PrepU Exam 3 Questions

The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis? a. Right lower quadrant b. Left lower quadrant c. Right upper quadrant d. Left upper quadrant

b. left lower quadrant rationale: Rovsing's sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant (see Fig. 48-3).

Which of the following would be considered a "free" item from the exchange list? a. Diet soda b. Green salad c. Medium apple d. 1 tsp olive oil

diet soda rationale: Free items include unsweetened iced tea, diet soda, and ice water with lemon. A green salad is exchanged for 1 vegetable. A medium apple is 1 fruit; 1 tsp of olive oil is 1 fat.

A client newly diagnosed with type 1 diabetes asks the nurse why injection site rotation is important. What is the nurse's best response? a. Avoid infection. b. Promote absorption. c. Minimize discomfort. d. Prevent muscle destruction.

promote absorption rationale: Subcutaneous injection sites require rotation to avoid breakdown and/or buildup of subcutaneous fat, either of which can interfere with insulin absorption in the tissue. Infection and discomfort are risks involved with injection site but not the primary reason for rotation of sites. Insulin is not injected into the muscle.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? a. "Maintain a high-fat diet and drink at least 3 L of fluid a day." b. "Maintain a high-sodium, high-calorie diet." c. "Maintain a high-carbohydrate, low-fat diet." d. "Maintain a high-fat, high-carbohydrate diet."

"maintain a high- carbohydrate, low- fat diet" rationale: A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? a. the client doesnt exhibit rectal tenesmus b. the client is free from esophagitis and achalasia c. the client reports diminished duodenal inflammation d. the client has normal gastric structures

b. the client is free from esophagitis and achalasia rationale: Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.

The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find? a. Blood glucose level of 250 mg/dL b. Blood pH of 6.9 c. Serum bicarbonate of 19 mEq/L d. PaCO2 of 40 mm Hg

blood pH of 6.9 rationale: With DKA, blood glucose levels are elevated to 300 to 1000 mg/dL or more. Urine contains glucose and ketones. The blood pH ranges from 6.8 to 7.3. The serum bicarbonate level is decreased to levels from 0 to 15 mEq/L. The compensatory breathing pattern can lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to levels of 10 to 30 mm Hg.

A nurse is assigned to care for a patient who is suspected of having type 2 diabetes. Select all the clinical manifestations that the nurse knows could be consistent with this diagnosis. a. Blurred or deteriorating vision b. Fatigue and irritability c. Polyuria and polydipsia d. Sudden weight loss and anorexia e. Wounds that heal slowly or respond poorly to treatment

blurred or deteriorating vision; fatigue and irritability; polyuria and polydipsia; wounds that heal slowly or respond poorly to treatment rationale: All the options are correct except for weight loss and anorexia. Obesity is almost always associated with type 2 diabetes.

A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem? a. Appendicitis b. Rectal fissures c. Bowel perforation d. Diverticulitis

bowel perforation rationale: Megacolon is a dilated and atonic colon caused by a fecal mass that obstructs the passage of colon contents. Symptoms include constipation, liquid fecal incontinence, and abdominal distention. Megacolon can lead to perforation of the bowel.

Which statement correctly identifies a difference between duodenal and gastric ulcers? a. Malignancy is associated with duodenal ulcer. b. Weight gain may occur with a gastric ulcer. c. A gastric ulcer is caused by hypersecretion of stomach acid. d. Vomiting is uncommon in clients with duodenal ulcers.

d. vomiting is uncommon in clients with duodenal ulcers rationale: Vomiting is uncommon in clients diagnosed with duodenal ulcer. Malignancy is associated with a gastric ulcer. Weight gain may occur with a duodenal ulcer. Duodenal ulcers cause hypersecretion of stomach acid.

The health care provider has explained to a client that the client has developed diabetic neuropathy in the right foot. Later that day, the client asks the nurse what causes diabetic neuropathy. What would be the nurse's best response? a. "Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years." b. "The cause is not known for sure but it is thought to have something to do with ketoacidosis." c. "The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years." d. "Research has shown that diabetic neuropathy is caused by a combination of elevated glucose and ketone levels."

"the cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years" rationale: The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugar (rather than fluctuations or variations in blood sugars) is thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies.

A client with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the client? a. Examine feet weekly for redness, blisters, and abrasions. b. Avoid the use of moisturizing lotions. c. Avoid hot-water bottles and heating pads. d. Dry feet vigorously after each bath.

avoid hot water bottles and heating pads rationale: High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the client should gently, not vigorously, pat feet dry to avoid injury.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? a. "lie down after meals to promote digestion" b. "avoid coffee and alcoholic beverages" c. "take antiacids with meals" d. "limit fluid intake with meals"

b. "avoid coffee and alcoholic beverages" rationale: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

The nurse is developing a plan of care for a patient with peptic ulcer disease. What nursing interventions should be included in the care plan? Select all that apply. a. making neurovascular checks every 4 hours b. frequenly monitoring hemoglobin and hematocrit levels c. observing stools and vomitus for color, consistency, and volume d. checking the blood pressure and pulse rate every 15 to 20 minutes e. insert an indwelling catheter for incontinence

b. frequenly monitoring hemoglobin and hematocrit levels c. observing stools and vomitus for color, consistency, and volume d. checking the blood pressure and pulse rate every 15 to 20 minutes rationale: The nurse assesses the patient for faintness or dizziness and nausea, which may precede or accompany bleeding. The nurse must monitor vital signs frequently and evaluate the patient for tachycardia, hypotension, and tachypnea. Other nursing interventions include monitoring the hemoglobin and hematocrit, testing the stool for gross or occult blood, and recording hourly urinary output to detect anuria or oliguria (absence of or decreased urine production).

A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to a. administer an increased dose of neutral protamine Hagedorn insulin in the evening. b. check blood glucose at 3:00 a.m. c. eat a complex carbohydrate snack in the evening before bed. d. skip the evening neutral protamine Hagedorn insulin dose on days when exercising and skipping meals.

check blood glucose at 3am rationale: In the Somogyi effect, the client has a normal or elevated blood glucose concentration at bedtime, which decreases to hypoglycemic levels at 2 to 3 a.m., and subsequently increases as a result of the production of counter-regulatory hormones. It is important to check blood glucose in the early morning hours to detect the initial hypoglycemia.

A nurse cares for a client who is post op open cholecystectomy. Upon assessment, the nurse notes the client's abdomen feels firm to palpation. What is the nurse's priority action? a. Contact the health care provider b. Auscultate the bowel sounds c. Ask the client the last bowel movement date d. Prepare to insert a nasogastric tube to intermittent suction

contact the healthcare provider rationale: A client who is post op from open abdominal surgery is at risk for internal bleeding, which may manifest as rigidity of the abdomen. The nurse's priority is to contact the health care provider. Additional interventions will be necessary but contacting the health care provider is priority.

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? a. Assessment of blood pressure and assessment for headaches and visual changes b. Assessments for signs and symptoms of venous thromboembolism c. Daily weights and abdominal girth measurement d. Blood glucose monitoring q4h

daily weights and abdominal girth measurement rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

A nurse is inspecting the feet of a client with diabetes and finds a tack sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding? a. In diabetes, the autonomic nerves are affected. b. Motor neuropathy causes muscles to weaken and atrophy. c. High blood sugar decreases blood circulation to nerves. d. Nephropathy is a common complication of diabetes mellitus.

high blood sugar decreases blood circulation to nerves rationale: Diabetic neuropathy results from poor glucose control and decreased blood circulation to nerve tissues. The lack of sensitivity increases the potential for soft tissue injury without awareness. Autonomic neuropathy is a complication of diabetes mellitus but not significant with peripheral injuries. Motor neuropathy does occur with poor glucose control but not specific to this injury. Nephropathy is a common complication that directly affects the kidneys.

A client has had a thyroidectomy. Which of the following would lead the nurse to suspect that the client is developing thyrotoxic crisis? a. Bradycardia b. Hoarseness c. Hyperthermia d. Tetany

hyperthermia rationale: Thyrotoxic crisis is manifested by hyperthermia (temperature possibly as high as 106oF (41Co). The pulse is rapid and cardiac dysrhythmias are common. The client may experience persistent vomiting, extreme restlessness with delirium, chest pain, and dyspnea. Hoarseness may be noted due to trauma to the vocal cords during surgery. Tetany indicating hypocalcemia would be manifested if the parathyroid glands are accidentally removed.

A nurse is providing care to a client with primary hyperparathyroidism. Which interventions would be included in the client's care plan? Select all that apply. a. Monitor gait, balance, and fatigue level with ambulation. b. Monitor for fluid overload. c. Monitor for signs and symptoms of diarrhea. d. Encourage intake of dairy products, seafood, nuts, broccoli, and spinach.

monitoring gait, balance, and fatigue level with ambulation; monitor for fluid overload rationale: Excessive calcium in the blood depresses the responsiveness of the peripheral nerves, accounting for fatigue and muscle weakness. A large volume of fluid is encouraged to keep the urine dilute. Possible effects include nausea, vomiting, and constipation. Client would be on a calcium-restricted diet.

Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly patient with diabetes mellitus? a. Patient's eating and sleeping habits b. Patient's ability to self-administer insulin c. Cognitive problems d. Patient's history

patient's eating and sleeping habits rationale: The eating and sleeping habits of older adults differ from those of young or middle-aged persons. The nurse should take this into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent. The nurse should evaluate the patient's ability to self-administer insulin before developing a teaching program. Cognitive problems and patient history may not be taken into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? a. Pigment b. Pearl c. Patterned d. Pixelated

pigment rationale: There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

The nurse is administering a medication to a client with hyperthyroidism to block the production of thyroid hormone. The client is not a candidate for surgical intervention at this time. What medication should the nurse administer to the client? a. Levothyroxine b. Spironolactone c. Propylthiouracil d. Propranolol

propylthiouracil (PTU) rationale: Antithyroid drugs, such as propylthiouracil and methimazole are given to block the production of thyroid hormone preoperatively or for long-term treatment for clients who are not candidates for surgery or radiation treatment. Levothyroxine would increase the level of thyroid and be contraindicated in this client. Spironolactone is a diuretic and does not have the action of blocking production of thyroid hormone and neither does propranolol, which is a beta-blocker.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide? a. Cure the cirrhosis. b. Treat the esophageal varices. c. Reduce fluid accumulation and venous pressure. d. Promote optimal neurologic function.

reduce fluid accumulation and venous pressure rationale: Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

A client with symptoms of Cushing syndrome is admitted to the hospital for evaluation and treatment. The nurse is creating a plan of care for the client. Which is an appropriate nursing diagnosis? a. Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns b. Insomnia related to increased nighttime voiding c. Impaired nutrition: more than body requirements related to polyphagia d. Activity intolerance related to muscle cramps, cardiac dysrhythmias, and weakness

self- care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns rationale: The major goals for the client include decreased risk of injury, decreased risk of infection, increased ability to perform self-care activities, improved skin integrity, improved body image, improved mental function, and absence of complications. The other nursing diagnoses do not apply in Cushing syndrome.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation? a. The client's hepatic function is decreasing. b. The client didn't take his morning dose of lactulose (Cephulac). c. The client is relaxed and not in pain. d. The client is avoiding the nurse.

the client's hepatic functioning is decreasing rationale: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.

A client with type 1 diabetes mellitus is being taught about self-injection of insulin. Which fact about site rotation should the nurse include in the teaching? a. Avoid the abdomen because absorption there is irregular. b. Choose a different site at random for each injection. c. Rotate sites from area to area every other day. d. Use all available injection sites within one area.

use all available injection sites within one area rationale: Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue. To promote consistency in insulin absorption, the client should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area.

Which foods should be avoided following acute gallbladder inflammation? a. Cooked fruits b. Cheese c. Coffee d. Mashed potatoes

cheese rationale: The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? a. a low-fat diet b. elevation of upper body on pillows c. pantoprazole d. metoclopramide

d. metoclopramide rationale: the instructions are important for the client experiencing gastroesophageal reflux disease. the client is prescrined carbidopa/ levodopa (Sinemet), which is used for parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment? a. Monitoring the client for dysrhythmias b. Maintaining and monitoring the client's fluid balance c. Assessing the client's level of consciousness d. Assessing the client for signs and symptoms of venous thromboembolism

maintaining and monitoring the client's fluid balance rationale: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the client for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.

Which outcome indicates effective client teaching to prevent constipation? a. The client verbalizes consumption of low-fiber foods. b. The client maintains a sedentary lifestyle. c. The client limits water intake to three glasses per day. d. The client reports engaging in a regular exercise regimen.

the client reports engaging in regular exercise regimen rationale: The client having a regular exercise program indicates effective teaching. A regular exercise regimen promotes peristalsis and contributes to regular bowel elimination patterns. A low-fiber diet, a sedentary lifestyle, and limited water intake would predispose the client to constipation.

A client newly diagnosed with type 2 diabetes has been told by their family that they can no longer consume alcohol. The client asks the nurse if abstaining from all alcohol is necessary. What is the nurse's best response? a. "You should stop all alcohol intake. Alcohol is absorbed by your body before other important nutrients and may lead to very high blood glucose levels." b. "You do not need to give up alcohol entirely but there are potential side effects specific to clients with diabetes that you should consider." c. "You should no longer consume alcohol since it causes immediate low blood glucose levels in diabetic clients." d. "You can still consume alcohol, but limit your consumption to no more than 3 glasses of wine or beer daily because of the high sugar content of alcohol."

"you do not need to give up alcohol entirely but there are potential side effects specific to clients with diabetes that you should consider" rationale: Clients with diabetes do not need to give up alcoholic beverages entirely. Moderation is the key. Moderate intake is no more than 1 alcoholic beverage (light beer, wine) for women and 2 drinks for men daily. Recommendations include avoiding mixed drinks and liqueurs because of the possibility of excessive weight gain, elevated glucose levels, and hyperlipidemia. Clients should be aware of potential side effects of alcohol consumption. These include diabetic ketoacidosis and hypoglycemia To combat possible hypoglycemia, clients with diabetes should not consume alcohol on an empty stomach.

The nurse is instructing a client on the self-administration of insulin. Place in order the steps that the nurse will instruct the client to take.

1. stabilize the skin by pinching an area 2. hold the syringe as if holding a pencil 3. insert the needle straight into the skin 4. push the plunger of the syringe 5. pull the needle straight out of the skin 6. press a cotton ball over the injection site 7. discard the syringe into a hard container rationale: When instructing a client to self-administer insulin, the first step is to stabilize the skin by pinching an area. Then, hold the syringe like a pencil and insert the needle straight into the skin. Next, push the plunger of the syringe and, afterwards, pull the needle straight out of the skin. A cotton ball is then pressed over the injection site and the syringe is discarded into a hard plastic container.

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply. a. "It can evaluate the presence and location of ductal stones and aid in stone removal." b. "It is used in the diagnostic evaluation of acute pancreatitis." c. "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." d. "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." e. "It can assess for ecchymosis in the body."

a. "it can evaluate the presence and location of ductal stones and aid in stone removal" c. "it can assess the anatomy of the pancreas and pancreatic and biliary ducts" d. "it can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts" rationale: ERCP can determine the difference between pancreatitis and other biliary disorders and is generally used in chronic pancreatitis. It is particularly useful in diagnosis and treatment of clients who have symptoms after biliary tract surgery, clients with intact gallbladders, and clients for whom surgery is particularly hazardous. It can be used to assist with the removal of stones. ERCP is a useful tool in providing anatomic details about the pancreas and biliary ducts. It can evaluate the presence and location of ductal stones and detect changes in the anatomy of the client with pancreatitis, such as obstruction in the pancreatic duct and tissue necrosis due to premature release of pancreatic enzymes, and assess for abscesses and pseudocysts and atrophy of the glands in the body. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the clients is acutely ill; however, it may be valuable in treating gallstone pancreatitis.

A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. Based on the client's assessment, what will the nurse suspect? a. Dumping syndrome b. Dehiscence of the surgical wound c. Peritonitis d. A normal reaction to surgery

a. dumping syndrome rationale: Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. Dehiscence of the surgical wound is characterized by pain and a pulling or popping feeling at the surgical site. Peritonitis presents with a rigid, board-like abdomen, tenderness, and fever. The client's signs and symptoms aren't a normal reaction to surgery.

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. a. Enlarged liver size b. Ascites c. Accelerated behaviors and mental processes d. Hemorrhoids e. Excess storage of vitamin C

a. enlarged liver size b. ascites d. hemorrhoids rationale: Early in the course of cirrhosis, the liver tends to be large, and the cells are loaded with fat. The liver is firm and has a sharp edge that is noticeable on palpation. Portal obstruction and ascites, late manifestations of cirrhosis, are caused partly by chronic failure of liver function and partly by obstruction of the portal circulation. The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and shunting of blood from the portal vessels into blood vessels with lower pressures. These distended blood vessels form varices or hemorrhoids, depending on their location. Because of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, and K), signs of deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Additional clinical manifestations include deterioration of mental and cognitive function with impending hepatic encephalopathy and hepatic coma, as previously described.

A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply. a. Instructing the client to remove salty and salted foods from the diet b. Administering prescribed spironolactone (Aldactone) c. Assisting with placement of a transjugular intrahepatic portosystemic shunt d. Mobilizing the client every 2 hours e. Taking the client's weight every 3 to 4 days

a. instrucing the client to remove salty and salted foods from the diet b. administering prescribed sprionolactone (Aldactone) c. assisting with placement of a transjugular intrahepatic portosystemic shunt rationale: The goal of treatment for the client with ascites is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all ordinary canned and frozen foods that are not specifically prepared for low-sodium diets should be avoided. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a method of treating ascites in which a cannula is threaded into the portal vein by the transjugular route. In clients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system. This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Therefore, bed rest may be a useful therapy, especially for clients whose condition is refractory to diuretics. Other measures include assessment and documentation of intake and output, abdominal girth, and daily weight to assess fluid status.

The nurse is caring for a client who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? Select all that apply. a. Measure urine output every 8 hours. b. Assess and document vital signs every 4 hours. c. Measure abdominal girth daily. d. Perform daily weights. e. Monitor number of bowel movements per day.

a. measure the urine output every 8 hours c. measure abdominal girth daily d. perform daily weights rationale: Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy. Monitoring the number of bowel movements is not required, though the volume would be recorded as part of output.

A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. a. Preparing the client to troubleshoot for problems b. Teaching the client and family strict aseptic technique c. Teaching the client and family how to set up the infusion d. Teaching the client to flush the line with sterile water e. Teaching the client when it is safe to leave the access site open to air

a. preparing the client to troubleshoot for problems b. teaching he client and the family strict aseptic technique c. teaching the client and family how to set up in the infusion rationale: An effective home care teaching program prepares the client to store solutions, set up the infusion, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Tap water is never used for flushes and the access site must never be left open to air.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control? a. The client exhibits signs of adequate GI perfusion. b. The client expresses positive feelings about himself. c. The client verbalizes a manageable level of discomfort. d. The client maintains skin integrity.

a. the client exhibits signs of adequate GI perfusion rationale: Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level? Select all that apply. a. Administration of calcitonin b. Administration of calcium carbonate c. Intravenous isotonic saline solution in large quantities d. Monitoring the patient for fluid overload e. Administration of a bronchodilator

administration of calcitonin; intravenous isotonic saline solution in large quantities; monitoring the patient for fluid overload rationale: Acute hypercalcemic crisis can occur in patients with hyperparathyroidism with extreme elevation of serum calcium levels. Serum calcium levels greater than 13 mg/dL (3.25 mmol/L) result in neurologic, cardiovascular, and kidney symptoms that can be life threatening (Fischbach & Dunning, 2009). Rapid rehydration with large volumes of IV isotonic saline fluids to maintain urine output of 100 to 150 mL per hour is combined with administration of calcitonin (Shane & Berenson, 2012). Calcitonin promotes renal excretion of excess calcium and reduces bone resorption. The saline infusion should be stopped and a loop diuretic may be needed if the patient develops edema. Dosage and rates of infusion depend on the patient profile. The patient should be monitored carefully for fluid overload.

What concepts does the nurse understand about gerontologic considerations related to acute pancreatitis? Select all that apply. a. As the client ages, there is an increased risk for the development of acute pancreatitis. b. As the client ages, there is an increased mortality rate for acute pancreatitis. c. As the client ages, there is an increased risk for the development of multiple organ dysfunction syndrome. d. As the client ages, the pattern of complications related to acute pancreatitis changes. e. As the client ages, the size of the pancreas decreases, increasing the risk of developing acute pancreatitis.

as the client ages, there is an increased mortality rate for acute pancreatitis; as the client ages, there is an increased risk for the devlopment of multiple organ dysfunction syndrome; as the client ages, the pattern of complications related to acute pancreatitis changes rationale: Gerontologic considerations must be remembered when caring for older adult clients with acute pancreatitis. Clients of all ages may develop acute pancreatitis; however, mortality rate for acute pancreatitis increases as the client ages. Additionally, as the client ages, the pattern of complications related to acute pancreatitis changes and the risk of developing multiple organ dysfunction syndrome (MODS) increases with age. The size of the pancreas does not decrease as the client ages.

A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by what he's facing and not sure he can handle giving himself insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because she needs the space for clients being admitted. How should the nurse handle the situation? a. Suggest the client find a supportive friend or family member to assist in his care. b. Ask the physician to delay the discharge because the client requires further teaching. c. Tell the charge nurse she doesn't believe this client will be safe and refuse to rush. d. Ask the physician for a referral for a diabetes nurse-educator to see the client before discharge.

ask the physician to delay the discharge because the client requires further teaching rationale: The nurse's primary concern should be the safety of the client after discharge. She should provide succinct information to the physician concerning the client's needs, express her concern about ensuring the client's safety, and ask the physician to delay the client's discharge. The nurse shouldn't suggest that the client rely on a friend or family member because she doesn't know if a friend or family member will be available to help. Refusing to rush and telling the charge nurse she isn't sure the client will be safe demonstrate appropriate intentions, but these actions don't alleviate the pressure to discharge the client. Asking a physician to refer the client to a diabetic nurse-educator addresses the client's needs, but isn't the best response because there's no guarantee a diabetic nurse-educator will be available on such short notice.

The nurse instructs a client with a peptic ulcer on modifications to make to their diet. Which statement indicates to the nurse that teaching has been effective? a. "I will begin eating small frequent meals." b. "I will stop drinking decaffeinated coffee." c. "I will limit my alcohol intake to two drinks a day." d. "I will eat a hot meal before it cools to room temperature."

b. "i will stop drinking decaffeinated coffee" rationale: The intent of dietary modification for clients with peptic ulcers is to avoid oversecretion of acid and hypermotility in the GI tract. These can be minimized by overstimulation from the consumption of coffee, including decaffeinated coffee, which also stimulates acid secretion. Small, frequent feedings are not necessary as long as an antacid or an H2 blocker is taken. Alcohol will cause the overstimulation of acid and hypermotility in the GI tract. Extremes of temperature in foods will cause oversecretion of acid and hypermotility in the GI tract.

Postoperatively, a client with a radical neck dissection should be placed in which position? a. supine b. fowler c. prone d. side- lying

b. fowler rationale: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

A client comes to the clinic to see the health care provider for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with? a. Hepatitis b. Biliary colic c. Cholelithiasis d. Cholecystitis

cholelithiasis rationale: Initially, with cholelithiasis clients experience belching, nausea, and right upper quadrant discomfort, with pain or cramps after high-fat meal. Symptoms become acute when a stone blocks bile flow from the gallbladder. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain called biliary colic. The symptoms do not correlate with hepatitis.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a. cirrhosis. b. peptic ulcer disease. c. appendicitis. d. cholelithiasis.

cirrhosis rationale: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A client has been recently diagnosed with an anorectal condition. The nurse is reviewing interventions that will assist the client with managing the therapeutic regimen. What would not be included? a. Encourage the client to avoid exercise. b. Instruct the client to cleanse perianal area with warm water. c. Teach the client how to do sitz baths at home using warm water three to four times each day. d. Encourage the client to follow diet and medication instructions.

encourage the client to avoid exercise rationale: Activity promotes healing and normal stool patterns. Proper cleansing prevents infection and irritation. Sitz baths promote healing, decrease skin irritation, and relieve rectal spasms. Encouragement promotes compliance with therapeutic regimen and prevents complications.

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.) a. Encouraging bed rest to decrease the metabolic rate b. Assisting the patient into the prone position c. Withholding oral feedings to limit the release of secretin d. Administering parenteral opioid analgesics as ordered e. Administering prophylactic antibiotics

encouraging bed rest to decrease metabolic rate; withholding oral feedings to limit the release of secretin; administering parenteral opioid analgesics as ordered rationale: The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased (Marx, 2009). Nonpharmacologic interventions such as proper positioning (not prone), music, distraction, and imagery may be effective in reducing pain when used along with medications. In addition, oral feedings are withheld to decrease the secretion of secretin.

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus? a. Respirations of 12 breaths/minute b. Cloudy urine c. Blood sugar 170 mg/dL d. Fruity breath

fruity breath rationale: The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.

When the nurse is caring for a patient with type 1 diabetes, what clinical manifestation would be a priority to closely monitor? a. Hypoglycemia b. Hyponatremia c. Ketonuria d. Polyphagia

hypoglycemia rationale: The therapeutic goal for diabetes management is to achieve normal blood glucose levels (euglycemia) without hypoglycemia while maintaining a high quality of life.

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should the nurse include in her teaching plan? a. Increase respiratory effectiveness. b. Eliminate the need for nasogastric intubation. c. Improve nutritional status during recovery. d. Decrease the amount of postoperative analgesia needed.

increase respiratory effectiveness rationale: The nurse must teach the client about using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients don't have a nasogastric tube in place after a cholecystectomy. It isn't appropriate to teach improved nutritional status before surgery. It isn't important for the client to be aware of how to decrease the amount of postoperative analgesia, because this is the responsibility of the health care team.

The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority? a. Fatigue b. Excess fluid volume c. Ineffective breathing pattern d. Imbalanced nutrition: less than body requirements

ineffective breathing pattern rationale: In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the respiratory rate and low oxygen saturation would indicate the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching? Select all that apply. a. "Insulin permits entry of glucose into the cells of the body." b. "Insulin promotes synthesis of proteins in various body tissues." c. "Insulin promotes the storage of fat in adipose tissue." d. "Insulin interferes with glucagon from the pancreas." e. "Insulin interferes with the release of growth hormone from the pituitary."

insulin permits entry of glucose into the cells of the body; insulin promotes synthesis of proteins in various body tissues; insulin promotes the storage of fat in adipose tissue rationale: Insulin is a hormone secreted by the endocrine part of the pancreas. In addition to lowering blood glucose by permitting entry of glucose into the cells, insulin also promotes protein synthesis and the storage of fat in adipose tissue. Somatostatin exerts a hypoglycemic effect by interfering with glucagon from the pancreas and the release of growth hormone from the pituitary.

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply. a. Ketosis-prone b. Little or no endogenous insulin c. Obesity at diagnoses d. Younger than 30 years of age e. Older than 65 years of age

ketosis- prone; little or no endogenous insulin; younger than 30 years of age rationale: Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent.

A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor: a. urine output. b. abdominal girth. c. stool frequency. d. level of consciousness (LOC).

level of consciousness (LOC) rationale: In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply. a. Normal bedtime blood glucose b. Rise in blood glucose about 11:00 AM c. Increase in blood glucose from 3:00 AM until breakfast d. Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM e. Elevated blood glucose at bedtime

normal bedtime glucose; increase in blood glucose from 3am until breakfast; decrease in blood sugar to a hypoglycemic level between 2 to 3 am rationale: The Somogyi effect is nocturnal hypoglycemia followed by rebound hyperglycemia in the morning.

A nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be: a. monitoring blood glucose every 4 hours and as needed. b. checking for the presence of ketones with each void. c. providing client education at every opportunity. d. administering insulin routinely and as needed via a sliding scale.

providing client education at every opportunity rationale: The nurse should use routine care responsibilities as teaching opportunities with the intention of preparing the client to understand and eventually manage his disease. Monitoring blood glucose, checking for the presence of ketones, and administering insulin are important when caring for a client with diabetes, but they aren't the priority of care.

A client with a new diagnosis of gallstones declines surgical intervention and requests information on midigating stratergies. The nurse anticipates teaching to focus on which client behaviors and monitoring strategies? a. Increase fiber intake, report any episodes of vomiting, and consider lithotripsy. b. Recommend a low fiber diet, monitor for fevers and increased abdominal girth. c. Report episodes of vomiting and severe abdominal pain, and limit alcohol consumption. d. Monitor for increased pruritus and jaundice; consider the use of analgesic medications prophylactically.

recommend a low fiber diet, monitor for fevers and increased abdominal girth rationale: The patient with gallbladder disease resulting from gallstones may develop two types of symptoms: those with disease to the gallbladder itself and those due to obstruction of the bile passages. The symptoms may be acute or chronic. Epigastric distress such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen may occur. Those at high risk may be encouraged to maintain an optimal body weight and consider reducing modifiable risk factors by avoiding consumption of sugar and sweet foods and maitaining a low fiber diet. If the gallstone obstructs the cystic duct the gallbladder becomes distended inflamed and eventually infected which results in acute cholecystitis. The patient develops a fever and may have a palpable abdominal mass. The pain of a acute cystitis may be so severe that analgesic medications are required but should not be given prophylactically which could mask a worsening condition. Jaundice occurs in a few patients with gallbladder disease usually with obstruction of the common bile duct which is frequently accompanied by pruritus (itching) of the skin. Lithotripsy is the use of shock waves to disintegrate gallstones and is a surgical procedure.

A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems? a. Contractile spasms of the gallbladder decreases appetite and leads to malnutrition. b. Inflammation of the gallbladder causes pain and impacts gastric motility. c. Reduced or absent bile as a result of obstruction impacts digestion. d. Increased bile as a result of inflammation leads to indigestion.

reduced or absent bile as a result of obstruction impacts digestion rationale: Digestion is impacted by cholecystitis because an obstruction of the gallbladder results in reduced or absent bile. Contractile spasms and inflammation of the gallbladder leads to pain, not problems with digestion.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? a. Relieving abdominal pain b. Preventing fluid volume overload c. Maintaining adequate nutritional status d. Teaching about the disease and its treatment

relieving abdominal pain rationale: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments? a. Monitoring the client's neutrophil levels b. Assessing the client for signs of impaired liver function c. Monitoring the client's level of consciousness and behavior d. Reviewing the client's creatinine and BUN levels

reviewing the clients creatinine and BUN levels rationale: Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the client's kidney function. This drug does not typically affect clients' neutrophils, liver function, or cognition.

A client is admitted from the emergency department with complaints of severe abdominal pain and an elevated white blood cell count. The physician diagnoses appendicitis. The nurse knows the client is at greatest risk for: a. rupture of the appendix. b. ulceration of the appendix. c. inflammation of the gallbladder. d. emotional distress related to the pain.

rupture of the appendix rationale: The most severe complication of appendicitis is rupture of the appendix, which can lead to a life-threatening infection. Ulceration of the appendix and inflammation of the gallbladder aren't risks in appendicitis. Although the client may have emotional distress because of the pain, this factor isn't the greatest risk to the client.

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? a. Serum calcium b. Serum lipase c. Serum bilirubin d. Serum amylase

serum lipase rationale: Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes (Feldman et al., 2010). In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.

A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find? a. tenderness and pain in the right upper abdominal quadrant b. jaundice and vomiting c. severe abdominal pain with direct palpation or rebound tenderness d. rectal bleeding and a change in bowel habits

severe abdominal pain with direct palpation or rebound tenderness rationale: Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (i.e., appendicitis, diverticulitis, ulcerative colitis, a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern? a. The skin on the client's abdomen has multiple spider-shaped blood vessels. b. The client has gained 2 kg from the previous day. c. The client reports nausea and anorexia. d. The client's hands flap back and forth when the arms are extended.

the client's hands flap back and forth when the arms are extended rationale: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy. It indicates that the client has hepatic encephalopathy and, if untreated, a hepatic coma may occur.

A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem? a. Ulcerative colitis b. Hypertension c. Gastroesophageal reflux disease d. Appendicitis

ulcerative colitis rationale: A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Although hypertension has familial tendencies, the client's symptoms aren't related to hypertension. A family history of gastroesophageal reflux disease or appendicitis isn't a significant factor in the client history because these conditions aren't considered familial traits.

A client with type 2 diabetes has recently been prescribed acarbose, and the nurse is explaining how to take this medication. The teaching is determined to be effective based on which statement by the client? a. "I will take this medication in the morning, 15 minutes before breakfast." b. "I will take this medication in the morning, with my first bite of breakfast." c. "This medication needs to be taken after the midday meal." d. "It does not matter what time of day I take this medication."

"i will take this medication in the morning, with my first bite of breakfast" rationale: Alpha-glucosidase inhibitors such as acarbose and miglitol, delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. They must be taken with the first bite of food to be effective.

Which of the following is the most common complication associated with peptic ulcer? a. Hemorrhage b. Vomiting c. Elevated temperature d. Abdominal pain

a. hemorrhage rationale: Hemorrhage, the most common complication, occurs in 28% to 59% of patients with peptic ulcers. Vomiting, elevated temperature, and abdominal pain are not the most common complications of a peptic ulcer.

A client has been experiencing lower GI difficulties that have increased in severity, and the gastroenterologist is concerned that the client's bowel is not functioning properly. What function of the lower GI tract is most likely to be affected by the client's disorder? a. water and electrolyte absorption b. protein digestion c. fat digestion d. All options are correct.

a. water and electrolyte absorption rationale: Disorders of the lower GI tract usually affect movement of feces toward the anus, absorption of water and electrolytes, and elimination of dietary wastes.

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The child's parent reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA? a. Give prescribed antiemetics. b. Begin fluid replacements. c. Administer prescribed dose of insulin. d. Administer bicarbonate to correct acidosis.

begin fluid replacements rationale: Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.

A client is recovering from gastric surgery. What is the correct position for the nurse to place this client? a. Supine b. Semi-Fowler's c. Trendelenburg d. Fowler's

d. Fowler's rationale: Placing the client in the Fowler's position after gastric surgery promotes comfort and allows emptying of the stomach.

A patient is prescribed Glucophage, an oral antidiabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to: a. Stimulate the beta cells of the pancreas to secrete insulin. b. Decrease the body's sensitivity to insulin. c. Inhibit the production of glucose by the liver. d. Increase the absorption of carbohydrates in the intestines.

inhibit the production of glucose by the liver rationale: The action of the biguanides can be found in Table 30-6 in the text.

The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply. a. May improve blood glucose levels b. Decrease the need for exogenous insulin c. Help reduce cholesterol levels d. May reduce postprandial glucose levels e. Increase potassium levels

may improve blood glucose levels; decrease the need for exogenous insulin; help reduce cholesterol levels rationale: Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood (ADA, 2008b; Geil, 2008).

The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know can be used intravenously? a. short-acting b. rapid acting c. intermediate-acting d. long-acting

short- acting rationale: Insulins may be grouped into several categories based on the onset, peak, and duration of action. Short-acting, also known as regular insulin, is the only insulin administered by IV.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? a. The patient requires more pain medication. b. The patient is developing a paralytic ileus. c. The patient has developed peritonitis. d. The patient has developed renal failure.

the patient has developed peritonitis rationale: Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 rationale: Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.

Which of the following clients with type 1 diabetes is most likely to experience adequate glucose control? a. A client who skips breakfast when the glucose reading is greater than 220 mg/dL (12.3 mmol/L) b. A client who never deviates from the prescribed dose of insulin c. A client who adheres closely to a meal plan and meal schedule d. A client who eliminates carbohydrates from the daily intake

a client who adheres closely to a meal plan and meal schedule rationale: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

Which is one of the primary symptoms of irritable bowel syndrome (IBS)? a. Diarrhea b. Pain c. Bloating d. Abdominal distention

diarrhea rationale: The primary symptoms of IBS include constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany changes in bowel pattern.

A group of students are reviewing the various types of drugs that are used to treat diabetes mellitus. The students demonstrate understanding of the material when they identify which of the following as an example of an alpha-glucosidase inhibitor? a. Metformin b. Glyburide c. Miglitol d. Rosiglitazone

miglitol rationale: Alpha-glucosidase inhibitors include drugs such as miglitol and acarbose. Metformin is a biguanide. Glyburide is a sulfonylurea. Rosiglitazone is a thiazolidinedione.

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis? a. Withholding all oral intake, as ordered, to decrease pancreatic secretions b. Administering meperidine, as ordered, to relieve severe pain c. Limiting I.V. fluids, as ordered, to decrease cardiac workload d. Keeping the client supine to increase comfort

withholding all oral intake, as ordered, to decrease pancreatic secretions rationale: The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Pain relief may require parenteral opioids such as morphine, fentanyl (Sublimaze), or hydromorphone (Dilaudid). No clinical evidence supports the use of meperidine for pain relief in pancreatitis, and, in fact, accumulation of its metabolites can cause CNS irritability and possibly seizures. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

A client who has just been diagnosed with hepatitis A asks, "How did I get this disease?" What is the nurse's best response? a. "You could have gotten it by using I.V. drugs." b. "You must have received an infected blood transfusion." c. "You probably got it by engaging in unprotected sex." d. "You may have eaten contaminated restaurant food."

"you may have eaten contaminated restaurant food" rationale: Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn't transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline? a. "You'll need more insulin when you exercise or increase your food intake." b. "You'll need less insulin when you exercise or reduce your food intake." c. "You'll need less insulin when you increase your food intake." d. "You'll need more insulin when you exercise or decrease your food intake."

"you'll need less insulin when you exercise or reduce your food intake" rationale: The nurse should advise the client that exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome? a. Administer 2 to 3 L of IV fluid rapidly. b. Administer 10 L of IV fluid over the first 24 hours. c. Administer a dextrose solution containing normal saline solution. d. Administer IV fluid slowly to prevent circulatory overload and collapse.

administer 2 to 3 L of IV fluid rapidly rationale: Regardless of the client's medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly ordered fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: a. a sedentary lifestyle and smoking. b. a history of hemorrhoids and smoking. c. alcohol abuse and a history of acute renal failure. d. alcohol abuse and smoking.

d. alcohol abuse and smoking rationale: The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function? a. Jaundice b. Pruritus of the arms and legs c. Fatigue during ambulation d. Irritability and drowsiness

irritability and drowsiness rationale: Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.

A nurse obtains a fingerstick glucose level of 45 mg/dl on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene? a. Give the client 4 oz of milk and a graham cracker with peanut butter. b. Obtain a serum glucose level. c. Obtain a repeat fingerstick glucose level. d. Notify the physician.

obtain a repeat fingerstick glucose level rationale: The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.

The most recent blood work of a client with a long-standing diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse's most appropriate action? a. Teach the client about actions to slow the progression of nephropathy. b. Ensure that the client receives a comprehensive assessment of liver function. c. Determine whether the client has been using expired insulin. d. Administer a fluid challenge and have the test repeated.

teach the client about actions to slow the progression of nephropathy rationale: Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted. Expired insulin does not cause nephropathy, and the client's liver function is not likely affected. There is no indication for the use of a fluid challenge.

A nurse is caring for a client who is suspected to have developed a peptic ulcer hemorrhage. Which action would the nurse perform first? a. Place the client in a recumbent position with the legs elevated. b. Prepare a peripheral and central line for intravenous infusion. c. Assess vital signs. d. Notify the healthcare provider.

a. Place the client in a recumbent position with the legs elevated. rationale: The treatment of hemorrhage includes complete rest for the GI tract, placing the client in a recumbent position with the legs elevated to increase blood flow to vital organs, blood transfusions, and gastric lavage with saline solution. Placing an IV, checking the client's vital signs, and notifying the healthcare provider are important, but not the priority action for the nurse when a client is actively bleeding.

A 1200-calorie diet and exercise are prescribed for a client with newly diagnosed type 2 diabetes. The nurse is teaching the client about meal planning using exchange lists. The teaching is determined to be effective based on which statement by the client? a. "For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon Italian dressing; 1 cup of watermelon; and a diet soda." b. "For dinner I ate 2 cups of cooked pasta with 3-ounces of boiled shrimp, 1 cup plum tomatoes, half a cup of peas in a garlic-wine sauce, 2 cups fresh strawberries, and ice water with lemon." c. "For dinner I ate 4-ounces of sliced roast beef on a bagel with lettuce, tomato, and onion; 1 ounce low-fat cheese; 1 tablespoon mayonnaise; 1 cup fresh strawberry shortcake; and unsweetened iced tea." d. "For dinner I ate 2 ounces of sliced turkey, 1 cup mashed sweet potatoes, half a cup of carrots, half a cup of peas, a 3-ounce dinner roll, 1 medium banana, and a diet soda."

"for dinner I ate a 3- ounce hamburger on a bun, with ketchup, pickle, and onion; a green salad with 1 teaspoon italian dressing; 1 cup watermelon; and a diet soda" rationale: There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. For example, 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1 cup watermelon; "free" items like diet soda are optional.

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it? a. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." b. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." c. "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." d. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."

"i can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual" rationale: The client stating that he'll remain hydrated and pay attention to his eating, drinking, and voiding needs indicates understanding of HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of non-diet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.

A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has? a. peptic ulcer disease b. ulcerative colitis c. appendicitis d. diverticulitis

a. peptic ulcer disease rationale: Peptic ulcer disease is characterized by dull, gnawing pain in the midepigastrium or the back that worsens with eating. Ulcerative colitis is characterized by exacerbations and remissions of severe bloody diarrhea. Appendicitis is characterized by epigastric or umbilical pain along with nausea, vomiting, and low-grade fever. Pain caused by diverticulitis is in the left lower quadrant and has a moderate onset. It's accompanied by nausea, vomiting, fever, and chills.

The nurse caring for a client with diverticulitis is preparing to administer the client's medications. The nurse anticipates administration of which category of medication because of the client's diverticulitis? a. Antianxiety b. Antispasmodic c. Antiemetic d. Anti-inflammatory

b. antispasmodic rationale: The nurse anticipates administration of antispasmodic medication to decrease intestinal spasm associated with diverticulitis. The client may also be ordered an opioid analgesic to relieve the associated pain. There is no indication that the client needs antianxiety, antiemetic, or anti-inflammatory medications at this time.

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding: a. physical assessment data b. fasting blood glucose level c. renal studies d. liver function tests

b. fasting blood glucose level rationale: An adverse reaction to tube feedings is an elevated blood glucose level. The physical assessment data and renal function and liver function studies are normal.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description? a. Coffee-ground-like b. Clay-colored c. Black and tarry d. Bright red

c. black and tarry rationale: Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

The most common symptom of esophageal disease is a. nausea. b. vomiting. c. dysphagia. d. odynophagia.

c. dysphagia rationale: This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? a. "I'll eat three large meals every day without any food restrictions." b. "I'll lie down immediately after a meal." c. "I'll gradually increase the amount of heavy lifting I do." d. "I'll eat frequent, small, bland meals that are high in fiber."

d. "I'll eat frequent, small, bland meals that are high in fiber." rationale: In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.

An older adult patient is in the hospital being treated for sepsis related to a urinary tract infection. The patient has started to have an altered sense of awareness, profound dehydration, and hypotension. What does the nurse suspect the patient is experiencing? a. Systemic inflammatory response syndrome b. Hyperglycemic hyperosmolar syndrome c. Multiple-organ dysfunction syndrome d. Diabetic ketoacidosis

hyperglycemic hyperosmolar syndrome rationale: Hyperglycemic hyperosmolar syndrome (HHS) occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes (Reynolds, 2012). The clinical picture of HHS is one of hypotension, profound dehydration (dry mucous membranes, poor skin turgor), tachycardia, and variable neurologic signs (e.g., alteration of consciousness, seizures, hemiparesis).

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? a. High-fiber foods b. Low-purine, nutrient-dense foods c. Low-fat foods high in proteins and carbohydrates d. Foods that are low-residue and low in fat

low- fat foods high in proteins and carbohydrates rationale: The nurse encourages the client to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. There is no specific need to increase fiber or avoid purines. A low-residue diet is not indicated.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: a. place the client in a private room. b. wear a mask when handling the client's bedpan. c. wash her hands after touching the client. d. wear a gown when providing personal care for the client.

wash her hands after touching the client rationale: To maintain enteric precautions, the nurse must wash her hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

Which factor is the focus of nutrition intervention for clients with type 2 diabetes? a. Protein metabolism b. Blood glucose level c. Weight loss d. Carbohydrate intake

weight loss rationale: Weight loss is the focus of nutrition intervention for clients with type 2 diabetes. A low-calorie diet may improve clinical symptoms, and even a mild to moderate weight loss, such as 10 to 20 pounds, may lower blood glucose levels and improve insulin action. Consistency in the total amount of carbohydrates consumed is considered an important factor that influences blood glucose level. Protein metabolism is not the focus of nutrition intervention for clients with type 2 diabetes.