2000 finale

26. The patient is scheduled for a plain abdominal x-ray in the morning. What pre-procedure teaching does the nurse provide? a. "Wear a hospital gown and remove any jewelry or belts" b. "You will receive nothing by mouth from midnight until after the procedure. c. "We will place a nasogastric tube before the procedure to decompress your stomach" d. " laxative will be given to move stool out of your bowel before the procedure".

"Wear a hospital gown and remove any jewelry or belts"

19. The nurse is caring for a patient who received a barium swallow with a small bowel follow through. What key points must the nurse include in teaching this patient after the procedure?(Select all that apply.) a. "Drink lots of fluids." b. "Depending on the results, you may need a colonoscopy." c. "You will be on bedrest for about 6 to 8 hours." d. "A laxative will be provided to help remove the barium." e. "Your stools will be chalky white for 1 to 3 days."

- "Drink lots of fluids." - "Depending on the results, you may need a colonoscopy." - "A laxative will be provided to help remove the barium." - "Your stools will be chalky white for 1 to 3 days."

9. The nurse is caring for a patient with abdominal pain. While assessing the patient, which questions will the nurse ask the patient?(Select all that apply.) a. "Is the pain burning, gnawing, or stabbing?" b. "Can you point to where you feel the pain?" c. "Do you have a family history of cancer?" d. "When did you first notice the pain?" e. "Does the pain spread anywhere?"

- "Is the pain burning, gnawing, or stabbing?" - "Can you point to where you feel the pain?" - "When did you first notice the pain?" - "Does the pain spread anywhere?"

21. The nurse is caring for a patient scheduled for a colonoscopy in three days after discharge. What does the nurse teach the patient about preparations for this diagnostic test?(Select all that apply.) a. "Take only clear liquids the day before your colonoscopy." b. "Drink lots of red, orange, or purple (grape) beverages the day before the test." c. "You should take nothing by mouth for 4 to 6 hours before the test." d. "Do not take aspirin, NSAIDs, or anticoagulants for several days before the test." e. "After you drink the bowel-cleansing solution, you will have watery diarrhea in about an hour." f. "You will have an IV placed to receive medication to help you relax during the procedure."

- "Take only clear liquids the day before your colonoscopy." - "You should take nothing by mouth for 4 to 6 hours before the test." - "Do not take aspirin, NSAIDs, or anticoagulants for several days before the test." - "After you drink the bowel-cleansing solution, you will have watery diarrhea in about an hour." - "You will have an IV placed to receive medication to help you relax during the procedure."

45. A patient is scheduled for an abdominal CT scan with contrast. What preprocedural teaching should the nurse give this patient? Select all that apply. a. "You will have an IV placed for injection of the contrast" b. "You may experience the presence of borborygmus" c. " You may feel warm and flushed or experience a metallic taste after the injection" d. " The CT technician may ask you to hold your breath while a series of images are taken" e. "If you are claustrophobic, we can give you a mild sedative before the procedure." f. The test takes 30-45 minutes"

- "You will have an IV placed for injection of the contrast" - " You may feel warm and flushed or experience a metallic taste after the injection" - " The CT technician may ask you to hold your breath while a series of images are taken" - "If you are claustrophobic, we can give you a mild sedative before the procedure."

11. When examining the abdomen, which technique for abdominal assessment is used second? a. Inspection b. Percussion c. Palpation d. Auscultation

- Auscultation

33. During abdominal assessment, the nurse detects a loud bruit near midline. What must the nurse do? a. Measure the patient's abdomen just under the diaphragm. b. Check the patient's record for a history of stomach ulcers. c. Avoid palpation or percussion of the abdomen. d. Ask the patient about nausea and gastric reflux.

- Avoid palpation or percussion of the abdomen.

13. On assessment, the patient has areas of the abdomen with pain that also show rebound tenderness. What is the correct term for this finding? a. Blumberg's sign b. Bruits c. Tympanic d. Cullen's sign

- Blumberg's sign

12. The nurse is performing an abdominal assessment on a patient. For which finding does the nurse alert the physician immediately? a. Borborygmus b. Blumberg's sign c. Bulging, pulsating mass d. Cullen's sign

- Bulging, pulsating mass

22. The nurse is monitoring a patient after endoscopy. Vital signs are stable and side rails are raised but the patient tells the nurse that he is very thirsty. What is the nurse's best action? a. Administer a small amount of ice chips only. b. Give the patient small sips of water through a straw. c. Check to see if the patient's gag reflex has returned. d. Keep the patient NPO for at least 4 hours.

- Check to see if the patient's gag reflex has returned.

25. A feeling of fullness, cramping, and passage of flatus can be expected for several hours after the test, and a small amount of blood may be in the first stool after the test if a biopsy specimen is taken or a polypectomy is performed. Vital signs should be checked every 15 minutes, the patient should be monitored for signs of perforation or hemorrhage, and excessive bleeding should be reported immediately. For which procedure is this follow-up care describing? a. EGD b. Enteroscopy c. Small bowel series d. Colonoscopy

- Colonoscopy

23. Which diagnostic test is a noninvasive imaging procedure that can get multidimensional views of the entire colon? a. Abdominal ultrasound b. Computed tomography colonography c. Colonoscopy d. Sigmoidoscopy

- Computed (virtual) tomography colonography

29. Which gastrointestinal changes occur in older adults? (Select all that apply.) a. Increased hydrochloric acid secretion b. Decreased absorption of iron and vitamin B12 c. Decreased peristalsis may cause constipation d. Increased cholesterol synthesis e. Decreased lipase with decreased fat digestion f. Increased risk for constipation or impaction.

- Decreased absorption of iron and vitamin B12 - Decreased peristalsis may cause constipation - Decreased lipase with decreased fat digestion - Increased risk for constipation or impaction.

1. What is the name of the first 12 inches of the small intestine? a. Jejunum b. Ileum c. Duodenum d. Esophagus

- Duodenum

39. Which body structures are located in the RUQ of the abdomen? Select all that apply. a. Duodenum b. Liver c. Stomach d. Spleen e. Gallbladder f. Pancreas head

- Duodenum - Liver - Gallbladder - Pancreas head

27. The patient should be monitored for signs of perforation such as pain, bleeding, or fever, and the patient is instructed not to drive for 12 hours after the test. A hoarse voice and sore throat may persist for several days; throat lozenges may be used to relieve the discomfort. For which procedure is this follow-up care describing? a. EGD b. ERCP c. Enteroscopy d. Small bowel series

- EGD

20. Which diagnostic test does the nurse expect the health care provider to order to visually examine a patient's liver, gallbladder, bile ducts, and pancreas to identify the cause and location of an obstruction? a. EGD b. Upper GI radiographic series c. Percutaneous transhepatic cholangiography (PTC) d. ERCP

- ERCP

26. The patient should be observed for cholangitis, perforation, sepsis, and pancreatitis, and the patient should report abdominal pain, fever, nausea, or vomiting that fails to resolve. The patient is on NPO status until the gag reflex returns. For which procedure is this follow-up care describing? a. Enteroscopy b. EGD c. ERCP d. PTC

- ERCP

17. A patient being seen the emergency department (ED) has been vomiting blood for the past 12 hours. What test will likely be ordered for the patient? a. Endoscopic retrograde cholangiopancreatography (ERCP) b. Upper GI radiographic series c. Esophagogastroduodenoscopy (EGD) d. Barium enema

- Esophagogastroduodenoscopy (EGD)

32. The patient tells the nurse that she is experiencing emotional stress related to concerns about her children and husband and whether she will be able to return to her job. Which GI condition is she at increased risk for? a. Exacerbation of irritable bowel syndrome b. Nausea accompanied with vomiting c. Stomach or duodenal ulcers d. Esophagitis

- Exacerbation of irritable bowel syndrome

31. The patient's potassium level is 3.1 mEq/L. Which condition would cause this value? a. Malabsorption b. Gastric suctioning c. Acute pancreatitis d. Kidney failure

- Gastric suctioning

15. What will laboratory values for a patient with liver disease most likely show?(Select all that apply.) a. Increased prothrombin time b. Increased aspartate transaminase (AST) and alanine aminotransferase (ALT) c. Increased albumin levels d. Decreased ammonia levels e. Increased unconjugated bilirubin

- Increased prothrombin time - Increased aspartate transaminase (AST) and alanine aminotransferase (ALT) - Increased unconjugated bilirubin

16. Laboratory values for a patient with acute pancreatitis may show which abnormal findings?(Select all that apply.) a. Increased hemoglobin b. Decreased serum amylase c. Increased serum lipase d. Decreased urine nitrates e. Increased serum amylase f. Increased cholesterol

- Increased serum lipase - Increased serum amylase - Increased cholesterol

8. Dyspepsia is characterized by which factors?(Select all that apply.) a. Indigestion associated with eating b. Loss of appetite for food c. Heartburn associated with eating d. Vomiting that occurs after eating e. Malabsorption

- Indigestion associated with eating - Heartburn associated with eating

4. Which statements about intrinsic factor are correct?(Select all that apply.) a. It is produced by the parietal cells. b. It is essential to fat emulsification. c. It aids in the absorption of vitamin B12. d. It forms and secretes bile. e. Its absence causes pernicious anemia.

- It is produced by the parietal cells. - It aids in the absorption of vitamin B12. - Its absence causes pernicious anemia.

18. The nurse is providing care for a patient after an EGD. What is the first priority action after this diagnostic study? a. Monitor vital signs. b. Auscultate breath sounds. c. Keep patient NPO until gag reflex returns. d. Keep accurate intake and output.

- Keep patient NPO until gag reflex returns.

2. Which structure is involved in the protective function of the liver? a. Sphincter of Oddi b. Gallbladder c. Pancreas d. Kupffer cells

- Kupffer cells

7. Which gastrointestinal problem is related to anorexia? a. Heartburn b. Constipation c. Steatorrhea d. Loss of appetite

- Loss of appetite

6. Which (substance)drugs predispose a patient to peptic ulcer disease and gastrointestinal (GI) bleeding?(Select all that apply.) a. Nonsteroidal antiinflammatory drugs b. Anticoagulants c. Aspirin d. Lasix e. Digitalis f. Caffeine

- Nonsteroidal antiinflammatory drugs - Anticoagulants - Aspirin - Caffeine

37. Following an endoscopic retrograde cholangiopancreatography (ERCP), the nurse would include which post-procedure follow-up care interventions in the plan of care? Select all that apply. a. Observe for cholangitis, perforation, sepsis, and pancreatitis b. Assess for nausea and vomiting c. Tell the patient to report any abdominal pain d. Assess for return of gag reflex e. Provide ice chips to moisten throat f. Insert a nasogastric tube for excessive nausea

- Observe for cholangitis, perforation, sepsis, and pancreatitis - Assess for nausea and vomiting - Tell the patient to report any abdominal pain - Assess for return of gag reflex

17. The nurse discovers that a patient has a recent change in bowel habits. What important information must the nurse gather from this patient? Select all the apply. a. Color and appearance of urine b. Occurrence of diarrhea or constipation c. Presence of abdominal distention or gas d. Intentional weight gain e. Occurrence of bloody or tarry stools f. Current pattern of bowel movements

- Occurrence of diarrhea or constipation - Presence of abdominal distention or gas - Occurrence of bloody or tarry stools - Current pattern of bowel movements

15. While performing an abdominal assessment on a patient with abdominal pain, the nurse performs inspection of the abdomen. Which inspection findings should the nurse be sure to document? Select all that apply. a. Overall shape of the abdomen b. Presence of discoloration or scarring c. Size of percussed abdominal organs d. Symmetry or asymmetry of the abdominal contour e. Family history of abdominal illnesses f. Distention of the abdomen.

- Overall shape of the abdomen - Presence of discoloration or scarring - Symmetry or asymmetry of the abdominal contour - Distention of the abdomen.

24. Mild gas pain and flatulence may be experienced as a result of air instilled into the rectum during the examination, and if a biopsy specimen is obtained, a small amount of bleeding may be observed. For which endoscopic procedure is this follow-up care describing? a. Colonoscopy b. Proctosigmoidoscopy c. Enteroscopy d. ERCP

- Proctosigmoidoscopy

10. In which quadrant does the abdominal examination usually begin? or When beginning an abdominal assessment, the nurse would begin in which quadrant? a. Right lower quadrant (RLQ) b. Left lower quadrant (LLQ) c. Left upper quadrant (LUQ) d. Right upper quadrant (RUQ)

- Right upper quadrant (RUQ)

3. The pancreas performs which functions?(Select all that apply.) a. Breaks down amino acids b. Secretes enzymes for digestion from the exocrine part of the organ c. Breaks down fatty acids and triglycerides d. Produces glucagon from the endocrine part of the organ e. Produces enzymes that digest carbohydrates, fats, and proteins

- Secretes enzymes for digestion from the exocrine part of the organ - Produces glucagon from the endocrine part of the organ - Produces enzymes that digest carbohydrates, fats, and proteins

34. Which findings does the nurse document after inspecting a patient's abdomen? (Select all that apply.) a. Symmetry of the abdomen b. Presence of borborygmus c. Distention of the abdomen d. Taut, glistening skin e. Discoloration or scars

- Symmetry of the abdomen - Distention of the abdomen - Taut, glistening skin - Discoloration or scars

5. Which statements about Kupffer cells are true?(Select all that apply.) a. They are located in the epithelial cell layer lining in the GI tract. b. They are cells found in the liver. c. They phagocytize harmful bacteria. d. They are part of the substance that aids in the absorption of vitamin B12. e. They are part of the body's reticuloendothelial system.

- They are cells found in the liver. - They phagocytize harmful bacteria. - They are part of the body's reticuloendothelial system.

14. The nurse ascultates a patient's abdomen and hears high-pitched, loud, musical sounds in an air-filled abdomen. How does the nurse best describe this finding? a. Bruits b. Tympanic c. Dull d. Medium-pitched

- Tympanic

30. The nurse is taking a GI health history from a newly admitted patient. Which questions would the nurse be sure to ask?(Select all that apply.) a. "Have you lost or gained weight recently?" b. "Have you had any recent cardiac or respiratory surgeries?" c. "Do you wear dentures and if so, how do they fit you?" d. "Do you have difficulty chewing or swallowing?" e. "Have you traveled in the USA recently and where?" f. "What is your usual bowel elimination pattern?"

-"Have you lost or gained weight recently?" - "Do you wear dentures and if so, how do they fit you?" - "Do you have difficulty chewing or swallowing?" - "What is your usual bowel elimination pattern?"

.

.

What quantity of daily sodium intake is typically recommended for Americans who are 60 years of age?

1500 mg

Which body mass index (BMI) value for a young patient may be of concern?

16

A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next? a. Administer another half-cup (120 mL) of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1mg of glucagon intramuscularly.

A

A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How would the nurse respond? a. "Your risk of diabetes is higher than the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes mellitus." c. "The risk for becoming a diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes mellitus, but male children will."

A

A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the client reports that he has a new onset of ankle edema. What assessment question would the nurse take? a. "Have you gained unexpected weight this week?" b. "Has your urinary output declined recently?" c. "Have you had fever and achiness this week?" d. "Have you had abdominal pain recently?"

A

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2L a day." c. "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."

A

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant site, I will call the surgeon immediately?" c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

A

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

A

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? a. Increased rate and depth of respiration. b. Extremity tremors followed by seizure activity. c. Oral temperature of 102° F (38.9° C). d. Severe orthostatic hypotension.

A

The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. "Be sure to take the drug with each meal." b. "Take the drug every evening before bedtime." c. "Take the drug on an empty stomach in the morning." d. "Decide on the best day of the week to take the drug."

A

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

A (A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the clients respiratory status.)

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

A (A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.)

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

A (ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure.)

A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia? a. A 34-year-old on NPO status who is receiving intravenous D5W b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

A (Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia)

A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the clients respiratory rate, rhythm, and depth. b. Measure the clients pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

A (In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy)

A client is taking furosemide 40 mg/day for management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the client's abdomen. d. Assess the client's diet history

A Furosemide is a loop diuretic that helps reduce fluid overload and hypertension in patients with early stages of CKD. One kilogram of weight equals about 1 L of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication. Heart and breath sounds would be assessed if there is fluid retention, as in heart failure. Palpation of the client's abdomen is not necessary, but the nurse would check for edema. The diet history of the client would be helpful to assess electrolyte replacement since potassium is lost with this diuretic, but this does not assess the effectiveness of the medication

A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the client's intake and output. d. Ask to have the laboratory redraw the blood specimen.

A The best action by the nurse would be to check the cardiac status with a monitor. High-potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action

A client with chronic kidney disease (CKD) has an elevated serum phosphorus level. What drug would the nurse anticipate to be prescribed for this client? a. Calcium acetate b. Doxycyline c. Magnesium sulfate d. Lisinopril

A The client with CKD often has a high phosphorus level which tends to lower the calcium level in an inverse relationship, and causes osteodystrophy. To prevent this bone disease, the client needs to take a drug that can bind with phosphorus for elimination via the GI tract. When phosphorus is lowered to within normal limits, normal calcium levels may be restored

A client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to the client. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis

A The initial action for the nurse is to assess anxiety, coping styles, and the client's acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the client's acceptance of the treatment would come first

A client comes into the emergency department with a serum creatinine of 2.2 mg/dL (1944 mcmol/L) and a blood urea nitrogen (BUN) of 24 mL/dL (8.57 mmol/L). What question would the nurse ask first when taking this client's history? a. "Have you been taking any aspirin, ibuprofen, or naproxen recently?" b. "Do you have anyone in your family with renal failure?" c. "Have you had a diet that is low in protein recently?" d. "Has a relative had a kidney transplant lately?"

A There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the patient since both the serum creatinine and BUN are elevated, indicating some renal problems. A diet high in protein could be a factor in an increased BUN

A marathon runner comes into the clinic and states "I have not urinated very much in the last few days." The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is most appropriate? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the patient to drink 2 to 3 L of water daily. d. Perform an electrocardiogram

A This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure. The nurse can start hydrating the client with a bottle of water first, followed by teaching the patient to drink 2 to 3 L of water each day. An intravenous line may be needed later, after the patient's degree of dehydration is assessed. An electrocardiogram is not necessary at this time

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for postrenal acute kidney injury (AKI)? (Select all that apply.) a. Client with prostate cancer b. Client with blood clots in the urinary tract c. Client with ureterolithiasis d. Client with severe burns e. Client with lupus

A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes postrenal AKI. Severe burns would be a prerenal cause. Lupus would be an intrarenal cause for AKI

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are correct regarding PD? (Select all that apply.) a. "You will not need vascular access to perform PD." b. "There is less restriction of protein and fluids." c. "You will have no risk for infection with PD." d. "You have flexible scheduling for the exchanges." e. "It takes less time than hemodialysis treatments."

A, B, D PD is based on exchanges of waste, fluid, and electrolytes in the peritoneal cavity. There is no need for vascular access. Protein is lost in the exchange, which allows for more protein and fluid in the diet. There is flexibility in the time for exchanges, but the treatment takes a longer period of time compared to hemodialysis. There still is risk for infection with PD, especially peritonitis

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness

A, B, E (Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.)

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia Flaccid paralysis with respiratory depression b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness c. Hyponatremia Decreased level of consciousness d. Hypercalcemia Positive Trousseaus and Chvosteks signs e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension

A, C (Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia)

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client's spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

A, C, E Many clients with AKI are too ill to meet caloric goals and require tube feedings with renal-specific formulas that are lower in sodium, potassium, and phosphorus, and higher in calories than are standard formulas

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse would prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

A, C, E The low urine output, sediment, and blood pressure would be reported to the primary health care provider. Postoperatively, the nurse would measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hr for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours would be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

A, D, E (Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.)

10. A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? A. Limiting the client's activities to one floor of the home B. Instructing the client to take an as-needed (PRN) sleeping medication at night C. Arranging for the client to have a nutritional consult to assess the client's diet D. Asking the health care provider for a request for PRN nasal oxygen

ANS. A Limiting the client's activities to one floor of the home Limiting the client's activities to one floor of the home is the highest priority nursing intervention. This will prevent tiring the client unnecessarily with stair climbing.A PRN sleeping medication will not increase the client's strength level or conserve strength.Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength. No information suggests that the client has any history of breathing difficulties.

18. After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain C. Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography D. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L)

ANS. A Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

9. A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority nursing instruction for this client to avoid further attacks of pancreatitis? A. "You may need a surgical consult for removal of your gallbladder." B. "See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." C. "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." D. "You'll need to drastically modify your alcohol intake."

ANS. B "See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." The highest priority nursing instruction for the client to avoid more attacks of pancreatitis is to report symptoms of gallbladder attacks immediately to the HCP.The client may not require removal of the gallbladder. That decision is made by the HCP. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.

1. A client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response? A. "Maybe you should find a support group to join." B. "Would you like me to contact the hospital chaplain for you?" C. "Do you want me to try to find a therapist for you?" D. "Do you have any friends whom you want me to call?"

ANS. B "Would you like me to contact the hospital chaplain for you?" Suggesting to contact the hospital chaplain is the best and most appropriate response for the nurse to take when talking with the cancer client's spouse.Suggesting that the client find a support group does not assist the client and the family with the problem. It is inappropriate for the nurse to suggest that the client and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.

6. The nurse expects that which client will be discharged to the home environment first? A. Older obese adult who has had a laparoscopic cholecystectomy B. Middle-aged thin adult who has had a laparoscopic cholecystectomy C. Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy D. Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy

ANS. B Middle-aged thin adult who has had a laparoscopic cholecystectomy A middle-aged client with a thin frame, who had a laparoscopic cholecystectomy, will be discharged first.Although the older obese client also had a laparoscopic cholecystectomy, the client's obesity and age probably will require a longer stay. A traditional cholecystectomy will always require a longer recovery time. The older obese client with a history of COPD will likely have a more lengthy recovery because of associated breathing problems.

12. The nurse suspects that which client is at highest risk for developing gallstones? A. Obese male with chronic obstructive pulmonary disease B. Obese female receiving hormone replacement therapy C. Thin male with a history of coronary artery bypass grafting D. Thin female who has recently given birth

ANS. B Obese female receiving hormone replacement therapy The client at highest risk is the obese female receiving hormone replacement therapy. Both obesity and hormone replacement therapy have been found to increase a woman's risk for developing gallstones. Other risk factors for developing gallstones are type 2 diabetes, dyslipidemia, and insulin resistance.Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, a woman's thin frame lessens that risk.

14. A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response? A. "Your spouse will sign up for the meetings only when he is ready to deal with his problem." B. "Keep mentioning the AA meetings to your spouse on a regular basis." C. "I'll get you some information on the support group Al-Anon." D. "Tell me more about your frustration with your spouse's refusal to participate in AA."

ANS. C "I'll get you some information on the support group Al-Anon." The nurse's best response involves putting the client's spouse in contact with an Al-Anon support group. This action may help with the spouse's frustration and help both to cope with the situation.Telling the spouse that the client will sign up for AA meetings when the client is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the client's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.

20. A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Measure intake and output every shift. B. Do not administer food or fluids by mouth. C. Administer opioid analgesic medication. D. Assist the client to assume a position of comfort.

ANS. C Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis.Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

17. The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? A. Deceased calcium, elevated amylase, decreased magnesium B. Elevated bilirubin, elevated alkaline phosphatase C. Elevated lipase, elevated white blood cell (WBC) count, elevated glucose D. Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

ANS. C Elevated lipase, elevated white blood cell (WBC) count, elevated glucose Elevated lipase, along with increased WBC and increased glucose, suggests acute pancreatitis. Also, increased are serum amylase, serum trypsin, and serum elastase.Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.

3. The nurse is assessing a client who has recurrent attacks of pancreatitis and is concerned about possible alcohol abuse as an underlying cause of these attacks. To elicit this information, what will the nurse do initially? A. Ask the client about binge drinking. B. Question the client whether drinking increases on weekends. C. Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) D. Ask the client's spouse to describe the client's drinking

ANS. C Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) Initially, the nurse needs to provide privacy and establish a trusting relationship to help obtain information from the client about alcohol use. The CAGE questionnaire is useful as well.Topics such as binge drinking or tending to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking. Asking the client client's spouse will decrease nurse-client trust.

7. The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? A. Steak and French fries B. Fried chicken and mashed potatoes C. Turkey sandwich on wheat bread D. Sausage and scrambled eggs

ANS. C Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, French fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

11. The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? A. "The diabetes could be related to your obesity." B. "Look online for general information about diabetes." C. "Do you consume alcohol on a frequent basis?" D. "Type 1 diabetes can occur when the pancreas is affected or destroyed by disease."

ANS. D "Type 1 diabetes can occur when the pancreas is affected or destroyed by disease." The nurse's best response is to tell the client that type 1 diabetes can occur when the pancreas is affected or destroyed by disease. This is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction.Type 2, not type 1, diabetes is usually related to obesity. Telling the client to look online for information is inappropriate because some information available online is incorrect at best.Many factors could produce acute pancreatitis other than alcohol consumption.

2. A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Assessing dietary risk factors for cholecystitis B. Checking for bowel sounds and distention C. Determining precipitating factors for abdominal pain D. Obtaining the admission weight, height, and vital signs

ANS. D Obtaining the admission weight, height, and vital signs Obtaining admission height, weight, and vital signs is included in the education for UAPs and usually is included in the job description for these staff members.Assessing for risk factors, checking bowel sounds, and determining precipitating factors for abdominal pain require assessment skills. Assessment skills require broader education and are within the scope of practice of licensed nursing staff and not UAPs.

15. Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? A. Absence of jaundice, pain of gradual onset B. Absence of jaundice, pain in right abdominal quadrant C. Presence of jaundice, pain worsening when sitting up D. Presence of jaundice, pain worsening when lying supine

ANS. D Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis.Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up. Also, jaundice is present.

16. A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. Carbohydrates B. High fat C. High fiber D. Protein

ANS. D Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss (Chart 59-3). Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease.No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.

13. The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? A. Supine, with a pillow supporting the abdomen B. Up in a chair between frequent periods of ambulation C. High-Fowler's position, with pillows used as needed D. Side-lying position, with knees drawn up to the chest

ANS. D Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to be the most comfortable possible position to relieve abdominal discomfort related to acute pancreatitis.No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position has any effect on abdominal discomfort related to acute pancreatitis.

1. A nurse works in an allergy clinic. What task performed by the nurse takes priority? a. Checking emergency equipment each morning b. Ensuring informed consent is obtained as needed c. Providing educational materials in several languages d. Teaching clients how to manage their allergies

ANS: A All actions are appropriate for this nurse; however, client safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a client to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.

2. A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

ANS: A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

8. A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. I dont need to go to the hospital after using it. b. I must carry two EpiPens with me at all times. c. I will write the expiration date on my calendar. d. This can be injected right through my clothes.

ANS: A Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment. DIF: Evaluating/Synthesis REF: 364 KEY: Allergic response| epinephrine| patient education MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

22. A nurse cares for a client with ulcerative colitis. The client states, I feel like I am tied to the toilet. This disease is controlling my life. How should the nurse respond? a. Lets discuss potential factors that increase your symptoms. b. If you take the prescribed medications, you will no longer have diarrhea. c. To decrease distress, do not eat anything before you go out. d. You must retake control of your life. I will consult a therapist to help.

ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response.

13. A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds

ANS: A Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

9. A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

ANS: A Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

13. A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. It increases the elimination of T lymphocytes from circulation. b. It inhibits cytokine production in most lymphocytes. c. It prevents DNA synthesis, stopping cell division in activated lymphocytes. d. It prevents the activation of the lymphocytes responsible for rejection.

ANS: A Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

4. A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

ANS: A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

3. A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. Avoid large crowds and people who are ill. b. Check over-the-counter meds for acetaminophen. c. Take this medicine exactly as prescribed. d. You have a higher risk of developing cancer.

ANS: A Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

5. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the- counter antihistamines. What response by the nurse is most appropriate? a. Antihistamines do not help poison ivy. b. There are different antihistamines to try. c. You should be seen in the clinic right away. d. You will need to take some IV steroids.

ANS: A Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the client about this. The client does not need to be seen right away. The client may or may not need steroids; they may be given either IV or orally. DIF: Understanding/Comprehension REF: 368 KEY: Hypersensitivities| immunity| antibodies| antihistamines MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

6. A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

ANS: A The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

11. A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the clients lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer? (Click the media button to hear the audio clip.) a. Albuterol (Proventil) via nebulizer b. Diphenhydramine (Benadryl) IM c. Epinephrine 1:10,000 5 mg IV push d. Methylprednisolone (Solu-Medrol) IV push

ANS: A The nurse has auscultated wheezing in the clients lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

12. A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease.

1. For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

ANS: A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

7. A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer e. Fistula Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

4. Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization

ANS: A, B, D, E The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

6. A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.

1. The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.) a. Type I Examples include hay fever and anaphylaxis b. Type II Mediated by action of immunoglobulin M (IgM) c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection e. Type V Examples include a positive tuberculosis test and sarcoidosis

ANS: A, C, D Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type V reactions include Graves disease and B-cell gammopathies.

5. The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

ANS: A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

3. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth

ANS: A, D, E The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

3. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for severe serum sickness b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client

ANS: B A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity. Latex allergies are a type I hypersensitivity.

6. A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest? a. Frequent eyedrops b. Home humidifier c. Strong moisturizer d. Tear duct plugs

ANS: B A humidifier will help relieve many of the clients Sjgrens syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin. DIF: Understanding/Comprehension REF: 369 KEY: Autoimmune disorders| skin| patient education| nonpharmacologic comfort interventions MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

9. After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will avoid large crowds and people who are sick. b. I will take this medication with my breakfast each morning. c. Nausea and vomiting are common side effects of this drug. d. I must wash my hands after I play with my dog.

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

9. A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important? a. Assess the clients bedside glucose reading. b. Instruct the client not to get up without help. c. Monitor the client frequently for tachycardia. d. Record the clients intake, output, and weight.

ANS: B Antihistamines can cause drowsiness, so for the clients safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.

5. A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

ANS: B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

19. A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the clients skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohns disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

4. A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition? a. Blood urea nitrogen: 12 mg/dL b. Creatinine: 3.2 mg/dL c. Hemoglobin: 8.2 mg/dL d. White blood cell count: 12,000/mm3

ANS: B The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.

11. The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

ANS: B The recipients immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

8. After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. Ill rinse my rectal area with warm water after each stool and apply zinc oxide ointment. b. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. c. I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry. d. I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

2. A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

ANS: B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

2. A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.) a. Elimination of any pets b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

ANS: B, C, D, E This client has manifestations of both allergic rhinitis and an overlying infection (probably sinus, as evidenced by purulent nasal drainage, high white blood cells, and high neutrophils). The client needs education on antihistamines such as chlorpheniramine, future allergy testing, the proper way to use decongestant nasal sprays, and ensuring that the full dose of antibiotics is taken. Since the nurse does not yet know what the client is allergic to, advising him or her to get rid of pets is premature.

10. A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

ANS: C A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

11. A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.

7. The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

ANS: C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. Inflammatory is not a type of immunity.

5. A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphys sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohns disease. A positive Murphys sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohns disease. Nightly worsening of abdominal cramping is not consistent with Crohns disease.

10. A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients call light, the client presents an appearance as shown below: What action by the nurse takes priority? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these manifestations will go away.

ANS: C The nurse should ensure the clients airway is patent and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs to be administered right away, but not without a prescription by the physician unless standing orders exist. The client may need oxygen, but a patent airway comes first. Reassurance is important, but airway and calling the Rapid Response Team are the priorities.

1. The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

ANS: C The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

2. A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best? a. Assess that the client has been NPO as directed. b. Communicate this information with dietary staff. c. Document the information in the clients chart. d. Ensure the information is relayed to the surgical team.

ANS: D A client with allergies to avocados, strawberries, bananas, or nuts has a higher risk of latex allergy. The nurse should ensure that the surgical staff is aware of this so they can provide a latex-free environment. Ensuring the clients NPO status is important for a client having surgery but is not directly related to the risk of latex allergy. Dietary allergies will be communicated when a diet order is placed. Documentation should be thorough but does not take priority.

12. An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

ANS: D Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the clients TB test could be a false negative.

7. A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem? a. Reduced physical activity related to the diseases effects on the lungs b. Inadequate family coping related to the clients hospitalization c. Inadequate knowledge related to the plasmapheresis process d. Potential for infection related to the site for organism invasion

ANS: D Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.

8. The nurse working with clients who have autoimmune diseases understands that what component of cell- mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

ANS: D Suppressor T cells help prevent hypersensitivity to ones own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

19. What is the most reliable method of assessing the return of peristalsis? a. Auscultate and count the number of bowel sounds over 30 seconds. b. Administer a laxative as ordered by the health care provider c. Monitor and document all oral intake of food and fluids d. Assess whether the patient has passed flatus or a stool

Assess whether the patient has passed flatus or a stool

Which assessment finding would the nurse expect in a patient with an increased ammonia level associated with hepatic encephalopathy?

Asterixis

38. Following an esophagogastroduodenoscopy, the nurse should instruct the patient in which activity? a. Avoid all strenuous activity for 2 weeks b. Maintain high-fat, low-protein diet after procedure. c. Use incentive spirometry for 24 hours after procedure. d. Avoid driving for 12 hours post procedure.

Avoid driving for 12 hours post procedure.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO5 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO≥ 98 mm Hg b. pH 7.28, HCO5 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO5 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO≥ 98 mm Hg d. pH 7.32, HCO5 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, POz 88 mm Hg

B

A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

B

A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? "ineed to start with mutipl injections until you become more proficient ar b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."

B

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

B

A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

B

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: • Fasting blood glucose: 75 mg/dL (4.2 mmol/L). • Postprandial blood glucose: 200 mg/dL (11.1 mmol/L). • Hemoglobin A1C level: 5.5%. How would the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

B

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: **see chart** What action would the nurse take? a. Administer the potassium and then consult with the primary health care provider about the fluid prescription. b. Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate for the client. d. Increase the intravenous flow rate before administering the potassium to the client.

B

A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching? a. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." b. "Monitor your blood glucose levels at least every 4 hours while sick." c. "If vomiting, do not use insulin or take your oral antidiabetic agent." d. "Try to continue your prescribed exercise regimen even if you are sick."

B

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."

B

A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this client's teaching to prevent bloodborne infections? a."Wash your hands after completing each test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip with a cotton ball." d. "Use gloves when monitoring your blood glucose."

B

The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin? a. 8:00 a.m. (0800) b. 4:00 p.m. (1600) c. 8:00 p.m. (2000) d. 11:00 p.m. (2300)

B

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position.

B (Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.)

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide (Lasix) b. Anxious client who has tachypnea c. Client who is on fluid restrictions d. Client who is constipated with abdominal pain

B (Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.)

After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching? a. I must drink a quart of water or other liquid each day. b. I will weigh myself each morning before I eat or drink. c. I will use a salt substitute when making and eating my meals. d. I will not drink liquids after 6 PM so I wont have to get up at night.

B (One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.)

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin (Calcimar).

B (This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.)

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse? a. Warm the dialysate solution in a microwave before instillation. b. Obtain a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

B An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic. Warming the dialysate in a microwave and flushing the tubing are not safe actions by the nurse. Checking the catheter for obstruction is a viable option but will not treat the peritonitis

The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first upon initial rounding? a. Client with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Client with skin itching from head to toe d. Client with halitosis and stomatitis

B Kussmaul respirations indicate that the client has metabolic acidosis which is a complication of CKD. The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs to lower serum pH. Hypertension is common in most patients with CKD, and skin itching increases with calcium-phosphate imbalances and elevations of nitrogenous wastes, another common finding in CKD. Uremia from CKD causes ammonia to be formed, resulting in the common findings of halitosis and stomatiti

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient's recent history? a. Pyelonephritis b. Dehydration c. Bladder cancer d. Kidney stones

B Prerenal causes of AKI are related to a decrease in perfusion, such as in clients who have prolonged dehydration. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are postrenal causes of AKI related to urine flow obstruction.

The nurse is caring for a client with a new diagnosis of chronic kidney disease. Which priority complications would the nurse anticipate? (Select all that apply.) a. Dehydration b. Anemia c. Hypertension d. Dysrhythmias e. Heart failure

B, C, D, E The client who has CKD has fluid overload and electrolyte imbalances, especially hyperkalemia, that can cause hypertension, heart failure, and dysrhythmias. Anemia results because erythropoietin production by the kidneys is decreased

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

B, D (Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.)

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L

B, E (Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the clients risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.)

How does the nurse accurately calculate a patient's body mass index (BMI)?

BMI = weight (kg)/height (in meters) 2

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? a. Document the finding in the client's chart. b. Assess tactile sensation in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the primary health care provider.

C

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I should increase my intake of vegetables with higher amounts of dietary fiber." b. "My intake of saturated fats should be no more than 10% of my total calorie intake." c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." d. "My intake of water is not restricted by my treatment plan or medication regimen."

C

The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is associated with this health condition? a. Hypotension b. Hyperthyroidism c. Abdominal obesity d. Hypoglycemia

C

The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? a.Assess the client's blood glucose level. b. Monitor the client's urinary output every hour. c. Establish intravenous access to provide fluids. d. Give regular insulin per agency policy.

C

The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. "Be sure to take the drug once a day before breakfast." b. "Take the drug every evening before bedtime." c. "Give your drug injection the same day every week." d. "Take the drug with dinner at the same time each day."

C

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. b. Provide a heart healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

C (A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the clients current potassium level)

After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

C (Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.)

A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond? a. Potatoes and avocados can be substituted for fruit. b. If you cook the fruit, the amount of potassium will be lower. c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in potassium.

C (Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.)

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure

C (Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.)

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include inthis clients teaching? a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.

C Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

A client with diabetes mellitus type 2 has been well controlled with metformin. The client is scheduled for magnetic resonance imaging (MRI) scan with contrast. What priority would the nurse take at this time? a. Teach the client about the purpose of the MRI. b. Assess the client's blood urea nitrogen and creatinine. c. Tell the client to withhold metformin for 24 hours before the MRI. d. Ask the client if he or she is taking antibiotics

C Contrast media can be nephrotoxic (damaging to the kidneys). Metformin can also be nephrotoxic and the client should not be exposed to two agents. Clients who have diabetes are already at risk for renal damage

A client is placed on fluid restriction because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client's fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the client's body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance

A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L (135 mmol/L) Potassium 5 mEq/L (5 mmol/L) Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L) Serum creatinine 2.5 mg/dL (221 mcmol/L) What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration

C The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point

The nurse is teaching assistive personnel (AP) about fluid restriction for a client who has acute kidney injury (AKI). The client's 24-hour urinary output is 120 mL. How much fluid would the client be allowed to have over the next 24 hours? a. 380 mL b. 500 mL c. 620 mL d. 750 mL

C The general principle for fluid restriction for clients is that they may have a daily fluid intake of 500 mL plus the amount of their urinary output. In this case, 120 mL urinary output plus 500 mL equals 620 mL fluid allowance

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

C The nurse would not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula would be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this patient's care? a. Edema and pain b. Cardiac and respiratory status c. Electrolyte and fluid imbalance d. Mental health status

C This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance are essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the client's cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

C, D (A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.)

The parent of a pediatric patient suffering from hepatitis A approaches the nurse and is worried about the spread of infection to other family members through use of the same bathroom. What should the nurse advise the patient's parent? Select all that apply.

Clean the bathroom and commode thoroughly. Ask your son to wash his hands thoroughly after using the bathroom. Ask all other family members to wash their hands thoroughly before eating and after using the bathroom.

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. c. Assess the client for other signs of cellulitis. d.Instruct the client to rotate sites for insulin injection.

D

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? a. Administration of oxygen via facemask. b. Intravenous administration of 10% glucose. c. Implementation of seizure precautions. d. Administration of intravenous insulin.

D

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? a. Serum chloride level of 98 mEq/L (98 mmol/L) b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L) c. Serum sodium level of 132 mEq (132 mmol/L) d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

D

A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect? a. 5.0% b. 5.7% c. 6.2% d. 7.4%

D

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury? a. "Examine your feet using a mirror every day?" b. "Rotate your insulin injection sites every week." c. "Check your blood glucose level before each meal." d. "Use a bath thermometer to test the water temperature."

D

A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2L a day." b. "Animal organ meat is high in insulin." c. "Limit your carbohydrate intake to 80 g a day?" d. "Walk at a moderate pace for 1 mile daily"

D

After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."

D

After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy? "I'll take this medicine during each of my meals." b. "I must take this medicine in the morning when I wake." c. "I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."

D

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

D

The nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 19-year-old Caucasian b. A 22-year-old African American c. A 44-year-old Asian American d. A 58-year-old American Indian

D

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? a. Diabetic ketoacidosis (DKA) b. Severe hypoglycemia c. Chronic kidney disease (CKD) d. Hyperglycemic-hyperosmolar state (HHS)

D

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How would the nurse respond? a. "I can give your injections to you while you are here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "Your disease will not be managed properly if you refuse to administer the shots." d. "Tell me what it is about the injections that are concerning you."

D

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

D (An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the clients urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency)

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole wheat crackers Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 69 d. Grilled chicken breast with glazed carrots

D (Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are often high in sodium.)

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the clients posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness

D (The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.)

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates that more teaching is needed? a. "I will probably lose weight by cutting out potato chips." b. "I will cut out bacon with my eggs every morning." c. "My cooking style will change by not adding salt." d. "I am thrilled that I can continue to eat fast food."

D Fast-food restaurants usually serve food that is high in sodium. This statement indicates that more teaching needs to occur. The other statements show a correct understanding of the teaching.

A client with acute kidney injury (AKI) has a blood pressure of 76/55 mm Hg. The primary health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client starts to develop shortness of breath. What is the nurse's priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the client's pulse. d. Decrease the rate of the IV infusion

D The nurse would assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the client's hemodynamic status, but this would not be the initial or priority action by the nurse. Vital signs are also important after adjusting the intravenous infusion

The nurse administers epoetin alfa to a client who has chronic kidney disease (CKD). Which laboratory test value would the nurse monitor to determine this drug's effectiveness? a. Potassium b. Sodium c. Renin d. Hemoglobin

D The purpose of giving epoetin alfa to a client with CKD is to manage anemia by stimulating the bone marrow to produce more red blood cells. Therefore, monitoring the client's hemoglobin, hematocrit, and red blood cell count would indicate if the drug was effective.

patient reports a sensation of tingling, tickling, and prickling in the fingers and toes. What does the nurse suspect as the possible reason for this patient's condition?

Deficiency of vitamin B 12

What could be the possible reason for the appearance of petechiae in a patient?

Deficiency of vitamin C

18. When the nurse assess a patient after abdominal surgery, assessment reveals diminished, hypoactive sounds. What is the nurse's best action? a. Notify the surgeon immediately b. Document the finding and continue to monitor c. Place an NG tube d. Obtain a stat abdominal x-ray

Document the finding and continue to monitor

25. Why is patient compliance higher with the fecal immunochemical test (FIT) than with the traditional fecal occult blood test (FOBT)? a. Anticoagulants, such as warfarin, and NSAIDs should be discontinued for 7 days before FIT testing begins. b. Drugs and food do not interfere with the FIT test results. c. Raw fruits and vegetables and red meat must be avoided before the FIT test. d. Vitamin C-rich foods, juices, and tablets must also be avoided before the FIT test.

Drugs and food do not interfere with the FIT test results.

A patient receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the patient most likely experiencing?

Fluid volume overload

The nurse cares for a patient with advanced cirrhosis. What indicates that the patient is experiencing a serious complication?

Frequent nosebleeds and bruising

20. The patient reports episodes of diarrhea for the past 2 days. What type of bowel sounds does the nurse expect auscultate when assessing this patient? a. Increased loud and gurgling sounds b. Decreased soft and diminished sounds c. Increased in the left lower quadrant only d. Decreased in the right upper quadrant only

Increased loud and gurgling sounds

When planning care for a patient with cirrhosis who has significant abdominal ascites, the nurse will give highest priority to which nursing diagnosis?

Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

A nurse is collecting data from a patient admitted with hepatitis A. Which information given by the patient may indicate the patient's susceptibility to contract hepatitis A? Select all that apply.

Living in slums Working as local plumber Working as a sewage cleaner

36. A patient is given midazolam hydrochloride before receiving a colonoscopy procedure. What is the priority assessment for the nurse during this procedure? a. Monitor rate and depth of respirations b. Auscultate for bowel sounds in all 4 quadrants. c. Place on a cardiac monitor and watch for dysrhythmias d. Suction secretions to prevent aspiration.

Monitor rate and depth of respirations

24. The patient presents with abdominal discomfort and a history of gastrointestinal cancer. Which cancer-specific laboratory studies does the nurse expect will be ordered by the health care provider? a. Oncofetal antigens (CA19-9 and CEA) b. Conjugated (direct) bilirubin and unconjugated (indirect) bilirubin c. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) d. Serum amylase and lipase

Oncofetal antigens (CA19-9 and CEA)

16. A patient reports decreased appetite over the past month along with simultaneous decreased intake or oral nutrition as well as episodes of nausea. What priority information should the nurse inquire about next? a. Favorite foods b. Bowel pattern c. Patient weight d. Vital signs

Patient weight

Which assessment findings are associated with complications of cirrhosis of the liver? Select all that apply.

Pedal edema Mental status changes Black, tarry stools

13. The nurse is auscultating a patient's abdomen. Which technique should the nurse use? a. Place the diaphragm of the stethoscope lightly on the abdominal wall. b. Place the bell of the stethoscope lightly on the abdominal wall. c. Hold the diaphragm of the stethoscope firmly on the abdominal wall. d. Hold the bell of the stethoscope firmly on the abdominal wall.

Place the diaphragm of the stethoscope lightly on the abdominal wall.

What clinical manifestations of refeeding syndrome may appear when tube feeding is started for a patient in a starvation state?

Seizures

A patient with cirrhosis of the liver is on furosemide. The nurse should monitor the patient for which findings to prevent complications of diuretic therapy? Select all that apply.

Tachycardia Hypotension Muscle weakness Cardiac arrhythmias

21. The nurse is supervising a student during assessment of the abdomen. When must the nurse intervene with the student? a. The nursing student inspects the patients abdomen for symmetry b. The nursing student auscultates for bowel sounds in an organized manner. c. The nursing student performs light palpation for areas of discomfort. d. The nursing student performs deep palpation for a pulsing midline mass

The nursing student performs deep palpation for a pulsing midline mass

What laboratory test is used to assess a patient's immune function?

Total lymphocyte count (TLC)

What solution is commonly used to flush a clogged feeding tube?

Water

A patient with cirrhosis of the liver is admitted to the hospital. What hematologic symptoms might be noted in this patient? Select all that apply.

anemia leukopenia thrombocytopenia