.Rice

A.Cola drinks

The nursing is caring for a patient who is experiencing dysphagia following a stroke. What is the priority risk associated with dysphagia that must be considered when planning nursing care? Impaired communication Nutritional imbalance Aspiration Dehydration

Aspiration

The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temp of 100.6 degrees F. Which intervention should the nurse implement first? Document the findings in the chart Assess the client's abdomen Notify the health-care provider Administer an oral antipyretic

Assess the client's abdomen

A client with chronic gastritis is being treated with medication and diet. What should the nurse teach the client when discussing the therapeutic regimen? Lie down after eating when possible Avoid using analgesics that contain aspirin Limit high-carbohydrate foods in the diet Take an antacid preparation with meals

Avoid using analgesics that contain aspirin

The client diagnosed with liver problems asks the nurse "Why are my stools clay-colored?" On which scientific rationale should the nurse base the response? A.There is an increase in serum ammonia levels. B.The liver is unable to excrete bilirubin. C.The liver is unable to metabolize fatty foods. D.A damaged liver cannot detoxify vitamins.

B.The liver is unable to excrete bilirubin.

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined AA. The nurse should give priority to which client history item? Black, tarry stools Frequent nausea Joining AA Pain that increases after meals

Black, tarry stools

The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital. Which statement is the best initial response by the nurse? A."I understand how frustrating this must be for you." B."You must keep thinking about the good things in your life." C."I can see you are very upset. I'll sit down and we can talk." D."Are you thinking about doing anything like committing suicide?"

C."I can see you are very upset. I'll sit down and we can talk."

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data requires further intervention? A.Bowel sounds auscultated 15 times in one minute B.Belching after eating a heavy and fatty meal late at night C.A decrease in systolic blood pressure of 22 mm Hg from lying to sitting D.A decreased frequency of distress located in the epigastric region

C.A decrease in systolic blood pressure of 22 mm Hg from lying to sitting

A nurse is providing dietary teaching to a patient with irritable bowel syndrome (IBS) who is experiencing anorexia. What should the nurse teach the patient to help to ensure sufficient intake of calories and nutrients? Consume frequent small meals of high-protein, high-calorie foods Consume seasoned, flavorful foods at each meal Eat three meals a day Eat high-fiber breakfasts

Consume frequent small meals of high-protein, high-calorie foods

The patient with inflammatory bowel disease (IBD) is receiving the following medications. Which one is prescribed to relieve symptoms, rather than to treat the disease? Diphenoxylate with atropine (Lomotil) Infliximab (Remicade) Sulfasalizine (Azulfidine) Corticosteroids

Diphenoxylate with atropine (Lomotil)

A nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client's discharge? A.Contact the client's healthcare provider to ask to substitute a liquid form of medications for the pill form. B.Teach the client and family members to crush the pills and administer them with applesauce. C.Teach the client and family members about addiction that may occur as a result of regular opioid use. D.Contact the client's healthcare provider to discuss use of transdermal medications for pain control.

D.Contact the client's healthcare provider to discuss use of transdermal medications for pain control.

When administering the albumin infusion through a vein in the right hand, the nurse notes that the peripheral edema in the client's arms and hands has changed from a +3 to a +2. It is most important for the nurse to implement which intervention? A.Administer a diuretic B.Check the IV site C.Stop the infusion and check the client's blood pressure D.Continue the albumin infusion

D.Continue the albumin infusion

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? A.Relief of constipation B.Relief of abdominal pain C.Decreased liver enzymes D.Decreased ammonia levels

D.Decreased ammonia levels

The nurse is counseling a client on how to prevent cholecystitis. What is the most important guideline for the nurse to include? A.Eat a low protein diet B.Eat a low fat, low cholesterol diet C.Limit exercise to 10 minutes a day D.Keep weight proportional to height

D.Keep weight proportional to height

The nurse is planning to teach the client with gastroesophageal reflux disease (GERD) about substances that will increase the lower esophageal sphincter pressure. Which item should the nurse include on this list? A.Coffee B.Chocolate C.Cheese curds D.Nonfat milk

D.Nonfat milk

Based on the prolonged APTT and PT/INR, what clinical manifestations would the nurse anticipate visualizing upon assessment? A.Weight loss B.Peripheral edema C.Jaundice D.Petechiae

D.Petechiae

A patient with advanced cirrhosis who has ascites is short of breath and has an increased respiratory rate. What is the most appropriate action by the nurse? A.Initiate oxygen therapy at 2 L/min to increase gas exchange. B.Notify the health care provider so that a paracentesis can be performed. C.Ask the patient to cough and breathe deeply to clear respiratory secretions. D.Place the patient in semi-Fowler's position to relieve pressure on the diaphragm.

D.Place the patient in semi-Fowler's position to relieve pressure on the diaphragm.

A patient is admitted for appendicitis. What manifestations does the nurse expect? A.LUQ or epigastric pain, radiating to the back B.LLQ pain, fever, and constipation C.RUQ pain, fatigue, anorexia, and jaundice D.RLQ pain, guarding, rebound tenderness

D.RLQ pain, guarding, rebound tenderness

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.Rigid, board-like abdomen

D.Rigid, board-like abdomen

The nurse is working with an admitted nursing student who completed the hepatitis B vaccination series 2 months ago. The student returns from the clinic with the following results: Hepatitis B Surface Antigen (HBsAg) = negative. How should the nurse interpret this result? A.The student is immune to hepatitis B B.The student is not immune to hepatitis B C.The student is infected with hepatitis B D.The student needs to return to the clinic

D.The student needs to return to the clinic

Adam is very anxious about being in the hospital and keeps saying he can't afford to be away from work right now. When discussing the management of his illness after he is discharged, you recognize that at this time it is probably most important for him to A.stop smoking again. B.recognize symptoms of disease recurrence. C.avoid the use of over-the-counter medications for minor pains. D.use effective coping mechanisms to reduce business-related stress.

D.use effective coping mechanisms to reduce business-related stress.

Which is the priority intervention for the dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? Apply oxygen Prepare to administer packed red blood cells Place the client in a side-lying position Assess the client's pulse and blood pressure

Place the client in a side-lying position

An important nursing intervention for the patient with a small intestinal obstruction who has an NG tube is to Offer clear liquids to sip PRN Provide mouth care every 1-2 hours Irrigate the tube with normal saline every 8 hours Keep the patient supine

Provide mouth care every 1-2 hours

The client is two hours post colonoscopy. Which assessment data warrants immediate intervention by the nurse? Passing large amounts of flatus Loose, watery stool Pulse 106, BP 94/58 Hyperactive bowel sounds

Pulse 106, BP 94/58

Which diagnostic test does the nurse anticipate will be ordered for the patient who reports new onset of severe diarrhea? Blood cultures Stool specimen Barium enema Colonoscopy

Stool specimen

The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? Explain some blood in the stool will be normal. Instruct the client in manual removal of feces. Encourage the client to use a cathartic laxative on a daily basis. Teach the client to eat a high fiber diet.

Teach the client to eat a high fiber diet.

The nurse is caring for a client diagnosed with GERD. Which intervention should be included for this problem? Teach the client to sleep with a foam wedge under the head. Encourage the client to decrease the amount of smoking. Instruct the client to take OTC medications for pain relief. Discuss the need to attend AA to quit drinking.

Teach the client to sleep with a foam wedge under the head.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) Apply gentle pressure for the shortest possible time after venipuncture. Provide a high-protein, low-carbohydrate diet. Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid aspirin and nonsteroidal anti-inflammatory (NSAIDs). Teach the patient to avoid vigorous blowing of nose and coughing. Use the smallest gauge needle possible when giving injections or drawing blood.

Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid aspirin and nonsteroidal anti-inflammatory (NSAIDs). Teach the patient to avoid vigorous blowing of nose and coughing. Use the smallest gauge needle possible when giving injections or drawing blood.

In a client with diarrhea, which outcome indicates fluid resuscitation was successful? The client exhibits moist mucous membranes and firm skin turgor The client passes formed stools at regular intervals The client reports a decrease in stool frequency and liquidity The client no longer experiences perianal burning

The client exhibits moist mucous membranes and firm skin turgor

A patient with Crohn's disease is receiving iron and cobalamin (B12) supplements for anemia from malabsorption. What assessment information will best indicate the treatment is effective? The patient reports less fatigue and increased activity tolerance The patient reports lessening of Crohn's-related diarrhea and abdominal pain. The patient adheres to the prescribed regimen, taking the iron twice daily with orange juice. The patient denies any GI upset when taking the supplements. PreviousNext

The patient reports less fatigue and increased activity tolerance

Postoperatively, a patient with an incisional cholecystectomy has a nursing diagnosis of ineffective breathing pattern related to shallow respirations secondary to a high abdominal incision. Which action should the nurse take first? a. Assess heart and lung sounds. b. Administer the prescribed analgesic. c. Position the patient on the operative side. d. Instruct the patient to cough and deep breathe.

b. Administer the prescribed analgesic.

When admitting a client to the hospital with suspected acute pancreatitis, which electrolyte disorder would be most expected? a.Hypoglycemia b.Hypernatremia c.Hypocalcemia d.hyperkalemia

c.Hypocalcemia

Which of the following assessment findings would be consistent with a client's diagnosis of cirrhosis? a.Increased amylase b.Increased pH level c.Increased prothrombin time d.Increased white blood cell count

c.Increased prothrombin time

For a definitive diagnosis of cirrhosis, the nurse will assist with which diagnostic test? a.Albumin level b.Colonoscopy c.Liver biopsy d.Liver enzyme levels

c.Liver biopsy

A patient with acute hepatitis B will be discharged tomorrow. The nurse should include which measures in the discharge teaching plan? a.Choose foods that are very hot or very cold. b.Participate in an exercise regimen to build stamina. c.Avoid alcohol for the first three weeks. d.Be sure to allow for periods of rest during the day.

d.Be sure to allow for periods of rest during the day.

The home health nurse is caring for a client with viral hepatitis. Which intervention should the nurse discuss with the client? a.Limit water intake to 1000 mL per day. b.Eat a high fat diet. c.Take acetaminophen for fever. d.Eat small, frequent meals.

d.Eat small, frequent meals.

Upon reviewing the history of a client with chronic gastritis, which of the following may be a risk factor for the development of this condition? a.Adolescent client b.Antibiotic usage c.Gallbladder disease d.Helicobacter pylori infection

d.Helicobacter pylori infection

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

A patient with Crohn's disease develops a fever and symptoms of a urinary tract infection. What does the nurse recognize may have caused this complication? drug therapy with sulfasalazine malabsorption due to small intestine involvement fistula formation between the bowel and bladder development of a toxic megacolon

fistula formation between the bowel and bladder