AH EXAM 4
A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How would the nurse respond? A. "Your friends will be happy that you are alive." B. "Tell me more about your concerns." C. "A therapist can help you resolve your concerns." D. "With time you will accept your new body."
B
The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? A. Musculoskeletal assessment B. Neurologic assessment C. Mental health assessment D. Cardiovascular assessment
D
The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? A. Metabolic syndrome B. Liver cancer C. Nonalcoholic fatty liver disease D. Hepatitis C
D
The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy B. Prone position C. Feet elevated on pillows D. Daily weights E. Physical therapy F. Respiratory therapy
ACDF
A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) A. Serum potassium of 2.8 mEq/L (2.8 mmol/L) B. Loss of 15 lb (6.8 kg) without dieting C. Abdominal pain in upper quadrants D. Low-pitched bowel sounds E. Serum sodium of 121 mEq/L (121 mmol/L)
ACE
The nurse is caring for a client who has perineal surgical wound. Which actions would the nurse take to promote comfort and wound healing? (Select all that apply.) A. Assist the client into a side-lying position. B. Use a rubber donut device when sitting up. C. Apply warm compresses three to four times a day. D. Instruct the client to wear boxer shorts. E. Place an absorbent dressing over the wound
ACE
The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) A. Registered dietitian nutritionist B. Nursing assistant C. Clinical pharmacist D. Certified herbalist E. Primary health care provider
ACE
The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group's teaching? (Select all that apply.) A. "Wash your hands after any contact with animals." B. "It is not necessary to buy a meat thermometer." C. "Stay away from people who are ill with diarrhea." D. "Use separate cutting boards for meat and vegetables." E. "Avoid swimming in backyard pools and using hot tubs."
AD
The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the nurse take for client care? (Select all that apply.) A. Assess for proper placement of the tube every 4 hours or per agency policy. B. Flush the tube with water every hour to ensure patency. C. Secure the NG tube to the client's chin. D. Disconnect suction when auscultating bowel peristalsis. E. Monitor the client's skin around the tube site for irritation.
ADE
After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.) A. "I will take the enzymes between meals." B. "The enteric-coated preparations cannot be crushed." C. "Swallowing the tables without chewing is best." D. "I will wipe my lips after taking the enzymes." E. "Enzymes should be taken with high-protein foods."
AE
A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? A. "You will have to wear an appliance for your permanent ileostomy." B. "You should be able to have better bowel continence after healing occurs." C. "You will have a large abdominal incision that will require irrigation." D. "This procedure can be performed under general or regional anesthesia."
B
A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? A. "Cap the catheter drain at night to prevent leakage and skin damage." B. "Position the drainage bag lower than the catheter insertion site." C. "Irrigate the catheter with an ounce of saline every night." D. "Pierce a hole in the top of the drainage bag to get rid of odors."
B
A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? A. Nausea and vomiting B. Severe boring abdominal pain C. Jaundice and itching D. Elevated temperature
B
A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the nurse include prior to the test? A. "This test will determine whether you have colorectal cancer." B. "You need to avoid red meat and NSAIDs for 48 hours before the test." C. "You don't need to have this test because you can have a virtual colonoscopy." D. "This test can determine your genetic risk for developing colorectal cancer."
B
The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? A. Urine output via indwelling urinary catheter is 20mL/hr B. Blood pressure increases from 110/58 to 120/62 mm Hg C. Respiratory rate decreases from 22 to 16 breaths/min D. A decrease in the client's weight by 3 lb (1.4 kg)
A
The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider? A. Pale and bluish stoma B. Liquid stool C. Ostomy pouch intact D. Blood-tinged output
A
The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? A. "Diarrhea is expected; that's how your body gets rid of ammonia." B. "You may take antidiarrheal medication to prevent loose stools." C. "Do not take any more of the medication until your stools firm up." D. "We will need to send a stool specimen to the laboratory as soon as possible."
A
The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? A. "Hepatitis C is not spread through casual contact." B. "If you wear a gown and gloves, you will not get this virus." C. "This virus is only transmitted through a fecal specimen." D. "I can give you an update on your brother's status from here."
A
The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? A. History of hepatitis B B. History of kidney disease C. History of cardiac disease D. History of rectal bleeding
A
The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? A. "Drink plenty of fluids to prevent dehydration." B. "You should only drink 1 L of fluids daily." C. "Increase your protein intake by drinking more milk." D. "Sips of cola or tea may help to relieve your nausea."
A
A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.) A. Administer pain medications as prescribed. B. Palpate the abdomen for distention. C. Assess for sudden changes in mental status. D. Provide the client with a high-fiber diet. E. Evaluate stools for occult blood.
ABCE
A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) A. Does your gym provide yoga classes? B. When should you contact your provider? C. What do you plan to eat for dinner? D. Do you have a scale for daily weights? E. How many bathrooms are in your home?
ABCE
The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which assessments would the nurse complete before marking the placement for the ostomy? (Select all that apply.) A. Contour of the abdomen when standing B. Location of the client's belt line C. Contour of the abdomen when lying D. Location of abdominal muscles E. Contour of the abdomen when sitting
ABCE
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I cannot drink any alcohol at all anymore." B. "I should not take over-the-counter medications." C. "I need to avoid protein in my diet." D. "I should eat small, frequent, balanced meals."
C
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? (Select all that apply.) 457 A. "Which food types cause an exacerbation of symptoms?" B. "Where is your pain or discomfort and what does it feel like?" C. "Have you lost a significant amount of weight lately?" D. "Are your stools soft, watery, and black?" E. "Do you often experience nausea and vomiting"
AB
A nurse cares for a client who has a new colostomy. Which action would the nurse take? A. Empty the pouch frequently to remove excess gas collection. B. Change the ostomy pouch and barrier every morning. C. Allow the pouch to completely fill with stool prior to emptying it. D. Use surgical tape to secure the pouch and prevent leakage.
A
A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How would the nurse respond? A. "Let's talk to the ostomy nurse to help you and your husband work through this." B. "You could try to wear longer lingerie that will better hide the ostomy appliance." C. "You should empty the pouch first so it will be less noticeable for your husband." D. "If you are not careful, you can hurt the stoma if you engage in sexual activity."
A
The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) A. "Avoid alcohol ingestion." B. "Be sure and balance rest with activity." C. "Avoid caffeinated beverages." D. "Avoid green, leafy vegetables." E. "Eat small meals and high-calorie snacks."
ABCE
A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? A. "I don't know. I wish I had an answer for you, but I don't." B. "It's important to keep a positive attitude for your family right now." C. "Scientists have not determined why cancer develops in certain people." D. "I think that this is a trial so you can become a better person because of it."
A
The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What factors present risks for developing this type of cancer? (Select all that apply.) A. Diabetes mellitus B. Cirrhosis C. Smoking D. Female gender E. Family history F. Older age
ABCEF
After teaching a patient who has a permanent ileostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) A. Corn B. String beans C. Carrots D. Wheat rice E. Squash
ABD
A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? A. Serum potassium of 2.6 mEq/L (2.6 mmol/L) B. Client ate 20% of breakfast meal C. White blood cell count of 8200/mm3 (8.2 109/L) D. Client's weight decreased by 3 lb (1.4 kg)
A
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? A. Severe, steady right lower quadrant pain B. Abdominal pain associated with nausea and vomiting C. Marked peristalsis and hyperactive bowel sounds D. Abdominal pain that increases with knee flexion
A
A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug? A. "Have you been experiencing any constipation?" B. "Are you eating a diet high in fiber and fluids?" C. "Do you have a history of high blood pressure?" D. "What vitamins and supplements are you taking?"
A
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? A. Drainage from a fistula B. Diminished bowel sounds C. Pain at the incision site D. Nasogastric (NG) tube drainage
A
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How would the nurse respond? A. "The stool will always be liquid with this type of colostomy." B. "Eating additional fiber will bulk up your stool and decrease diarrhea." C. "Your stool will become firmer over the next couple of weeks." D. "This is abnormal. I will contact your primary health care provider."
A
The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) A. Lower gastrointestinal bleeding—erosion of the bowel wall B. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining C. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria D. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer E. Fistula—dilation and colonic ileus caused by paralysis of the colon
ABD
The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.) A. Need to have drug administered by a primary health care provider. B. Need to avoid crowds and individuals who have infection. C. Need to report injection reactions such as redness and swelling. D. Awareness of a rare but potentially fatal drugcomplication. E. Need to report any signs and symptoms of infection immediately.
ABDE
The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) A. Infection B. GI bleeding C. Irritable bowel syndrome D. Constipation E. Anemia F. Hypovolemia
ABDF
The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) A. "Apply lotion to the client's dry skin areas." B. "Use a basin with warm water to bathe the patient." C. "For the patient's oral care, use a soft toothbrush." D. "Provide clippers so the patient can trim the fingernails." E. "Bathe with antibacterial and water-based soaps."
ACD
The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) A. Ascites B. Weight gain C. Steatorrhea D. Jaundice E. Polydipsia F. Polyuria
ACDEF
The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) A. Nausea and vomiting B. Distended rigid abdomen C. Abdominal pain D. Bradycardia E. Decreased urinary output F. Fever
ACDEF
The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) A. "How old are you?" B. "Do you work in health care? C. "Are you receiving hemodialysis?" D. "Do you use IV drugs?" E. "Did you receive blood before 1992?" F. "Have you even been in prison or jail?"
ALL OF THEM
The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) A. Jaundice B. Clay-colored stools C. Icterus D. Ascites E. Petechiae F. Dark urine
ALL OF THEM
The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) A. Elevated amylase B. Elevated lipase C. Elevated glucose D. Decreased calcium E. Elevated bilirubin F. Elevated leukocyte count
ALL OF THEM
The nurse is caring for a client who just had a minimally invasive inguinal hernia repair. Which nursing actions would the nurse implement? (Select all that apply.) A. Apply ice to the surgical area for the first 24 hours after surgery. B. Encourage ambulation with assistance within the first few hours after surgery. C. Encourage deep breathing after surgery but teach the client to avoid coughing. D. Assess vital signs frequently for the first few hours after surgery. E. Teach the client to rest for several days after surgery when at home. F. Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.
ALL OF THEM
After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I will avoid large crowds and people who are sick." B. "I will take this medication with my breakfast each morning." C. "Nausea and vomiting are common side effects of this drug." D. "I should wash my hands after I play with mydog."
B
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? A. "The anti-rejection drugs you are taking make you susceptible to infection." B. "You should go to the hospital immediately to get checked out." C. "You should take an additional dose of cyclosporine today." D. "Take acetaminophen every 4 hours until you feel better soon."
B
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? A. "Some medications have been known to cause hepatitis A." B. "I may have been exposed when we ate shrimp last weekend." C. "I was infected with hepatitis A through a recent blood transfusion." D. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."
B
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? A. Ham sandwich on white bread, cup of applesauce, carbonated beverage B. Broiled chicken with brown rice, steamed broccoli, glass of apple juice C. Grilled cheese sandwich, small banana, cup of hot tea with lemon D. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
B
The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan c. Amitiptyline d. Amlodipine
B
The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? A. "This drug will make you very dry because it will decrease your diarrhea." B. "Be sure to take this drug with food and water to help manage constipation." C. "Avoid people who have infection as this drug will suppress your immune system." D. "Include high-fiber foods in your diet to help produce more solid stools."
B
The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? A. Monitor intake and output. B. Provide a low-sodium diet. C. Increase oral fluid intake. D. Weigh the patient daily
B
The nurse is caring for a client who is planning to have a laparoscopic colon resection for colorectal cancer tomorrow. Which statement by the client indicates a need for further teaching? A. "I should have less pain after this surgery compared to having a large incision." B. "I will probably be in the hospital for 3 to 4 days after surgery." C. "I will be able to walk around a little on the same day as the surgery." D. "I will be able to return to work in a week or two depending on how I do."
B
The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? A. "Are you taking Vitamin C or B? B. "Do you have any allergy to sulfa drugs?" C. "Can you swallow pills pretty easily?" D. "Do you have insurance to cover this drug?"
B
The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? A. Clamp the nasogastric tube. B. Place the patient in semi-Fowler position. C. Assess vital signs once every shift. D. Provide oral rehydration.
B
The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? A. "A low-protein diet will help the liver rest and will restore liver function." B. "Less protein in the diet will help prevent confusion associated with liver failure." C. "Increasing dietary protein will help the patient gain weight and muscle mass." D. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."
B
The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? A. Low-fiber diet B. Skin protection C. Antibiotic administration D. Intravenous glucocorticoids
B
A nurse cares for a young client with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How would the nurse respond? A. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." B. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." C. "Let's talk to the ostomy nurse about options for ostomy supplies and dress styles." D. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."
C
The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) A. Pancreatitis B. Polyarthritis C. Heart disease D. Myalgia E. Peptic ulcer disease F. Ulcerative colitis
BCD
A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment finding(s) alert(s) the nurse to a complication from this surgery? (Select all that apply.) A. Clay-colored stools B. Substernal chest pain C. Shortness of breath D. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
BCDE
The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) A. Stool consistency is similar to paste. B. Stoma becomes dark and dull. C. Skin around the stoma becomes excoriated. D. Skin around stoma becomes protruded. E. Stoma becomes retracted into the abdomen.
BCDE
The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.) A. Weight gain B. Rectal bleeding C. Anemia D. Change in stool shape E. Electrolyte imbalances F. Abdominal discomfort
BCDF
A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) A. Weight gain B. Anorexia C. Constipation D. Anal fistula E. Abdominal pain
BCE
A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) A. Cleanse the perineum with an antibacterial soap. B. Use medicated wipes instead of toilet paper. C. Identify foods that decrease constipation. D. Apply a thin coat of aloe cream to the perineum. E. Gently pat the perineum dry after cleansing
BDE
A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) A. Elevated aspartate transaminase B. Elevated international normalized ratio (INR) C. Decreased serum globulin levels D. Decreased serum alkaline phosphatase E. Elevated serum ammonia F. Elevated prothrombin time (PT)
BEF
A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which complication would the nurse monitor? A. Paralytic ileus B. Bowel volvulus C. Sepsis D. Colitis
C
A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? A. Temperature of 100.1° F (37.8° C) B. Positive Murphy sign C. Clay-colored stools D. Upper abdominal pain after eating
C
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? A. Inspection of oral mucosa B. Recent dietary intake C. Heart rate and rhythm D. Percussion of abdomen
C
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action would the nurse take? A. Ask if the client is experiencing pain in the right shoulder. B. Perform a rectal examination and assess for polyps. C. Recommend that the client have computed tomography. D. Administer a laxative to increase bowel movement activity.
C
A nurse cares for a client with colorectal cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How would the nurse respond? A. "I have a good friend with a colostomy who would be willing to talk with you." B. "The ostomy nurse will be able to answer all of your questions." C. "I will make a referral to the United Ostomy Associations of America." D. "You'll find that most people with colostomies don't want to talk about them."
C
A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation would the nurse teach the client? A. "Eat low-fiber and low-residual foods." B. "White rice and bread are easier to digest." C. "Add vegetables such as broccoli and cauliflower to your diet." D. "Foods high in animal fat help to protect the intestinal mucosa."
C
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I'll ride my bike or take a long walk at least three times a week." B. "I must try to include at least 25 g of fiber in my diet every day." C. "I will take a laxative nightly at bedtime to avoid becoming constipated." D. "I should use my legs rather than my back muscles when I lift heavy objects."
C
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? A. "The capsules can be opened and the powder sprinkled on applesauce if needed." B. "I will wipe my lips carefully after I drink the enzyme preparation." C. "The best time to take the enzymes is immediately after I have a meal or a snack." D. "I will not mix the enzyme powder with food or liquids that contain protein."
C
The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? A. Positive Murphy sign with rebound tenderness to palpitation B. Dull, hypoactive bowel sounds in the lower abdominal quadrants C. High-pitched, rushing bowel sounds in the right lower quadrant D. Reports of abdominal cramping that is worse at night
C
The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/minRespirations = 28 breaths/minBlood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? A. Electrolyte imbalance B. Pleural effusion C. Internal bleeding d. Pancreatic pseudocyst
C
The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? A. Blacks B. Asian/Pacific Islanders C. Latinos D. French
C
The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? A. "You should make peace with your family." B. "This is not unusual. My family hates me too." C. "I will help you identify a support system." D. "You must attend Alcoholics Anonymous."
C
The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? A. Abdominal distention B. Nausea C. Electrolyte imbalance D. Obstipation
C
The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle change would the nurse include? A. Avoiding alcohol B. Quitting smoking C. Decreasing fluid intake D. Increasing dietary fiber
C
The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? A. Decreased potassium level B. Increased sodium level C. Elevated leukocyte count D. Decreased thrombocyte count
C
After teaching a client who is recovering from a colon resection to treat early-stage colorectal cancer (CRC), the nurse assesses the client's understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) A. "I must change the ostomy appliance daily and as needed." B. "I will use warm water and a soft washcloth to clean around the stoma." C. "I might start bicycling and swimming again once my incision has healed." D. "I will make sure that I make lifestyle changes to prevent constipation." E. "I will be sure to have the recommended colonoscopies."
CDE
A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? A. Urinary tract infection B. Chronic kidney disease C. Heart failure D. Fluid and electrolyte imbalances
D
A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test? A. "You'll have to drink a contrast medium right before the test." B. "You'll need to do a bowel prep the nursing before the test." C. "You'll be able to drink liquids up until the test begins." D. "You'll have a large camera close to you during the test."
D
A nurse assesses clients at a community health center. Which client is at highest risk for developing colorectal cancer? A. A 37-year-old who drinks eight cups of coffee daily. B. A 44-year-old with irritable bowel syndrome (IBS). C. A 60-year-old lawyer who works 65 hours per week. D. A 72-year-old who eats fast food frequently.
D
A nurse cares for a client who has a family history of colorectal cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How would the nurse respond? A. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." B. "You are safe. This is an autosomal dominant disorder that skips generations." C. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." D. "You should have a colonoscopy more frequently to identify abnormal polyps early."
D
After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? A. Lasagna, tossed salad with Italian dressing, and low-fat milk B. Grilled cheese sandwich, tomato soup, and coffee with cream C. Cream of potato soup, Caesar salad with chicken, and a diet cola D. Roasted chicken breast, baked potato with chives, and orange juice
D
After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching? A. Roasted chicken with rice pilaf and a cup of coffee with cream B. Spaghetti with meat sauce, a fresh fruit cup, and hot tea C. Garden salad with a cup of bean soup and a glass of low-fat milk D. Baked fish with steamed carrots and a glass of apple juice
D
The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? A. Consuming too much fruit B. Consuming fried or pickled foods C. Consuming dairy products Consuming raw seafood
D
The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? A. Have the client sign the informed consent form. B. Get the patient into a chair before the procedure. C. Help the client lie flat in bed on the right side. D. Assist the client to void before the procedure.
D
The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed? a. Prone b. Supine c. Recumbent d. Semi-Fowler
D
The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? A. "Follow up on all appointments to monitor your lab values." B. "Do not take amiodorone at any time while on this drug." C. "Monitor for jaundice, rash, and itchy skin while on this drug." D. "Report any changes in urinary elimination while on this drug.
D
The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? A. "I won't let anyone use my dishes or glasses." B. "I'll wash my hands with antibacterial soap." C. "I'll keep my bathroom extra clean." D. "I'll cook all the meals for my family."
D
