SU2020 Adult Health Exam 2
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? (a) "I should increase the fiber in my diet." (b) "I will need to avoid caffeinated beverages." (c) "I'm going to learn some stress reduction techniques." (d) "I can have exacerbations and remissions with Crohn's disease."
(a) "I should increase the fiber in my diet." Crohn's disease is an inflammatory disease that can occur anywhere in the GI tract, but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid GI stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbations.
A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? (a) "I will plan to limit fiber in my diet." (b) "I will restrict fluid intake during meals." (c) "I will switch to black tea instead of drinking coffee." (d) "I will try to eat cold foods rather than warm when my stomach feels upset."
(a) "I will plan to limit fiber in my diet."
A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? (a) Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion (b) Give potassium as a rapid IV bolus (c) Administer 3 units of ultralente insulin subcutaneously (d) Obtain an HbA1c level stat
(a) Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion When the child's blood glucose level falls between 250-300mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. Otherwise, hypoglycemia might occur.
A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings indicates the client is experiencing acute kidney rejection? (a) Blood pressure 160/90mmHg (b) Creatinine 0.8mg/dL (c) Sodium 137mg/dL (d) Urinary output 100mL/hr
(a) Blood pressure 160/90mmHg Due to the kidney's role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension.
A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet? (a) Calcium (b) Phosphorous (c) Potassium (d) Sodium
(a) Calcium A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement dietary calcium.
A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? (a) Children (b) Older adults (c) Women who are pregnant (d) Middle-aged men
(a) Children
A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? (a) Digesting fats (b) Producing chyme (c) Stimulating gastric acid secretion (d) Providing energy
(a) Digesting fats Bile is a product in the liver and aids in the digestion of fats. Chyme is a semi-solid mixture of food and gastric secretions that is formed in the stomach. Gastrin is a hormone produced by the stomach mucosa that stimulates the release of gastric secretions during the process of digestion. Glycogen is stored in the liver and is released in the form of glucose to meet the body's energy needs.
The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding? (a) Elevated creatinine level (b) Decreased hemoglobin level (c) Decreased red blood cell count (d) Increased number of white blood cells in the urine
(a) Elevated creatinine level The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.
A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? (a) Ensure bowel rest (b) Offer sparkling water frequently (c) Administer a stool softener (d) Offer plain warm tea frequently
(a) Ensure bowel rest
A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use? (a) Gamma-glutamyl transferase (GGT) (b) Alkaline phosphatase (ALP) (c) Serum bilirubin (d) Alanine aminotransferase
(a) Gamma-glutamyl transferase (GGT) The GGT lab test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use. ALP is elevated in biliary obstruction and most forms of liver dysfunction. It does not differentiate between alcohol and other causative factors for liver disease. The serum bilirubin test is used to detect the function of the liver and its ability to excrete bilirubin. Elevated levels can determine liver disease or biliary tract disease. The largest concentration of the enzyme ALT is found in liver tissue. However, it is also present in kidney, heart, and skeletal muscle tissue. Because it is elevated in various types of tissue damage, it is not helpful in identifying excessive alcohol use.
A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? (a) Grilled chicken (b) Potato soup (c) Fish sticks (d) Baked ham
(a) Grilled chicken The nurse should identify that a client who has cirrhosis requires protein to compensate for disease-related weight loss. Increasing protein intake from animal or plant sources will also provide the client with more energy.
A nurse is caring for a client who has manifestations of acute tubular necrosis (ATN) following a kidney transplantation. Which of the following interventions should the nurse anticipate for this client? (Select all that apply) (a) Hemodialysis (b) Biopsy (c) Immunosuppression (d) Balloon angioplasty (e) Surgical repair
(a) Hemodialysis (b) Biopsy (c) Immunosuppression Clients who develop ATN after transplantation surgery might need dialysis until they have an adequate urine output and their BUN and creatinine levels stabilize. Because the development of ATN after transplantation surgery mimics the symptoms of rejection of the transplanted kidney, clients have to undergo a biopsy to determine the correct diagnosis. Immunosuppressive medication therapy is essential after kidney transplantation to protect the new kidney. Balloon angioplasty corrects renal artery stenosis. Surgery corrects several other complications of kidney transplantation such as graft rupture.
A nurse is completing discharge teaching with a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include? (a) Keep a food diary to identify triggers to exacerbation. (b) Consume 15 to 20g of fiber daily. (c) Plant three moderate to large meals per day. (d) Limit fluid intake to 1L each day.
(a) Keep a food diary to identify triggers to exacerbation.
A nurse is teaching a client who has CKD. Which of the following instructions should the nurse include? (a) Limit fluid intake (b) Limit caloric intake (c) Eat a diet high in phosphorus (d) Eat a diet high in protein
(a) Limit fluid intake A client who has CKD should limit fluid intake to prevent hypervolemia (excessive fluid overload). A client who has CKD should increase caloric intake so that the body can use protein for protein synthesis instead of energy consumption. Using protein for energy can lead to a negative nitrogen balance and malnutrition. A client who has CKD should limit phosphorus intake because the kidneys are unable to excrete it. A client who has CKD should not eat excessive protein to prevent the build-up of protein waste products and uremia.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? (a) Malaise (b) Dark stools (c) Weight gain (d) Left upper quadrant discomfort
(a) Malaise Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify which of the following as a risk factor for cholecystitis? (a) Obesity (b) Rapid weight gain (c) Decreased blood triglyceride level (d) Male sex
(a) Obesity
A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? (a) Potassium and magnesium (b) Calcium and bicarbonate (c) Hemoglobin and hematocrit (d) Arterial pH and PaCO2
(a) Potassium and magnesium Clients who have CKD have hyperkalemia, hyperphosphatemia, and hypermagnesia as well as elevations in serum creatinine and blood urea nitrogen.
A nurse is teaching a client with chronic kidney disease about predialysis dietary recommendations. The nurse should recommend restricting the intake of which of the following nutrients? (a) Protein (b) Carbohydrates (c) Calcium (d) Monounsaturated fats
(a) Protein Dietary restrictions for clients who have chronic kidney disease vary based on the degree of kidney function; however, most clients need protein limitations. Predialysis protein restriction can help preserve some kidney function.
A nurse is caring for a client with diabetic ketoacidosis who has a prescription for an intravenous infusion of insulin. The nurse should document that which of the following types of insulin was administered intravenously to treat ketoacidosis? (a) Regular insulin (b) Insulin lispro (c) Insulin aspart (d) Insulin glargine
(a) Regular insulin Treatment of diabetic ketoacidosis is directed at correcting hyperglycemia and acidosis. Therefore, the client's insulin levels are restored with an initial IV bolus of regular insulin followed by continuous infusion.
A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? (a) Regulation of acid-base balance (b) Reabsorption of nutrients for cellular growth (c) Regulation of body temperature (d) Secretion of hormones needed for growth
(a) Regulation of acid-base balance
A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? (a) The client will be placed on mechanical ventilation prior to this proceduce. (b) The tube will be inserted into the client's trachea. (c) The client will receive a bowel preparation with cathartics prior to this procedure. (d) The tube allows the application of a ligation band to the bleeding varices.
(a) The client will be placed on mechanical ventilation prior to this procedure. The client will require intubation and mechanical ventilation prior to this procedure to protect the airway. The tube is inserted through the client's nose or mouth into the client's stomach to stop the bleeding in the esophageal varices. It is used to provide pressure to the varices to stop the bleeding. An endoscopic variceal ligation involves the application of a ligation band to the bleeding varices.
A nurse is caring for a client who is receiving intermittent peritoneal dialysis. The nurse observes that the peritoneal fluid is not adequately draining. Which of the following actions should the nurse take? (a) Turn the client from side to side (b) Elevate the height of the dialysate bag (c) Lower the head of the client's bed (d) Advance the catheter approximately 2.5cm (1 in) further
(a) Turn the client from side to side The nurse should assist the client in turning from side to side to facilitate the removal of peritoneal drainage. This action helps ensure there are no kinks in the tubing or an air lock in the peritoneal catheter. The nurse should raise the height of the dialysate bag to increase the rate of inflow; however, this action will not promote outflow of peritoneal fluid. The nurse should not push the peritoneal catheter further into the peritoneal cavity because this action introduces bacteria into the peritoneal cavity and increases the client's risk of peritonitis.
A nurse is caring for a client who is scheduled to receive peritoneal dialysis. Which of the following actions should the nurse take? (a) Warm the dialysate solution prior to administration (b) Cleanse the catheter site using a back and forth motion, beginning at the end of the catheter and moving inward (c) Place the drainage bag at the level of the client's chest (d) Apply clean gloves and cleanse the client's catheter site with cold water
(a) Warm the dialysate solution prior to administration The nurse should warm the dialysate solution prior to administration to prevent pain and abdominal cramping.
A nurse is planning post-procedure care for a client who received hemodialysis. Which fo the following interventions should the nurse include in the plan of care? (Select all that apply) (a) Check BUN and blood creatinine. (b) Administer medications the nurse withheld prior to dialysis. (c) Observe for findings of hypovolemia. (d) Assess the access site for bleeding. (e) Evaluate blood pressure on the arm with AV access.
(a), (b), (c), (d)
A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic hyperosmolar state (HHS)? (Select all that apply) (a) Evidence of recent myocardial infarction (b) BUN 35mg/dL (c) Takes a calcium channel blocker (d) Age 77 years (e) Daily insulin injections
(a), (b), (c), (d) A client with DM2 who has had a recent MI has increased hormone production during illness or stress, which can stimulate the liver to produce glucose and decrease the effects of insulin. A BUN 35mg/dL is a sign of kidney dysfunction and inability of the kidney to filter high levels of blood glucose into the urine. A calcium channel blocker is one of several medications that increase for HHS in a client with DM2. The older adult client may be unaware of associated manifestations of DM2, including HHS. Taking insulin does not increase the risk for HHS.
A nurse is admitting a client who has cirrhosis. Which of the following prescriptions should the nurse anticipate? (Select all that apply) (a) Obtain the client's PT and INR measurements (b) Administer lactulose 30mL PO 4 times daily (c) Obtain daily weight and abdominal girth measurement (d) Administer a daily multivitamin (e) Place the client on a high-protein diet
(a), (b), (c), (d) Cirrhosis interferes with the liver's ability to produce clotting factors, which places the client at a risk of hemorrhage. The PT and INR are usually prolonged due to decreased synthesis of prothrombin. A client who has cirrhosis is unable to eliminate ammonia from the body once protein is broken down. Therefore, lactulose should be administered to increase the client's production of stool, which will help eliminate ammonia from the client's body. Additionally, the nurse should anticipate a prescription to assess the client's weight daily to assess the client's fluid status. An increase of 1kg (2.2lb) in the client's weight indicates 1L of fluid retention. The nurse should also expect to measure the client's abdominal girth daily to determine if ascites is increasing or decreasing. Cirrhosis also leads to deficiencies in many daily vitamins; therefore, the nurse should anticipate a prescription to administer a daily multivitamin to the client. A client who has cirrhosis needs a diet that is high in protein, especially vegetable protein. When protein is broken down, serum ammonia increases and the liver is unable to form urea from ammonia.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? (Select all that apply) (a) Check the level of the drainage bag. (b) Reposition the client to her or his side. (c) Place the client in good body alignment. (d) Check the peritoneal dialysis system for kinks. (e) Contact the primary health care provider (PHCP). (f) Increase the flow rate of the peritoneal dialysis solution.
(a), (b), (c), (d) If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the side or making sure the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open. There is no reason to contact the PHCP. Increasing the flow rate should not be done and also is not associated with the amount of outflow solution.
A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply) (a) Assess for jugular vein distention. (b) Provider frequent mouth rinses. (c) Auscultate for a pleural friction rub. (d) Provide a high-sodium diet. (e) Monitor for dysrhythmia.
(a), (b), (c), (e)
A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? (Select all that apply) (a) Drink 2L fluids daily. (b) Monitor blood glucose every 4hr when ill. (c) Administer insulin as prescribed when ill. (d) Notify provider when blood glucose is 200mg/dL. (e) Report ketones in the urine after 24hr illness.
(a), (b), (c), (e) Notify the provider when blood glucose remains greater than 250mg/dL despite treatment.
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply) (a) Diuretic (b) Beta-blocking agent (c) Opioid analgesic (d) Lactulose (e) Sedative
(a), (b), (d) Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. Opioid analgesics are metabolized in the liver. They should not be administered to a client who has cirrhosis. Lactulose is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool. Sedatives are metabolized in the liver. They should not be administered to a client who has cirrhosis.
A client with acute kidney injury has a serum potassium level of 7.0mEq/L (7.0mmol/L). The nurse should plan which actions as a priority? Select all that apply. (a) Place the client on a cardiac monitor. (b) Notify the primary health care provider (PHCP) (c) Put the client on NPO (nothing by mouth) status except for ice chips. (d) Review the client's medications to determine whether nay contain or retain potassium. (e) Allow an extra 500mL of intravenous fluid intake to dilute the electrolyte concentration.
(a), (b), (d) The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. The nurse should notify the PHCP and also review medications to determine whether any contain potassium or are potassium retaining. The client does not need to be put on NPO status. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly.
A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply) (a) Anuria (b) Marked azotemia (c) Increased calcium level (d) Crackles in the lungs (e) Proteinuria
(a), (b), (d), (e)
A nurse is caring for several clients. Which of the following clients are at risk for developing pyelonephritis? (Select all that apply) (a) A client who is at 32 weeks of gestation (b) A client who has kidney calculi (c) A client who has a urine pH of 4.2 (d) A client who has a neurogenic bladder (e) A client who has diabetes mellitus
(a), (b), (d), (e)
A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply) (a) Review the medications the client currently takes. (b) Assess the AV fistula for a bruit. (c) Calculate the client's hourly urine output. (d) Measure the client's weight. (e) Check blood electrolytes. (f) Use the access site area for venipuncture.
(a), (b), (d), (e) Reviewing the medications the client currently takes can help determine which medications to withhold until after dialysis. Assessing the AV fistula for bruits determines the patency of the fistula for dialysis. The client's hourly urine output can vary withe the remaining kidney function and does not determine the need for dialysis. Checking the blood electrolytes determines the need for dialysis. Never use the access site area for venipuncture because compression from the tourniquet can cause loss of vascular access.
A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (Select all that apply) (a) Limit physical activity (b) Avoid alcohol (c) Take acetaminophen for comfort (d) Wear a mask when in public places (e) Eat small frequent meals
(a), (b), (e) Limiting physical activity and taking frequent rest breaks conserves energy and assists in the recovery process for a client who has hepatitis B. Alcohol and acetaminophen are metabolized in the liver and should be avoided by the client who has hepatitis B. Hepatitis B is blood-borne, so wearing a mask is unnecessary. The client who has hepatitis B should eat small, frequent meals to promote improved nutrition to the presence of anorexia.
A nurse is teaching a client who is scheduled for a kidney transplant about organ rejection. Which of the following statements should the nurse include? (Select all that apply) (a) "Expect an immediate removal of the donor kidney for a hyperacute rejection." (b) "You might need to begin dialysis to monitor your kidney function for a hyperacute rejection." (c) "A fever is a manifestation of an acute rejection." (d) "Fluid retention is a manifestation of an acute rejection." (e) "Your provider will increase your immunosuppressive medications for a chronic rejection."
(a), (c), (d)
A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse plan to take? (Select all that apply) (a) Provide a referral for nutrition counseling. (b) Encourage daily fluid intake of 1L. (c) Palpate the costovertebral angle. (d) Monitor urinary output. (e) Administer antibiotics.
(a), (c), (d), (e)
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) (a) Fever (b) Positive Cullen's sign (c) Complaints of indigestion (d) Palpable mass in the left upper quadrant (e) Pain in the upper right quadrant after a fatty meal (f) Vague lower right quadrant abdominal discomfort
(a), (c), (e)
A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? (a) "During this illness, she may take acetaminophen for fevers or discomfort." (b) "Encourage her to eat foods that are high in carbohydrates." (c) "The provider will prescribe a medication to help her liver heal faster." (d) "Have her perform moderate exercise to restore her strength more quickly."
(b) "Encourage her to eat foods that are high in carbohydrates."
A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? (a) "You need to conserve energy at this time." (b) "Lying quietly in bed helps slow down the activity in your intestines." (c) "Staying in bed promotes the rest and comfort you need." (d) "Staying in bed will help prevent injury and minimize your fall risk."
(b) "Lying quietly in bed helps slow down the activity in your intestines." The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and GI bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.
A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should be included in the teaching? (a) "The scope will be passed though your rectum." (b) "You might have shoulder pain after surgery." (c) "You will have a Jackson-Pratt drain in place after surgery." (d) "You should limit how often you walk for 1 to 2 weeks."
(b) "You might have shoulder pain after surgery." Shoulder pain is expected postoperatively due to free air that is introduced into the abdomen during laparoscopic surgery.
A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? (a) Jaundice (b) Anorexia (c) Dark urine (d) Pale feces
(b) Anorexia Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. Jaundice, dark urine, and pale feces are late manifestations of hepatitis A.
A nurse is reviewing lab reports of a client who has HHS. Which of the following findings should the nurse expect? (a) Blood pH 7.2 (b) Blood osmolarity 350mOsm/L (c) Blood potassium 3.8mg/dL (d) Blood creatinine 0.8mg/dL
(b) Blood osmolarity 350mOsm/L Blood pH 7.2 is an indication of DKA. Blood potassium 3.8mg/dL is within normal range. A patient with HHS would initially has a decreased blood potassium level due to diuresis. Blood creatinine 0.8mg/dL is within normal range. A patient with HHS would have a blood creatinine greater than 1.5mg/dL secondary to dehydration.
A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? (a) Decrease intake of calorie-dense foods. (b) Drink canned protein supplements. (c) Increase intake of high fiber foods. (d) Eat high-residue foods.
(b) Drink canned protein supplements. A high-protein diet is recommended for the client who has Crohn's disease. Canned protein supplements are encouraged.
A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? (a) Maternal-fetal (b) Fecal-oral contamination (c) Genital sexual contact (d) Blood to blood
(b) Fecal-oral contamination
A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For which of the following electrolyte imbalances should the nurse monitor? (a) Hypercalcemia (b) Hyperkalemia (c) Hypomagnesemia (d) Hypophosphatemia
(b) Hyperkalemia
A nurse is reviewing the laboratory report of a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8mEq/L, calcium 7.4mg/dL, hemoglobin 10.2g/dL, and phosphate 4.8mg/dL. Which finding is the priority for the nurse to report to the provider? (a) Hypocalcemia (b) Hyperkalemia (c) Anemia (d) Hypoalbuminemia
(b) Hyperkalemia
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? (a) Select foods high in fat. (b) Increase intake of fluids, including juices. (c) Eat a good supper when anorexia is not as severe. (d) Eat less often, preferably only 3 large meals daily.
(b) Increase intake of fluids, including juices. Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast.
A nurse is preparing an in-service program about the stages of acute kidney injury (AKI). Which of the following pieces of information should the nurse include about prerenal azotemia? (a) Prerenal azotemia begins prior to the onset of symptoms. (b) Interference with renal perfusion causes prerenal azotemia (c) Prerenal azotemia is irreversible, even in the early stages. (d) Infections and tumors cause prerenal azotemia.
(b) Interference with renal perfusion causes prerenal azotemia. Prerenal azotemia results from interference with renal perfusion, such as from heart failure or hypovolemic shock.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. Then 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? (a) Administer the prescribed pain medications. (b) Notify the primary health care provider. (c) Call and ask the operating room team to perform surgery as soon as possible. (d) Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
(b) Notify the primary health care provider. The nurse should suspect peritonitis and notify the PHCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the PHCP would probably perform the surgery earlier than the prescheduled time.
A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection? (a) Positive for hyaline casts (b) Positive for leukocyte esterase (c) Positive for ketones (d) Positive for crystals
(b) Positive for leukocyte esterase
A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? (a) WBC 6000/mm3 (b) Potassium 3.0mEq/L (c) Clear, pale yellow drainage (d) Report of abdominal fullness
(b) Potassium 3.0mEq/L A potassium level of 3.0mEq/L is below the expected reference range and can cause dysrhythmias. Dialysis removes fluid, waste products, and electrolytes from the blood and can cause hypokalemia. Abdominal fullness is an expected finding during the dwell period, when dialysate stays in the peritoneal cavity. A supine low-Fowler's position can reduce abdominal pressure.
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? (a) Upper right quadrant abdominal pain (b) Rigid abdomen (c) Hyperactive bowel sounds (d) Bradycardia
(b) Rigid abdomen Right lower quadrant abdominal pain is an expected manifestation of appendicitis. Decreased or absent bowel sounds are an expected manifestation of appendicitis. Tachycardia and rapid, shallow breathing are expected manifestations of appendicitis.
A nurse is providing dietary teaching to a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? (a) Raw vegetable salad with low-fat dressing (b) Roast chicken and white rice (c) Fresh fruit salad and milk (d) Peanut butter on whole wheat bread
(b) Roast chicken and white rice Clients who have ulcerative colitis are restricted to a low-fiber diet, which omits whole grains and raw fruits and vegetables. Roast chicken with white rice is the best choice.
A nurse is reviewing the laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following blood laboratory results should the nurse expect to be elevated? (Select all that apply) (a) Hematocrit (b) Erythrocyte sedimentation rate (c) WBC (d) Folic acid (e) Albumin
(b), (c) Hematocrit is decreased as a result of chronic blood loss. Increased ESR is a finding in patients with Crohn's as a result of inflammation. Decrease in folic acid and albumin levels is indicative of malabsorption due to Crohn's.
A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply) (a) Take baths rather than showers. (b) Resume a diet of choice. (c) Cleanse the puncture site using mild soap and water. (d) Remove adhesive strips from the puncture site in 24hr. (e) Report nausea and vomiting to the surgeon.
(b), (c), (e)
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply) (a) Anorexia (b) Change in orientation (c) Asterixis (d) Ascites (e) Feta hepaticus
(b), (c), (e) Anorexia is present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. Ascites can be present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy.
A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? (a) "I am unable to donate blood." (b) "I will need to get a booster shot of immune serum globulin every year." (c) "I should stop eating raw clams." (d) "I can develop this disease by getting a tattoo."
(c) "I should stop eating raw clams." Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish. Individuals who eat raw or steamed shellfish are at increased risk of acquiring hepatitis A.
A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? (a) "Decrease your intake of protein-rich foods." (b) "Take this medication with grapefruit juice." (c) "Monitor for and report a sore throat to your provider." (d) "Expect your skin to turn yellow."
(c) "Monitor for and report a sore throat to your provider."
A nurse is caring for a school-age child who has glomerulonephritis. The child has decreased urinary output and a blood pressure of 160/78mmHg and is receiving hydralazine. Which of the following lunch choices should the nurse recommend? (a) 1 hot dog, 22 potato chips, and 120mL (4oz) of OJ (b) 1 sandwich with lettuce, tomato, and 4 slices of bacon; a small apple; and 240mL (8oz) of milk (c) 3oz grilled chicken, 1 cup of pear slices, and 120mL (4oz) of apple juice (d) 1 cup of cottage cheese, a small banana, and 240mL (8oz) of soda
(c) 3oz grilled chicken, 1 cup of pear slices, and 120mL (4oz) of apple juice A child who has glomerulonephritis has moderate sodium restriction, and further restriction is given to foods that are high in potassium for children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This menu option consists of 571g of potassium and 268g of sodium.
A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving the vaccine? (a) Shellfish (b) Gelatin (c) Baker's yeast (d) Eggs
(c) Baker's yeast
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that his abdomen is distended. Which of the following actions should the nurse take? (a) Insert an indwelling urinary catheter (b) Administer pain medication to the client (c) Change the client's position (d) Place the drainage bag above the client's abdomen
(c) Change the client's position The client is retaining the dialysate solution after the dwell time. The nurse should ensure that the clamp is open and the tubing is not kinked and should reposition the client to facilitate the drainage of the solution from the peritoneal cavity.
A nurse is planning care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan? (a) Restrict the client's fluid intake (b) Restrict the client's calcium intake (c) Decrease the client's fat intake (d) Decrease the client's potassium intake
(c) Decrease the client's fat intake
A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse identify as a manifestation of this complication? (a) Slow heart rate (b) Protruding eyeballs (c) Deep, rapid respirations (d) Decreased urinary output
(c) Deep, rapid respirations Deep, rapid respirations are known as Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern is caused by the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones.
A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? (a) Blood amylase 80units/L (b) WBC 9000/mm3 (c) Direct bilirubin 2.1mg/dL (d) Alkaline phosphatase 25units/L
(c) Direct bilirubin 2.1mg/dL Expect the client with cholelithiasis to have elevated direct bilirubin if the bile duct is obstructed.
A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? (a) Elevated BUN (b) Bradycardia (c) Headache (d) Temperature 39.2C (102.5F)
(c) Headache DDS is a CNS disorder that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood pH. Clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes headaches, nausea, vomiting, a decreased level of consciousness, seizures, and restlessness. When the condition is severe, clients progress to confusion, seizures, coma, and death.
A nurse is reviewing the lab results of a client who is taking a medication and notes that the client's blood tests show an elevated level of the enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The nurse should recognize that these findings are potential indications of which of the following conditions? (a) Renal dysfunction (b) Myelotoxicity (c) Hepatic toxicity (d) Cardiac dysrhythmia
(c) Hepatic toxicity
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? (a) Urine negative for ketones (b) Distended neck veins (c) Kussmaul respirations (d) Elevated blood pressure
(c) Kussmaul respirations
A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? (a) Endoscopic sclerotherapy (b) Liver lobectomy (c) Liver transplant (d) Transjugular intrahepatic protal-systemic shunt placement
(c) Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. Liver lobectomy is for localized cancer. TIPS is used to treat esophageal varices.
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27mmHg, and HCO3 25mmEq/L. The nurse should identify that the client has which of the following acid-base imbalances? (a) Respiratory acidosis (b) Metabolic acidosis (c) Respiratory alkalosis (d) Metabolic alkalosis
(c) Respiratory alkalosis
A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client states she does not understand how she will be alright without he gallbladder. The nurse should explain to the client that which of the following is the main function of the gallbladder? (a) Producing bile (b) Adding digestive enzymes to bile (c) Storing bile (d) Eliminating bile
(c) Storing bile The primary function of the gallbladder is to store bile. Because this organ is only for storage, the client's liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum, where it will perform various functions. The liver produces bile. The stomach, pancreas, and small intestines produce the various fluids and enzymes that help accomplish the process of digestion. The GI tract eliminates bile as well as other byproducts and waste via feces.
A client arrives at the ED with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? (a) Pyelonephritis (b) Glomerulonephritis (c) Trauma to the bladder or abdomen (d) Renal cancer in the client's family
(c) Trauma to the bladder or abdomen Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.
A nurse in the ED is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? (a) Famotidine (b) Esomeprazole (c) Vasopressin (d) Omeprazole
(c) Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices. Famotidine is an H2 receptor antagonist used to treat stress ulcers. Esomeprazole is a proton pump inhibitor used to treat GI reflux disease. Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers.
A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? (a) Monitor the child's blood pressure twice per day (b) Maintain the child on bed rest for 3 days (c) Weigh the child once each day (d) Increase the child's daily intake of sodium
(c) Weight the child once each day The nurse should weigh the child at the same time each day to monitor fluid balance. Glomerulonephritis can cause hypertension that can lead to cerebral ischemia. Therefore, the nurse should monitor the child's blood pressure every 4 hours.
A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply) (a) Reduced BUN (b) Elevated cardiac enzymes (c) Reduced urine output (d) Elevated blood creatinine (e) Elevated blood calcium
(c), (d)
A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse? (a) Offer a warm sitz bath. (b) Recommend drinking cranberry juice. (c) Encourage increased fluids. (d) Administer an antibiotic.
(d)
A nurse is reviewing the lab values of a client who has diabetic ketoacidosis. Which of the following lab values is consistent with diabetic ketoacidosis? (a) Blood glucose 30mg/dL (b) Negative urine ketones (c) Blood pH 7.38 (d) Bicarbonate level 12 mEq/L
(d) Bicarbonate level 12 mEq/L
A nurse is assessing a client who is receiving peritoneal dialysis. Which of the following findings should the nurse report to the provider immediately? (a) Difficulty draining the effluent (b) Redness at the access site (c) Fluid flowing from the catheter site (d) Cloudy effluent
(d) Cloudy effluent A cloudy or opaque effluent indicates the client is at high risk for peritonitis, a bacterial infection of the peritoneum. Therefore, this is the priority finding for the nurse to report to the provider.
A nurse is monitoring a client who is receiving lactulose for cirrhosis. Which of the following lab values related to this medication should indicate to the nurse that the treatment is effective? (a) Increase aspartate aminotransferase (AST) (b) Decreased alanine aminotransferase (ALT) (c) Increased prothrombin time (PT) (d) Decreased serum ammonia
(d) Decreased serum ammonia The nurse should identify that lactulose is a laxative that improves the client's condition by enhancing intestinal secretion of ammonia so that it can be eliminated from the body.
A nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? (a) Increasing the workload of the liver by releasing stored glycogen (b) Causing ulceration of liver tissues that can lead to bleeding (c) Dilating veins in the portal circulation (d) Destroying liver cells that are later replaced with scar tissue
(d) Destroying liver cells that are later replaced with scar tissue The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the necrotic liver cells. Alcohol consumption does not cause a release of stored glycogen that increases the workload of the liver. However, alcohol consumption can cause a decrease in liver function. Clients who have peptic ulcer disease can develop bleeding ulcers in the GI lining, not alcohol consumption. Portal hypertension is caused by the development of nodules that constrict blood flow through the liver veins, but alcohol consumption does not cause dilated portal circulation.
A nurse is reviewing the laboratory findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect? (a) Hypernatremia (b) Hypomagnesemia (c) Hypercalcemia (d) Hyperkalemia
(d) Hyperkalemia
A week after kidney transplantation, a client develops a temperature of 101 F (38.3 C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The X-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? (a) Antibiotic therapy (b) Peritoneal dialysis (c) Removal of the transplanted kidney (d) Increased immunosuppression therapy
(d) Increased immunosuppression therapy Acute rejection most often occurs within 1 week after transplantation but can occur any time post-transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Treatment consists of increasing immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis cannot be used with a newly transplanted kidney due to the recent surgery. Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours of the transplant surgery.
A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? (a) Decreased lactate dehydrogenase (b) Increased serum albumin (c) Decreased serum ammonia (d) Increased prothrombin time
(d) Increased prothrombin time Clients who have end-stage liver failure have an inadequate supply of clotting factors and increased (i.e. prolonged) prothrombin time. Lactate dehydrogenase levels increase for clients with end-stage liver failure, indicating liver cell destruction. Serum albumin levels decrease, and serum ammonia levels increase.
A nurse is assessing a client who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings indicates that the client has end-stage kidney disease? (a) <0.5mL/kg of urine output for 12hr (b) No urine output for 12hr (c) No urine output without renal replacement therapy for 4-12wks (d) No urine output without renal replacement therapy for more than 3 months
(d) No urine output without renal replacement therapy for more than 3 months In the RIFLE classification, R stands for risk, I stands for injury, F stands for failure, L stands for loss, and E stands for end-stage kidney disease. According to the RIFLE classification (a) indicates injury, (b) indicates failure, and (c) indicates loss.
A nurse is assessing a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? (a) Hypokalemia (b) Decreased blood pressure (c) Increased urine volume (d) Periorbital edema
(d) Periorbital edema Periorbital edema is a manifestation of acute glomerulonephritis. Swelling is usually worse in the mornings and spreads throughout the day to the genitalia, abdomen, and extremities.
A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? (a) Diarrhea (b) Increased serum albumin (c) Hypoglycemia (d) Peritonitis
(d) Peritonitis Peritonitis is an adverse effect of peritoneal dialysis. Prevention requires using sterile technique and frequently assessing the catheter exit site. The nurse should obtain cultures of the dialysate outflow (effluent) if peritonitis is suspected.
A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? (a) Initiate contact precautions (b) Weight the client weekly (c) Measure abdominal girth at the base of the ribcage (d) Provide a high-calorie, high-carbohydrate meal
(d) Provide a high-calorie, high-carbohydrate meal Hepatitis B is transmitted through blood, so standard precautions are adequate. Daily weights are obtained to monitor fluid status. The client's abdominal girth is measured over the largest part of the abdomen, which will vary by client. The client who has hepatitis B should have a diet high in calories and carbohydrates.
A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects? (a) Increases blood pressure (b) Prevents esophageal bleeding (c) Decreases heart rate (d) Reduces ammonia levels
(d) Reduces ammonia levels
A nurse is performing a GI assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention? (a) Percuss the abdomen for tympanic sounds (b) Inspect the contour of the abdominal wall (c) Instruct the client to report increased abdominal discomfort (d) Take serial measurements of the abdomen with a tape measure
(d) Take serial measurements of the abdomen with a tape measure Measuring the abdomen is the most effective way to assess for a change in abdominal distention because it provides concrete, objective data that can be compared at various points in time to monitor changes. Percussing the abdomen for tympanic sounds is not the most effective way to assess for a change in abdominal distention. It may help the nurse identify the presence of distention but will not indicate any changes in the amount of distention. Visual inspection is not the most effective way to assess for a change in abdominal distention because it provides a visual estimate rather than measurable, objective data.
The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? (a) "I need to limit my intake of dietary fiber." (b) "I need to drink plenty, at least 8 to 10 cups daily." (c) "I need to eat regular meals and chew my food well." (d) "I will take the prescribed medications because they will regulate my bowel patterns."
(a) "I need to limit my intake of dietary fiber." IBS is a functional GI disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help promote normal bowel function.
A nurse in the ED is caring for a client who has a fruity breath odor, a dry mouth, and extreme thirst. Which of the following assessments should the nurse make? (a) Blood glucose level (b) Pupillary reaction to light (c) Deep tendon reflexes (d) Liver function tests
(a) Blood glucose level
A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? (a) Administer an opioid medication. (b) Monitor for hypertension. (c) Assess level of consciousness. (d) Increase the dialysis exchange rate.
(c) Assess level of consciousness.
A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? (a) Hemodialysis restores kidney function. (b) Hemodialysis replaces hormonal function of the renal system. (c) Hemodialysis allows an unrestricted diet. (d) Hemodialysis returns a balance to blood electrolytes.
(d) Hemodialysis returns a balance to blood electrolytes.
