Adult Nursing Exam III evolve

A patient had a gastric resection for stomach cancer. The nurse plans to teach the patient about decreased secretion of which hormone? A. Gastrin B. Secretin C. Cholecystokinin D. Gastric inhibitory peptide

A

A patient with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? A.Fever and abdominal pain B. Flatulence and liquid stool C. Loudly audible bowel sounds D. Sleepiness and abdominal cramps

A

The nurse is preparing a patient for a capsule endoscopy. What should the nurse ensure is included in the preparation? A. Ensure the patient understands the required bowel preparation. B. Have the patient return to the procedure room for removal of the capsule. C. Teach the patient to maintain a clear liquid diet throughout the procedure. D. Explain to the patient that conscious sedation will be used during capsule placement.

A

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care should the incoming nurse plan to deliver (select all that apply.)? A. Giving the patient insulin if needed B. Ensuring that the next bag has been ordered C. Checking amount of solution left in the bag D. Assessing the insertion site and change the tubing E. Verifying the accuracy of the new solution and ingredients

A, B, C, E

The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply.)? A. Administer bolus or continuous feedings. B. Evaluate the nutritional status of the patient. C. Administer medications through the gastrostomy tube. D. Monitor for complications related to the tube and enteral feeding. E. Teach the caregiver about feeding via the gastrostomy tube at home.

A, C

A malnourished patient has been diagnosed with protein deficiency. Which complications should the nurse anticipate (select all that apply.)? A. Edema B. Asthma C. Anemia D. Malabsorption syndrome E. Impaired wound healing F. Gastrointestinal bleeding

A, C, E

A patient is scheduled for surgery with general anesthesia in 1 hour and is observed with a moist but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? A. Easily heard, loud gurgling in abdomen B. High-pitched, hollow sounds in abdomen C. Tenderness in left upper quadrant upon palpation D. Flat abdomen without movement upon inspection

A.

A frail older adult with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. Which foods would the nurse suggest for breakfast? A. Orange juice and dry toast B. Oatmeal with butter and cream C. Waffles with fresh strawberries D. Banana and unsweetened yogurt

B

A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? A. Muscle weakness B. Cardiac dysrhythmias C. Increased urine output D. Anemia and leukopenia

B

A patient is being admitted with anorexia nervosa. Which clinical manifestations should the nurse anticipate? A. Sensitivity to heat, fatigue, and polycythemia B. Hair loss; dry, yellowish skin; and constipation C. Tented skin turgor, hyperactive reflexes, and diarrhea D. Dysmenorrhea, hypoactive bowel sounds, and hunger

B

A patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? A. "I am allergic to bee stings." B. "My tongue swells when I eat shrimp." C. "I have had epigastric pain for 2 months." D. "I have a pacemaker because my heart rate was slow."

B

A patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse? A. Blood glucose level of 125 mg/dL B. Serum phosphate level of 1.9 mg/dL C. White blood cell count of 10,500/µL D. Serum potassium level of 4.6 mEq/L

B

A patient who cannot afford enough food for her family states she only eats after her children have eaten. At a clinic visit, she reports bleeding gums; loose teeth; and dry, itchy skin. Which vitamin deficiency would the nurse suspect? A. Folic acid B. Vitamin C C. Vitamin D D. Vitamin K

B

A patient who has sustained severe burns in a motor vehicle accident is starting parenteral nutrition (PN). Which principle should guide the nurse's administration of PN? A. Administration of PN requires clean technique. B. Central PN requires rapid dilution in a large volume of blood. C. Peripheral PN delivery is preferred over the use of a central line. D. Only water-soluble medications may be added to the PN by the nurse.

B

An older adult patient is seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? A. Anosmia B. Xerostomia C. Hypochlorhydria D. Salivary gland tumor

B

Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What does the nurse recognize is the most likely etiology for this abnormal assessment finding? A. Herpesvirus B. Candida albicans C. Vitamin deficiency D. Irritation from ill-fitting dentures

B

The nurse is evaluating the nutritional status of a patient undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would best indicate the patient has protein-calorie malnutrition (PCM)? A. Serum transferrin B. Serum prealbumin C. C-reactive protein (CRP) D. Alanine transaminase (ALT)

B

The nurse is teaching a patient with type 1 diabetes mellitus who had surgery to revise a lower leg stump with a skin graft about nutrition. What food should the nurse teach the patient to eat to best facilitate healing? A. Nonfat milk B. Chicken breast C. Fortified oatmeal D. Olive oil and nuts

B

Which focused assessments would have priority in the care of a patient recently started on parenteral nutrition (PN)? A. Skin integrity and skin turgor B. Electrolyte levels and daily weights C. Auscultation of lung and bowel sounds D. Peripheral edema and level of consciousness

B

The nurse should recognize that the liver performs which functions (select all that apply.)? A. Bile storage B. Detoxification C. Protein metabolism D. Steroid metabolism E. Red blood cell (RBC) destruction

B, C, D, E

A patient is suspected of having acute pancreatitis after presenting to the emergency department with severe abdominal pain. Which laboratory result would best indicate the presence of acute pancreatitis? A. Gastric pH of 1.4 B. Blood glucose of 104 C. Serum amylase of 420 U/L D. Serum potassium of 3.5 mEq/L

C

A patient who has dysphagia after a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into the plan of care? A. Use 30 mL of normal saline to flush the tube every 4 hours. B. Avoid flushing the tube any time the patient is receiving continuous feedings. C. Flush the tube before and after feedings if the patient's feedings are intermittent. D. Flush the PEG with 100 mL of sterile water before and after medication administration.

C

A patient with abdominal pain is being prepared for surgery to make an incision into the common bile duct to remove stones. What procedure will the nurse prepare the patient for? A. Colectomy B. Cholecystectomy C. Choledocholithotomy D. Choledochojejunostomy

C

The nurse is assessing a patient admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? A. Tympany to abdominal percussion B. Aortic pulsation visible in epigastric region C. High-pitched sounds on abdominal auscultation D. Liver border palpable 1 cm below the right costal margin

C

The nurse is performing an abdominal assessment for a patient. Which assessment technique by the nurse is most accurate? A. Palpate the abdomen before auscultation. B. Percuss the abdomen before auscultation. C. Auscultate the abdomen before palpation. D. Perform deep palpation before light palpation

C

The nurse is providing care for a patient who is a strict vegetarian. Which dietary choices would the nurse recommend to prevent iron deficiency? A. Brown rice and kidney beans B. Cauliflower and egg substitutes C. Soybeans and hot breakfast cereal D. Whole-grain bread and citrus fruits

C

The nurse recognizes that the majority of patients' caloric needs should come from which source? A. Fats B. Proteins C. Polysaccharides D. Monosaccharides

C

When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? A. Ingestion B. Digestion C. Absorption D. Elimination

C

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. Which action has the highest priority before initiating enteral feedings? A. Testing aspirated fluid pH B. Auscultating while instilling air C. Elevating head of bed to 40 degrees D. Verifying NG tube placement on x-ray

D

A patient reports severe pain when the nurse assesses for rebound tenderness. What may this assessment finding indicate? A. Hepatic cirrhosis B. Hypersplenomegaly C. Gallbladder distention D. Peritoneal inflammation

D

A patient was involved in a motor vehicle crash and reports an inability to have a bowel movement. What is the best response by the nurse? A. "You are just too nervous to eat or drink, so there is no stool." B. "Your parasympathetic nervous system is now working to slow the GI tract." C. "The circulation in the GI system has been increased, so less waste is removed." D. "Your sympathetic nervous system was activated, so there is slowing of the GI tract".

D

A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Irrigate the tube between feedings. B. Provide wound care at the gastrostomy site. C. Administer prescribed liquid medications through the tube. D. Position the patient with a 45-degree head of bed elevation.

D

After identifying that a patient has possible nutritional deficits, which action will the nurse perform next? A. Provide supplements between meals. B. Encourage eating meals with others. C. Have family bring in food from home. D. Complete a full nutritional assessment.

D

The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen? A. Left lower quadrant B. Left upper quadrant C. Right lower quadrant D. Right upper quadrant

D

The nurse is reviewing the home medication list for a patient admitted with suspected hepatic failure. Which medication reviewed by the nurse could cause hepatotoxicity? A. Digoxin B. Nitroglycerin C. Ciprofloxacin D. Acetaminophen

D

The nurse is reviewing the laboratory test results for a patient with metastatic lung cancer who was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. How will the nurse interpret these results? A. The albumin level is normal therefore the patient does not have protein malnutrition. B. The albumin level is increased, which is common in patients with cancer who have malnutrition. C. Both the serum albumin and prealbumin levels are reduced, consistent with the diagnosis of malnutrition. D. Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

D.

Lung Volume NORMAL VALUES Tidal Volume (Tv)- Expiratory Reserve Volume (ERV)- Residual Volume (RV)- Inspiratory Reserve Volume (IRV)-

0.5 L 1.0 L 1.5 L 3.0 L

A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? 1 "Cover your cough with your forearm." 2 "Dispose of used paper tissues in a paper bag." 3 "Encourage your roommate to get the flu vaccine." 4 "Move out of your apartment until you are over the cold."

1

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding? 1 There is less chance of aspiration. 2 This procedure does not require a pump. 3 Self-administration of the feeding is possible. 4 More tube feeding mixture can be given each time.

1

A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How does the preceptor evaluate the suitability of the instructions given to the client by the orientee? 1 Appropriate; oral intake after the procedure may result in aspiration 2 Appropriate; it is important to limit painful swallowing 3 Inappropriate; the client is too groggy after general anesthesia to comprehend information 4 Inappropriate; fluid replacement should begin immediately after the procedure

1

After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, how is mild exercise expected to affect respirations? 1 Increase to 24 breaths per minute 2 Become progressively more difficult 3 Decrease in rate as their depth increases 4 Become irregular but remain within normal rates

1

What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder? 1. Palpate the lymph nodes. 2. Inspect the mouth. 3. Inspect the neck symmetry. 4. Assess the symmetry of enlarged tonsils, if present. 5. Observe the rise and fall of the soft palate.

1. Inspect the mouth. 2. Observe the rise and fall of the soft palate. 3. Assess the symmetry of enlarged tonsils, if present. 4. Inspect the neck symmetry. 5. Palpate the lymph nodes.

Which order of actions should a nurse follow when performing a chest examination of a client with a pulmonary disorder? 1. Monitor the respiratory rate. 2. Observe for any abnormalities of the sternum. 3. Observe for any evidence of respiratory distress. 4. Observe the shape and symmetry of the chest.

1. Observe for any evidence of respiratory distress. 2. Observe the shape and symmetry of the chest. 3. Observe for any abnormalities of the sternum. 4. Monitor the respiratory rate.

A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client? 1 Localized tissue necrosis 2 Carbon dioxide retention 3 Increased respiratory rate 4 Saturated hemoglobin molecules

2

A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home? 1 Oximetry 2 Spirometry 3 Capnography 4 Ventilation-perfusion

2

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1 Low purine 2 Low calcium 3 High phosphorus 4 High alkaline ash

2

Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? 1 Asthma 2 Emphysema 3 Chronic bronchitis 4 Centrilobular emphysema

2

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. 1 Polyps 2 Gag reflex 3 Shotty nodes 4 Poor dentition 5 Gum retraction

2, 4, 5

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood

3

A nurse evaluates that a client with chronic kidney disease understands an adequate source of high biologic-value (HBV) protein when the client selects which food from the menu? 1 Apple juice 2 Raw carrots 3 Cottage cheese 4 Whole wheat bread

3

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? 1 Administering oxygen 2 Using an incentive spirometer 3 Having the client breathe into a paper bag 4 Administering an IV containing bicarbonate ions

3

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? 1 Dyspnea 2 Hyperpnea 3 Kussmaul breathing 4 Cheyne-Stokes breathing

3

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? 1 Initiate oxygen therapy 2 Obtain chest x-ray film immediately 3 Place client in a high-Fowler position 4 Assess the client for a pleural friction rub

3

The parents of a toddler with newly diagnosed cystic fibrosis (CF) tell a nurse that even though they were told it is an inherited disorder, there is no history of CF in the family. How can the nurse clarify the way in which the disease was inherited? 1 It is a mutated gene. 2 It involves an X-linked gene. 3 The inheritance is autosomal recessive. 4 The inheritance is autosomal dominant.

3

Which sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs? 1 Vesicular 2 Bronchial 3 Adventitious 4 Bronchovesicular

3

Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate 3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli

3

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? 1 Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history 2 Assess vital signs, obtain a history, and arrange for emergency x-ray films 3 Conduct a thorough physical assessment, assess vital signs, and cover open wounds 4 Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

4

A nurse is planning an evening snack for a child receiving NPH insulin. What is the reason for this nursing action? 1 It encourages the child to stay on the diet. 2 Energy is needed for immediate utilization. 3 Extra calories will help the child gain weight. 4 Nourishment helps counteract late insulin activity.

4

A nurse is teaching parents about treating their infant's recurrent attacks of spasmodic croup at home. What is the desired effect of the actions that the nurse teaches the parents? 1 Dilation of the bronchi 2 Reduction of the fever 3 Depression of the cough 4 Interruption of the spasm

4

A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do? 1 Request that the client's food be pureed. 2 Feed the client to conserve the client's energy. 3 Have a family member assist the client with each meal. 4 Encourage the client to participate in the feeding process.

4

The nurse assists with a client's yearly physical examination. After the examination is completed, the client is diagnosed with tuberculosis. Which action best reflects appropriate epidemiological follow-up? 1 Obtaining a list of people the client has had contact with over the past year 2 Suggesting that the client notify acquaintances that the disease has developed 3 Requiring employees at the client's work site to have chest x-rays as soon as possible 4 Encouraging close family members, friends, and coworkers of the client to have a skin test

4

Which diagnostic test may be used to distinguish vascular from nonvascular structures? 1 Chest X-ray 2 Pulmonary angiogram 3 Computed tomography 4 Magnetic resonance imaging

4