Saunders Test Questions

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

sputum culture

A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of severe allergy to what substance?

A previous dose of hepatitis B vaccine or component

A client has been started on long term therapy with rifampin. The nurse should provide which information to the client about the medication?

Causes orange discoloration of sweat, tears, urine, and feces

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of this treatment?

Checking the frequency and consistency of bowel movements

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions of the client states that he or she will immediately report which finding?

Difficulty in discriminating the color red from green

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Document the findings

The mother of an 8 year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lie on the right side

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-operative period for which most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

The Heath care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

I ate shellfish about 2 weeks ago at a local restaurant

The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions?

I must take the medication exactly as prescribed

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

I should increase the fiber in my diet

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client has made which statement?

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

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure the nurse determines that the client needs further information if the client makes which statement?

I'm glad I don't have to lie still for this procedure

A client is diagnosed with viral hepatitis, complaint of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juices

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the first dose, the nurse should ensure that which baseline study has been completed?

Liver enzyme levels

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

Malaise

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and includes what in the plan?

Providing a quiet atmosphere with dimmed lighting

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the healthcare provider?

Purple discoloration of the stoma

A client is to begin a 6 month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?

Report yellow eyes or skin immediately

The nurse provides home care instructions to the client with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

Rice

The client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

This is a normal, expected event

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

1. Activities should be resumed gradually 2. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated 3. Respiratory isolation is not necessary because family members already have been exposed 4. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

1. Dyspnea 2. Night sweats 3. A bloody, productive cough 4. A cough with the expectoration of mucoid sputum

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply

1. Fever 2. Complaints of indigestion 3. Pain in the upper right quadrant after a fatty meal

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.

1. Gray-blue color at the flank 2. Abdominal guarding and tenderness 3. Left upper quadrant pain with radiation to the back

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.

1. Maintain NPO (nothing by mouth) status 2. Encourage coughing and deep breathing 3. Give hydromorphone intravenously as prescribed for pain

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply

1. Providing a low-fat, well-balanced diet. 2. Teaching the child effective hand-washing techniques. 3. Instructing the parents to avoid administering medications unless prescribed.

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

Notify the health care provider (HCP)

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

Particulate respirator, gown, and gloves

A client has been taking isoniazid for two months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Peripheral neuritis

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3 year old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

Positive