322 EXAM 3 Practice

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? 1- First 2- Second 3- Third 4- Mixed

Second-intention healing is characterized by a cavity-like defect. This requires gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss. First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.

The nurse is caring for an older adult male client who reports stomach pain and heartburn. Which symptom is most significant in determining whether the client's ulceration is gastric or duodenal in origin? 1- Pain occurs 1½ to 3 hours after a meal, usually at night. 2- Pain is worsened by the ingestion of food. 3- The client has a malnourished appearance. 4- The client is a man older than 50 years.

1 A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m., occurring 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

How does the nurse accurately calculate a client's body mass index (BMI)? 1- BMI = weight (kg)/height (in meters)2 2- BMI = weight (lb)/height (in inches)2 3- BMI = weight (kg)/height (in meters)d. 4-BMI = weight (lb)/height (in meters)

1 BMI = weight (kg)/height (in meters)2 is the only formula that will correctly calculate BMI.

An RN is assessing a client who has Crohn's disease. Which of the following findings should the nurse expect? 1- Fatty Diarrheal stools 2- Hyperkalemia 3- Weight gain 4- Sharp epigastric pain

1 - Steatorrhea (fatty stool) is an expected finding in Crohn's disease

The nurse working during the day shift on the medical unit has just received report. Which client does the nurse plan to assess first? 1- Young adult with epigastric pain, hiccups, and abdominal distention after having a total gastrectomy 2- Adult who had a subtotal gastrectomy and is experiencing dizziness and diaphoresis after each meal 3- Middle-aged client with gastric cancer who needs to receive omeprazole (Prilosec) before breakfast 4- Older adult with advanced gastric cancer who is scheduled to receive combination chemotherapy

1 The client with epigastric pain is experiencing symptoms of acute gastric dilation, which can disrupt the suture line. The surgeon should be notified immediately because the nasogastric tube may need irrigation or re-positioning. The client who had a subtotal gastrectomy is not in a life-threatening situation and does not require immediate assessment. The client with gastric cancer and the older adult with advanced gastric cancer are in stable condition and do not require immediate assessment.

The nurse case manager is discussing community resources with a client who has colorectal cancer and is scheduled for a colostomy. Which referral is of greatest value to this client initially? 1 Certified Wound, Ostomy, and Continence Nurse (CWOCN) 2- Home health nursing agency 3- Hospice 4- Hospital chaplain

1 A CWOCN (or an enterostomal therapist) will be of greatest value to the client because the client is scheduled to receive a colostomy. The client is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill client. Referral to a chaplain may be helpful later in the process of adjusting to the disease.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? 1- Face tent 2- Venturi mask 3- Nasal cannula 4- Non-rebreather mask

1 A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

An older adult resident in a long-term-care facility becomes confused and agitated, telling the nurse, "Get out of here! You're going to kill me!" Which action will the nurse take first? 1- Check the resident's oxygen saturation. 2- Do a complete neurologic assessment. 3- Give the prescribed PRN lorazepam (Ativan). 4- Notify the resident's primary care provider.

1 A common reason for sudden confusion in older clients is hypoxemia caused by undiagnosed pneumonia. The nurse's first action should be to assess oxygenation by checking the pulse oximetry.

The RN who usually works on the pediatric unit is floated to the GI medical-surgical unit. Which client is appropriate for the charge nurse to assign to the float nurse? 1- A 20-year-old with anorexia nervosa receiving total parenteral nutrition through a central venous line 2- A 35-year-old who had a laparoscopic gastroplasty yesterday and is now taking sips of clear liquids 3- A 60-year-old with gastric cancer receiving elemental feedings through a jejunostomy tube 4- A 65-year-old with morbid obesity who requires a preoperative bariatric surgery assessment

1 A pediatric nurse would be familiar with the pathophysiology and collaborative treatment of the client with anorexia nervosa. The client with a laparoscopic gastroplasty, the client with gastric cancer with a jejunostomy tube, and the client with morbid obesity requiring a preoperative bariatric surgery assessment all require care by a nurse with more familiarity with adult nutritional disorders and bariatric surgery.

An RN is caring for 4 clients. Which of the folloiwing is at greatest risk for pulmonary embolism? 1- Pt is 48 hrs post-op following a total hip arthroplasty 2- Pt is 8 hrs post-op open surgical appendectomy 3- Pt is 2hrs post-op open reduction external fixation 4- Pt is 4hrs post-op laparoscopic cholecystectomy

1 A pt who has undergone a total hip arthoplasty has the highest risk due to decreased mobility of the affected extremity and increased amount of blood clots form in the veins of the thigh. DVTs are most likely to occur within 48-72 hrs after surgery. This can be reduced by applying SCDs or TED stockings and my prophylactically administering anticoag meds.

Because clients with cystic fibrosis (CF) are at increased risk for infection, what will the nurse advise the client with CF who is infected with Burkholderia cepacia to do? 1- Avoid Cystic Fibrosis Foundation-sponsored events. 2- Avoid the hospital. 3- Stay at home most of the time. 4- Use an antiseptic hand gel.

1 A serious bacterial infection for clients with CF is Burkholderia cepacia, which is spread by casual contact from one CF client to another. For this reason, the Cystic Fibrosis Foundation bans infected clients (those who have had a positive sputum culture) from participating in any foundation-sponsored events.

A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? 1- "A change in position may be what is needed for you to have intercourse with your wife." 2- "Have you considered going to see a marriage counselor with your wife?" 3- "What has your wife said about your pouch system?" 4- "You must get clearance from your health care provider before you attempt to have intercourse."

1 A simple change in positioning during intercourse may alleviate the client's apprehension and facilitate sexual relations with his wife. Suggesting marriage counseling may address the client's concerns, but it focuses on the wrong issue; the client has not stated that he has relationship problems. Asking the client what his wife has said about the pouch may address the client's concerns, but it similarly focuses on the wrong issue. Telling the client that he needs to get clearance from his health care provider is an evasive response that does not address the client's primary concern.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? 1- Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min 2- Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain 3- Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography 4- Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL

1 Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. 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.

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? 1- Administering preoperative antibiotics and anxiolytics 2- Assessing the client's nutritional status and need for nutrition supplements 3- Having the client sign the operative consent form 4- Teaching the client about the need for tracheal suctioning after surgery

1 Administering medication is a skill within the LPN/LVN scope of practice. As a reminder, anxiolytics must be administered after the operative consent has been signed, or the consent will be invalid. The client's nutritional status and need for nutritional supplements should be assessed by the RN or a RD as part of the multidisciplinary care team. The surgeon is responsible for discussing the laryngectomy procedure, answering any questions, and having the client sign the operative consent form. Client teaching is the responsibility of the RN because it requires complex critical thinking skills.

A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? 1- Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. 2- Administer 2 g of cephalothin (Keflin) IV now. 3- Give morphine sulfate 4 to 6 mg IV for pain. 4- Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.

1 Airway and oxygenation are main priorities in the immediate postoperative period. The client will likely be intubated, so coordination of care with respiratory therapy will be important. Antibiotic therapy, pain management, may be ordered, but are not a priority at this time. however. PRBCs are unlikely to be needed with minimally invasive techniques.

A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first? 1- Albuterol (Proventil) 2 inhalations 2- Fluticasone (Flovent) 2 inhalations 3- Ipratropium (Atrovent) 2 inhalations 4- Salmeterol (Serevent) 2 inhalations

1 Albuterol is a beta2 agonist that acts rapidly as a bronchodilator. Fluticasone is a corticosteroid; it is used to prevent asthma attacks and is not used as a rescue medication. Ipratropium is an anticholinergic drug that allows the sympathetic system to dominate and cause bronchodilation; it is not as effective as a beta2 agonist, so it is not a first-line drug. Salmeterol is a long-acting beta2 agonist that must be used regularly over time; this client needs a rescue medication.

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease? 1- Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall 2- Decreased WBC count, visualization of calcified gallstones, increased alkaline phosphatase 3- Increased WBC count, visualization of noncalcified gallstones, edema of the gallbladder wall 4- Decreased WBC count, visualization of noncalcified gallstones, increased alkaline phosphatase

1 An increased WBC count is evidence of inflammation. Only calcified gallstones will be visualized on abdominal x-ray. Ultrasonography of the right upper quadrant is the best diagnostic test for cholecystitis. Acute cholecystitis is seen as edema of the gallbladder wall and pericholecystic fluid. Alkaline phosphatase will be elevated if liver function is abnormal; this is not common in gallbladder disease.

A client diagnosed with ulcerative colitis is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? 1- "Be aware of the symptoms of toxic megacolon that we discussed." 2- "If diarrhea increases, you should let your health care provider know." 3- "Pregnancy should be avoided." 4- "You will need to decrease your dose of sulfasalazine (Azulfidine)."

1 Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia. Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first? 1- Assess the airway, breathing, and circulation. 2- Call for the Rapid Response Team. 3- Check the patency of the chest tubes. 4- Listen for breath sounds.

1 Assessing the "ABCs" is the priority to determine possible causes of burning in the client's chest. Listening for breath sounds would be an appropriate action for the nurse to take to evaluate the client's reported symptoms; however, this would not be the nurse's first action.

A client is scheduled for discharge after surgery for inflammatory bowel disease. The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care? 1- Ability of the client and spouse to perform incision care and dressing changes 2- Effective coping mechanisms for the client and spouse after the surgical experience 3- Knowledge about the client's requested pain medications 4- Understanding of the importance of keeping scheduled follow-up appointments

1 Assessing the client's and the spouse's ability to carry out incision care and dressing changes is essential for avoiding further development of the infectious process, as well as infection of the surgical incision itself. Assessing coping mechanisms and knowledge of the client's pain medication are important, but are not the priority. Understanding the importance of scheduled follow-up appointments is important, but is not the priority.

All of these clients are being cared for on the intensive care stepdown unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit? 1- Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask. 2- Client with chronic pleural effusions who is scheduled for a paracentesis in the next hour. 3- Client with emphysema who requires instruction about correct use of oxygen at home. 4- Client with lung cancer who has just been transferred from the intensive care unit after having a left lower lobectomy the previous day.

1 Because asthma is a common pediatric diagnosis, the pediatric nurse would be familiar with the assessment and care needed for a client with this diagnosis.

The community health nurse is planning tuberculosis treatment for a client who is homeless and heroin-addicted. Which action will be most effective in ensuring that the client completes treatment? 1- Arrange for a health care worker to watch the client take the medication. 2- Give the client written instructions about how to take prescribed medications. 3- Have the client repeat medication names and side effects. 4- Instruct the client about the possible consequences of nonadherence.

1 Because this client is unlikely to adhere to long-term treatment unless directly supervised while taking medications, the best option is to arrange for directly observed therapy.

The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? 1- Continuous oozing of bright-red blood 2- Decreased level of consciousness 3- Effective pain management 4- Heart rate and blood pressure trending up over several hours

1 Bright-red blood indicates a rupture in the carotid artery and requires immediate attention. A ventilated postoperative client will be sedated, so a decreased level of consciousness is to be anticipated. Effective pain management should be evaluated during assessment of vital signs and that information relayed to the nurse. Changes in vital signs, including trends, need to be reported to the nurse responsible for the client's care. Increasing heart rate and blood pressure can be an indication that the client is not adequately sedated or is in pain or anxious, for example.

A 70-year-old client has a complicated medical history, including chronic obstructive pulmonary disease. Which client statement indicates the need for further teaching about the disease? 1- "I am here to receive the yearly pneumonia shot again." 2- "I am here to get my yearly flu shot again." 3- "I should avoid large gatherings during cold and flu season." 4- "I should cough into my upper sleeve instead of my hand."

1 Clients 65 years and older, as well as those who have chronic health problems, should be encouraged to receive the pneumonia vaccine, which is not given annually but only once.

Aside from chemotherapeutic agents, what other medications does the nurse expect to administer to a client with advanced colorectal cancer for relief of symptoms? 1- Analgesics and antiemetics 2- Analgesics and benzodiazepines 3- Steroids and analgesics 4- Steroids and anti-inflammatory medications

1 Clients with advanced colorectal cancer and metastasis also receive drugs such as analgesics and antiemetics for relief of symptoms, specifically pain and nausea. Benzodiazepines, steroids, and anti-inflammatory medications are not routinely requested for these clients.

The nurse is preparing to admit an adult client with pertussis. Which symptom does the nurse anticipate finding in this client? 1- "Whooping" after a cough 2- Hemoptysis 3- Mild cold-like symptoms 4- Post-cough emesis

4 Clients with pertussis will have paroxysms of coughing often followed by changes in color and/or vomiting.

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? 1- "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." 2- "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe." 3- "Because your tongue may be blocking your throat, and you wake up because you are choking." 4- "It isn't really that often. It just feels that way."

1 During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep. After the client returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is re-obstructed. Too much carbon dioxide, not a lack of oxygen, is the trigger that causes the client to awaken and breathe. Technically the client is not choking. Telling the client he or she isn't really awakening that often minimizes the client's concern and is not accurate. The client may be awakening every 5 minutes as the cycle repeats.

A client is taking isoniazid, rifampin, pyrazinamide, and ethambutol for tuberculosis. The client calls to report visual changes, including blurred vision and reduced visual fields. Which medication may be causing these changes? 1- Ethambutol 2- Isoniazid 3- Pyrazinamide 4- Rifampin

1 Ethambutol can cause optic neuritis, leading to blindness at high doses. When discovered early and the drug is stopped, problems can usually be reversed. Both isoniazid and pyrazinamide may cause liver failure; side effects of major concern include jaundice, bleeding, and abdominal pain. Rifampin will cause the urine and all other secretions to have a yellowish-orange color; this is harmless.

The nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take in the event that the client develops fever, increased triglycerides, and clotting problems? 1- Discontinues the IVFE infusion 2- Documents the findings and continues to monitor 3- Slows the rate of flow of the IVFE infusion 4- Switches to total parenteral nutrition (TPN)

1 For clients receiving fat emulsions, the nurse should monitor for manifestations of fat overload syndrome, especially in those who are critically ill. These manifestations include fever, increased triglycerides, clotting problems, and multisystem organ failure. The IVFE infusion should be discontinued, and the nurse must report any of these changes to the health care provider immediately if this complication is suspected.

What does the nurse advise a client diagnosed with irritable bowel syndrome (IBS) to take during periods of constipation? 1- Bulk-forming laxatives 2- Saline laxatives 3- Stimulant laxatives 4- Stool-softening agents

1 For treatment of constipation-predominant IBS, bulk-forming laxatives are generally taken at mealtimes with a glass of water. Saline and stimulant laxatives are not used for the treatment of constipation-predominant IBS. Stool-softening agents are not effective.

While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do? 1- Calmly continues talking 2- Checks the tube for blocks or kinks 3- Immediately calls the health care provider 4- Strips the chest tube

1 Gentle bubbling in the water seal chamber is normal during the client's exhalation, forceful cough, or position changes. Any bubbling that is occurring would stop if a kink or a blockage is present in the chest tube. The chest tube is functioning normally; there is no need to notify the health care provider. "Stripping the chest tube" greatly increases pressure inside the chest and could potentially damage lung tissue; any excessive manipulation should be avoided.

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? 1- Having a home health consultation for wound care 2- Requesting an antianxiety medication 3- Requesting pain medication for the client's osteoarthritis 4- Placing the client in a skilled nursing facility for rehabilitation

1 Home health services are most appropriate for this client because wound care will be extensive and the client's mobility may be limited. No indication suggests that the client is experiencing anxiety regarding postoperative care. Pain medication may be needed for the client's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the client can remain in his or her home with sufficient support services.

A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question? 1- "Give ibuprofen 800 mg every 8 hours as needed for pain." 2- "Encourage bedrest, with the head of the bed elevated 45 to 60 degrees." 3- "Provide humidified air." 4- "Suction at the bedside."

1 Ibuprofen is contraindicated in a client with a nosebleed because NSAIDs inhibit clotting. At least initially, bedrest is suggested because significant amounts of blood may have been lost owing to a posterior nosebleed; elevation of the head of the bed is recommended for client comfort and to facilitate drainage of secretions. Humidified air and humidified oxygen, if oxygen is ordered, are recommended because dryness of the nasal mucosa is a cause of epistaxis (nosebleed). Any client who is admitted for epistaxis needs suction at the bedside in the event of further bleeding.

Which assessment finding is associated with obstructive lung disease and not with interstitial lung disease? 1- Barrel chest 2- Cough 3- Dyspnea 4- Reduced gas exchange

1 Interstitial lung diseases are restrictive, not obstructive, so they do not cause barrel chest, which is the result of air trapping. Both types of pulmonary disease cause cough, dyspnea, and reduced gas exchange.

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? 1- "I can only take baths, but no showers." 2- "I can put normal saline in my tracheostomy to keep the secretions from getting thick." 3- "I should put cotton or foam over the tracheostomy hole." 4- "I will have to learn to suction myself."

1 The client does not understand that he or she can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary. Normal saline should be instilled into the artificial airway 10 to 15 times a day, as prescribed. The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Clients with tracheostomies should be taught clean suction technique.

A "do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? 1- Ensure that the tubing is patent and that oxygen flow is high. 2- Notify the chaplain and the family member of record. 3- Call the Rapid Response Team and prepare to intubate. 4- Comfort the client and confirm that signed DNR orders are in the chart.

1 Labored breathing and ultimately suffocation can occur if the reservoir bag on a non-rebreather mask kinks, or if the oxygen source disconnects or is not set to high flow levels. The chaplain and the family member of record should not be notified, because death is not imminent at this time. Equipment malfunction must be ruled out before intubation of the client is performed. Additionally, the client may not want to be intubated, as indicated in the DNR orders. Troubleshooting and reversal of nonresuscitative equipment is the standard of care; DNR does not mean "do not treat."

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? 1- Limiting the client's activities to one floor of the home 2- Instructing the client to take an as-needed (PRN) sleeping medication at night 3- Arranging for the client to have a nutritional consult to assess the client's diet 4- Asking the health care provider for a request for PRN nasal oxygen

1 Limiting the client's activities to one floor of the home will prevent tiring the client with stair climbing. Taking a PRN sleeping medication may not necessarily increase the client's strength level or conserve strength; also, the client may not be experiencing difficulty sleeping. 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.

A client who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the client can take oral nutrition? 1- Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) 2- Liquid steroids 3- Opioid antagonists 4- Oral diazepam

1 NSAIDs are an excellent adjunct when used with narcotics or opioid analgesia. Steroids will not help in pain relief and will delay healing. An opioid antagonist will reverse the effect of the narcotic. Diazepam has no pain-relieving properties.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best? 1- The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula 2- The client with chronic lung disease who is being evaluated for possible home oxygen use 3- The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar 4- The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

1 Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas. Orthopedic nurses do not specialize in chronic lung conditions; such care is best assigned to an RN with experience in chronic lung conditions and in the use of various home oxygen delivery devices and the use of various types of oxygen delivery equipment. Orthopedic nurses do not specialize in airway surgery; such care is best assigned to an RN with experience in postoperative tracheostomy care and tracheostomy collar care.

An RN receives Rx from the provider for performing nasopharyngeal suctioning on 4 clients. For which fof the following pts should the RN clarify the provider's order? 1- A pt w/ epistaxis 2- A pt w/ Amyotrophic lateral sclerosis 3- A pt who has pneumonia 4- A Pt who has emphysema

1 Suctioning should be avoided on a pt with a nosebleed as this intervention might cause an increase in the bleeding

An RN is assessing a client who has lung cancer. Which of the following clinical manifestations should the Rn expect? 1- Blood tinged sputum 2- Decreased tactile fremitus 3- resonance w/ percussion 4- Peripheral edema

1 The RN should expect bleeding from the tumor, thus blood tinged sputum other signes include increasted tactile fremitus, dullness or flat sounds on percussion and cyanosis of the lips or fingertips

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? 1- "It is usually ready to be closed in about 1 to 2 months." 2- "This is something that you will have to discuss with your health care provider." 3- "The period of time is indefinite—I am sorry that I cannot say." 4- "You will probably have it for 6 months or longer, until things heal.

1 The RPC-IPAA has become the most effective alternate method for UC clients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the client begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months. Telling the client that he or she will have to discuss it with the health care provider evades the question; the nurse can give generalities to the client based on past practice and available data. The time that the client has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch should heal in 1 to 2 months, not 6 months; this estimate is not based on the expected outcome.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? 1- Kidney failure 2- Refractory ascites 3- Fetor hepaticus 4- Paracentesis scheduled for today

1 The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first? 1- Assess the client's respiratory status. 2- Decrease the sensitivity of the alarm. 3- Ensure that the connecting tubing is not kinked. 4- Suction the client.

1 The client must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening client condition, reducing the sensitivity is harmful. S uctioning the client may not even be needed; the client's respiratory status must be assessed before such a determination can be reached.

A nurse is teaching a client with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? 1- "Avoid large crowds and anyone who is sick." 2- "Do not take the medication if you are allergic to foods with fatty acids." 3- "Expect difficulty with wound healing while you are taking this drug." 4- "Monitor your blood pressure and report any significant decrease in it."

1 The client should avoid being around large crowds to prevent developing an infection. The client should not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the client should not experience difficulty with wound healing while taking adalimumab. The client should not experience a decrease in blood pressure from taking this drug.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? 1- Hyperoxygenate before and after suctioning. 2- Repeat suctioning until the tube is clear. 3- Apply suction during insertion of the tube. 4- Suction for 30 seconds.

1 The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10 to 15 seconds.

The nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed? 1- "I can drive my car in about 2 weeks." 2- "I should avoid drinking carbonated sodas." 3- "It may take 6 weeks to see the effects of some foods on my bowel patterns." 4- "Stool softeners will help me avoid straining."

1 The client who has had a bowel resection and colostomy should avoid driving for 4 to 6 weeks. The client should avoid drinking sodas and other carbonated drinks because of the gas they produce. He or she may not be able to see the effects of certain foods on bowel patterns for several weeks. The client should avoid straining at stool.

Which morbidly obese client is the least likely candidate for bariatric surgery? 1- A 34-year-old woman experiencing mental confusion 2- A 44-year-old man with a history of hypertension 3- A 50-year-old woman with a history of sleep apnea 4- A 52-year-old man with a history of type 1 diabetes mellitus

1 The client who is experiencing mental confusion is not a good candidate for bariatric surgery because the client may have difficulty complying with the postoperative treatment regimen. The client with hypertension, the client with sleep apnea, and the client with diabetes are all candidates for bariatric surgery despite having these complications.

Which two factors in combination are the greatest risk factors for head and neck cancer? 1- Alcohol and tobacco use 2- Chronic laryngitis and voice abuse 3- Marijuana use and exposure to industrial chemicals 4- Poor oral hygiene and use of chewing tobacco

1 The combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer. Chronic laryngitis and voice abuse in combination are not the greatest risk factors; however, each one individually is a risk factor for head and neck cancer. No large, randomized, controlled studies have identified a relationship between marijuana use and head and neck cancer. Exposure to industrial chemicals may increase a person's risk. Poor oral hygiene is a risk factor, as is chewing tobacco; however, no studies have reported that a combination of the two will lead to increased risk. The same cancer-causing agents in smoking tobacco may be present in smokeless (chewing) tobacco.

A client who has been homeless and has spent the past 6 months living in shelters has been diagnosed with confirmed tuberculosis (TB). Which medications does the nurse expect to be ordered for the client? 1- Isoniazid (INH), rifampin (Rifadin), pyrazinamide (Zinamide), ethambutol (Myambutol) 2- Metronidazole (Flagyl), acyclovir (Zovirax), flunisolide (AeroBid), rifampin (Rifadin) 3- Prednisone (Prednisone), guaifenesin (Organidin), ketorolac (Toradol), pyrazinamide (Zinamide) 4- Salmeterol (Serevent), cromolyn sodium (Intal), dexamethasone (Decadron), isoniazid (INH)

1 The combination of isoniazid, rifampin, pyrazinamide, and ethambutol is used to treat TB.

An RN is preparing for a pt to DC following a broncoscopy w/ the use of moderate sedation. The RN should place the priority on which of the following assessments? 1- presence of a gag reflex 2- pain level using a numerical scale 3- Hydration status 4- Appearance of the IV insertion site

1 The greatest risk to the pt is aspiration due to a depressed gag reflex.

A client with colorectal cancer had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem overwhelming." What does the nurse do first for this client? 1- Encourages the client to look at and touch the colostomy stoma 2- Instructs the client about complete care of the colostomy 3- Schedules a visit from a client who has a colostomy and is successfully caring for it 4- Suggests that the client involve family members in the care of the colostomy

1 The initial intervention is to get the client comfortable looking at and touching the stoma before providing instructions on its care. Instructing the client about colostomy care will be much more effective after the client's anxiety level has stabilized. Talking with someone who has gone through a similar experience may be helpful to the client only after his or her anxiety level has stabilized. The client has begun to express feelings regarding the colostomy and its care; it is too soon to involve others. The client must get comfortable with this body image change first.

An RN is assessing a client who is post-op following gastrectomy. The RN should identify which of the following findings as an indication of abdominal distension? 1- Hiccups 2- Hypertension 3- Bradycardia 4- Chest Pain

1 - Hiccups can be caused by irritation to the phrenic nerve d/t abdominal distension. If the hiccups are intractable, the RN should anticipate a Rx for clorpromazine b/c persistent hiccups are distressful to the client and can lead to other complications such as vomiting

An RN is assessing a client who has acute Hep B. Which of the following findings should the RN suspect? 1- Joint pain 2- Obstipation 3- Abdominal distension 4- Periumbilical discoloration

1 - Joint pain is an expected finding in a client with acute Hep B

A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? 1- Client on warfarin (Coumadin) with epistaxis with profuse bleeding 2- Client with facial burns caused by a mattress fire while sleeping 3- Client with possible facial fractures after a motor vehicle collision (MVC) 4- Client with suspected bilateral vocal cord paralysis and stridor

1 The initial treatment for epistaxis is upright positioning with direct lateral pressure to the nose. A nurse with minimal ED experience could be expected to safely provide care for this client. In addition, laboratory work should be obtained to assess the client's ability to clot, given that the client is on warfarin (Coumadin). A client who has sustained facial burns in an enclosed setting is at high risk for airway involvement and requires observation by an experienced nurse. An experienced nurse should take care of a client with possible facial fractures after an MVC due to the potential for airway compromise from bleeding or swelling. Facial fractures may be accompanied by cervical spine fracture and/or spinal trauma that requires monitoring and evaluation by an RN with experience. Stridor is an indication of respiratory distress; this requires an RN with experience.

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? 1- Ask the client whether CPAP has been used consistently at night. 2- Discuss the use of autotitrating positive airway pressure (APAP). 3- Plan to teach the client about treatment with modafinil (Provigil). 4- Suggest that a nasal mask be used instead of a full facemask.

1 The nurse should assess whether the client has actually consistently been using CPAP at night, because clients may have difficulty with the initial adjustment to this therapy. With APAP, the pressures are adjusted continuously depending on the client's needs; this may be more comfortable for the client. Modafinil treats narcolepsy or daytime sleepiness; it does not treat the cause of sleep apnea, but may be used to help some of the side effects of obstructive sleep apnea. A nasal mask may be an option for the client if he or she is finding the facemask used with CPAP uncomfortable.

Which client has the most urgent need for frequent nursing assessment? 1- An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year, 2-pack-per-day smoking history and is receiving 50% oxygen through a Venturi mask 2- A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percentages in the upper 90s, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties 3- An older adult client who is eager to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy 4- A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

1 The older adult with a long history of smoking and chronic lung disease is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen; this client must be assessed frequently while receiving high-flow oxygen. The young client with no signs or symptoms of respiratory compromise, and the client who meets discharge criteria, do not require frequent assessment. Although the middle-aged client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the older client on higher-flow oxygen is at greater risk for respiratory demise and therefore needs frequent assessment more urgently.

A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? 1- Adjust the position of the oxygen tubing. 2- Assess for signs and symptoms of hypoventilation. 3- Change the O2 flow rate to keep SpO2 as prescribed. 4- Choose which O2 delivery device should be used for the client.

1 The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort. Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are beyond the scope of practice for unlicensed personnel.

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? 1- Colon cancer with metastasis to the liver 2- Hypertension 3- Hepatic encephalopathy 4- Ascites and shortness of breath

1 Transplantation is performed for hepatitis and primary (not secondary) liver cancers. Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation; they can be managed with diuretics and paracentesis.

The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? 1- A slice of 5-grain bread 2- Chuck steak patty (6 ounces) 3- Strawberries (1 cup) 4- Tomato (1 medium)

1 Whole-grain breads are recommended to be included in the diet of clients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat should be reduced in clients with diverticular disease. If the client wants to eat beef, it should be of a leaner cut. Foods containing seeds, such as strawberries, should be avoided. Tomatoes should be avoided unless the seeds are removed. The seeds may block diverticula in the client and present problems leading to diverticulitis.

An RN is admitting a client who has active TB. Which of the following isolation precautions should the RN implement? 1- Airbourne 2- Neutropenic 3- Contact 4- Droplet

1 because TB is a respiratory infection that is spread through the air. Pts should be placed in the negative (IN) pressure room. HCPs shouldn't enter the room without an N95 respiratory mask

An RN is developing a plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the RN include in the plan? 1- Measure the abdominal girth daily 2- Check mental status once daily 3- Provide daily intake of 4g of sodium for the client 4- Assess the client's breath sounds Q12H

1 - An RN should measure the client's girth and weight daily to monitor for the amount of fluid accumulation in the abdomen and the effectiveness of treatment measures.

An RN is providing DC teaching for a client who has peptic ulcer disease and a ew RX for famotidine. Which of the following statements by the client indicates an understanding of the teaching? 1- I should take this medication at bedtime 2- I should expect thus med to discolor my stools 3- I will drink iced tea with my meals and snacks 4- I will monitor my blood glucose levels regularly while taking this med

1 - The RN should instruct the client to take the med at bedtime to inhibit the action of histamine at the H2 receptor site in the stomach

An RN is assisting the MD who is performing a thoracentesis at the bedside of a pt. which of the following actions should the RN take? (SATA) 1- Wear googles/mask during procedure 2- Cleanse the procedure area w/ antiseptic solution 3- Instruct the pt to take a deep breath during the procedure 4- Position the client laterally on the affected side before the procedure 5- Apply pressure to the site after the procedure

1 - reduces the risk of exposure to pleural fluid 2 - Decreases the risk of infection for the pt 5 - Decreases risk of bleeding at the site

An RN is providing DC teaching for a client who has GERD. Which of the following statements by the client indicates an understanding of the teaching? 1- I will decrease the amount of carbonated beverages i drink 2- I will avoid drinking liquids for 30min after taking a chewable antacid tab 3- I will eat a snack before going to bed 4- I will lie down for at least 30 mins after eating each meal

1 - the RN should instruct the client that fatty foods, cofee, cola, tea, carbonated drinks, and chocolate should be minimized or eliminated from his diet as they can irritate the lining of the stomach.

A client has recently been released from prison and has just tested positive for tuberculosis (TB). What teaching points does the community health nurse want to stress for this client regarding medications? (SATA) 1- Not taking the medication could lead to an infection that is difficult to treat or to total drug resistance. 2- The medications may cause nausea. The client should take them at bedtime. 3- The client is generally not contagious after 2 to 3 consecutive weeks of treatment. 4- These medications must be taken for 2 years. 5- These medications may cause kidney failure.

1,2 Not taking the medication as prescribed could lead to an infection that is difficult to treat or to total drug resistance. The medications may cause nausea and are best taken at bedtime to prevent this. The client is generally not contagious after 2 to 3 weeks of consecutive treatment AND improvement in the condition has been observed.

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? (SATA) 1- Prolonged partial thromboplastin time 2- Icterus of skin 3- Swollen abdomen 4- Elevated magnesium 5- Currant jelly stool 6- Elevated amylase level

1,2,3 The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? (SATA.) 1- Check blood glucose often. 2- Check bowel sounds and stools. 3- Ensure that drainage color is clear. 4- Monitor mental status. 5- Place the client in the supine position.

1,2,4 Glucose should be checked often to monitor for diabetes mellitus. Bowels sounds and stools should be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage. Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis. The client should be placed in semi-Fowler's position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker require the nurse to intervene? (Select all that apply.) 1- Checking tube placement every 12 hours 2- Keeping the bed flat 3- Placing the client upright when taking sips of water 4- Providing mouth care every 8 hours 5- Securing the tube

1,2,4 The nasogastric tube should be checked every 4 to 8 hours. The head of the bed should be elevated at least 30 degrees. Oral hygiene should be provided every 2 to 4 hours. The client should be placed upright when taking sips or small amounts of water to prevent choking and to allow observation of the client for dysphagia. The tube should be secured to prevent dislodgment.

xA client with tuberculosis (TB) who is homeless and has been living in shelters for the past 6 months asks the nurse why he must take so many medications. What information will the nurse provide in answering this question? (SATA) 1- Combination drug therapy is effective in preventing transmission. 2- Combination drug therapy is the most effective method of treating TB. 3- Combination drug therapy will decrease the length of required treatment to 2 months. 4- Multiple drug regimens destroy organisms as quickly as possible. 5- The use of multiple drugs reduces the emergence of drug-resistant organisms.

1,2,4,5 Combination drug therapy is the most effective method for treating TB and preventing transmission. Multiple drug regimens are able to destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. Although combination drug therapy will decrease the required length of time for treatment, the length of treatment is decreased to 6 months from 6 to 12 months.

The nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? (SATA) 1- Broccoli 2- Buttermilk 3- Mushrooms 4- Onions 5- Peas 6- Yogurt

1,3,4,5 Broccoli, mushrooms, onions, and peas often cause flatus. Buttermilk will help prevent odors. Yogurt can help prevent flatus.

The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (SATA) 1- Acupuncture 2- Decreasing physical activities 3- Herbs (moxibustion) 4- Meditation 5- Peppermint oil capsules 6- Yoga

1,3,4,5,6 Acupuncture is recommended as a complementary therapy for IBS. Moxibustion is helpful for some clients with IBS. Meditation, yoga, and other relaxation techniques help many clients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination.

The RN is assessing a client who has appendicitis. Which of the following findings should the RN expect? (SATA) 1- Oral temp 38.4( 101.1F) 2- WBC 6,000/mm3 3- Bloody diarrhea 4- Nausea & Vomiting 5- RLQ pain

1,4,5 A low grade fever, N&V and RLQ pain are all expected findings for appendicitis

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (SATA.) 1- Esophageal varices 2- Hematuria 3- Fever 4- Ascites 5- Hemorrhoids

1,4,5 Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

An RN is caring for a client who has UC. The client has had several exacerbations over the past 3 yrs. Which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbation? (SATA) 1- Use progressive relaxation techs 2- Increase dietary fiber intake 3- Drink two 240mL glasses of milk per day 4- Arrange activities to allow for daily rest periods 5- Restrict intake of carbonated beverages

1,4,5 Relax techs help minimize stress which can precipitate an exacerbation. Daily rest periods decrease stress as well and reduce intestinal motility. Avoidance of GI stimulates such as carbonated beverages, nuts, peppers, and smoking are advised. A client should RESTRICT fiber intake which can cause diarrhea and cramping. Dairy products such as milk are poorly tolerated by clients with UC as well and should be avoided.

The nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the client to report to the health care provider? (SATA) 1- Anorexia 2- Depression 3- Drowsiness 4- Frequent urination 5- Headache 6- Vomiting

1,5,6 Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that should be reported to the health care provider. Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.

An emergency nurse is preparing to care for a client arriving by ambulance after a motor vehicle crash. The client has severe facial and neck injuries and emergency airway measures have been taken. Which type of airway does the nurse prepare for? 1- Cricothyroidotomy 2- Endotracheal intubation 3- Nasal bi-level positive airway pressure (BiPAP) 4- Tracheotomy

1- Cricothyroidotomy is an emergency procedure performed by emergency medical personnel to hold an airway open until a tracheotomy may be performed. Endotracheal intubation is not likely in a client with severe head and neck injuries. Nasal BiPAP depends on a patent upper airway. Tracheotomy is a surgical procedure, not a field procedure.

The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN? 1- Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road 2- Adult client who needs to be admitted for a grafting of a second-degree burn on the right leg 3- Middle-aged adult client who needs discharge teaching before going home after receiving steroids for Stevens-Johnson syndrome 4- Older adult client with stage I pressure ulcers who needs to be turned every 2 hours

1- An LPN/LVN would be familiar with wound monitoring for potentially contaminated wounds and would recognize the manifestations of infection.

When the nurse is assessing the skin of an older adult client, which of these findings will be most important to report to the health care provider? 1- A multicolored lesion is present on the client's thigh. 2- Liver spots are present on both hands. 3- Cherry hemangiomas are scattered on the client's back. 4- The skin on the extremities is paper-thin.

1- Color variation within a lesion is associated with skin cancer; the health care provider should be informed so that the lesion can be further assessed. Liver spots, cherry hemangiomas, and loss of skin elasticity are findings that are associated with aging and are normal for an older adult.

An RN is assessing a client who has emphysema. Which of the following findings should the RN report to the provider? 1- Rhonchi on inspiration 2- Elevated temp 3- Barrel-shaped chest 4- Diminished breath sounds

2 An elevated temp can indicate respiratory infection. Pts w/ emphysema are at risk for developing pneumonia and other infections.

Which nursing action is best for the charge nurse to delegate to an experienced LPN/LVN? 1- Retape the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy. 2- Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis. 3- Document instructions for a client with chronic gastritis about how to use "triple therapy." 4- Assess the gag reflex for a client who has arrived from the postanesthesia care unit after a laparoscopic gastrectomy.

2 Reinforcement of teaching done by the RN is within the scope of practice for an LPN/LVN. Retaping the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy is a complex task that should be done by the RN. Assessment and documenting instructions about how to use triple therapy are nursing functions that should be done by the RN.

The admission assessment for a client with acute gastric bleeding indicates blood pressure 82/40 mm Hg, pulse 124 beats/min, and respiratory rate 26 breaths/min. Which admission request does the nurse implement first? 1- Type and crossmatch for 4 units of packed red blood cells. 2- Infuse lactated Ringer's solution at 200 mL/hr. 3- Give pantoprazole (Protonix) 40 mg IV now and then daily. 4- Insert a nasogastric tube and connect to low intermittent suction.

2 The client's most immediate concern is the hypotension associated with volume loss. The most rapidly available volume expanders are crystalloids to treat hypovolemia. A type and crossmatch, administration of pantoprazole, and insertion of a nasogastric tube must all be done, but the nurse's immediate concern is correcting the client's hypovolemia.

The nurse is reviewing admitting requests for a client admitted to the intensive care unit with perforation of a duodenal ulcer. Which request does the nurse implement first? 1- Apply antiembolism stockings. 2- Place a nasogastric (NG) tube, and connect to suction. 3- Insert an indwelling catheter, and check output hourly. 4- Give famotidine (Pepcid) 20 mg IV every 12 hours.

2 To decrease spillage of duodenal contents into the peritoneum, NG suction should be rapidly initiated. This will minimize the risk for peritonitis. Antiembolism stockings will need to be applied, monitoring output is important, and famotidine (Pepcid) will need to be administered, but the nurse's first priority is to minimize the risk for peritonitis.

A malnourished client is being discharged on enteral nutrition products. Which suggestion from the registered dietitian does the nurse implement to make the enteral feeding experience more normal for the client? 1- Administering the feeding product on a regular schedule 2- Bringing the enteral product and napkin to the client on a tray 3- Emphasizing the need to take iron medications before the feeding 4- Once feeding is completed, putting equipment out of view

2 "Serving" the enteral product and napkin on a tray will help normalize the feeding experience for the client. Administering the product according to the prescribed schedule and putting equipment away after use will not necessarily normalize the client's experience. Although taking iron medications before the feeding may be helpful in preventing constipation, encouraging their use will do nothing to make the enteral feeding experience more normal for the client.

An older client presents to the emergency department with a 2-day history of cough, pain on inspiration, shortness of breath, and dyspnea. The client never had a pneumococcal vaccine. The client's chest x-ray shows density in both bases. The client has wheezing upon auscultation of both lungs. Would a bronchodilator be beneficial for this client? 1- It would not be beneficial for this client. 2- It would help decrease the bronchospasm. 3- It would clear up the density in the bases of the client's lungs. 4- It would decrease the client's pain on inspiration.

2 A bronchodilator would help decrease bronchospasm and would open up the airways, so it would be beneficial for this client. It would decrease dyspnea and feelings of shortness of breath.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? 1- Client with ascites who had a paracentesis 2 hours ago and is reporting a headache 2- Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse 3- Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL and thrombocytopenia 4- Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

2 A change in the level of consciousness (LOC) of the client with PSE is the greatest concern; actions to improve the client's LOC should be rapidly implemented. Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates a correct understanding of the nurse's instructions? 1 "I should take Ex-Lax after the surgery to 'keep things moving'." 2- "I will need to eat a diet high in fiber." 3- "Limiting my fluids will help me with constipation." 4- "To help with the pain, I'll apply ice to the surgical area."

2 A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. Stimulant laxatives are discouraged because they are habit-forming. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications; cold therapy is sometimes recommended and useful before surgery for inflamed hemorrhoids.

A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms? 1- Bacteria on the client's hands 2- Ingestion of parasites in the water 3- Insufficient vaccinations 4- Overcooked food

2 A main cause of gastroenteritis when traveling outside the country is ingestion of water that is infested with parasites. Bacteria on the client's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

A client diagnosed with irritable bowel syndrome (IBS) is discharged home with a variety of medications for IBS symptoms. Upon returning to the clinic, the client states, "Most of my symptoms have improved, except for the diarrhea." What does the nurse anticipate will be prescribed for this client? 1- Antidiarrheal agent 2- Muscarinic receptor antagonist 3- Serotonin antagonist 4- Tricyclic antidepressant

2 A muscarinic (M3) receptor antagonist can also inhibit intestinal motility. Antidiarrheal agents and serotonin antagonists are not the MOST effective choices for this client. A tricyclic antidepressant is not going to be effective for this client's diarrhea.

The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement? 1- Alphabet board 2- Picture board 3- Translator at the bedside 4- Word board

2 A picture board overcomes language barriers and can be used to communicate with clients who do not speak English well if a translator or a translation phone is not readily available. An alphabet board may or may not be useful if the client does not speak English; this is not the best answer, but may be an option depending on what is available at the facility. A translator at the bedside would be beneficial for the nurse to speak with the client, but not for the client to ask questions or communicate concerns to the nurse. Unless the nurse is able to read the language the client speaks, a word board would not be beneficial.

Which statement by a client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? 1- "I don't need to use my oxygen all the time." 2- "I don't need to get a flu shot." 3- "I need to eat more protein." 4- "It is normal to feel more tired than I used to."

2 An annual influenza vaccine (flu shot) is important for all clients with COPD. At the same time, a pneumonia vaccine could be offered, since pneumonia is one of the most common complications of COPD.

A client is being admitted for pneumonia. The sputum culture is positive for streptococcus, and the client asks about the length of the treatment. On what does the nurse base the answer? 1- The client will be treated for 5 to 7 days. 2- The client will require IV antibiotics for 7 to 10 days. 3- The client will complete 6 days of therapy. 4- The client must be afebrile for 24 hours.

2 Anti-infectives usually are used for 5 to 7 days in uncomplicated community-acquired pneumonia, and for up to 21 days in an immunocompromised client or one with hospital-acquired pneumonia. A client may become afebrile early in the course of treatment with anti-infective medications; this may cause many clients to fail to complete their course of treatment.

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? 1- "I hope I can learn esophageal speech." 2- "I will have to take special care not to aspirate while eating." 3- "I won't be able to breathe through my nose anymore." 4- "It is hard to believe that I will never hear my own voice again."

2 Aspiration cannot occur after a total laryngectomy because the airway is completely separated from the esophagus. The client will not be able to breathe through the nose. The client will be able to vocalize after working with a speech/language pathologist if he or she chooses; however, the voice will sound different than the client is used to. Esophageal or mechanical speech will permit the client to speak, but the voice will not sound like his or her own.

A male client in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? 1- Assessing the client's incision for signs of infection 2- Assisting the client to stand to void 3- Instructing the client in how to deep-breathe 4- Monitoring the client's pain level

2 Assisting the client with activities is part of the UAP role. Assessment of the client's incision and pain level requires broader education and scope of practice and should be done by licensed nursing personnel. Client teaching—even about something as fundamental as taking "deep breaths"—likewise requires broader education and scope of practice and should be done by licensed nursing personnel.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? 1- Auscultate the client's breath sounds while applying a nasal cannula. 2- Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. 3- Apply a 100% non-rebreather mask while administering high-flow oxygen. 4- Replace the obturator while reinserting the tracheostomy tube.

2 Because a fresh tracheostomy stoma will collapse, the client will lose airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to recannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client. Auscultation of the client's breath sounds at this time will not improve the client's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.

Which client does the medical-surgical unit charge nurse assign to an LPN/LVN? 1- A 41-year-old who needs assistance with choosing a site for a colostomy stoma 2- A 47-year-old who needs to receive "whole gut" lavage before a colon resection 3- A 51-year-old who has recently arrived on the unit after having an open herniorrhaphy 4- A 56-year-old who has obstipation and a recent emesis of foul-smelling liquid

2 Because administration of medications is within the LPN/LVN scope of practice, this preoperative client can be assigned to the LPN/LVN. Assistance with choosing a site for a colostomy stoma is an intervention that should be provided by an RN. The recent postoperative client and the critically ill client will need assessments and interventions that can only be done by an RN.

The nurse suspects that which client is at highest risk for developing gallstones? 1- Obese male with a history of chronic obstructive pulmonary disease 2- Obese female on hormone replacement therapy 3- Thin male with a history of coronary artery bypass grafting 4- Thin female who has recently given birth

2 Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.

An RN is caring for a client who is in respiratory distress and requires endotrachial suctioning. Which of the following actions should the RN take? 1- Use clean technique when suctioning the client's ET Tube 2- Use a rotating motion when removing the suction cath 3- Suction the oropharyngeal cavity prior to suctioning the ET tube 4- Suction the pt's ET tube Q2H

2 By rotating the suction cath while withdrawing, the RN reduces the risk of tissue trauma Sterile tech should be used. The ET tube should be suctioned, THEN the oropharyngeal cavity ONLY suction when needed

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? 1- Decrease in liver function test results 2- Elevated carcinoembryonic antigen 3- Elevated hemoglobin levels 4- Negative test for occult blood

2 Carcinoembryonic antigen may be elevated in many clients diagnosed with CRC. Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC.

A client has a primary problem of inadequate nutrition caused by the effects of chemotherapy. The client is receiving continuous enteral feedings through a nasogastric (NG) tube. What does the RN ask the LPN/LVN to do for this client? 1- Assess nutritional parameters on the client every 3 days. 2- Check the residual volume of the NG tube every 4 hours. 3- Monitor the client for signs and symptoms of pneumonia. 4- Teach the client about the purpose of enteral feedings.

2 Checking the residual volume of the client's NG tube every 4 hours is within the scope of knowledge and practice for the LPN/LVN. Assessing nutritional parameters on the client, monitoring the client for signs and symptoms of pneumonia, and teaching the client about the purpose of enteral feedings are complex and require broad knowledge about the physiology associated with malnutrition and possible complications of tube feedings. These activities should be performed by an RN.

A client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)? 1- Abdominal pain relieved by bending the knees 2- Chronic diarrhea, abdominal pain, and fever 3- Epigastric cramping 4- Hypotension with vomiting

2 Chronic diarrhea, abdominal pain, and fever are symptoms more indicative of CD than of other acute inflammatory bowel disorders. Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the client to do in the meantime? 1- "Avoid all solid foods to allow complete bowel rest." 2- "Consume extra fluids to replace fluid losses." 3- "Take an over-the-counter antidiarrheal medication." 4- "Contact your provider for an antibiotic medication."

2 Clients should be taught to drink extra fluids to replace fluid lost through vomiting and diarrhea. It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? 1- Complete the referral form for a home health agency. 2- Suction the tracheostomy using sterile technique. 3- Teach the client and spouse about tracheostomy care. 4- Consult with the health care provider about using a fenestrated tube.

2 Complex sterile procedures are within the education and scope of practice of the experienced LPN/LVN. Completion of client referral forms, client and family teaching, and consulting with the health care provider are all actions that must be performed by an RN.

An RN is assessing a client who has a chest tube in place following thoracic sx. For which of the following findings should the RN notify the provider? 1- Fluctuation in drainage in the tubing with inspiration 2- Continuous bubbling in the water seal chamber 3- Drainage of 75mL in the 1st hr of sx 4- Several small dark red blood clots in the tubing

2 Continuous bubbling suggests an air leak and requires notification of the provider.

A client is receiving nutritional supplements to restore nutritional status. What does the nurse do to assess the effectiveness of the supplements for the client? 1- Keeps an accurate and precise food and fluid intake record daily 2- Makes certain the client is weighed daily at the same time 3- Monitors vital signs every 4 hours and as needed 4- Assesses the client's skin for evidence of breakdown weekly

2 Daily weigh-ins will best show the effects of nutritional supplements by showing how much weight the client is regaining. Although it is important to identify everything that the client is taking in orally, monitor vital signs, and assess for any evidence of skin breakdown, these assessments do not help determine the effects of nutritional supplements on the client.

In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider? 1- Increased blood pressure, increased respiratory rate 2- Decreased blood pressure, increased heart rate 3- Increased respiratory rate, increased apical pulse, pallor 4- Tachypnea, diaphoresis, increased blood pressure

2 Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.

The RN on the medical-surgical unit receives a shift report about four clients. Which client does the nurse assess first? 1- A 34-year-old who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink 2- A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern 3- A 40-year-old with pneumonia who has abdominal distention and decreased bowel sounds in all quadrants 4- A 51-year-old with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy

2 Ecchymoses in the abdominal area may indicate intraperitoneal or intra-abdominal bleeding; this client requires rapid assessment and interventions. The client who is post colon resection, the client with pneumonia, and the client with FAP do not have an urgent need for further assessment or intervention.

The client says, "I hate this stupid COPD." What is the best response by the nurse? 1- "Then you need to stop smoking." 2- "What is bothering you?" 3- "Why do you feel this way?" 4- "You will get used to it."

2 Encourage the client, and the family, to express their feelings about limitations on their lifestyle and about disease progression. This is not the time to lecture the client regarding his smoking habits; the client is expressing a need for support. "Why" questions can seem accusatory and may make a client less likely to talk about what he or she is feeling. The client's feelings should never be minimized.

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test? 1- "During the test, you will drink small amounts of an antacid as directed by the technician." 2- "If you have IBS, hydrogen levels may be increased in your breath samples." 3- "The test will take between 30 and 45 minutes to complete." 4- "You must have nothing to drink (except water) for 24 hours before the test."

2 Excess hydrogen levels are produced in clients with IBS. This is due to bacterial overgrowth in the small intestine that accompanies the disease. The hydrogen travels to the lungs to be excreted. The client will ingest small amounts of sugar during the test, not an antacid. The test takes longer than 45 minutes. The client has breath samples taken every 15 minutes for 1 to 2 hours. The client needs to be NPO (except for water) for 12 hours before the test.

A client with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The client asks the nurse how this is helpful for improving symptoms. How does the nurse reply? 1- "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." 2- "It provides key nutrients and extra calories to promote healing." 3- "It is bland and reduces the secretion of gastric acids." 4- "It does not contain caffeine or other GI tract stimulants."

2 For less severe exacerbations, an elemental or semi-elemental product such as Vivonex PLUS may be prescribed to induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest. Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol should be avoided, but this is not the reason for using Vivonex PLUS.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? 1- Clients with CD experience about 20 loose, bloody stools daily. 2- Clients with UC may experience hemorrhage. 3- The peak incidence of UC is between 15 and 40 years of age. 4- Very few complications are associated with CD.

2 Hemorrhage is commonly experienced by clients with UC. Five to six stools daily is common with CD. T he peak incidences of UC are between 15 to 25 and 55 to 65 years of age. Fistulas commonly occur as a complication of CD.

A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these health care provider requests are received. Which action will the nurse take first? 1- Give oxygen to keep O2 saturation greater than 93%. 2- Immobilize the neck with a cervical collar. 3- Infuse normal saline by large-bore IV catheter. 4- Obtain computed tomography (CT) scan of head, neck, and chest.

2 If the cervical spine has not already been stabilized by emergency medical services, this is the nurse's top priority. The neck should be held in place manually until a properly fitted cervical collar can be applied. Innervation of the diaphragm is between cervical spine levels C3 and C5. Oxygen administration is important; however, this is not the nurse's first priority and is considered separate from establishing an airway. Two large-bore (16- or 18-gauge) IV catheter lines should be established, and an isotonic fluid such as normal saline should be infused at a rate determined by the client's condition and vital signs. CT scans are not the top priority and should be based on the client's reported problems and condition.

A client admitted with severe gastroenteritis has been started on an IV, but the client continues having excessive diarrhea. Which medication does the nurse ask the health care provider about prescribing? 1- Balsalazide (Colazal) 2- Loperamide (Imodium) 3- Mesalamine (Asacol) 4- Milk of Magnesia (MOM)

2 If the health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily. Balsalazide is not the BEST choice for control of diarrhea in this scenario. Mesalamine is used for clients with ulcerative colitis for long-term therapy. MOM is a laxative.

A certified Wound, Ostomy, and Continence Nurse is teaching a client about caring for a new ileostomy. What information is most important to include? 1- "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." 2- "Call the health care provider if your stoma has a bluish or pale look." 3- "Notify the health care provider if output from your stoma has a sweetish odor." 4- "Remember that you must wear a pouch system at all times."

2 If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the health care provider must be notified immediately. It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the client will be required to wear a pouch system at all times, this is not the highest priority for instruction.

The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery? 1- Educate the client about ways to avoid aspiration when swallowing after the surgery. 2- Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. 3- Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. 4- Teach the client and significant others about how to suction and do wound care of the stoma.

2 In the immediate postoperative period, relieving pain and anxiety is going to be a major priority. Because the client will be unable to communicate verbally, establishing a way to communicate before the surgery will help by having a plan in place. Aspiration is not a risk after a total laryngectomy because no connection is present between the mouth and the respiratory system. It will be several weeks before the client will need to address appropriate clothing; overloading the client with too much information before surgery is unnecessary. Suctioning and wound care is discharge teaching that can be started after the surgery, when the client and significant others are more likely to retain the information owing to decreased preoperative anxiety. The significant others can observe the care and then can begin to take over more of the care while the client is still in the hospital in a supervised environment.

A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority instruction for this client to avoid further attacks of pancreatitis? 1- "You may need a surgical consult for removal of your gallbladder." 2- "See your health care provider immediately when experiencing symptoms of a gallbladder attack." 3- "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." 4- "You'll need to drastically modify your alcohol intake."

2 In this case, the client's pancreatitis was likely triggered by the development of gallstones. A diagnostic statement must come from the provider. Also, the client may not require removal of the gallbladder. 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.

A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching? 1- "A drink of diet soda with dinner is OK for me." 2- "I need to go for a walk every evening." 3- "Maintaining a low-fiber diet will manage my constipation." 4- "Watching the amount of fluid that I drink with meals is very important."

2 Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages. Caffeinated beverages can cause bloating or diarrhea and should be avoided in clients with IBS. Fiber is encouraged in clients with IBS because it produces a bulky soft stool and aids in establishing regular bowel habits. At least 8 to 10 cups of fluid should be consumed daily to promote normal bowel function.

Which activity by the nurse will best relieve symptoms associated with ascites? 1- Administering oxygen 2- Elevating the head of the bed 3- Monitoring serum albumin levels 4- Administering intravenous fluids

2 The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation.

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? 1- "Maybe you should find a support group to join." 2- "Would you like me to contact the hospital chaplain for you?" 3- "Do you want me to try to find a therapist for you?" 4- "Do you have any friends whom you want me to call?"

2 It is appropriate for the nurse to suggest contacting the hospital chaplain as a counseling option for the client and family. 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.

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? 1- Preventing hypotension 2- Keeping the T-tube in a dependent position 3- Administering antibiotic vaccinations 4- Administering immune-suppressant drugs

2 Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccinations will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.

When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? 1- Clients who work with shellfish 2- Men who prefer sex with men 3- Clients traveling to a third-world country 4- Clients with elevations of aspartate aminotransferase and alanine aminotransferase

2 Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

A client is admitted with severe viral gastroenteritis caused by norovirus. The client asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? 1- "You may have contracted it from an infected infant." 2- "You may have consumed contaminated food or water." 3- "You may have come into contact with an infected animal." 4- "You may have had contact with the blood of an infected person."

2 Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne. Campylobacter can be transmitted by contact with infected infants or animals. Escherichia coli may be spread via animals and contaminated food, water, or fomites. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

A client with pneumonia caused by aspiration after alcohol intoxication has just been admitted. The client is febrile and agitated. Which health care provider order should the nurse implement first? 1- Administer levofloxacin (Levaquin) 500 mg IV. 2- Draw aerobic and anaerobic blood cultures. 3- Give lorazepam (Ativan) as needed for agitation. 4- Refer to social worker for alcohol counseling.

2 Obtaining aerobic and anaerobic cultures is the first action the nurse should perform and is standard procedure in a febrile client for whom antibiotics have been requested. Levofloxacin, an antibiotic, is important to administer, but blood cultures should be drawn before antibiotics are started.

Which symptom of pneumonia may present differently in the older adult than in the younger adult? 1- Crackles on auscultation 2- Fever 3- Headache 4- Wheezing

2 Older adults may not have fever and may have a lower-than-normal temperature with pneumonia.

What does the nurse do first when setting up a safe environment for the new client on oxygen? 1- Ensures that staff members wear protective clothing 2- Ensures that no combustion hazards are present in the room 3- Sets the oxygen delivery to maintain no fewer than 16 breaths/min 4- Uses a pulse oximetry unit

2 Oxygen is highly flammable. The nurse must ensure that no open flames or combustion hazards are present in a room where oxygen is in use.

A client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? 1- Increasing carbon dioxide levels 2- Decreasing respiratory rate 3- Increasing adventitious breath sounds 4- Increased coughing

2 Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive. The COPD client is not sensitive to PaCO2; oxygen administration can cause high PaO2 levels. Monitoring for adventitious breath sounds is important, but these would not be a result of the oxygen that the client is receiving. The ability to cough and breathe deeply is a positive sign.

The nurse is teaching a client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques? 1- Hair loss 2- Increased risk for sunburn 3- Loss of appetite 4- Pain at site of treatment

2 Skin in the path of radiation is more sensitive to sun damage; therefore, clients must avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed.

A client has been diagnosed with asthma. Which statement below indicates that the client correctly understands how to use an inhaler with a spacer? 1- "I don't have to wait between the two puffs if I use a spacer." 2- "If the spacer makes a whistling sound, I am breathing in too rapidly." 3- "I should rinse my mouth and then swallow the water to get all of the medicine." 4- "I should shake the inhaler only if I want to see whether it is empty."

2 Slow and deep breaths ensure that the medication is reaching deeply into the lungs. The whistling noise serves as a reminder to the client of which technique needs to be used. The client must wait 1 minute between puffs. The client should rinse the mouth but not swallow the water. Shaking an inhaler helps ensure that the same dose is delivered in each puff.

A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? 1- "But you know you need this to breathe, right?" 2- "Do you have a scarf or a large loose collar that you could place over it?" 3- "Your family and friends probably won't even care." 4- "It won't take you long to learn to manage."

2 Suggesting strategies to cover the tracheostomy recognizes client concerns and explores options for dealing with the effects of the procedure. Reiterating the reason for the tracheostomy, suggesting that the client's loved ones won't care, and telling the client that he or she will learn to live with the tracheostomy are insensitive responses and minimize the client's concerns.

A client with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? 1- Asks the client whether family members could be trained in stoma care 2- Has another client with a stoma who performs self-care talk with the client 3- Requests that the health care provider request antidepressants and a psychiatric consult 4- Suggests that the health care provider request a home health consultation so stoma care can be performed by a home health nurse

2 Talking with another client who successfully cares for his or her stoma may give the client the confidence to begin his or her self-care. If at all possible, the client should perform stoma care so that he or she can be as independent as possible. Although the client may need medication for depression, the priority is to encourage the client to look at, touch, and begin caring for the stoma. A home health nurse can be a support, but cannot provide all of the care that the client will need.

1. Which of these clients should the charge nurse assign to the LPN/LVN working on the medical-surgical unit? 1- Client with group A beta-hemolytic streptococcal pharyngitis who has stridor 2- Client with pulmonary tuberculosis who is receiving multiple medications 3- Client with sinusitis who has just arrived after having endoscopic sinus surgery 4- Client with tonsillitis who has a thick-sounding voice and difficulty swallowing

2 The LPN/LVN scope of practice includes medication administration, so a client receiving multiple medications can be managed appropriately by an LPN/LVN. Stridor is an indication of respiratory distress; this client needs to be managed by the RN. A client in the immediate postoperative period requires frequent assessments by the RN to watch for deterioration. A client with a thick-sounding voice and difficulty swallowing is at risk for deterioration and needs careful assessment and monitoring by the RN.

Which client does the charge nurse assign to an experienced LPN/LVN? 1- A 28-year-old who requires teaching about how to catheterize a Kock ileostomy 2- A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy 3- A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 4- A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

2 The LPN/LVN should be familiar with the purpose, adverse effects, and client teaching required for neomycin. Teaching about how to catheterize a Kock ileostomy, assessing the client with UC with a high white blood cell count, and monitoring the client with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

The change-of-shift report has just been completed on the medical-surgical unit. Which client will the oncoming nurse plan to assess first? 1- Client with chronic obstructive pulmonary disease (COPD) who is ready for discharge, but is not able to pay for prescribed home medications. 2- Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38 breaths/min. 3- Hospice client with terminal pulmonary fibrosis and an oxygen saturation level of 89%. 4- Client with lung cancer who needs an IV antibiotic administered before going to surgery.

2 The client with CF with an elevated temperature and respiratory rate is exhibiting signs of an exacerbation and needs to be assessed first. An oxygen saturation of 89% may be normal for a hospice client with terminal pulmonary fibrosis; not enough information is provided to determine whether this client is in distress.

The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? 1- Client with hepatitis A reporting severe and ongoing itching 2- Client with severe ascites who has a temperature of 101.4° F (38° C) 3- Client with cirrhosis who has had a 3-pound weight gain over 2 days 4- Client with esophageal varices and mild right upper quadrant pain

2 The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.

An older adult with severe rheumatoid arthritis in the upper extremities is malnourished. What does the nurse suspect as the cause for this client's malnutrition? 1- A decrease in the client's appetite 2- Decreasing ability to manipulate eating utensils 3- Inadequate income to purchase sufficient food 4- Metabolic requirements that are increased owing to immobility

2 The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils. No evidence suggests that the client is experiencing a decrease in appetite or is financially unable to purchase adequate food. No evidence suggests that the client is immobile because of osteoarthritis in the extremities; metabolic requirements would decrease with less mobility.

The nurse expects that which client will be discharged to the home environment first? 1- Older obese adult who has had a laparoscopic cholecystectomy 2- Middle-aged thin adult who has had a laparoscopic cholecystectomy 3- Middle-aged thin adult with a heart murmur who has had a traditional cholecystectomy 4- Older obese adult with chronic obstructive pulmonary disease (COPD) who has had a traditional cholecystectomy

2 The combination of client age, a thin frame, and the type of procedure performed will determine that the middle-aged thin client who had a laparoscopic cholecystectomy will be discharged first. Although the older obese client who had a laparoscopic cholecystectomy will have a faster discharge time than one with a traditional 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.

What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? 1- Keep the mouth moist during treatments 2- Keep the teeth from turning yellow after treatment 3- Prevent radiation scatter when the beam hits metal in the mouth 4- Protect the taste buds on the tongue

2 The gel trays help prevent radiation scatter when the beam hits metal in the mouth. They will not provide additional moisture to the mouth. Gel trays with fluoride are not used to prevent yellowing; fluoride is used to prevent demineralization and to help with uptake of calcium and phosphate ions by the teeth. Gel trays fit over the teeth and do not protect the taste buds on the tongue.

A 67-year-old male client reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? 1- Femoral 2- Reducible 3- Strangulated 4- Ventral

2 The hernia is reducible because its contents can be pushed back into the abdominal cavity. Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. It cannot be a ventral hernia because it would have to occur at the site of a previous surgical incision.

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? 1- "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." 2- "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." 3- "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." 4- "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

2 The most effective way to manage diverticulitis is with a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. Neither an exclusively low-fiber diet or an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

The nurse is teaching a group of adults in the community about the 2010 Dietary Guidelines for Americans. What does the nurse include with respect to the consumption of alcohol? 1- Men should limit their drinking to 1 drink per day. 2- Men may have 2 drinks every day. 3- Older adults should have only 1 drink each week. 4- Women should be limited to 2 drinks a day.

2 The most recent guidelines in 2010 emphasize the need to include preferences of specific racial/ethnic groups, vegetarians, and other populations when selecting foods to maintain a healthful diet that is balanced with moderation and variety. If alcohol is consumed, it should be limited to 1 drink per day for women and 2 drinks per day for men.

An RN is caring for a pt who is in respiratory distress. Which of the following low flow delivery devices should the RN use to provide the client with the highest level of O2? 1- Nasal Cannula 2- Nonrebreather mask 3- Simple Face Mask 4- Partial ReBreather mask

2 The nonrebreather is able to deliver greater than 90% FiO2. A partial rebreather delivers between 60-75 A simple face mask between 40-60 a N/C between 24-44

Which serum albumin level does the nurse expect to see in a healthy, ambulatory adult client? 1- 2.3 g/dL 2- 3.7 g/dL 3- 5.1 g/dL 4- 5.8 g/dL

2 The normal serum albumin level for men and women is 3.5 to 5.0 g/dL. A level of 2.3 g/dL is considered extremely low. Levels of 5.1 g/dL and 5.8 g/dL would be considered high.

A client is being discharged home with active tuberculosis. Which information does the nurse include in the discharge teaching plan? 1- "You are not contagious unless you stop taking your medication." 2- "You will not be contagious to the people you have been living with." 3- "You will have to take these medications for at least 1 year." 4- "Your sputum may turn a rust color as your condition gets better."

2 The people the client has been living with have already been exposed and need to be tested. They cannot be re-exposed simply because the diagnosis has now been confirmed. The client with active tuberculosis is contagious, even while taking medication. The length of time for treatment is 6 months. Fluid from the pulmonary capillaries and red blood cells moving into the alveoli is a result of the inflammatory process. Rust-colored sputum is an indication that the tuberculosis is getting worse.

Which method is the best way to prevent outbreaks of pandemic influenza? 1- Avoiding public gatherings at all times 2- Early recognition and quarantine 3- Vaccinating everyone with pneumonia vaccine 4- Widespread distribution of antiviral drugs

2 The recommended approach to disease prevention consists of early recognition of new cases and implementing community and personal quarantine to reduce exposure to the virus. When a cluster of cases is discovered in an area, the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed to help reduce the severity of the infection and to decrease mortality.

The RN receives a change-of-shift report about four clients. Which client does the nurse assess first? 1 A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift 2- A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F 3- A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it 4- A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

2 This client with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed. The client with UC who had six liquid stools, the client whose colostomy bag does not have any stool in it, and the client who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications.

The RN is caring for a newly admitted client who has emphysema. The RN should place the pt in which of the following position to promote effective breathing? 1- Lateral w/ pillow at back and over the chest to support the arm 2- High Fowler's w/ the arms supported on the over bed table 3- Semi-Fowler's w/ pillows supporting both arms 4- Supine w/ HOB elevated to 15 degrees

2 This position allows for greater expansion of the chest, such as sitting upright and slightly leaned forward (tripodding)

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? 1- Having a larger meal early in the morning 2- Consuming increased carbohydrates and moderate protein 3- Restricting fluids to 1500 mL/day 4- Limiting alcoholic beverages to once weekly 14.

2 To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. The client with hepatitis feels full easily and should have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

An RN is assessing a client who is 4 hrs PostOp following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the MD? 1- Bleeding at the surgical site 2- Decreased SpO2 3- Urinary retention 4- Increased pain level

2 Using the ABC approach to client care, the nurse should identify decreased O2 sat is a priority finding. people having this surgery are at higher risk for hypoxia d/t airway obstruction

An RN in a provider's ofc is assessing a pt who has COPD. Which of the following findings is a priority for the RN to report to the MD? 1- Increased AP chest diameter 2- Productive cough w/ green sputum 3- Clubbing of the fingers 4- Pursed lip breathing w/ exertion

2 Using the Urgent VS Non Urgent approach to care, the RB should report this finding because it can indicate infection. All the others are expected findings in patients with COPD

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure? 1-"I may have trouble urinating immediately after the surgery." 2-"I will need to stay in the hospital overnight." 3-"I should not eat after midnight the day of the surgery." 4-"My chances of having complications after this procedure are slim."

2 Usually, the client is discharged 3 to 5 hours after MIIHR surgery. Male clients who have difficulty urinating after the procedure should be encouraged to force fluids and to assume a natural position when voiding. Clients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most clients who have MIIHR surgery have an uneventful recovery.

An RN is providing DC instructions for a client who has a new Rx for meds to treat Peptic Ulcer Disease. The RN should identify which of the following meds inhibits gastric acid secretion? 1- Ca+ cabonate 2- famotidine 3- Al hydroxide 4- Sucralfate

2 - Famotidine is an H2 receptor antagonist that is prescribed for the treatment of PUD to inhibit secretion of gastric acid.

An RN is reviewing the Rxs for a client who has Campylobacter enteritis. Which of the following Rxs should the RN clarify with the provider? 1- 0.45% NaCl IV 2- Mg hydroxide 3- Ciproflaxin 4- K+

2 - N/V/D are manifestations of gastroenteritis. The RN should clarify the Rx for Mg Hydroxide (milk of Mag) which increased GI motility and can increase the client's risk for electrolyte imbalance and contribute to dehydration.

An RN is reviewing the lab results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? 1- Blood glucose 110 2- Increased serum amylase 3- WBC 9,000 4- Decreased bilirubin

2 - Serum amylase levels are increased in a client who has acute pancreatitis due to cell injury

An RN is providing dietary teaching for a client who is post-op following a gastrectomy. Which of the following foods should the RN encourage the client to include in her diet to prevent dumping syndrome? 1- Ice cream 2- Eggs 3- Grape juice 4- Honey

2 - The RN should instruct the client to increase dietary intake of PROTEIN CONTAINING FOODS such as eggs, to decrease the risk of manifestations of dumping syndrome.

An RN is caring for a client who has colorectal cancer and is receiving chemotherapy. The client asks the RN whi his blood is being drawn for a CEA level. Which of the following responses should the nurse make? 1- The CEA determines the current stage of your colon cancer 2- The CEA determines the efficacy of your chemo 3- The CEA determines if the neutrophil count is below the expected ref range 4- The CEA determines if you are experiencing occult bleeding from the GI tract

2 - The provider uses the CEA level to determine is the CHEMO is being effective.

An RN is providing teaching for a client who has cirrhosis and a new Rx for lactulose. The RN should include which of the following instructions in the teaching? 1- Notify the provider if bloating occurs 2- Expect to have 2-3 soft stools per day 3- Restrict carbs in the diet 4- Limit oral fluid intake to 1,000mL per day of clear liquids

2 - The purpose of lactulose is to promote excretion of ammonia in the stool. The nurse should instruct the pt to take the medication every day and inform the client that 2-3 BMs every day is the treatment goal

An obese client has been taking orlistat (Xenical) 60 mg orally three times a day for 4 weeks, but has only lost 10 pounds. The health care provider doubles the dosage and recommends behavioral changes. What behavioral changes does the nurse include in the teaching plan? (SATA) 1- Cognitive restructuring to learn negative coping statements 2- Keeping a daily food diary 3- Identifying emotional and situational factors that stimulate eating 4- Increasing exercise 5- Seeking behaviors in others that one can model

2,3,4 Self-monitoring techniques include keeping a record of foods eaten (food diary), exercise patterns, and emotional and situational factors. Stimulus control involves controlling the external cues that promote overeating. Cognitive restructuring involves modifying negative beliefs by learning positive coping self-statements. Healthy eating behaviors must be learned or modified by the client as an individual; copying or modeling others' behaviors does not change the client's way of coping.

The nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? (SATA) 1- "Begin a weight-training program for building muscle mass." 2- "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." 3- "Eat a variety of foods, especially grain products, vegetables, and fruits." 4- "Engage in moderate physical activity for at least 30 minutes each day." 5- "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." 6- "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight."

2,3,4,5 Consuming a diet that is moderate in salt and sugar and low in fats and cholesterol, and moderate physical activity for at least 30 minutes each day are smart strategies for a person who wants to lose weight. Eating a variety of foods, especially grain products, vegetables, and fruits, helps people achieve weight loss. These are foods that "burn" more calories as they are metabolized. Many foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home.

A client is diagnosed with irritable bowel syndrome (IBS). What factors does the nurse suspect as possible causes of the client's problem? (SATA) 1- Antihistamines 2- Caffeinated drinks 3- Stress 4- Sleeping pills 5- Anxiety

2,3,5 Factors such as ingestion of coffee or other gastric stimulants, stress, anxiety, and milk allergy are being investigated as possible causes of IBS. Antihistamines and sleeping pills are not suspected as causing IBS.

A client with colorectal cancer was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to the treatment regimen. What does the nurse tell the client about the diarrhea and mouth ulcers? 1- "A combination of chemotherapeutic agents has caused them." 2- "GI problems are symptoms of the advanced stage of your disease." 3- "5-FU cannot discriminate between your cancer and your healthy cells." 4- "You have these as a result of the radiation treatment."

3 5-FU cannot discriminate between cancer and healthy cells; therefore, the side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and skin ulcers. The 5-FU treatment, not a combination of chemotherapy drugs, radiation, or the stage of the disease, is what is causing the client's GI problems.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? 1- Hemoglobin of 22 g/dL 2- PaCO2 of 30 mm Hg 3- PaO2 of 65 mm Hg 4- Oxygen saturation of 88%

3 A PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is considered hypoxemia. Hemoglobin measures oxygen-carrying capacity. PaCO2 of 30 mm Hg indicates low carbon dioxide levels in the blood. Oxygen saturation measures tissue perfusion.

The medical-surgical unit has one negative-airflow room. Which of these four clients who have just arrived on the unit should the charge nurse admit to this room? 1- Client with bacterial pneumonia and a cough productive of green sputum 2- Client with neutropenia and pneumonia caused by Candida albicans 3- Client with possible pulmonary tuberculosis who currently has hemoptysis 4- Client with right empyema who has a chest tube and a fever of 103.2° F

3 A client with possible tuberculosis should be admitted to the negative-airflow room to prevent airborne transmission of tuberculosis. A client with bacterial pneumonia does not require a negative-airflow room but should be placed in Droplet Precautions. A client with neutropenia should be in a room with positive airflow. The client with a right empyema who also has a chest tube and a fever should be placed in Contact Precautions but does not require a negative-airflow room.

An RN is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? 1- Extra drainage system 2- Suture removal kit 3- Container of sterile water 4- Non adherent pads

3 A container of sterile water is necessary in case tubing becomes disconnected in order to place the open end of the tubing into the container and prevent a pneumothorax

An RN is caring for a client who is 1Hr post-op following a thoracentesis. Which of the following is a priority assessment finding? 1- Pallor 2- Insertion site pain 3- Persistent cough 4- Temp 37.3 (99.1)

3 A persistent cough can indicate a tension pneumothorax which is a medical emergency

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? 1- Computer keyboard 2- Magic Slate 3- Picture board 4- Pen and paper

3 A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable. A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a client with degenerative arthritis.

An RN is providing DC teaching to a client who has pulmonary TB and a new RX for rifampin. Which of the following instructions should the nurse include? 1- Ringing in the ears is an adverse s/e of this medication 2- Have your skin test repeated in 4 months to show a positive result 3- Expect your urine and other secretions to be orange while taking this med 4- Remember to take this med w/ a sip of H2O just before your first bite of food

3 Additionally, the med is hepatotoxic so the nurse should also mention the pt needs to notify the MD if they experience jaundice, fatigue, or malaise which are manifestations of hepatitis.

After an automobile crash, a client is admitted to the emergency department with possible abdominal trauma. Which health care provider request does the nurse implement first? 1- Insert a nasogastric tube and connect it to intermittent suction. 2- Obtain a complete blood count and coagulation panel. 3- Start an IV line and infuse normal saline at 200 mL/hr. 4- Arrange for a computed tomography (CT) scan of the abdomen.

3 After the initial airway, breathing, and circulation assessment is completed, the most immediate concerns are the high risks for hemorrhage and shock. To rapidly treat for these possible complications, IV access and infusion of fluids are necessary as the priority intervention. Inserting a nasogastric tube, laboratory studies, and arranging a CT scan are secondary to establishing IV access and instilling fluids.

The nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? 1- "One to two hours of cardiovascular exercise every day is a good idea." 2- "Joining a fitness program or gym will help greatly with your exercise." 3- "Walking 30 minutes provides the same benefit as long periods of exercise." 4- "You will benefit most if you get into a group that shares your exercise goals."

3 Although some people think that regular exercise has to include joining a fitness program or exercising for long periods of time, simple forms of exercise like walking 30 minutes provide the same type of benefit. A 30-minute walk can be accomplished with a group (such as "mall walking") or alone.

An RN is caring for a client who is receiving mechanical ventilation which the low pressure alarm sounds. Which of the following situations should the RN recognize as a possible cause of the alarm? 1- Excess secretions 2- Kinks in the tubing 3- Artificial airway cuff leak 4- Biting on the ET tube

3 An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound All the others would cause the high pressure sound to alarm!

An RN is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the RN expect? 1- Decreased fremitus 2- SpO2 95% on room air 3- Temp 38.8C (101.8) 4- Bradypnea

3 An elevated temp is an expected finding for a pt with bacterial pneumonia You'd also expect to find : Increased fremitus, SpO2 lower than 95% and tachypnea

The nurse is assessing a client's alcohol intake to determine whether it is the underlying cause of the client's attacks of pancreatitis. Which question does the nurse ask to elicit this information? 1- "Do you usually binge drink?" 2- "Do you tend to drink more on holidays or weekends?" 3- "Tell me more about your alcohol intake." 4- "Estimate how many episodes of binge drinking you do in a week."

3 Asking the client about his or her alcohol intake is the only way that will allow the client to provide information in the client's own words and to the extent that the client wishes to provide it. Asking the client if he or she binge drinks or tends 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.

A client with colorectal cancer is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this client? 1- "Are you afraid of what your spouse will think of the colostomy?" 2- "Don't worry. You will get used to the colostomy eventually." 3- "Tell me what worries you the most about this procedure." 4- "Why are you so afraid of having this procedure done?"

3 Asking the client about what worries him or her is the only question that allows the client to express fears and anxieties about the diagnosis and treatment. Asking the client if he or she is afraid is a closed question (i.e., it requires only a "yes" or "no" response); it closes the dialogue and is not therapeutic. Telling the client not to worry offers reassurance and is a "pat" statement, making it nontherapeutic. "Why" questions place clients on the defense and are not therapeutic because they close the conversation.

After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates a correct understanding of the nurse's instructions? 1- "Asthma drugs help everybody breathe better." 2- "I must carry my emergency inhaler only when activity is anticipated." 3- "I must have my emergency inhaler with me at all times." 4- "Preventive drugs can stop an attack."

3 Because asthma attacks cannot always be predicted, clients with asthma must always carry a rescue inhaler such as a short-acting beta agonist (e.g., albuterol [Proventil]).

A client receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing? 1- Calcium imbalance 2- Fluid volume deficit 3- Fluid volume overload 4- Potassium imbalance

3 CHF and pulmonary edema are symptoms of fluid overload. Calcium imbalance, fluid volume deficit, and potassium imbalance do not manifest with CHF and pulmonary edema.

What is the greatest risk factor for lung cancer? 1- Alcohol consumption 2- Asbestos exposure 3- Cigarette smoking 4- Smoking marijuana

3 Cigarette smoking is the number-one risk factor for lung cancer and chronic obstructive pulmonary disease.

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client? 1- LPN/LVN who has worked with many home health clients after colostomy surgeries 2- LPN/LVN with 20 years of experience in the home health agency 3- RN who is new to the agency with 5 years experience in the emergency department 4- Social worker who is experienced with case management of older clients

3 Clients with medical or surgical diagnoses have complex physiologic needs that should be assessed by an RN. For this reason, Medicare requires that the initial assessment must be done by an RN, although LPN/LVNs and social workers are likely to be part of the health care team.

The nurse is preparing a client for discharge who has undergone percutaneous needle aspiration of a peritonsillar abscess. Which is most important to teach the client about follow-up care? 1- Completing the antibiotic medication regimen 2- Taking pain medications every 4 to 6 hours 3- Contacting the provider if the throat feels more swollen 4- Using warm saline gargles and irrigations

3 Clients with peritonsillar abscess are at risk for airway obstruction due to swelling and should notify the provider if signs of obstruction occur, such as stridor or drooling. I

A client admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this client? 1- Applying hydrocortisone cream 2- Cleaning the area with soap and hot water 3- Using sitz baths three times daily 4- Wearing absorbent cotton underwear

3 Clients with skin breakdown may use sitz baths for comfort 2 or 3 times daily. Barrier creams, not hydrocortisone creams, may be used. The skin should be cleaned gently with soap and warm water. Absorbent cotton underwear helps keep the skin dry, but is not a comfort measure.

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? 1- Ecchymosis 2- Edema 3- Excessive swallowing 4- Sore throat

3 Excessive swallowing in a client who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention. Because of the very vascular nature of the face, ecchymosis is a normal finding in the client who has undergone a nasoseptoplasty. Edema is a normal reaction to any kind of trauma, including that caused by surgery, so it is not an unexpected finding for this client. A sore throat is a common side effect of endotracheal intubation.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? 1- Hemoglobin and hematocrit 2- Leukocytes 3- Alpha-fetoprotein 4- Serum albumin

3 Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? 1- Measure intake and output every shift. 2- Do not administer food or fluids by mouth. 3- Administer opioid analgesic medication. 4- Assist the client to assume a position of comfort.

3 For the client with acute pancreatitis, pain relief is the highest priority. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The nurse is performing a health assessment on an obese client who states, "I have tried many diets in an effort to lose weight, but have been unsuccessful." How does the nurse assess whether the client's response to stress is related to the client's obesity? 1- "Do you have a history of mental problems, especially depression?" 2- "Do you usually use alcohol or drugs when you feel stressed?" 3- "Tell me what you do to relieve stress in your daily life." 4- "What is it about your obesity that causes you to feel uncomfortable?"

3 Having the client talk about what he or she does to relieve stress allows the client to verbalize stress-relieving mechanisms. It is also a question that cannot be answered with a simple "yes-or-no" response. Asking the client about mental health problems will cause the client to feel uncomfortable with the assessment; problems in handling stress do not mean mental health or depression problems. More effective methods can be used to determine the client's alcohol and drug habits. Having the client tell you what makes him or her uncomfortable about obesity will only cause the client to restate the obvious; it does not determine the effect that stress has on the client.

A client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? 1- The low PaO2 level may result in oxygen toxicity. 2- The 100% oxygen delivery requirement indicates immediate extubation. 3- Lung sounds may indicate absorption atelectasis. 4- The level of oxygen delivery may indicate absorption atelectasis.

3 High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. High PaO2 levels may result in oxygen toxicity. The need for 100% oxygen delivery does not suggest that the client should be extubated; rather, it suggests that the client continues to require intubation and mechanical ventilation. Although high levels of oxygen delivery can result in absorption atelectasis, this is not an indicator; rather, it is a cause.

A client is admitted to the emergency department (ED) with a possible diagnosis of avian influenza ("bird flu"). Which of these actions included in the hospital protocol for avian influenza will the nurse take first? 1- Ensure that ED staff members receive oseltamivir (Tamiflu). 2- Obtain specimens for the H5 polymerase chain reaction test. 3- Place the client in a negative air pressure room. 4- Start an IV line and administer rehydration therapy.

3 If a client is exhibiting symptoms of avian flu or any other pandemic influenza, he or she is assumed to be contagious until proven otherwise. Preventing the spread of disease to the community is the top priority, so placing the client in a negative air pressure room is the nurse's first action.

An older malnourished client who is taking digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel) develops a severe case of diarrhea. What does the nurse suspect is a possible cause? 1- Digoxin (Lanoxin) 2- Gastritis 3- Potassium chloride (Kay Ciel) 4- Ranitidine (Zantac)

3 In some cases, diarrhea may be the result of liquid medications such as elixirs and suspensions that have a very high osmolality. Diarrhea is not a frequent side effect of digoxin or ranitidine (Zantac). Gastritis does not cause diarrhea, and the other signs and symptoms of gastritis are not mentioned in this scenario.

A local hunter is admitted to the intensive care unit with a diagnosis of inhalation anthrax. Which medications does the RN anticipate the health care provider will order? 1- Amoxicillin (Amoxil, Triamox) 500 mg orally every 8 hours 2- Ceftriaxone (Rocephin) 2 g IV every 8 hours 3- Ciprofloxacin (Cipro) 400 mg IV every 12 hours 4- Pyrazinamide (Zinamide) 1000 to 2000 mg orally every day

3 Intravenous ciprofloxacin (Cipro) is a first-line drug for treatment of inhaled anthrax. A dose of 400 mg IV every 12 hours is typically used for treatment of anthrax, while a dose of 500 mg orally twice daily is usually prescribed for anthrax prophylaxis.

A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? 1- "Drinking carbonated beverages will help with your abdominal distress." 2- "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." 3- "Lactose-containing foods should be reduced or eliminated from your diet." 4- "Raw vegetables and high-fiber foods may help to diminish your symptoms."

3 Lactose-containing foods are often poorly tolerated and should be reduced or eliminated from the diet of clients with UC. Carbonated beverages are GI stimulants that can cause discomfort and should be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms; nurses should never advise clients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in clients with UC.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? 1- Provides enzymes necessary to digest dairy products 2- Reduces portal pressure 3- Promotes gastrointestinal (GI) excretion of ammonia 4- Decreases GI bleeding

3 Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

A client is placed on orlistat (Xenical) as part of a treatment regimen for morbid obesity. What side effects does the nurse tell the client to expect from using this drug? 1- Dry mouth, constipation, and insomnia 2- Insomnia, dry mouth, and blurred vision 3- Loose stools, abdominal cramps, and nausea 4- Palpitations, constipation, and restlessness

3 Loose stools, abdominal cramps, and nausea are side effects unique to orlistat (Xenical). Dry mouth, constipation, and insomnia are not side effects of orlistat. Insomnia, dry mouth, blurred vision, palpitations, constipation, and restlessness are all side effects of short-term therapy drugs such as phentermine (Adipex-P), diethylpropion (Tenuate), and phendimetrazine (Bontril).

Which problem for a client with cirrhosis takes priority? 1- Insufficient knowledge related to the prognosis of the disease process 2- Discomfort related to the progression of the disease process 3- Potential for injury related to hemorrhage 4- Inadequate nutrition related to an inability to tolerate usual dietary intake

3 Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse effectively plan nutritional care for this client? 1- Calculates his body mass index (BMI) 2- Keeps a 24-hour diary of his physical activities 3- Maintains a 24-hour recall (diary) of his food intake 4- Obtains his accurate height and weight measurements

3 Maintaining a 24-hour recall of food intake will determine the client's food preferences and eating patterns so that they can be incorporated into the diet to the greatest extent possible. Although calculating a BMI and measuring height and weight are important parts of a nutritional assessment, they do not address the issue of the client's food preferences. Keeping an activity diary will also not reveal any information related to the client's food preferences.

The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success? 1- Peak flowmeter readings that are yellow after the third reading 2- Productive cough 3- SpO2 level of 92% after ambulating 50 feet 4- Stable arterial blood gases (ABGs)

3 Maintaining a baseline SpO2 of 92% after ambulating 50 feet is an excellent indicator that the client has achieved better airflow, and that the nurse's teaching has been effective.

A client has asthma that gets worse during the summer. She tells the nurse that she takes a medication every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client? 1- Albuterol (Proventil) inhaler 2- Guaifenesin (Organidin) 3- Montelukast (Singulair) 4- Omalizumab (Xolair)

3 Montelukast is a leukotriene antagonist that works well for asthma that occurs during certain seasons. It is taken on a daily basis as a preventive medication.

A client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication? 1- IV ketorolac (Toradol) 2- IV midazolam (Versed) 3- IV morphine sulfate (Morphine) 4- Oral acetaminophen (Tylenol)

3 Morphine or other opioids are the best choice for this client in the immediate postoperative period. They can be given both as a bolus dose and continuously by patient-controlled analgesia. The client's airway and respiratory status must be carefully observed. Although nonsteroidal anti-inflammatory drugs do provide pain relief, at this stage of the client's recovery, Toradol is not the best choice. Midazolam is an antianxiety medication; it has no narcotic properties. Oral acetaminophen is not appropriate in the immediate postoperative period as it will not provide sufficient pain control, and the client still will be unable to take oral medication.

A female client is concerned that her inability to conceive a child is connected to her morbid obesity. How does the nurse respond? 1- "Do you feel that your obesity is keeping you from getting pregnant?" 2- "Have you considered adoption as an option?" 3- "Tell me about changes, if any, in your menstrual cycle each month." 4- "What has your health care provider told you about your problems in getting pregnant?"

3 Obesity has been known to produce changes in the menstrual cycle, thus causing difficulties in getting pregnant. Asking the client about her menstrual cycle directly addresses the client's concern and is designed to elicit helpful assessment information. Asking the client if she feels her obesity is keeping her from getting pregnant only asks the client to restate the obvious. It is also a closed question that requires only a "yes-or-no" response. Telling the client that adoption is an option is an intrusive response by the nurse and may alienate the client. It also does not address the client's concern about obesity. Asking what her health care provider told her is an evasive response from the nurse and does not address the client's concerns.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? 1- Instructing the client about the use of electrolyte-containing oral rehydration products 2- Administering loperamide (Imodium) 4 mg from the client's medicine cabinet 3- Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions 4- Teaching the client how to clean the perineal area after each loose stool

3 Obtaining the client's blood pressure and heart rate is included in the education of home health aides and other UAP. Client teaching and medication administration are complex skills that should be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

A client with ulcerative colitis is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client's medication regimen? 1- Corticosteroid therapy will be stopped. 2- Sulfasalazine (Azulfidine) will be stopped. 3- Corticosteroid therapy will be tapered. 4- Sulfasalazine (Azulfidine) will be tapered.

3 Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period. Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in clients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the client's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

An obese client is prescribed orlistat (Xenical). The client asks the nurse how the drug works. How does the nurse respond? 1- "It decreases the amount of norepinephrine in your brain. This action will increase your feeling of being satisfied on less food." 2- "It increases the amount of serotonin in your brain. This action will greatly increase your metabolic rate, and you will burn calories quicker." 3- "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." 4- "It will alter the chemistry of your brain. Consequently, you will feel full before you overeat."

3 Orlistat inhibits lipase and leads to partial hydrolysis of triglycerides. Because fats are only partially digested and absorbed, calorie intake is decreased. Orlistat does not decrease the amount of norepinephrine in the brain, increase the amount of serotonin in the brain, or alter the chemistry of the brain.

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? 1- "Your spouse will sign up for the meetings only when he is ready to deal with his problem." 2- "Keep mentioning the AA meetings to your spouse on a regular basis." 3- "I'll get you some information on the support group Al-Anon." 4- "Tell me more about your frustration with your spouse's refusal to participate in AA."

3 Putting the client's spouse in contact with an Al-Anon support group assists with the spouse's frustration. 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.

An RN is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? 1- Schedule respiratory treatments following meals 2- have the client sit up in a chair for 2hrs 3x/day 3- Provide a diet that is high in calories and protein 4- Combine activities to allow for longer rest periods between

3 Since people with COPD expend so much more energy for respiratory, they typically require higher calories with more protein through out the day

A client asks the nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting colorectal cancer?" Which dietary selection does the nurse suggest? 1- Steak with pasta 2- Spaghetti with tomato sauce 3- Steamed broccoli with turkey 4- Tuna salad with wheat crackers

3 Steamed broccoli with turkey contains low-fat meat and no refined carbohydrates. Animal fat from red meats is carcinogenic, and pasta is high in refined carbohydrates, which are known to contribute to colon cancer. Spaghetti and wheat crackers also contain large amounts of refined carbohydrates.

A client with a bowel obstruction is ordered a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client? 1- Attaching the tube to high continuous suction 2- Auscultating for bowel sounds and peristalsis while the suction runs 3- Connecting the tube to low intermittent suction 4- Flushing the tube with 30 mL of normal saline every 24 hours

3 The NG tube should be attached to intermittent low suction unless otherwise requested by the health care provider. Continuous suction is rarely used because it can injure the gastric mucosa of the client's stomach. Bowel sounds should not be auscultated with suction on and running. The tube should be flushed every 4 hours, minimally.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? 1- Client who is taking lactulose and has diarrhea 2- Client with hepatitis C who requires a dressing change 3- Client with end-stage cirrhosis who needs teaching about a low-sodium diet 4- Obtunded client with alcoholic encephalopathy who needs a blood draw

3 The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

The RN is caring for a pt in Acute Respiratory Failure who is receiving mech ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current tx regimen? 1- BP 2- Cap refill 3- ABG 4- HR

3 The RN should place priority on evaluating ABGs to determine serum O2 saturation and acid-base balance

An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action? 1- Pain when coughing 2- States, "I am too tired to walk very much" 3- States, "I feel like the incision is splitting open" 4- Temperature of 100.8° F (38.2° C).

3 The client feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence; the nurse should immediately assess the wound and notify the health care provider. Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8° F (38.2° C) all require further assessment or intervention, but are not as great a concern as the possibility of wound dehiscence for this client.

A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? 1- High Fowler's 2- Lateral Sims' (side-lying) 3- Semi-Fowler's 4- Supine

3 The client is maintained in semi-Fowler's position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion. High-Fowler's position would be too high for the client postoperatively; it would place strain on the abdominal incision(s), and, if the client was still drowsy from anesthesia, this position would not enhance the client's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion; the client would be more likely to develop complications (wound drainage stasis and atelectasis) in this position.

A client who has recently traveled to Vietnam comes to the emergency department with fatigue, lethargy, night sweats, and a low-grade fever. What is the nurse's first action? 1- Contact the health care provider for tuberculosis (TB) medications. 2- Perform a TB skin test. 3- Place a respiratory mask on the client. 4- Test all family members for TB.

3 The concern is that this client has TB. A respiratory mask should be placed on the client immediately. Performing a TB test will be important, but this is not the top priority. It is important to remember to let the client know that results will not be available for at least 48 hours after the test is administered.

A client has just arrived in the postanesthesia care unit following a successful tracheostomy procedure. Which nursing action must be taken first? 1- Suction as needed. 2- Clean the tracheostomy inner cannula and stoma. 3- Listen to lung sounds. 4- Change the tracheostomy dressing as needed.

3 The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the client's respiratory status before cleaning or performing a dressing change.

The nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" about what the BMI number means. Which client statement indicates a need for further instruction? 1- "If I could get my BMI below 25, my risk for malnutrition would decrease." 2- "I realize that this means that I have some increased health risks." 3- "My goal should be to get my BMI below 18.5." 4- "This means that I have an increased amount of total fat stored in my body."

3 The least risk for malnutrition is actually seen in adult clients whose BMI is between 18.5 and 25. Older adults should have a BMI between 23 and 27. The client with a BMI greater than 24.9 does have increased health risks that a client with a lower number would not have. The client's BMI of 27.5 does mean that an increased amount of fat is stored in the body in relation to the client's height.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? 1- Obtain the charts from the previous admission. 2- Listen for bowel sounds in all quadrants. 3- Obtain pulse and blood pressure. 4- Ask about abdominal pain.

3 The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Assessment for adequate perfusion is the highest priority at this time. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized.

An 87-year-old resident from an extended-care facility has not been eating for several days and is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). The nurse checks the gastric pH of the feeding tube and obtains a value of 6.0, which may indicate that the feeding tube is in the client's lungs. Is there another possible explanation for the nurse to consider? 1- No; the feeding tube must be removed. 2- No; the potassium effect will prevent the pH from reaching 6.0. 3- Yes; the client is taking Zantac. 4- Yes; the pH paper has expired and is giving a false reading.

3 The pH may be as high as 6.0 if the client takes certain medications, such as histamine2 blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]). This finding, given the circumstances, does not mean that the tube is displaced and in the client's lungs. The potassium effect would not cause the pH to become more alkaline. Expired pH paper will provide no data that are reliable, so it would be impossible to have a reading of "6.0."

The home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates a correct understanding of the instructions? 1- "A dark or purplish-looking stoma is normal and should not concern me." 2- "If the skin around the stoma is red or scratched, it will heal soon." 3- "I need to check for leakage underneath my colostomy." 4- "I should strive for a very tight fit when applying the barrier around the stoma."

3 The pouch system should be checked frequently for evidence of leakage to prevent excoriation. A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma should be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma.

The RN is providing DC instructions to a client who has a temp tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? 1- I should dip a cotton-tipped applicaiton into full strength hydrogen peroxide to clease around my stoma 2- I should cut a 4in gauze dressing and place it around mt T-tube to absorb drainage 3- I should remove the old twill ties after the new ones are in place 4- I should apply suction while inserting the cath into the trach tube

3 This is a safety measure the RN should teach the pt to prevent accidental decannulation

A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response? 1- "This may be an indication that you are developing sepsis." 2- "The gallstones are present, but have become fibrotic and contracted." 3- "This type of gallbladder inflammation is associated with hypovolemia." 4- "This may be an indication of pancreatic disease."

3 This type of gallbladder inflammation is associated with hypovolemia. Although this type of gallbladder inflammation is associated with sepsis, it is not an indicator that sepsis is developing. Fibrotic and contracted gallstones are associated with chronic cholecystitis. The presence of acalculous cholecystitis is not an indicator that pancreatic disease has developed.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? 1- The client must not consume alcohol. 2- Avoid sharing the bathroom with the client. 3- Members of the household must not share toothbrushes. 4- Drink only bottled water and avoid ice.

3 Toothbrushes, razors, towels, and items that may spread blood and body fluids should not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water should be avoided.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? 1- Steak and French fries 2- Fried chicken and mashed potatoes 3- Turkey sandwich on wheat bread 4- Sausage and scrambled eggs

3 Turkey is an appropriate low-fat selection for this client. Steak, French fries, fried chicken, and sausage are too fatty, and eggs are too high in cholesterol for a client with gallbladder disease.

The nurse manager in a long-term care facility plans nutritional assessments of all residents. Which nutritional assessment activity does the nurse delegate to unlicensed assistive personnel (UAP) at the facility? 1- Assessing residents' abilities to swallow 2- Determining residents' functional status 3- Measuring the daily food and fluid intake of residents 4- Screening a portion of the residents with the Mini Nutritional Assessment

3 UAP education includes measurement of clients' oral intake; this skill does not require clinical judgment to be completed accurately. Assessing residents' abilities to swallow, determining residents' functional status, and screening with the Mini Nutritional Assessment require broad knowledge of normal physiology, nutrition, and factors that affect nutrition and should be done by licensed nursing staff.

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? 1- Deceased calcium, elevated amylase, decreased magnesium 2- Elevated bilirubin, elevated alkaline phosphatase 3- Elevated lipase, elevated white blood cell count, elevated glucose 4- Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

3 levated lipase is more specific to a diagnosis of acute pancreatitis. 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.

An RN is caring for a client who has asthma and is recieving albuterol. For which of the following adverse side effects should the RN monitor the pt? 1- Hyperkalemia 2- Dyspnea 3- Tachycardia 4- Candidiasis

3 tachycardia is a common adverse side effect of this medication, especially if used frequently

An RN is providing DC instructions for a client who has chronic Hep C. Which of the following statements by the client indicates an understanding of the teaching? 1- I will avoid alcohol until I am no longer contagious 2- I will avoid medications that contain acetaminophen 3- I will decrease my intake of calories 4- I will need treatment for 3 months

3 - A client who has hep C should avoid meds that contain acetaminophen which can cause additional liver damage

An RN is assessing a client who has super upper gastrointestinal bleeding. Which of the following findings should the nurse expect? 1- Bradycardia 2- Bounding peripheral pulses 3- Hypotension 4- Increased hematocrit levels

3 - A client with upper GI bleeding is at risk for hemorrhagic shock. Hypotension, tachycardia, weak peripheral pulses and decreased hematocrit and hemoglobin are all manifestations to be expected

An RN is teaching a client how to prepare for a colonoscopy. Which of the following instructions should the RN include with teaching? 1- Begin drinking the oral liquid prep for bowel cleansing on the morning of the procedure 2- Drink full liquids for breakfast the day of the procedure, and then take NPO for 2 hrs prior to the procedure 3- Drink clear liquids for a 24 hr period prior to the procedure, then take NPO for 6 hrs before the procedure 4- Drink the oral liquid prep for bowel cleansing slowly

3 - Clear liquids 24 hrs prior to the procedure promotes adequate bowel cleansing. maintaining NPO status for 4-6 hrs prior to the colonoscopy preserves the bowel's cleansed state

The RN is providing dietary teaching for a client who has a new dx of celiac disease. Which fo the following statements by the client indicates an understanding of the teaching? 1- I can return to my regular diet when I am free of symptoms 2- I will need to avoid taking vitamin supplements while on this diet 3- I will eat beans to ensure I get enough fiber in my diet 4- I need to avoid drinking liquids with my meals while on this diet

3 - Clients w/ celiac disease must maintain a GLUTEN FREE diet which eliminates fiber-rich whole wheat products. Clients should replace fiber with beans, nuts, fruits, and vegetables to ensure adequate intake

An RN is assessing a client who has peritonitis. Which of the following findings should the nurse expect? 1- Bloody diarrhea 2- Board-like abdomen 3- Periumbilical cyanosis 4- Increased bowel sounds

3 - Rigidity, distension, and extreme pain or tenderness are all expected findings of peritonitis

An RN is admitting a client who has acute pancreatitis. Which of the following actions should the RN take first? 1- Insert an NG tube for the client 2- Admin ceftazidime to the client 3- Identify the client's current pain level 4- Instruct the client to remain NPO

3 - The 1st action in the nursing process is assessment. Clients w/ acute pancreatitis often have severe abdominal pain.

An RN is providing DC instructions for a client who has a new colostomy and is concerned about flatus and odor. which of the following foods should the RN recommend for this client? 1- Eggs 2- Fish 3- Yogurt 4- Broccoli

3 - The R should recommend yogurt, crackers and toast which can prevent flatus and stool odor

An RN is providing DC instructions for a client following an ileostomy. The RN should instruct the client to report which of the following findings to the provider? 1- Intolerance to high fiber foods 2- Liquid ileostomy output 3- Dark purple stoma 4- Sensation of burning during bowel elimination

3 - The dark purple color is an indication of bowel ischemia

A RN is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider? 1- Spider angiomas 2- Peripheral edema 3- Bloody stools 4- Jaundice

3 - The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding of the esophageal varices. Therefore, blood stools are the priority finding to report. The other 3 are NORMAL expected findings is a pt with cirrhosis

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (SATA) 1- Recent influenza infection 2- Brown stool 3- Tea-colored urine 4- Right upper quadrant tenderness 5- Itching

3,4,5 The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.

An RN is caring for a client who is post-op and has respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABGs indicates the client is experiencing respiratory acidosis? 1- pH 7.5 PO2 95 PaCO2 25 HCO3 22 2- pH 7.5 PO2 87 PaCO2 35 HCO3 30 3- pH 7.3 PO2 90 PaCO2 35 HCO3 20 4- pH 7.3 PO2 80 PaCO2 55 HCO3 22

4 A pH less than 7.35 indicates acidosis A PaCO2 greater than 45 indicates respiratory acidosis

The nurse reviews a medication history for a client newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil) frequently for chronic knee pain. The nurse anticipates that the health care provider will request which medication for this client? 1- Bismuth subsalicylate (Pepto-Bismol) 2- Magnesium hydroxide (Maalox) 3- Metronidazole (Flagyl) 4- Misoprostol (Cytotec)

4 Misoprostol is a prostaglandin analogue that protects against nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers. Bismuth subsalicylate is an antidiarrheal drug that contains salicylates, which can cause bleeding and should be avoided in clients who have PUD. Magnesium hydroxide is an antacid that may be used to neutralize stomach secretions, but is not used specifically to help prevent NSAID-induced ulcers. Metronidazole is an antimicrobial agent used to treat Helicobacter pylori infection.

A client who has undergone a bariatric surgical procedure is recuperating after surgery. Which nursing intervention most effectively prevents injury to the client who is being re-positioned postoperatively? 1- Administering pain medication 2- Making sure not to move the client's nasogastric (NG) tube 3- Monitoring skinfold areas and keeping them clean and dry 4- Using a weight-rated extra-wide bed for the client

4 Using a special bed will allow adequate room for re-positioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury. Pain medication and monitoring skinfold areas will not prevent injury to the client that might occur during re-positioning. Not moving the client's NG tube will prevent disruption of the suture line, but will not prevent re-positioning injuries.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? 1- "Cirrhosis is a chronic disease that has scarred my liver." 2- "The scars on my liver create problems with blood circulation." 3- "Because of the scars on my liver, blood clotting and blood pressure are affected." 4- "My liver is scarred, but the cells can regenerate themselves and repair the damage."

4 Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

A client is being evaluated in the emergency department for a possible small bowel obstruction. Which signs and/or symptoms does the nurse expect to assess? 1- Cramping intermittently, metabolic acidosis, and minimal vomiting 2- Intermittent lower abdominal cramping, obstipation, and metabolic alkalosis 3- Metabolic acidosis, upper abdominal distention, and intermittent cramping 4- Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

4 A SMALL bowel obstruction is characterized by upper or epigastric abdominal distention, metabolic alkalosis, and a great amount of vomiting. Intermittent lower abdominal cramping, metabolic acidosis, and minimal vomiting are all symptoms of a LARGE bowel obstruction.

A new client arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action? 1- Apply a hot pack over the flap site. 2- Massage the flap site vigorously. 3- Place a tight dressing over the flap. 4- Use a Doppler device to assess flow to the area.

4 A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed and the surgeon must be notified, because the client may have to be returned to the operating room immediately. Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam (Valium) 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? 1- The client is not being treated for asthma. 2- The client has a mental disorder. 3- The client received a dose of Valium. 4- The client is receiving oxygen at 4 L/min.

4 A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client. The client had a panic attack, not an asthma attack. A panic attack is not a definitive diagnostic indicator of a mental disorder. A small dose of Valium does not place a client at increased risk for respiratory distress; a large dose is required to place a client at high risk.

A client comes to the emergency department with a sore throat. Examination reveals redness and swelling of the pharyngeal mucous membranes. Which diagnostic test does the nurse expect will be requested first? 1- Chest x-ray 2- Complete blood count (CBC) 3- Tuberculosis (TB) skin test 4- Throat culture

4 A throat culture is important for distinguishing a viral infection from a group A beta-hemolytic streptococcal infection. A chest x-ray or TB skin test is not indicated by the symptoms given. A CBC might be indicated to evaluate infection and dehydration, but would not be the first action.

An RN is planning care for a client who has asthma. Which of the following medicaitons should the RN plan to administer during an acute asthma attack? 1- Cromolyn sodium 2- Prednisone 3- Fluticasone/Salmeterol 4- Albuterol

4 Albuterol is a rapid B2 bronchodilator that can be used as a rescue inhaler

The nurse is preparing to administer oxygen to a client with chronic obstructive pulmonary disease (COPD) who is hypoxemic and hypercarbic. How will the nurse administer the oxygen for this client? 1- By nasal cannula at a rate of no more than 1 to 3 L/min 2- By nasal cannula at a rate of no more than 2 to 4 L/min 3- By Venturi mask at a rate of at least 60% 4- By maintaining oxygen saturations greater than 88%

4 All hypoxic clients, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SpO2 levels up between 88% and 92%

An RN receives the change-of-shift report about these four clients. Which client does the nurse assess first? 1- A 30-year-old admitted 2 hours ago with malnutrition associated with malabsorption syndrome 2- A 45-year-old who had gastric bypass surgery and is reporting severe incisional pain 3- A 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL 4- A 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min

4 Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. The client with dementia who has a respiratory rate of 38 breaths/min needs respiratory assessment and interventions immediately. T he client with malnutrition associated with malabsorption syndrome, the client with incisional pain from gastric bypass surgery, and the client receiving TPN with a BG of 300 mg/dL all need assessments and/or interventions by the RN, but maintaining respiratory function in the client with tachypnea is the highest priority.

A 21-year-old with a stab wound to the abdomen has come to the emergency department. Once stabilized, the client is admitted to the medical-surgical unit. What does the admitting nurse do first for this client? 1- Administer pain medication. 2- Assess skin temperature and color. 3- Check on the amount of urine output. 4- Take vital signs.

4 Assessment of vital signs should be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the client's condition. The client should not be medicated for pain until his or her alertness level is determined. Skin temperature and color are not specifically indicative of the client's overall condition. If the client is in shock, urine output will be scant and will not be an accurate assessment variable.

The nurse notices a visitor walking into the room of a client on airborne isolation with no protective gear. What does the nurse do? 1- Ensures that the client is wearing a mask 2- Tells the visitor that the client cannot receive visitors at this time 3- Provides a particulate air respirator to the visitor 4- Provides a mask to the visitor

4 Because the visitor is entering the client's isolation environment, the visitor must wear a mask. It would not be necessary for the visitor to wear an air respirator.

What is the mechanism of action for the chemotherapeutic drug cetuximab (Erbitux)? 1- It destroys the cancer's cell wall, which will kill the cell. 2- It decreases blood flow to rapidly dividing cancer cells. 3- It stimulates the body's immune system and stunts cancer growth. 4- It blocks factors that promote cancer cell growth.

4 Cetuximab, a monoclonal antibody, may be given for advanced disease. This drug works by binding to a protein (epidermal growth factor receptor) to slow cell growth. The medication does not destroy the cancer's cell walls and does not stimulate the body's immune system or stunt cancer growth in that manner. The treatment does not decrease blood flow to rapidly dividing cancer cells.

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? 1- Vitamin K-containing products 2- Potassium-sparing diuretics 3- Nonabsorbable antibiotics 4- NSAIDs

4 Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

Which nursing care activity for a malnourished client does the nurse safely delegate to unlicensed assistive personnel (UAP)? 1- Completing the Mini Nutritional Assessment 2- Determining body mass index (BMI) 3- Estimating body fat using skinfold measurements 4- Measuring current height and weight

4 Determining height and weight is the only activity that can be safely delegated to UAP. The nurse is responsible for completing the Mini Nutritional Assessment, determining the client's BMI, and estimating body fat using skinfold measurements.

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? 1- Carbohydrates 2- High fat 3- High fiber 4- Protein

4 Enzyme preparations should not be mixed with foods containing protein because the enzymes will dissolve the food into a watery substance. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.

An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first? 1- Administer acetaminophen (Tylenol) 650 mg rectally. 2- Draw blood for a complete blood count and serum electrolytes. 3- Obtain a stool specimen for culture and sensitivity. 4- Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

4 Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure. Acetaminophen 650 mg should be rapidly administered rectally, and blood draws and stool specimen collection should be implemented rapidly, but prevention and treatment of dehydration are the priorities for this client.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond? 1- "Have you asked your health care provider what he or she thinks your chances are?" 2- "It is hard to know what can predispose a person to develop a certain disease." 3- "No. Just because they both had CRC doesn't mean that you will have it, too." 4- "The only way to know whether you are predisposed to CRC is by genetic testing."

4 Genetic testing is the only definitive way to determine whether the client has a predisposition to develop CRC. A higher incidence of the disease has been noted in families who have a history; however, it is not the responsibility of the nurse to engage in genetic counseling, and this client might not be predisposed to developing CRC. Asking the client what the health care provider thinks is an evasive response by the nurse and does not address the client's concerns.

Community health nurses are tasked with providing education on prevention of respiratory infection for diseases such as the flu. Which target audience is given the highest priority? 1- Homeless people 2- Hospital staff 3- Politicians 4- Prison staff and inmates

4 High-risk groups for respiratory infection include those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities. Although homeless people are a high priority, they are not the group at greatest risk of those listed.

A client who is receiving total enteral nutrition exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begins to have a generalized seizure, how does the nurse interpret this client's signs and symptoms? 1- The enteral tube is misplaced or dislodged. 2- Abdominal distention is present. 3- Severe hyperglycemia is present. 4- This is refeeding syndrome.

4 In refeeding syndrome, insulin secretion decreases in response to the physiologic changes in the body; when refeeding begins, insulin production resumes and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels. Symptoms of refeeding syndrome include shallow respirations, weakness, acute confusion, seizures, and increased bleeding tendency. If the enteral tube becomes misplaced or dislodged, the client may develop aspiration pneumonia displayed by increased temperature, increased pulse, dehydration, diminished breath sounds, and shortness of breath. Abdominal distention is most frequently accompanied by nausea and vomiting.

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation completed as an outpatient. What does the nurse tell her? 1- "Give him Phenergan (promethazine) by rectum around the clock so he does not vomit." 2- "He can only drink milk and eat ice cream until the wires come off." 3- "He must brush his teeth every 2 hours." 4- "Make sure he always has wire cutters with him."

4 It is extremely important that the client always have wire cutters in the event of emesis, so the wires can be cut to prevent aspiration. Remind the client to contact the surgeon as soon as possible if the wires have been cut, so that fixation can be re-established. Antiemetics such as promethazine, ondansetron (Zofran), and prochlorperazine (Compazine) are prescribed by a health care provider on an as-needed basis only for nausea. Good nutrition, ensuring adequate protein intake for healing, must be maintained. A specific dental liquid diet will be reviewed with the client and significant others before surgery. Dental hygiene will be maintained with an irrigation device such as a Waterpik or SoniCare, not with a brush.

A client who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? 1- A list of medical supply facilities where wound care supplies may be purchased 2- Proper handwashing techniques to avoid cross-contamination of the client's wound 3- The amount of pain medication that the client is allowed to take in each dose 4- Written and oral instructions regarding symptoms to report to the health care provider

4 It is most important to provide the client and case manager with both written and oral instructions on reportable symptoms to avoid the development of complications. Although instruction on proper handwashing and the client's medication regimen are important, they are not the highest priority. It will be the home health nurse's responsibility to bring supplies to the client's home.

An Rn is assessing a client who has duodenal ulcer. Which of the following findings should the nurse expect? 1- The client states that the pain is in the upper epigastrium 2- The client in malnourished 3- The client states that ingesting food intensifies the pain 4- The client reports that pain occurs during the night

4 - Pain associated w/ duodenal ulcers occurs when the stomach is empty, which is typically 1.5-3hrs after meals and during the night time.

Which client on the medical-surgical unit does the charge nurse assign to the LPN/LVN? 1- A 28-year-old with morbid obesity who had bariatric surgery today 2- A 30-year-old recently admitted with severe diarrhea and Clostridium difficile infection 3- A 36-year-old whose family needs instruction about how to use a gastric feeding tube 4- A 39-year-old with a jejunal feeding tube who needs elemental feedings administered

4 LPN/LVN education includes administration of tube feedings and associated client care and monitoring. Initial assessment of a postoperative client, a new admission, and client and family teaching all require RN education and scope of practice.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? 1- Provides small frequent meals for the client 2- Suggests taking daily potassium supplements 3- Elevates the head of the bed in high-Fowler's position 4- Requests a bedside commode for the client

4 Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? 1- Positive Babinski's sign 2- Hyperreflexia 3- Kehr's sign 4- Asterixis

4 Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

Which statement by a client with a laryngectomy indicates a need for further discharge teaching? 1- "I must avoid swimming." 2- "I can clean the stoma with soap and water." 3- "I can project mucus when I laugh or cough." 4- "I can't put anything over my stoma to cover it."

4 Loose clothing or a covering such as a scarf can be used to cover the stoma if the client desires. To avoid aspiration, the client with a laryngectomy should not swim. Mild soap and water is the proper way to clean the stoma; however, a shield should be used in the shower so a large amount of water does not enter it. The client may project mucus when he laughs or coughs; reinforce with the client and the family that this is normal and is to be expected.

A client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list? 1- Amitriptyline (Elavil) 2- Diazepam (Valium) 3- Ketorolac (Toradol) 4- Lorazepam (Ativan)

4 Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this client. Although diazepam is an effective medication for anxiety, it is more likely to cause respiratory depression; the location of this tumor makes diazepam not the best choice for anxiety. Amitriptyline is a tricyclic antidepressant that would not be used specifically for this client's anxiety. Ketorolac is a nonsteroidal anti-inflammatory drug and should not be used before surgery. Ketorolac should be used with caution, or not at all, if the client is taking medication for anxiety.

An RN in the ED is caring for a client who is experiencing acute respiratory failure. Which of the following lab values should the RN expect? 1- Arterial pH 7.5 2- PaCO2 25 mm Hg 3- SaO2 92% 4- PaO2 58 mm Hg

4 Lower partial pressires of oxygen are to be expected in ARF

An RN is providing teaching to a client who has chronic asthma and a new Rx for montelukast. Which of the following client statements indicates an understanding of the teaching? 1- I'll monitor my HR every day while taking this med 2- I'll make sure I have this med w/ me at all times 3- I will need to carefully rinse my mouth after this med 4- I will take this med every night even if I don't have symptoms

4 Montelukast is used for the prophylactic tx of asthma and is taken on a daily basis at night

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be best for the nurse to delegate to unlicensed assistive personnel (UAP)? 1- Assessing dietary risk factors for cholecystitis 2- Checking for bowel sounds and distention 3- Determining precipitating factors for abdominal pain 4- Obtaining the admission weight, height, and vital signs

4 Obtaining height, weight, and vital signs is included in the education for UAP and usually is included in the job description for these staff members. Assessment, checking bowel sounds, and determining precipitating factors for abdominal pain require broader education and are within the scope of practice of licensed nursing staff.

The nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? 1- Bowel sounds are not audible in all quadrants. 2- Client's skin under the panniculus is excoriated. 3- The client reports pain when being re-positioned. 4- Urine output total is 15 mL for the past 2 hours.

4 Oliguria may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure. Inaudible bowel sounds would typically require intervention, but on the day of surgery, bowel sounds will probably be absent normally for some time. The other findings, excoriated skin under the panniculus and subjective reports of pain, may require nursing interventions, but do not require immediate intervention by the surgeon.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? 1- Absence of jaundice, pain of gradual onset 2- Absence of jaundice, pain in right abdominal quadrant 3- Presence of jaundice, pain worsening when sitting up 4- Presence of jaundice, pain worsening when lying supine

4 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.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication? 1- Administer pancrelipase before taking an antacid. 2- Chew tablets before swallowing. 3- Take pancrelipase before meals. 4- Wipe your lips after taking pancrelipase.

4 Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks and followed with a glass of water.

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant? 1- Administering throat-numbing lozenges 2- Assessing the mouth for inflammation and infection 3- Teaching about skin care while receiving radiation 4- Washing the skin with soap and water

4 Personal hygiene is within the scope of practice of the nursing assistant. Throat-numbing lozenges should not be administered by nursing assistants because they are medication Assessment is a complex task that must be completed by licensed nursing staff. Educating the client is the responsibility of licensed nursing staff and is an ongoing part of the client's care.

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? 1- Assessing skin integrity and abdominal distention 2- Drawing blood from a central venous line for electrolyte studies 3- Evaluating laboratory study results for the presence of hypokalemia 4- Placing the client in a semi-Fowler's position

4 Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.

An older adult client needs additional dietary protein, but refuses to drink the prescribed liquid protein supplements. Which nursing intervention is most effective in increasing the client's protein intake? 1- Administering the liquid supplement with routine medications 2- Giving a glucose polymer modular supplement 3- Keeping a food and fluid intake diary for at least 3 days 4- Providing protein modular supplements in the form of puddings

4 Providing protein modular supplements in the form of puddings would increase the client's protein intake in a format other than a liquid supplement. Administering the liquid supplement with routine medications will not be effective because the client has already refused to drink the supplements. Glucose polymer modular supplements will increase the client's calorie intake but not protein intake. A food and fluid diary will provide information about the client's typical intake pattern, but will not increase protein intake.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the heath care provider? 1- The dressing has a 2-cm area of serous drainage. 2- The client's platelet count is 135,000/mm3. 3- The client's albumin level is 2.8 mg/dL. 4- The client's heart rate is 122 beats/min.

4 Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when associated with hypotension, should be reported to the provider. A small amount of serous fluid may leak; the dressing should be reinforced. Platelets will be checked before the procedure; these are slightly low, but this is not a cause for concern. An albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life threatening.

The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler? 1- Corticosteroids 2- Long-acting beta agonists 3- NSAIDs 4- Short-acting beta agonists

4 Short-acting beta agonist medications have a rapid onset and cause bronchodilation; they would be excellent for marathon running because some types of asthma may be exercise-induced.

A newly diagnosed client with asthma says that his peak flowmeter is reading 82% of his personal best. What does the nurse do? 1- Nothing. This is in the green zone. 2- Provide the rescue drug and reassess. 3- Provide the rescue drug and seek emergency help. 4- Repeat the peak flow test.

4 Since the client is newly diagnosed with asthma, this would be an excellent opportunity for the nurse to observe the client using the peak flowmeter to ensure that the client is using it properly, so readings are accurate and in the green zone, at least 80% of the client's personal best. The result of 82% is in the green zone, but this is not the best answer for a newly diagnosed client. Rescue drugs should be used only in the yellow zone, between 50% and 80% of the client's personal best. The nurse does not need to seek emergency help until readings are in the red zone, or below 50% of the client's personal best.

A client has undergone bariatric surgery. Which nursing intervention is the highest priority in preventing dehydration in this client? 1- Ambulating the client as quickly as possible after surgery 2- Applying an abdominal binder daily when the client is out of bed 3- Observing for tachycardia, nausea, diarrhea, and abdominal cramping 4- Providing six small feedings daily and offering fluids frequently

4 Small daily feedings and adequate fluids will prevent the development of dehydration in the client after bariatric surgery, which is the priority intervention. Ambulation will prevent pulmonary embolism and other circulatory problems. An abdominal binder will help support the abdomen and may prevent dehiscence of the wound. Observing for tachycardia, nausea, diarrhea, and abdominal cramping will prevent the development of postoperative dumping syndrome.

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? 1- "An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." 2- "It is inherited, so it could run in your family." 3- "It might be caused by a virus, so you could have gotten it almost anywhere." 4- "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."

4 Stating that the disorder is the result of flattening of the mucosa of the large intestine is the only statement that is physiologically accurate. Malabsorption syndrome is not associated with an excessive intake of alcohol. It is not inherited, although a genetic immune defect is present in the related disease, celiac sprue. It is not caused by a virus.

Which clinical manifestation in the client with facial trauma is the nurse's first priority? 1- Bleeding 2- Decreased visual acuity 3- Pain 4- Stridor

4 Stridor is an indication of a partial airway obstruction and requires immediate attention. Although bleeding is important in all trauma clients, it is not the first priority in assessing the "ABCs". The question does not specify where the bleeding is occurring. The type (venous or arterial) and quantity of the bleeding need to be noted. Visual acuity will be assessed in the secondary survey because it is not considered life-threatening. Pain must be addressed to fully evaluate a client and complete a reliable examination; however, it is not the nurse's first priority.

Respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? 1- Humidifying the oxygen source 2- Increasing oxygenation 3- Removing the inner cannula of the tracheostomy 4- Suctioning the client

4 Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern. Humidifying the oxygen source will help mobilize secretions, but an active cough response is also required to clear the airway; a sedated client has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

A client newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the client about why this therapy has been prescribed? 1- "It is to stop the diarrhea and bloody stools." 2- "This will minimize your GI discomfort." 3- "With this medication, your cramping will be relieved." 4- "Your intestinal inflammation will be reduced."

4 Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation. Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the client's pain as the inflammation subsides, but this is not the purpose of the drug—it is not an analgesic.

Which clinical manifestation requires immediate action by the nurse for a client with laryngeal trauma? 1- Aphonia 2- Hemoptysis 3- Hoarseness 4- Tachypnea

4 Tachypnea is a sign of respiratory distress that may accompany laryngeal trauma; this requires immediate action on the part of the nurse. Aphonia (the inability to produce sound) is a manifestation of laryngeal trauma and may be caused by nerve damage, swelling, cartilage fracture, or other events; it does not require immediate action by the nurse. Hemoptysis (bleeding from the airway) may occur as the result of laryngeal trauma. The quantity needs to be observed; an increase in the amount of bleeding can become an emergency because it affects airway patency. Hoarseness is commonly associated with laryngeal trauma, but does not require immediate attention.

An environmental assessment of a factory finds inhalation exposure with a high level of particulate matter. What does the factory nurse do to generate the quickest compliance? 1- Encourages proper building ventilation 2- Refers workers to a tobacco cessation program 3- Suggests that workers find another job 4- Teaches workers how to use a mask

4 Teaching everyone to use a mask when working in areas with high levels of particulate matter can reduce individual exposure.

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? 1- "The diabetes could be related to your obesity." 2- "What has your doctor told you about your disease?" 3- "Do you consume alcohol on a frequent basis?" 4- "Type 1 diabetes can occur when the pancreas is destroyed by disease."

4 Telling the client that type 1 diabetes can occur when the pancreas is destroyed by disease 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. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's question. Many factors could produce acute pancreatitis other than alcohol consumption.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? 1- A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula 2- A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas 3- A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir 4- A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

4 The ICU nurse is familiar with the care of a client with peritonitis, including monitoring for complications such as sepsis and kidney failure. The client with CD who has a draining enterocutaneous fistula, the client with UC who needs discharge teaching, and the client with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for clients with their respective disorders.

An RN working the ED is caring for a pt following an acute chest trauma. Which of the following findings infdicates to the RN the client is possibly experiencing a tension pneumothorax? 1- Collapsed neck veins on the affected side 2- Collapsed neck veins on the unaffected side 3- Tracheal deviation towards the affected side 4- Tracheal deviation towards the unaffected side

4 The RN should recognize that a deviation to the unaffected side is an indicator for a pt experiencing a tension pneumothorax. This results from fee air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

An RN is assessing a client who has acute respiratory distress syndrome. Which of the following findings should the nurse report to the provider? 1- Decreased bowel sounds 2- SpO2 of 92% 3- CO2 of 24 mEq/L 4- Intercostal retractions

4 The RN should report retractions becuase this finding indicates that respiratory compromise is increasing in a pt who has ARDS

A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? 1- Requesting vaccination for hepatitis A 2- Using a needleless system in daily work 3- Getting the three-part hepatitis B vaccine 4- Requesting an injection of immunoglobulin

4 The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. T he vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

Based on nutritional screening findings and assessments, which client will be most successful with surgical treatment for obesity? 1- Man with a body mass index (BMI) of 40, weight 75% above ideal body weight 2- Man with a BMI of 41, weight 80% above ideal body weight 3- Woman with a BMI of 38, weight 50% above ideal body weight 4- Woman with a BMI of 42, weight 100% above ideal body weight

4 The best candidate for surgical intervention is the one with a BMI of 40 or more and a weight 100% above the ideal body weight. The other clients do not have a high enough BMI-to-weight ratio to be considered for surgical intervention.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? 1- Administers medication for pain 2- Changes the nasogastric suction level from "intermittent" to "constant" 3- Positions the client in high-Fowler's position 4- Prepares the client for emergency surgery

4 The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention. Pain medication may mask the client's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use. A high-Fowler's position will have no effect on an intestinal perforation or peritonitis, which this client is likely experiencing.

A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders? 1- It affects only young people. 2- The client has dyspnea. 3- The client is coughing. 4- The client is symptom-free between exacerbations.

4 The client may be completely symptom-free between exacerbations.

The nurse answers a client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action? 1- Attempt to remove the obstruction. 2- Call the Rapid Response Team to intubate immediately. 3- Call the Rapid Response Team to perform an emergency cricothyroidotomy. 4- Determine the cause of the obstruction.

4 The first step the nurse should take is to determine the cause of the obstruction. After the cause has been determined (e.g., tongue, food, inflammation), the nurse can decide the next course of action. The obstruction cannot be removed until its origin has been determined. Although notifying the Rapid Response Team is important and the client may require intubation, this is not the first action. An emergency cricothyroidotomy is not the first step to take in relieving an upper airway obstruction. This is an invasive procedure that requires specialized training and equipment that is not readily available at the bedside.

A client demonstrates the manifestations of diverticulitis with a suspected complication of peritonitis. What is the priority nursing intervention? 1- Assessing the client for changes in vital signs 2- Medicating the client for pain 3- Monitoring for changes in the client's mentation 4- Preparing the client for emergency surgery

4 The highest priority for this client is to prepare him or her for emergency surgery so that the source of the infection can be removed. It is expected that the client will experience changes in vital signs as a result of the infectious process and accompanying pain. Although monitoring the client's vital signs is important, the client has an immediate need to go to surgery. Medicating the client for pain and determining whether the client is experiencing changes in mentation are important, but are not the highest priority.

The nurse has taught a client about influenza infection control. Which client statement indicates the need for further teaching? 1- "Handwashing is the best way to prevent transmission." 2- "I should avoid kissing and shaking hands." 3- "It is best to cough and sneeze into my upper sleeve." 4- "The intranasal vaccine can be given to everybody in the family."

4 The intranasal flu vaccine is approved for healthy clients ages 2 to 49 who are not pregnant.

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? 1- "You can quit when you are ready." 2- "It's never too late to quit." 3- "Just turn off your oxygen when you smoke." 4- "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

4 The nurse should use this opportunity to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting. Telling the client it is OK to quit when ready, or that it's never too late to quit, does not address the safety issue of smoking in the presence of oxygen. Recommending that the client turn off the oxygen when smoking encourages the client to remove his or her oxygen source, which could harm the client.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? 1- Providing a quiet environment 2- Encouraging use of the incentive spirometer every 1-2hrs 3- Obtain a blood sample for an electrolyte study 4- Administer heparin via continuous IV infusion

4 The priority should be stabilizing circulation to the lungs by administering heparin to prevent further clot formation.

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? 1- Supine, with a pillow supporting the abdomen 2- Up in a chair between frequent periods of ambulation 3- High-Fowler's position, with pillows used as needed 4- Side-lying position, with knees drawn up to the chest

4 The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis. No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position have any effect on abdominal discomfort related to acute pancreatitis.

The Certified Wound, Ostomy, and Continence Nurse is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects a correct understanding of the necessary self-management skills? 1- "I will have my spouse change the bag for me." 2- "If I have any leakage, I'll put a towel over it." 3- "I need to call my home health nurse to come out if I have any problems." 4- "I will make certain that I always have an extra bag available.

4 The statement that the client will be certain to bring an extra bag is the only statement illustrating that the client is taking responsibility to care for the colostomy. Using a towel is not an acceptable or effective way to cope with leakage. It is not realistic that the home health nurse can make frequent visits for the purpose of colostomy care.

A client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client? 1- Mucolytics decrease secretion production. 2- Mucolytics increase gas exchange in the lower airways. 3- Mucolytics provide bronchodilation in clients with chronic obstructive pulmonary disease. 4- Mucolytics thin secretions, making them easier to expectorate.

4 The term mucolytic means "breaking down mucus." Mucolytics cause secretions to thin, making them easier to expectorate; this is important for a client with chronic bronchitis.

An obese client with a body mass index of 30 and hypertension has been taking over-the-counter (OTC) orlistat (Xenical) 60 mg orally three times a day for 4 weeks and has lost only 10 pounds. What does the nurse anticipate the health care provider will do for this client? 1- Change the medication to phendimetrazine (Bontril). 2- Decrease the amount of the client's medication. 3- Encourage the client to decrease the activity level. 4- Order the prescription-strength orlistat.

4 The usual dosage of orlistat can be 120 mg three times a day, depending on the client's response, but this is prescription-only. The lower-dose formulation may be used OTC. Phendimetrazine (Bontril) is a sympathomimetic drug that suppresses appetite for short-term use along with a structured weight management and exercise program. It acts on the central nervous system, including suppressing the appetite center in the hypothalamus. Clients with hypertension should not take phendimetrazine. Orlistat is being given at a low dose (60 mg), and decreasing it would cause weight loss to occur more slowly. All diet plans include an increase in physical activity; having the client decrease his or her activity level would cause weight loss to be more gradual.

The nurse is caring for a client with severe acute respiratory syndrome. What is the most important precaution the nurse should take when preparing to suction this client? 1- Keeping the head of the bed elevated 30 to 45 degrees 2- Performing oral care after suctioning the oropharynx 3- Washing hands and donning gloves prior to the procedure 4- Wearing a disposable particulate mask respirator and protective eyewear

4 To protect health care workers during procedures that induce coughing or promote aerosolization of particles, nurses should wear a particulate mask respirator and protective eyewear to prevent the spread of infectious organisms.

A client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? 1- Cut a sterile 4 × 4 gauze to fit around the tracheostomy tube. 2- Reinforce the dressing with a sterile 4 × 4 gauze. 3- Replace the dressing with a clean, folded 4 × 4 gauze. 4- Replace the dressing with a sterile, folded 4 × 4 gauze.

4 Tracheostomy dressings may be used to keep the tracheostomy clean and dry. These dressings resemble a 4 × 4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, fold standard sterile 4 × 4s to fit around the tube. The dressing should never be cut because small bits of gauze could then be aspirated through the tube. Dressings should be changed often, not reinforced, because moist dressings provide a medium for bacterial growth, leading to infection.

Which intervention is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today? 1- Measure and record drainage. 2- Monitor aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. 3- Obtain informed consent for the procedure. 4- Have the client void before the procedure is performed.

4 Voiding before the procedure prevents bladder injury. The drainage color and amount will be recorded after the procedure. Liver enzymes are expected to be elevated; this is the purpose of the procedure. The health care provider performing the procedure should discuss the intervention and potential complications with the client and obtain informed consent.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? 1- Right shoulder pain 2- Polyuria 3- Bone marrow suppression 4- Bleeding

4 When monitoring a client post hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority. Discomfort may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

A client has an anal fissure. Which intervention most effectively promotes perineal comfort for the client? 1- Administering a Fleet's enema when needed 2- Applying heat to acute inflammation for pain relief 3- Avoiding the use of bulk-forming agents 4- Using hydrocortisone cream to relieve pain

4 Witch hazel wipes may be effective in relieving the pain associated with anal fissures. Enemas should be avoided when an anal fissure is present. Cold packs should be applied to acute inflammation to diminish discomfort. Bulk-forming agents should be used to decrease pain associated with defecation.

An RN is providing dietary teaching for a client who has chronic pancreatitis. Which of the following food selections by the client indicates an understanding of the teaching? 1- 8oz of whole milk 2- One slice of beef bologna 3- 1 oz cheddar cheese 4- 1 cup sliced banana

4 - Foods that are high in fat can cause diarrhea for clients with pancreatitis. So LOW-FAT and/or HIGH PROTEIN food options should be chosen with an adequate amount of carbs or calories

An RN is assessing a client immediately following a paracentesis for the treatment of acites. Which of the following findings in dicates the procedure was effective? 1- Presence of a fluid wave 2- Increased HR 3- Equal pre & post procedure weights 4- Decreased shortness of breath

4 - Increased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking deep breaths. Once excess fluid is removed, the lungs can expand more freely.

An RN is providing DC instructions for an older adult client who has mild diverticulitis. Which of the following statements by the client indicates an understanding of the teaching? 1- I may experience right lower quad pain 2- I will remain active by working in my garden every day 3- I should eat foods that are low in fiber 4- I will use a mild laxative every day

4 - The RN should instruct the client to eat a LOW fiber diet when inflammation is present. however once inflammation subsides, the client should resume a high fiber diet.

An RN is reviewing the lab values of a client who has colorectal cancer. Which of the following findings should the nurse expect? 1- Neg fecal occult blood test 2- Decreased serum carcinoembryonic antigen level 3- Hematocrit 43% 4- Hemoglobin 9.1 g/dL

4 - This Hbg level is below expected reference range which is an expected finding in colorectal cancer due to occult intestinal bleeding

An RN is reviewing the lab results of a client who has hepatic cirrhosis. Which of the following lab findings should the nurse report to the provider? 1- Albumin 4.0 g/dL 2- INR 1.0 3- Direct bilirubin 0.5mg/dL 4- Ammonia 180 mcg/dL

4 An ammonia level of 180 mcg/dL is above the expected reference range of 10-80 mcg/dL.

An RN is caring for a client who has GERD and a new Rx for metoclopramide. The RN should plan to monitor for which of the following? 1- Thrombocytopenia 2- Hearing loss 3- Hypersalivaiton 4- Ataxia

4 The RN should plan to monitor for signs of EPS such as Ataxia & report any of these findings to the provider.

A client with a tracheostomy is at increased risk for aspiration. Which nursing interventions will reduce this risk? (SATA) 1- Encourage frequent sipping from a cup. 2- Encourage water with meals. 3- Inflate the tracheostomy cuff during meals. 4- Maintain the client upright for 30 minutes after eating. 5- Provide small, frequent meals. 6- Teach the client to "tuck" the chin down in the forward position to swallow.

4,5,6 At least 30 minutes is required for thinner liquids in the stomach to be thickened in combination with stomach contents and/or removed from the stomach; this reduces the chance of aspiration. Eating requires significant time and energy; when the client becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the client less and reduce the chance of aspiration. Tucking the chin downward helps to open the upper esophageal sphincter. Liquids should not be given frequently and should be taken using a spoon to ensure that the client is attempting to swallow only small volumes of liquid; thin liquids such as water are easily aspirated. The tracheostomy cuff should be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? 1- Apply a barrier cream. 2- Assess the area for skin breakdown. 3- Clean the client. 4- Place the client in a side-lying position.

Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection. Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.

The nurse is reviewing orders for a client with possible esophageal trauma after a car crash. Which request does the nurse implement first? 1- Give total parenteral nutrition (TPN) through a central venous catheter. 2- Administer cefazolin (Kefzol) 1 g intravenously. 3- Obtain a computed tomography (CT) scan of the chest and abdomen. 4- Keep the client nothing by mouth (NPO) for possible surgery.

Clients with possible esophageal tears should be NPO until diagnostic testing is completed, because leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing. TPN is prescribed to provide calories and protein for wound healing; although this is important, it is not a priority for the nurse to implement first. Antibiotics may be requested to prevent possible infection, but this is not the priority. A CT of the chest and abdomen will be needed, but is not the nurse's initial action.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective? 1- "I know that I need to avoid warm climates." 2- "I must cover up the affected areas to prevent spread to my family." 3- "I should practice good handwashing technique." 4- "Psoriasis can be cured with steroids."

Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection. Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

The nurse is caring for a client prescribed linezolid (Zyvox) for treatment of methicillin-resistant Staphylococcus aureus infection. The nurse plans to monitor the client for which adverse effect of linezolid? 1- Depression 2- Hyperglycemia 3- Hypertension 4- Incontinence

Linezolid constricts blood vessels and may trigger hypertensive crisis. Depression, hyperglycemia, and incontinence are not adverse effects of linezolid.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? 1- A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis 2- A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography 3- A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy 4- A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes

Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN. Assessment and client teaching should be done by an RN. IV hypnotic medications should be administered by an RN.

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a client diagnosed with esophageal cancer. Which instruction to the client is the highest priority? 1- Place food at the back of the mouth as you eat. 2- Do not be overly concerned with tongue or lip movements. 3- Before swallowing, tilt the head back to straighten the esophagus. 4- Do not attempt to reach food particles that are on the lips or around the mouth.

Placing food at the back of the mouth when eating will help the client avoid aspirating. Both tongue movements and sealing of the lips should be monitored in this client. The client's head should be tilted forward in the chin-tuck position. The client should be able to reach food particles on her or his lips and around the mouth with the tongue.

The nurse admits a client to the clinic who is reporting severe itching of the arms and legs caused by exposure to poison ivy. The nurse anticipates that the health care provider will prescribe which medication? 1- Anthralin (Drithocreme) 2- Benzyl benzoate (Ascabiol) 3- Calcipotriene (Dovonex) 4- Diphenhydramine (Benadryl)

Treatment for inflammations such as poison ivy is aimed at removal of the triggering substance and relief of symptoms. Because the skin reaction is caused by histamine release, antihistamines such as diphenhydramine are helpful. Anthralin is indicated for treatment of psoriasis. Benzyl benzoate is a scabicide indicated for treatment of scabies. Calcipotriene is a synthetic form of vitamin D that is used to treat psoriasis.

An RN in the ED is caring for a pt who is experiencing a pulmonary embolism. Which of the following actions should the RN take first? 1- Apply O2 2- Increase rate of IV fluids 3- Admin pain meds 4- Initiate cardiac monitoring

Using the ABC approach to care the greatest risk to this client is severe hypoxemia. Therefore the priority action should be to apply O2.

A client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? 1- Starting a large-bore IV 2- Administering IV pain medication 3- Preparing equipment for intubation 4- Monitoring the client's anxiety level

1 A large-bore IV should be placed as requested, so that blood products can be administered. IV pain medication is not a recommended treatment for gastrointestinal bleeding. Intubation is not a recommended treatment for bleeding related to PUD. The mental status of the client should be monitored, but it is not necessary to monitor the anxiety level of the client.

A client has been discharged home after surgery for gastric cancer, and a case manager will follow up with the client. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority? 1- Schedule of the client's follow-up examinations and x-ray assessments 2- Information on family members' progress in learning how to perform dressing changes 3- Copy of the diet plan prepared for the client by the hospital dietitian 4- Detailed account of what occurred during the client's surgical procedure

1 Because recurrence of gastric cancer is common, it will be a priority for the client to have follow-up examinations and x-rays, so that a recurrence can be detected quickly. It may take family members a long time to become proficient at tasks such as dressing changes. Although the case manager should be aware of the diet, family members will likely be preparing the client's daily diet, and they should be provided with this information. It is not necessary for the case manager to have details of the client's surgical procedure unless a significant event has occurred during the procedure.

The nurse has placed a nasogastric (NG) tube in a client with upper gastrointestinal (GI) bleeding to administer gastric lavage. The client asks the nurse about the purpose of the NG tube for the procedure. What is the nurse's best response? 1- "Saline goes down the tube to help clean out your stomach." 2- "Medication goes down the tube to help clean out your stomach." 3- "The provider requested the tube to be placed just in case it was needed." 4- "We'll start feeding you through it once your stomach is cleaned out."

1 Gastric lavage involves the instillation of water or saline through an NG tube to clear out stomach contents and blood clots. It does not involve the instillation of medication. An NG tube is not typically placed in a client without a particular purpose in mind. Gastric lavage does not involve enteral feeding.

An older female client is diagnosed with gastric cancer. Which statement made by the client's family demonstrates a correct understanding of the disorder? 1- "This may be related to her recurring ulcer disease." 2- "This is probably curable with surgery." 3- "Gastric cancer has a strong genetic component." 4- "Thank goodness she won't have to undergo surgery."

1 Infection with Helicobacter pylori is the largest risk factor for gastric cancer because it carries the cytotoxin-associated antigen A (CagA) gene. Clients with chronic ulcers are probably infected with this organism. Surgery is not curative; most gastric cancers do not present with symptoms until late in the disease and have a high fatality rate. There is no strong genetic predisposition to gastric cancer. Surgery is part of the treatment.

The nurse is teaching a client with peptic ulcer disease about the prescribed drug regimen. Which statement made by the client indicates a need for further teaching before discharge? 1- "Nizatidine (Axid) needs to be taken three times a day to be effective." 2- "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." 3- "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." 4- "Omeprazole (Prilosec) should be swallowed whole and not crushed."

1 Nizatidine is most effective if administered once daily. A dose of ranitidine at bedtime should decrease acid production throughout the night. Sucralfate should be taken 1 hour before and 2 hours after meals. Because omeprazole is a delayed-release capsule, it should be swallowed whole and not crushed.

A client is scheduled to be discharged after a gastrectomy. The client's spouse expresses concern that the client will be unable to change the surgical dressing adequately. What is the nurse's highest priority intervention? 1- Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the provider 2- Asking the provider for a referral for home health services to assist with dressing changes 3- Asking the spouse whether other family members could be taught how to change the dressing 4- Trying to determine specific concerns that the spouse has regarding dressing changes

1 Providing the client and spouse with both oral and written instructions on symptoms to report to the provider, as well as on how to perform the dressing change, will reinforce important points and boost the spouse's confidence. Obtaining a referral and recruiting other family members prevent the client and spouse from taking responsibility for the client's care. The spouse's concerns have already been clearly expressed.

A client has been diagnosed with terminal gastric cancer and is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? 1- "Pain control is a major component of the care provided by hospice and its staff members." 2- "What has your provider told you about participating in hospice?" 3- "I can speak to your provider about requesting adequate pain medication." 4- "You don't want to become too dependent on pain medication and become an addict."

1 Telling the client that pain control is a major component of hospice care correctly describes the services provided by hospice and its staff members, and reassures the client about their expertise in pain management. Asking the client what the provider has said is an evasive response by the nurse and does not address the client's concerns. The nurse does not need to speak to the provider because pain control is an integral part of hospice services. It is inappropriate to tell a terminally ill client in need of pain control that he or she may become too dependent on pain medication.

While providing teaching to a client undergoing excisional biopsy, which statement does the nurse include? 1- "Administration of local anesthetic agents may cause burning." 2- "The biopsy results will be available within 2 hours of the procedure." 3- "The dressing must remain in place for the first 48 hours." 4- "Redness and swelling at the puncture site are expected."

1- Local anesthetic agents may cause a burning sensation for the client. Biopsy results are typically available 2 to 3 days, or even several weeks, after the procedure. Typically, dressings must remain in place for 8 hours, not 48 hours. Redness and swelling are unexpected after an excisional biopsy, and may be an indication of infection.

A client has a long-term history of Crohn's disease and has recently developed acute gastritis. The client asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response? 1- "Yes, Crohn's disease is known to be a direct cause of the development of chronic gastritis." 2- "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." 3- "What has your doctor told you about how your gastritis developed?" 4- "Yes, a familial tendency to inherit Crohn's disease and gastritis has been reported. Have your other family members been tested for Crohn's disease?"

2 Crohn's disease may be an underlying disease process when chronic gastritis develops, but not when acute gastritis occurs. It is not known to be a direct cause of the disease. Although Crohn's disease tends to run in families, gastritis is a symptom of other disease processes and is not a disease process in and of itself. Asking the client what the doctor has said is an evasive response on the part of the nurse and does not help answer the client's question.

A client with peptic ulcer disease asks the nurse whether a maternal history of gastric cancer will cause the client to develop gastric cancer. What is the nurse's best response? 1- "Yes, it is known that a family history of gastric cancer will cause someone to develop gastric cancer." 2- "If you are concerned that you are at high risk, I recommend speaking to your provider about the possibility of genetic testing." 3- "Have you spoken to your health care provider about your concerns?" 4- "I wouldn't be too concerned about that as long as your diet limits pickled, salted, and processed food."

2 Genetic counseling will help the client determine whether he or she is at exceptionally high risk to develop gastric cancer. The client cannot know for certain whether family history places him or her at exceptionally high risk to develop gastric cancer unless specific testing is done. Asking the client what the provider has said is an evasive answer by the nurse and does not help answer the client's question. Although a diet high in pickled, salted, and processed foods does increase the risk for gastric cancer, a family history of specific types of cancer can also increase the risk.

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? 1- "I will need to avoid sweetened fruit juice beverages." 2-"I can eat ice cream in moderation." 3- "I cannot drink alcohol at all." 4- "It is okay to have a serving of sugar-free pudding."

2 Milk products such as ice cream must be eliminated from the diet of the client with dumping syndrome. The client with dumping syndrome can no longer consume sweetened drinks. Alcohol must be eliminated from the diet. The client can eat sugar-free pudding, custard, and gelatin with caution.

A 49-year-old woman comes to the emergency department with reports of black tarry stools that started 2 weeks ago. In taking a gastrointestinal (GI) history, which questions does the nurse ask that pertain to Gordon's Functional Health Patterns? (Select all that apply.) 1- "Are you having any difficulty having sex? How frequently do you have sex?" 2- "Do you have any difficulty chewing or swallowing?" 3- "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" 4- "What is your usual bowel elimination pattern? Frequency? Character?" 5- "When was your last colonoscopy?"

2,3,5 Chewing or swallowing difficulties affect the client's ability to get food into her GI system. Pain, diarrhea, gas, and foods that cause these symptoms constitute very important data for collection in the GI history. The client needs to be questioned about usual bowel elimination patterns—frequency and character are two descriptors. Colonoscopy history is also elicited from the client. Sexual difficulties and frequency are not generally affected by GI problems; this would not be a routine question in a GI problem inquiry.

The nurse is caring for a client with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the client about porfimer sodium? (Select all that apply.) 1- Avoid sunlight for 2 weeks. 2- Cover all exposed body areas. 3- Follow a clear liquid diet for 3 to 5 days after the procedure. 4- Monitor for hypertension. 5- Tissue particles may be found in the sputum

2,3,5 Porfimer sodium causes photosensitivity, and sunglasses and protective clothing covering all exposed body areas are essential. A clear liquid diet should be followed for 3 to 5 days after the procedure and then should be advanced to full liquids as tolerated. The client should be warned that tissue particles may be released from the tumor site and may be present in the sputum. Sunlight should be avoided for 1 to 3 months. Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium.

The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? (Select all that apply.) 1- Blood-tinged sputum 2- Dyspepsia 3- Excessive salivation 4- Flatulence 5- Regurgitation

2,4,5 Dyspepsia, also known as heartburn, is one of the main symptoms of GERD. Flatulence is common after eating, as well as regurgitation (backward flow into the throat) of food and fluids. Blood-tinged sputum and excessive salivation are not symptoms of GERD.

Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? 1- Clustered round lesions to the chest 2- Five clustered circumscribed lesions on the chest 3- Five diffuse circinate lesions on the chest 4- Several lesions in one area that have well-defined borders

2- "Five clustered circumscribed lesions on the chest" is specific, with correct terminology. "Clustered round lesions to the chest" and "five diffuse circinate lesions on the chest" use incorrect terminology. "Several lesions in one area that have well-defined borders" is too vague to describe the condition accurately.

Which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? 1- 1-mm ecchymotic area on the upper extremity 2- Presence of one of the "ABCDE" features 3- Dark red color 4- Round and raised appearance

2- A lesion with one or more of the ABCDE features (asymmetry, border irregularity, color variation, diameter, evolving features) should be evaluated by a dermatologist or a surgeon. Ecchymosis is a bruise and is not necessarily problematic; it is common after minor trauma. A dark red color or a round and raised appearance is not necessarily problematic.

An older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response? 1- "How does this make you feel?" 2- "How is this affecting you?" 3- "Wear a hat outside to stay warm." 4- "You could wear a wig."

2- Asking the client how she is affected assesses the need for additional counseling. Although asking how the client feels assesses the psychosocial aspect of the problem, it does not direct further action for the nurse.

Which activity for a long-term-care client does the nurse plan to assign to the LPN/LVN? 1- Develop a care plan for a client who has blisters caused by herpes zoster. 2- Administer an antihistamine to a client who is describing pruritus. Correct 3- Teach a client how to self-assess for changes in skin lesions. 4- Perform a baseline skin assessment for a newly admitted client.

2- LPN/LVNs are familiar with safe administration of medications, including monitoring for medication effectiveness and adverse effects.

Which skin condition will the emergency department nurse assess first? 1- Localized redness of the surgical site 2- Pitting edema 3- Poor skin turgor 4- Red bony prominences

2- Pitting edema indicates an electrolyte, cardiac, or renal insufficiency. Localized redness of the surgical site is the body's normal response to trauma. Poor skin turgor is not an urgent finding; it may be caused by age or dehydration. Bony prominences that are red are an important finding, but are not the first priority in this situation.

Which method does the nurse use to assess skin lesions for cancer? 1- American Cancer Society Skin Assessment 2- Asymmetry, border, color, diameter, evolving Correct 3- Dermatologist skin review 4- Size, location, and inflammation

2- The ABCDE (asymmetry, border, color, diameter, evolving) method is the accepted technique for assessing skin lesions. The American Cancer Society Skin Assessment, dermatologist skin review, and "size, location, and inflammation" are not methods for assessing skin lesions.

An older immobile client has "sunk" to the bottom of the bed. What does the nurse do first? 1- Gently pull the client up. 2- Get help and lift the client. 3- Look for broken skin areas. 4- Pad the bony prominences.

2- The client should be gently lifted with a sheet. Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences is not the priority.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan? 1- Take daily tub baths using a mild soap. 2- The infected area should be covered with a clean, dry bandage. 3- Wash the infected areas first, then wash the uninfected areas. 4- Use bath sponges or puffs when bathing.

2- The infected area should be covered with a clean, dry bandage to prevent the spread of infection. The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered; washcloths should be used only once before laundering.

The nurse notices yellowing at the corners of the sclera in an African-American client admitted for hepatitis. What does the nurse do next? 1- Palpates the liver 2- Checks the oral mucosa 3- Examines the client's hair 4- Monitors pulse oximetry

2- To assess dark-skinned clients for jaundice, check for a yellow tinge to the oral mucous membranes, especially the hard palate, and examine the sclera nearest to the iris rather than the corners of the eye

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? 1- Administering a histamine2 (H2) antagonist 2- Initiating enteral nutrition 3- Administering intravenous (IV) fluids 4- Administering antianxiety medication

3 Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding. Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. Administration of antianxiety medication will not treat the basic problem causing the client's change in mental status, which is hypovolemia.

The nurse and the dietitian are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is best for this client? 1- Chicken salad on whole wheat bread 2- Liver and onions 3- Chicken and rice 4- Cobb salad with buttermilk ranch dressing

3 Chicken and rice is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not be allowed to have mayonnaise, onions, or buttermilk ranch dressing; the dressing is made from milk products. The client can have whole wheat bread only in very limited amounts.

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? 1- "It is okay to continue to drink coffee in the morning when I get to work." 2- "I will need to take vitamin B12 shots for the rest of my life." 3- "I should avoid alcohol and tobacco." 4- "I should eat small meals about six times a day."

3 The client with chronic gastritis should avoid alcohol and tobacco. The client should eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client should not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The nurse is instructing a client on skin and sun protection. Which statement by the client indicates a need for further teaching? 1- "I am better protected from the sun because I am dark skinned." 2- "Sunscreen should be applied liberally." 3- "I use a tanning bed to avoid the sun's harmful rays." 4- "My sunglasses are UVA and UVB protected."

3- Tanning beds are just as damaging to the skin as the sun's rays; the client stating that he or she uses a tanning bed indicates that the client needs further teaching.

A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity does the nurse assign to an LPN/LVN working with this client? 1-Teach the client about signs of incisional infection. 2- Instruct the client about how to do dressing changes. 3- Apply an antibiotic ointment and place a sterile dressing on the incision. Correct 4- Complete the written discharge instructions for the long-term-care facility.

3- Wound care is included in practical nursing education.

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs is most indicative of bleeding related to cancer? 1- Respiratory rate from 24 to 20 breaths/min 2- Apical pulse from 80 to 72 beats/min 3- Temperature from 98.9° F to 97.9° F 4- Blood pressure from 140/90 to 110/70 mm Hg

4 A decrease in blood pressure is the most indicative sign of bleeding. A slight decrease in respiratory rate, apical pulse, and temperature is not the primary indication of bleeding.

A client with gastric cancer is scheduled to undergo surgery to remove the tumor once 5 pounds of body weight has been regained. The client is not drinking the vanilla-flavored enteral supplements that have been prescribed. Which is the highest priority nursing intervention for this client? 1- Explain to the client the importance of drinking the enteral supplements prescribed. 2- Ask the client's family to try to persuade the client to drink the supplements. 3- Inform the client that a nasogastric tube may be necessary if he or she fails to comply. 4- Ask the client if a change in flavor would make the supplement more palatable.

4 Asking the client if a change in flavor would help shows that the nurse is attempting to determine why the client is not drinking the supplements. The nurse should not assume that the client does not understand the importance of drinking the supplements or that the client requires persuasion to drink the supplements. The problem may be entirely different. Telling the client that a nasogastric tube may be necessary could be construed as threatening the client.

Which client assessment information is correlated with a diagnosis of chronic gastritis? 1- Anorexia, nausea, and vomiting 2- Frequent use of corticosteroids 3- Hematemesis and anorexia 4- Treatment with radiation therapy

4 Treatment with radiation therapy is known to be associated with the development of chronic gastritis. Anorexia, nausea, and vomiting are all symptoms of acute gastritis. Corticosteroid use and hematemesis are also more likely to be signs of acute gastritis.

During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response? 1- Clubbing of the nail beds 2- Cool extremities 3- Café au lait spots 4- Reddish blue area on the calf

4- A reddish blue area on the calf is indicative of decreased tissue perfusion and requires urgent attention. Clubbing of the nail beds is a chronic symptom, not a postoperative concern. Cool extremities are a normal postoperative occurrence. Café au lait spots are not a postoperative concern.

The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term-care client who has areas of skin breakdown in the skinfolds and the perineal area. Which intervention is best for the RN to delegate to the nursing assistant? 1- Check the client's skin weekly for areas of redness or breakdown. 2- Teach the client and family about the importance of good hygiene in skinfolds. 3- Evaluate the client's ability to provide skin hygiene independently. 4- Bathe the client, and apply a protective barrier to skinfolds and perineum.

4- Assisting clients with personal hygiene is included in nursing assistant education.

The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? 1- "Every morning, I check the biopsy site for signs of infection." 2- "I have been cleaning my face with soap and water." 3- "My appetite is improving lately." 4- "I have been working in my garden for several hours every day."

4- Basal cell carcinomas of the skin are associated with sun exposure. The nurse should further assess the client for knowledge about the association between sun exposure and skin cancers and for use of sunscreens.

The RN is performing an assessment on an older adult client who is in congestive heart failure. Which skin finding during palpation of the extremities is the nurse specifically concerned about? 1- Slight tears on the forearms 2- Fairly widespread dry flakiness 3- Several smaller bruises on the extremities 4- Marked dependent pitting edema

4- Dependent pitting edema may indicate venous and cardiac insufficiency in clients with congestive heart failure. Skin tears may occur where adhesive tapes or dressings have been applied and removed, especially in older clients with fragile skin. Dry skin usually has scaling and flaking, and may be especially marked in areas of limited circulation such as the feet and lower legs. It is a common problem during the winter months when the air contains less moisture, in geographic areas with little humidity, and in the hospital environment where humidity is often low. In older adults, bruising is common after minor trauma to the skin.

The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition? 1- Cystic fibrosis 2- Iron deficiency anemia 3- Isolated periods of severe malnutrition 4- Psoriasis

4- Pitting of the nails may be associated with plate thickening and onycholysis and most often involves several or all of the fingernails; it is seen in clients with psoriasis and alopecia areata. Late clubbing of the fingernails is a sign of cystic fibrosis. Spoon nails (koilonychias) are a sign of iron deficiency anemia. Beau's grooves are a sign of isolated periods of severe malnutrition.

The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action does the nurse take first? 1- Add potassium hydroxide to the specimen to check for a possible fungal infection and inspect it under the microscope. 2- Soak the crust of a possible bacterial lesion with normal saline. 3- Instruct the client who has had a punch biopsy about wound care. 4- Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.

4- To obtain accurate results for clients who need viral cultures, the cultures should be immediately placed on ice and transported to the laboratory. Adding potassium hydroxide to the specimen to check for a possible fungal infection before inspecting it under the microscope, soaking the crust of a possible bacterial lesion with normal saline, and instructing the client about wound care do not require immediate action.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? 1- Auscultate the abdomen to determine the presence of bowel sounds. 2- Notify the provider about this finding immediately. 3- Palpate the client's abdomen to determine the outlines of the mass. 4- Question the client about recent stool habits.

A bulging, pulsating mass may indicate an abdominal aortic aneurysm, and the nurse should notify the provider immediately. Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) unit? 1- A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) 2- A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy 3- A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention 4- A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure

A nurse who has experience with chronic GI problems will have experience and training in instructing clients on colonoscopy preparation.

Which factors place a client at risk for gastrointestinal (GI) problems? (Select all that apply.) 1- Eating a high-fiber diet 2- Smoking a half-pack of cigarettes per day 3- Socioeconomic status 4- Some herbal preparations 5- Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

ALL except 1 Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding. High-fiber diets are generally believed to be healthy for most clients.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ)? 1- LLQ, RLQ, LUQ, RUQ 2- LUQ, LLQ, RUQ, RLQ 3- RLQ, LLQ, RUQ, LUQ 4- RUQ, LUQ, RLQ, LLQ

Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult.

A client with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? 1- "Consume carbonated beverages if you experience stomach upset." 2- "Remain on a soft diet for about a week and avoid raw fruits and vegetables." 3- "You may resume running and weight lifting if you wish." 4- "You may stop taking your anti-reflux medications after 1 week."

After LNF, clients should be taught to remain on a soft diet for 1 week. Carbonated beverages should be avoided. Clients may walk, but should avoid heavy lifting. Anti-reflux medications should be taken for 1 month after the procedure.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration? 1- Calcium 2- Hematocrit 3- Numbers of immature white blood cells (WBCs) 4- Serum albumin

Albumin measures protein, which is necessary for healing; increased serum albumin indicates successful collaboration with the dietitian. Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? 1- "No, they probably won't be useful. You should use only prescription medications in your treatment plan." 2- "These herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen." 3- "Yes, these are known to be effective in managing this disease, but make sure you research the herbs thoroughly before taking them." 4- "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe."

Although licorice and slippery elm may be helpful in managing PUD, the client should consult his or her health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her provider.

The nurse is caring for a client with a hiatal hernia who had an open fundoplication yesterday. Which task does the nurse delegate to unlicensed assistive personnel (UAP)? 1- Using a pillow to support the incision when the client coughs 2- Adjusting the position of the nasogastric (NG) tube 3- Assessing the level of postoperative pain using a 0-to-10 scale 4- Giving the client sips of water once bowel sounds are heard

Assisting a client to cough is a task within the education and skill level of UAP. NG tube maintenance, pain assessment, and assessment of bowel sounds require more knowledge of the potential complications associated with this surgical procedure, and are actions best performed by licensed nursing staff.

What is a common gastrointestinal problem that older adults experience more frequently as they age? 1- Decreased hydrochloric acid 2- Excess lipase production 3- Increased liver enzymes 4- Increased peristalsis

Atrophy of the gastric mucosa causes a decreased ratio of gastrin-secreting cells to somatostatin-secreting cells. This results in a decrease in hydrochloric acid, causing decreased absorption of iron and vitamin B12.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? 1- Avoiding or reducing skin exposure to sunlight 2- Avoiding tanning beds 3- Being aware of skin markings and performing skin self-examination 3- Wearing SPF 40 sunscreen

Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). Avoiding tanning beds is significant, but is not the most important technique. It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2° F (37.9° C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? 1- Give cefazolin (Ancef) 500 mg IV. 2- Infuse normal saline at 200 mL/hr. 3- Give morphine sulfate 2 mg IV. 4- Provide oxygen at 6 L/min per nasal cannula. Correct

Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation. The most immediate concern involves respiratory status, so the client should be placed on oxygen first. An antibiotic request is important, but is not the first priority. Fluid supplementation is important, but the client's oxygen saturation level places the client's respiratory status as the priority. The client's need for analgesia should be delayed until respiratory status is addressed. Morphine depresses respiratory status and therefore might not be the right choice for this client.

The nurse is working with the dietitian to plan a menu for a client who has persistent difficulty swallowing. What is a suitable breakfast selection for this client? 1- Scrambled eggs and toast 2- Oatmeal and orange juice 3- Puréed fruit and English muffin 4- Cream of wheat and applesauce

Both cream of wheat and applesauce are foods of semi-solid consistency and are appropriate for this client. The client who is having difficulty swallowing should be given semi-solid foods and thickened liquids. Toast would not be appropriate, and orange juice would have to be thickened before it is given to this client. An English muffin would be inappropriate for this client because it is not a semi-solid food.

A client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea? 1- Ensure that the client takes adequate amounts of fluids with meals. 2- Advance the diet to solid food and encourage eating as much as possible at meals. 3- Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal. 4- Encourage the client to take fluids between meals rather than with meals.

Diarrhea is believed to be the result of vagotomy syndrome and can be managed by taking fluids between meals rather than with meals. For this client, fluids with meals can lead to the development of diarrhea immediately after eating. The client may not be physically ready to advance to a solid diet. The client should eat six to eight small meals daily. Magnesium hydroxide is a magnesium-based antacid that can cause diarrhea.

The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea? 1- Loperamide (Imodium) 2- Mesalamine (Pentasa) 3- Minocycline (Minocin) 4- Pantoprazole (Protonix)

Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery. It can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide. Mesalamine is used to treat clients with mild to moderate ulcerative colitis. Minocycline is an antibiotic used for treatment of infection. Pantoprazole is used to treat gastroesophageal reflux disease.

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? 1- A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) 2- A 54-year-old who is ready for discharge following a colonoscopy 3- A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing 4- A 60-year-old with questions about an endoscopic ultrasound examination

ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The other clients are not at risk for depressed respiratory status.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? 1- Encourages participation in care of the wound 2- Encourages visitors 3- Says, "I know how you feel" 4- Assures the client that it will be all right

Encouraging participation in wound care gives the client a sense of autonomy. Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.

A client has a routine sigmoidoscopy with a tissue biopsy. What complication is the nurse looking for in a post-op assessment? 1- Excessive diarrhea 2- Heavy bleeding Correct 3- Nausea and vomiting 4- Severe rectal pain

Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Excessive diarrhea, nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy.

The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? 1- "After I hear bowel sounds, you can have a drink." 2- "Twenty minutes after the procedure was completed, you may have some liquids." 3- "When you are able to pass flatus (gas), you can have a drink." 4- "You can have fluids when you get home and are settled."

Fluids are permitted after the client's peristalsis has returned, which is validated by the client's passing flatus, not by auscultation of bowel sounds. There is no set time period after the procedure that is considered safe for the client to have something to drink.

A client has an odorous, purulent wound. How does the nurse best support this client? 1- Changes the dressing frequently 2- Encourages a diet high in protein 3- Suggests whirlpool therapy 4- Places room deodorizers in the room

Frequent dressing changes help the client feel clean. A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? 1- Massage the reddened areas. 2- Pad the ulcer. 3- Promote mobility and/or frequent re-positioning. 4- Suggest an egg crate mattress.

Frequent re-positioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer. Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option

The nurse working in the same-day-surgery unit has just received report and plans to assess which client first? 1- Adult with a basal cell carcinoma excised who needs discharge teaching about wound care 2- Young adult who has had rhinoplasty and is swallowing frequently 3- Middle-aged adult who reports 7/10 pain after removal of a cyst 4- Older adult ready to be transferred to a long-term-care facility after débridement of a pressure ulcer

Frequent swallowing after rhinoplasty may indicate bleeding, which requires immediate action by the nurse. Discharge teaching, controlling pain, and client transfers are all important, but are not priorities because each of these clients is stable and not experiencing a postoperative complication that requires immediate attention.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? 1- Hyperbaric oxygen 2- Nutrition therapy 3- Topical growth factors 4- Vacuum-assisted wound closure

Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers. Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically débrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? 1- Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation 2- Examines the RUQ of the abdomen last 3- Has the client lie in a supine position with legs straight and arms at the sides 4- Views the abdomen by looking directly down while standing over the client's abdominal area

If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult. The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation.

A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother? 1- "Wash your hands frequently." 2- "Your child may return to school, but must be isolated from the rest of the class." 3- "Keep the site covered with a bandage." 4- "Keep your child out of school until the infection has cleared."

Keeping the site covered prevents spread of the infection. Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.

The nurse is teaching a client with loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client's teaching plan? 1- Lift hips off the chair at least every hour. 2- Eat a low-fat diet. 3- Massage reddened areas. 4- Complete a pressure map.

Lifting the hips off the chair at least every hour relieves pressure and can prevent pressure ulcers. Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.

The nursing instructor reviews instructions with the nursing student on caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? 1- Massages bony prominences 2- Avoids reddened areas 3- Re-positions the client every 1 to 2 hours 4- Uses a moisturizing lotion

Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be re-positioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.

Which substance, produced in the stomach, facilitates the absorption of vitamin B12? 1- Glucagon 2- Hydrochloric acid 3- Intrinsic factor 4- Pepsinogen

Parietal cells in the stomach produce intrinsic factor, a substance that facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.

A client has had a melanoma lesion removed. For secondary prevention, what is important for the nurse to teach the client? 1- Ensure that all lesions are reviewed by a dermatologist or a surgeon. 2- Avoid sun exposure. 3- Perform a total skin self-examination monthly. 3- Perform a total skin self-examination monthly with a partner.

Performing a monthly total skin self-examination with another person is the best secondary preventive measure. If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. It is difficult for a person to assess all of the skin surfaces of his or her body by him- or herself, even with the use of mirrors. It is better to involve a partner with the assessment.

The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? 1- Acute diarrhea 2- Aortic aneurysm 3- Intestinal obstruction 4- Pancreatitis

Peristaltic movements are rarely seen except in thin clients and should be reported since the finding may indicate an intestinal obstruction.

A client who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? 1- "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." 2- "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed." 3- "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." 4- "You need to talk to your doctor about your concerns. The doctor may recommend that you join a support group for cancer survivors."

Suggesting that the client invite people over for a meal provides psychosocial support to the client and assists the client in finding a solution to the problem. Telling the client not to worry about it or to call the provider is evasive and unhelpful; it is used to placate the client and does not address the client's concerns. The client should use problem-solving and coping skills before resorting to the use of medication.

A client has been diagnosed with mild gastroesophageal reflux disease and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this client? 1- "Avoid caffeine-containing foods and beverages." 2- "Eat three meals each day and avoid snacking between meals." 3- "Peppermint lozenges help to reduce stomach upset." 4- "Sleep on your left side with a pillow between your knees."

Teach the client to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn, such as peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Remind the client to eat four to six small meals each day rather than three large ones. Peppermint decreases LES pressure and increases the risk of symptoms. Clients should be taught to elevate the head by 6 to 12 inches for sleep to prevent nighttime reflux

The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? 1- "A barium enema every 5 years is a screening option." 2- "I will need to have a routine colonoscopy every 5 years." 3- "My routine flexible sigmoidoscopy every 5 years is OK." 4- "The 'virtual' colonoscopy every 5 years is acceptable."

The 2010 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years. Other options are performed at 5-year intervals. A barium enema every 5 years is a screening option. A flexible sigmoidoscopy and a "virtual" colonoscopy every 5 years are also acceptable for screening.

The nurse is assessing a client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? 1- Asking the client whether he or she has passed flatus (gas) 2- Auscultating bowel sounds in all abdominal quadrants 3- Counting the number of bowel sounds in each abdominal quadrant 4- Observing the abdomen for symmetry and distention

The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method.

A client has been diagnosed with terminal esophageal cancer. The client is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? 1- "Haven't you received adequate pain management in the hospital?" 2- "Would you like me to get a nurse from hospice to come talk with you?" 3- "Do you want me to call the hospital chaplain to explain hospice to you?" 4- "Talk to your health care provider about hospice services."

The best way to alleviate the client's concerns would be to have a hospice nurse talk with the client and answer any questions. Suggesting that the client has had adequate pain management sounds defensive. Referring the client to the chaplain or the health care provider is evasive and attempts to shift responsibility away from the nurse.

A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? 1- "Begin a clear liquid diet 12 to 24 hours before the test." 2- "Do not eat or drink anything for 12 hours before the test." 3- "Give yourself tap water enemas until the fluid returns are clear." 4- "You will have to drink a contrast liquid 2 hours before the test."

The client is instructed to be on a liquid diet for 12 to 24 hours to cleanse the bowel before a colonoscopy. The client must be NPO (except for water) 4 to 6 hours before a colonoscopy. The client is instructed to drink a liquid preparation for cleaning the bowel (such as sodium phosphate) the evening before the colonoscopy, and may repeat that procedure on the morning of the test. In some cases, the client may require laxatives, suppositories, or one or more small-volume (i.e., Fleet) cleansing enemas. The client is not given an oral contrast liquid to swallow for a colonoscopy.

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a client's hiatal hernia. Which change does the nurse recommend to this client? 1- Eat only two or three meals daily. 2- Sleep flat in a left side-lying position. 3- Drink tea instead of coffee. 4- Avoid working while bent over the computer.

The client should avoid working while bent over because this position presses on the diaphragm, causing discomfort. The client with a hiatal hernia should eat four to six meals a day. The head of the client's bed should be elevated approximately 6 inches. Both tea and coffee should be eliminated from this client's diet because of the caffeine content.

A client with newly diagnosed irritable bowel syndrome (IBS) reports having five to six loose stools daily. What is the common psychological client response to this gastrointestinal health problem? 1- Acceptance 2- Embarrassment 3- Euphoria 4- Grief

The client who has a new onset of IBS with frequent stools most likely would be embarrassed. The client normally would not react to a new onset of IBS with acceptance or grief. It would be an abnormal reaction for the client to feel euphoria over a new onset of IBS.

The nurse is teaching a client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client? 1- Body image counseling 2- Respiratory protection 3- Self-suctioning 4- Tobacco cessation education

The epidermis is the outer layer of the skin. Damage to the epidermis can cause body image disturbance for clients. Respiratory protection, self-suctioning, and tobacco cessation education are not related to damage to the epidermis.

A client in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? 1- Teach the client about antacid effects and side effects. 2- Ask the client about medications and dietary intake. 3- Suggest that the client sleep with the head elevated 6 inches. 4- Tell the client to avoid drinking alcohol late in the evening.

The nurse's initial action should be further assessment of the client's risk factors for gastroesophageal reflux disease. Before suggesting interventions or beginning client teaching, the nurse must elicit more information about the client's symptoms. The nurse needs additional data before telling the client to avoid drinking alcohol late in the evening.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? 1- Use the Braden Scale to determine pressure ulcer risk for a newly admitted client. 2- Complete daily sterile dressing changes for a client with a venous leg ulcer. 3- Every 2 hours, re-position a client who has had a stroke and is incontinent. 4- Admit a newly transferred client who had pedicle flap surgery 1 week ago.

The nursing assistant has the education and scope of practice to re-position a client. Using the Braden Scale, changing a sterile dressing, and client admissions are actions that should be done by licensed nursing staff who have broader education and scope of practice.

Which of these assigned clients does the nurse assess first after receiving the change-of-shift report? 1- Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography (CT) scan in 30 minutes 2- Adult with gastroesophageal reflux disease (GERD) who is describing epigastric pain at a level of 6 (0-to-10 pain scale) 3- Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube 4- Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as-needed (PRN) basis

The presence of blood in NG drainage is an unexpected finding 2 days after esophagogastrectomy and requires immediate investigation. The young adult scheduled for a CT scan, the adult with GERD, and the older adult with an ileus are all stable and do not require the nurse's immediate attention.

The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease who has been prescribed esomeprazole (Nexium) once daily. The client reports that the drug doesn't completely control the symptoms. The nurse contacts the provider to discuss which intervention? 1- Adding a second proton pump inhibitor medication 2- Increasing the dose of esomeprazole 3- Changing to a twice-daily dosing regimen 4- Switching to omeprazole (Prilosec)

The proton pump inhibitors are usually effective when given once daily, but can be given twice daily if symptoms are not well controlled. Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.

A client with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? 1- Teaching family members how to determine whether the client is obtaining adequate nutrition 2- Assessing lung sounds for possible aspiration when the client is swallowing clear liquids 3- Reminding the client to use the chin-tuck technique each time the client attempts to swallow 4- Instructing family members about symptoms that may indicate a need to call the provider

The role of a home health aide when caring for a client with swallowing difficulty includes reinforcement of previously taught swallowing techniques. Client teaching and providing instructions to family members are not within the scope of practice of a home health aide and should be done by the nurse. Likewise, assessment is part of the nursing process and should be done by a nurse.

In teaching a client about skin cancer prevention, which instruction does the nurse include? 1- "Avoid sun exposure between 11 a.m. and 3 p.m." 2- "Examine your skin quarterly for possible cancerous or precancerous lesions." 3- "Wear transparent clothing to protect your skin from the sun." 4- "If you feel you must tan, use a tanning bed."

The sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time. Skin should be examined at least monthly. Opaque clothing should be worn to protect the skin from the sun. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

A client is admitted to the hospital with elevated serum amylase and lipase levels and a decreased calcium level. Which gastrointestinal health problem is indicated by these laboratory findings? 1- Acute pancreatitis 2- Cirrhosis 3- Crohn's disease 4- Diarrhea

These laboratory values are commonly found in clients with acute pancreatitis. They are not indicative of cirrhosis of the liver or Crohn's disease. These laboratory values are not found in a client with diarrhea.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for? 1- Anemia 2- Decreased wound healing 3- Pressure ulcer development 4- Weight gain

This client is at risk for pressure ulcer if he or she remains bedridden. Anemia and weight gain have no correlation with this client's protein deficiency. The client does not have an indicated wound.

A client with bacteremia associated with a bacterial skin infection is receiving clindamycin (Cleocin) intravenously. Which assessment finding indicates the need for immediate action by the nurse? 1- Blood pressure of 88/40 mm Hg 2- White blood cell count of 15,000/mm3 3- Oral temperature of 101° F (38.3° C) 4- Heart rate of 102 beats/min

Too-rapid administration of clindamycin can cause shock and cardiac arrest; the client's low blood pressure indicates a need to slow the rate and re-assess the client. An elevated white blood cell count, an elevated temperature, and an elevated heart rate are expected findings in a client with bacteremia.

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? 1- "A tanning bed will supply the ultraviolet light I need." 2- "Medicine can prevent the growth of new skin cells." 3- "I can never be cured." 4- "Stress can cause my flare-ups."

Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients; this statement indicates that the client requires further teaching. Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

The nurse prepares to administer vancomycin (Vancocin) to a client diagnosed with methicillin-resistant Staphylococcus aureus infection. How does the nurse administer this medication? 1- By bolus 2- IV push 3- Infused over 60 minutes 4- Mix with the primary IV bag

Vancomycin is irritating to the veins and can trigger thrombophlebitis; it should be given over at least 60 minutes. Vancomycin should not be given by bolus or by IV push, and it should not be mixed with the primary IV bag. It is administered IV piggyback or through a saline or heparin lock.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? 1- Asks the client if he is squeamish 2- Demonstrates how to change the dressing 3- Determines whether the client can reach the affected area 4- Provides all of the necessary dressing materials

Whether the obese client can access the dressing site is the most important thing to assess; if the dressing site cannot be accessed by the client, it will be difficult for the client to perform frequent dressing changes at home. The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

A client is being discharged after a minimally invasive esophagectomy. Which teaching point does the nurse consider to be of the highest priority during the predischarge teaching session? 1- Instruct the client to eat three meals daily. 2- Emphasize the importance of lying down after meals. 3- Encourage the client to ask his or her health care provider for antidepressant medication. 4- Report the presence of fever and a swollen, painful neck incision.

Wound management and prevention of infection are major concerns because the client who has had an esophagectomy typically has multiple drains and incisions. The client should eat six to eight small meals daily, and should sit up after meals to encourage satisfactory swallowing. The client's coping skills should be assessed, as well as his or her level of anxiety and/or depression, before antidepressant medication is prescribed.