AH1 NCLEX CH. 1-4, 13-14, 16, 21, 23, 51-52, 55

The nurse is caring for a client with a complete large bowel obstruction. What assessment findings would the nurse expect? Select all that apply. A. Obstipation B. Dehydration C. Metabolic alkalosis D. Abdominal distention E. Abdominal pain F. Profuse vomiting

A. Obstipation D. Abdominal distention E. Abdominal pain

On assessment, the client is noted to have conjunctival xerosis, dry skin, follicular hyperkeratosis, and a purple tongue. 4. Which vitamin deficiency does the nurse anticipate? A. Vitamin A B. Vitamin C C. Vitamin D D. Vitamin K

A. Vitamin A

A 51-year-old client is in the emergency department with cellulitis of the right leg. Laboratory results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA. 1. Based on the information provided from the ED during the SBAR report, what type of isolation room should the medical-surgical nurse prepare for the client?

ANS: The client should be admitted to a private room under Contact Isolation precautions.

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol) D. 20 mEq (mmol)

B. 15 mEq (mmol)

Which nursing activities may be safely delegated to competent assistive personnel (AP)? Select all that apply. A. Discharge teaching B. Blood pressure monitoring C. Gastrostomy feeding D. Oxygen administration E. Ambulation assistance

B. Blood pressure monitoring E. Ambulation assistance

For which electrolyte imbalance will the nurse monitor a client with Clostridium difficile infection and significant diarrhea? A. Dehydration B. Hypokalemia C. Hyponatremia D. Hypocalcemia

B. Hypokalemia •Potassium re-absorption primarily occurs through the renal system. However, approximately 10% of potassium regulation occurs in the gut. Hypokalemia can result when clients experience significant diarrhea.

An older adult's furosemide dosage was increased 2 days ago to 40 mg daily. This morning the nurse observes that the client has become confused and very weak. What is the nurse's best action? A. Encourage fluid intake. B. Withhold this morning's dose of furosemide. C. Review the most recent serum electrolyte levels. D. Place the patient on strict intake and output.

B. Withhold this morning's dose of furosemide.

A nurse provides discharge teaching for a male client who had a minimally invasive hernia repair this morning. Which statement by the client indicates a need for further teaching? A. "I should avoid coughing if at all possible." B. "I can shower in a day or two after I remove my surgical bandage." C. "I can't go back to work for at least 6 weeks." D. "I should use an ice pack to help relieve my pain."

C. "I can't go back to work for at least 6 weeks."

What possible complication does the nurse observe for when administering total parenteral nutrition (TPN)? A. Infection B. Dehydration C. Hyperglycemia D. Electrolyte imbalance

C. Hyperglycemia Monitor serum electrolytes and glucose daily or per facility protocol. (Some facilities require finger-stick blood sugars [FSBSs] every 4 hours.) If insulin is added to the TPN to manage hyperglycemia, FSBSs should be checked frequently. Infection at the catheter site is a serious risk, as are fluid and electrolyte imbalances.

Which cells, products, or actions are involved in long-lasting immunity resulting from exposure to a specific antigen? Select all that apply. A. Antibody attenuation B. Interleukin 10 (IL-10) C. Memory B-cells D. Monocyte maturation E. Neutrophilia F. Phagocytosis

C. Memory B-cells D. Monocyte maturation

The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? A. Increased itching B. Temperature of 100°F C. Presence of new plaques on leg D. Expression of impaired self-image

C. Presence of new plaques on leg

A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.

C. The lesion borders have expanded and are shaped differently in the second picture.

The client states, "I am afraid I'll never get to go out with my friends again because I can't be away from the toilet." Which nursing response is appropriate? A. "What makes you say that?" B. "Your friends will understand." C. "I wouldn't worry about it if I were you." D. "It sounds like you are concerned about managing this disorder."

D. "It sounds like you are concerned about managing this disorder." This response verbalizes the implied concern. Response A does not address the concern and requires the client to give an answer that defends her feelings. Responses B and C minimize the client's feelings and do not address concerns.

Which change would the nurse expect to see in the white blood cell differential of a client who has a prolonged, severe intestinal helminth infestation? A. Band neutrophils outnumber segmented neutrophils. B. Macrophage count is low. C. Monocyte count is high. D. Eosinophil count is high.

D. Eosinophil count is high.

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. 1. Caring 2. Teaching 3. Collaborating 4. Advocating 5. Researching 6. Prescribing

1. Caring 2. Teaching 3. Collaborating 4. Advocating 5. Researching

After lunch, the client asks how MRSA was contracted. What is the appropriate nursing response? A. "MRSA is spread by direct contact in the hospital and community settings." B. "People who travel to third-world countries always return with MRSA." C. "MRSA is transmitted through the air like TB." D. "The most common way to get MRSA is when someone coughs on you."

A. "MRSA is spread by direct contact in the hospital and community settings." MRSA is spread by direct contact, such as with indwelling catheters, vascular access devices, and endotracheal tubes, in the hospital and community settings.

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply. A. Beneficence B. Social justice C. Autonomy D. Fidelity E. Veracity

A. Beneficence D. Fidelity E. Veracity

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

A. Calcium D. Potassium

The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the client to avoid? A. Cucumber B. Beans C. Carrot D. Radish

A. Cucumber

The client is discharged (CRC patient after colostomy surgery), and home health services are arranged. What is the home health nurse's assessment priority? (Select all that apply.) A. GI status B. Condition of the stoma C. Peristomal skin condition D. Patient and family's coping skills E. Results of daily laxative prescription

A. GI status B. Condition of the stoma C. Peristomal skin condition D. Patient and family's coping skills The home health nurse's priorities are related to the client's stoma care, GI status, and psychosocial status of the client and family as a result of the surgery. clients with a colostomy are often prescribed a stool softener, but usually not prescribed a laxative.

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1-hour time period? A. Plasma volume osmolarity increases; blood pressure increases B. Plasma volume osmolarity decreases; blood pressure increases C. Plasma volume osmolarity increases; blood pressure decreases D. Plasma volume osmolarity decreases; blood pressure decreases

A. Plasma volume osmolarity increases; blood pressure increases

The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A. Quality Improvement B. Ethics C. Health Care Disparities D. Systems Thinking E. Teamwork and Collaboration

A. Quality Improvement D. Systems Thinking E. Teamwork and Collaboration

The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A. Situation B. Background C. Assessment D. Recommendation

A. Situation

When caring for a client with MRSA, which precaution will the nurse institute? A. Droplet B. Contact C. Airborne D. Neutropenic

B. Contact MRSA is spread by contact; therefore, the nurse will institute contact precautions.

Total enteral nutrition (TEN) has been prescribed for a client with terminal cancer. When the nurse notes that no advanced directives are in place, yet a durable power of attorney exists, what is the appropriate action? A. Withhold TEN indefinitely B. Contact the durable power of attorney C. Begin administration of TEN immediately D. Turn over care to the interprofessional ethics committee

B. Contact the durable power of attorney

A client reports increasing diffuse pain in the entire right leg. What is the nurse's priority action at this time? A. Elevate the right leg on a pillow. B. Perform a peripheral vascular assessment. C. Check for swelling in the right leg. D. Notify the Rapid Response Team immediately.

B. Perform a peripheral vascular assessment.

What symptom does the nurse expect the client with intussusception to exhibit? A. Decrease in pulse B. Singultus (hiccups) C. Frequent bloody stools D. Extremely elevated body temperature

B. Singultus (hiccups) Intussusception is a telescoping of the intestine within itself. Singultus (hiccups) is common with all types of intestinal obstruction. The vagus and phrenic nerves stimulate the hiccup reflex. Intestinal obstruction can increase the intraabdominal pressure, causing pressure on the phrenic nerve and the symptom of singultus (hiccups).

The nurse is caring for a client who is preparing for bariatric surgery. What is the appropriate nursing response when the client states, "I am afraid this surgery won't work"? A. "Do you think you will stay overweight for life?" B. "This surgery always works. It will be fine." C. "Tell me what concerns you most about the surgery." D. "We will postpone the surgery until you decide how you feel."

C. "Tell me what concerns you most about the surgery." The nurse needs to allow the client to explore his or her feelings by asking what concerns the client most. The surgery does not need to automatically be postponed. Telling the client that "it will be fine" minimizes their feelings. Asking if they think they will be overweight for life is insensitively phrased.

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

C. Assess the client's oxygen saturation

A client had a colectomy with creation of an ileo-anal pouch and temporary ileostomy yesterday morning. The nurse assesses the ostomy and its functioning. Which assessment finding will the nurse report to the primary health care provider? A. Client's report of abdominal pain of 3 on a 0 to 10 pain intensity scale B. Slight abdominal distention C. No drainage from the ileostomy D. Serosanguinous effluent from the drain

C. No drainage from the ileostomy

A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatologic health care provider. B. Ask if there are any other lesions that are bothersome. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

C. Perform a head-to-toe skin assessment and document the findings.

An hour later, the nurse is preparing to administer the client's medications. Which drug was likely ordered by the health care provider to address MRSA? A. Amoxicillin B. Ciprofloxacin C. Vancomycin D. Erythromycin

C. Vancomycin MRSA is susceptible to only a few antibiotics such as vancomycin (Vancocin) and linezolid (Zyvox), as well as ceftaroline fosamil.

A client has recently been placed on corticosteroids to treat ulcerative colitis. The nurse will monitor the client's laboratory results for evidence of which condition? A. Hyperkalemia B. Hypernatremia C. Hypercalcemia D. Hyperglycemia

D. Hyperglycemia Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection.

An older adult client diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse will monitor the client for what condition? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

A. Dehydration In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool.

Which environments of care will the nurse recognize as components of the health care system? Select all that apply. A. Long-term care B. Primary care C. Free-standing emergency department D. National League of Nursing E. Patient-centered medical home F. World Health Organization

A. Long-term care B. Primary care C. Free-standing emergency department E. Patient-centered medical home

An older adult is admitted to the hospital. The client's height is 5 feet, 6 inches (1.68 m), and weight is 250 lb (113.3 kg). The nurse calculates the client's current body mass index (BMI) as _______. Fill in the blank. Round your answer to the nearest whole number.

40.0

The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply. A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." C. "Be sure to take a laxative every day to clean out your bowels and prevent toxins." D. "Exercise several times a week to keep our bowels working for regular elimination." E. "Drink at least 3 caffeinated beverages every day to keep your bowels stimulated." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." D. "Exercise several times a week to keep our bowels working for regular elimination." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

Which statements by assistive personnel indicate understanding regarding infection control measures needed to care for a client who has possible Clostridium difficile infection? Select all that apply. A. "I'll wear an isolation gown when providing direct care." B. "I'll wear gloves when providing direct care." C. "I'll wear a mask each time I enter the client's room." D. "I'll use a hand sanitizer when I can't wash my hands." E. "I'll wear goggles to protect my eyes."

A. "I'll wear an isolation gown when providing direct care." B. "I'll wear gloves when providing direct care." D. "I'll use a hand sanitizer when I can't wash my hands."

The nurse is conducting assessments for clients at potential risk for infection. Which client is most at risk for acquiring an infection? A. A client who had an open incision for abdominal surgery B. A client who has not been immunized for pneumonia or influenza C. A client who works in a high-stress job for an accounting practice D. A client who is 85 years old and in good health

A. A client who had an open incision for abdominal surgery

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

A. Blood pressure D. Pulse rate and quality F. Urine output

Which assessment findings indicate to the nurse that a client taking warfarin may have decreased clotting ? Select all that apply. A. Frequent nosebleeds B. Lower leg swelling C. Upper extremity bruising D. Difficulty breathing E. Intermittent chest pain F. Dark stools

A. Frequent nosebleeds C. Upper extremity bruising F. Dark stools

The nurse performs an initial health assessment of an older adult. Which assessment findings indicate that the client may be at risk for falls? Select all that apply. A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts F. Has thin papery skin

A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts

A client had an open partial colectomy and colostomy placement 6 hours ago. Which assessment would concern the nurse? A. Purple, moist stoma B. Stoma edema C. Liquid stool collecting in the drainage bag D. Serosanguineous fluid draining from the drain(s)

A. Purple, moist stoma

2. When providing care, what special precautions does the nurse implement based on the client's diagnosis? (Select all that apply.) A. Keep the door closed at all times. B. Wear gloves when entering the room. C. Wear a mask when working within 3 feet of the client. D. Wear a gown to prevent contact with contaminated items. E. Dedicated equipment should be used for this client alone.

B. Wear gloves when entering the room. D. Wear a gown to prevent contact with contaminated items. E. Dedicated equipment should be used for this client alone. Health care personnel and visitors should wear gloves upon entering the room to prevent contact with the client, contaminated items, or uncontrolled body fluids. There should also be dedicated equipment for this client to prevent the spread of infection. A mask should be worn with Airborne and Droplet Precautions. The door should be kept closed with Airborne Precautions, not Contact Precautions.

The nurse is caring for an older adult client who smokes and does not exercise. Which finding requires immediate further nursing assessment? A. BMI of 35 B. Temperature 99° F C. Cool, pale feet D. Respirations 20 breaths/min

C. Cool, pale feet The client with cool, pale feet may have impaired peripheral perfusion; this should be further assessed immediately. Although the client's BMI is above normal, this can be assessed later. A temperature of 99° F and respirations of 20 breaths/min are at the high end of normal and do not require immediate further assessment.

In reviewing the electrolytes of a client, the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

C. Pulse rate and rhythm

Three days later the stoma is functioning. What stool assessment finding does the nurse anticipate? A. Very little stool and mostly gas B. Diarrhea liquid stool C. Pasty stool D. More solid stool

D. More solid stool Immediate postoperative stool may be liquid, but it becomes more solid depending on the location of the colostomy. Stool from an ascending colon colostomy will be more liquid, stool from a transverse colon colostomy will be more pasty, and stool from a descending or sigmoid colostomy is more solid and similar to the usual stool expelled from the rectum.

The nurse is caring for a 69-year old female client with multiple chronic health conditions, who is taking 8 types of drugs. What assessment finding will the nurse prioritize? A. ALT 30 units/L and AST 20 units/L B. Hemoglobin 14 g/dL, hematocrit 40% C. Sodium 140 mEq/L and potassium 4.8 mEq/L D. Serum creatinine 0.3 mg/dL, creatinine clearance 60 mL/min

D. Serum creatinine 0.3 mg/dL, creatinine clearance 60 mL/min All values in this scenario are within normal limits with the exception of the serum creatinine and creatinine clearance. Both of these values are low, indicating that kidney function is impaired. Many drugs are excreted by the kidneys. Renal drug excretion decreases as people age normally. When kidney function is impaired, renal drug excretion is even slower, which can increase the effects of drugs remaining in the body. The nurse will address this assessment finding of low serum creatinine and creatinine clearance, recognizing that polypharmacy can complicate this concern.

The nurse is evaluating laboratory assessment data of a client with uncontrolled metabolic acidosis. What finding does the nurse anticipate? A. pH 7.40 B. Pao2 98 mm Hg C. Bicarbonate 38 mEq/L D. Serum potassium 5.7 mEq/L

D. Serum potassium 5.7 mEq/L Metabolic acidosis is reflected by several changes in ABG values. The pH is low (<7.35). The bicarbonate level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because gas exchange is adequate. The serum potassium level is often high in acidosis as the body attempts to maintain electroneutrality during buffering

An 87-year old male has been admitted for dehydration. The nurse's assessment reveals dry mucous membranes, generalized weakness, difficulty ambulating, and anorexia. His weight is down from 112 to 98 pounds over the past 3 months. His dentures are loose and poor fitting. 1. Which assessment findings support a risk for undernutrition? 2. Which assessment findings support failure to thrive?

1. Decreased appetite, weight loss, dry mouth, generalized weakness, poor fitting dentures, and difficulty ambulating. 2. Weakness, unintentional weight loss. Other symptoms include slow walking speed, low physical activity, and exhaustion.

The nurse is delegating a specific client's morning hygiene to a nursing assistant (NA). What teaching will the nurse provide to the NA? Select all that apply. A. "Use a soft toothbrush for brushing." B. "The client can help by combing hair." C. "Fully dry the client's skin after bathing with gentle soap." D. "Use an electric razor, not a blade, on facial hair." E. "If you have questions, don't hesitate to page me." F. "Please let me know how the client tolerates care."

A. "Use a soft toothbrush for brushing." B. "The client can help by combing hair." C. "Fully dry the client's skin after bathing with gentle soap." D. "Use an electric razor, not a blade, on facial hair." E. "If you have questions, don't hesitate to page me." F. "Please let me know how the client tolerates care." The nurse will observe all of the "rights" (below) of delegation. He or she will give specific information about the task to the NA, provide supervision, and have the NA communicate results back. In this scenario: Right task - hygiene, which is within the NA's abilities Right circumstances - morning, so the timing and circumstances are specific Right person - specific client Right communication - instructions given regarding toothbrushing, fully drying the skin, using a gentle soap and an electric razor. Also explained what the client can do (comb hair). Right supervision - offered to be paged; has asked for report when care is done

A client who has been hiking in the woods comes to the ED with urticaria. After administering an antihistamine as prescribed, what teaching does the nurse provide? A. Avoid outdoor activity. B. Use a sauna to relieve pain. C. Apply tea bags to the lesions. D. Consume 1 to 2 alcoholic beverages.

A. Avoid outdoor activity. ´Management of urticaria (hives) focuses on removing the triggering substance and relieving symptoms. The client should stay indoors at this time, as something in the woods likely triggered the reaction. Because the skin reaction is caused by histamine release, topical and/or oral antihistamines such as diphenhydramine (Benadryl) are helpful. Teach the client to avoid overexertion, alcohol consumption, and warm environments such as warm or hot showers, which contribute to blood vessel dilation and make the symptoms worse. Nothing further needs to be applied to the lesions at this time.

How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A. Carbon dioxide loss through exhalation can raise arterial pH levels.

The client is ordered daily multiple vitamins with zinc and iron supplements. Which nursing intervention promotes oral nutrition intake? (Select all that apply.) A. Delegating an AP to feed the client B. Providing mouth care before each meal C. Placing a small-bore nasoduodenal tube D. Assisting the client to sit upright in a chair E. Ordering foods that the client likes and prefers to eat

A. Delegating an AP to feed the client B. Providing mouth care before each meal D. Assisting the client to sit upright in a chair E. Ordering foods that the client likes and prefers to eat

Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? A. Diabetes mellitus B. Hypotension C. Osteoarthritis D. Peptic ulcer disease

A. Diabetes mellitus

The nurse takes a history for a client admitted to the hospital. Which factors in the nursing history indicate that the client is at risk for infection? Select all that apply. A. Diabetes mellitus type 2 for 20 years B. 52-pack year history of cigarette smoking C. Admitted from a long-term care facility D. Has a history of multiple urinary tract infections E. Is 84 years of age

A. Diabetes mellitus type 2 for 20 years B. 52-pack year history of cigarette smoking C. Admitted from a long-term care facility D. Has a history of multiple urinary tract infections E. Is 84 years of age

A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? Select all that apply. A. Fever B. Pain C. Redness around the spider bite D. Warmth in the affected arm E. Swelling of the affected arm

A. Fever B. Pain C. Redness around the spider bite D. Warmth in the affected arm E. Swelling of the affected arm

The nurse is talking with a group of older clients about colorectal cancer (CRC) risk factors. Which of the following factors are considered to be common CRC risk factors? Select all that apply. A. High-fat diet B. Crohn's disease C. Smoking D. Alcoholism E. Family history of cancer F. Obesity

A. High-fat diet B. Crohn's disease C. Smoking D. Alcoholism E. Family history of cancer F. Obesity

The nurse reviews medications the client has been taking recently. Which medication will the nurse question? A. Ibuprofen (Motrin) B. Mesalamine (Asacol) C. Loperamide (Imodium) D. Prednisone (Deltasone)

A. Ibuprofen (Motrin) uIbuprofen is a nonsteroidal antiinflammatory drug (NSAID); NSAIDs increase the risk for bleeding.

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea and rectal bleeding that have lasted a week. For which complication(s) will the nurse assess? Select all that apply. A. Increased BUN B. Hypokalemia C. Leukocytosis D. Anemia E. Hyponatremia

A. Increased BUN B. Hypokalemia C. Leukocytosis D. Anemia E. Hyponatremia

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed with a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

A. Nits can be removed with a fine-tooth comb. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

Later in the afternoon, the client states that the abdominal pain is worsening. Which nursing intervention is appropriate to address the client's discomfort? (Select all that apply.) A. Provide sitz baths as needed B. Administer analgesics as ordered C. Teach music therapy or guided imagery D. Give antidiarrheal medications if ordered E. Evaluate tomorrow's diet for foods that cause pain

A. Provide sitz baths as needed B. Administer analgesics as ordered C. Teach music therapy or guided imagery Sitz baths will help prevent skin excoriation or irritation. Complementary therapies used in conjunction with analgesics can be very helpful in controlling pain. Antidiarrheal medications may provide symptomatic relief but does not directly address pain or discomfort. Evaluating tomorrow's foods would not address the client's immediate symptom of pain.

The oncoming nurse has received report regarding a 79-year-old client with delirium. Which assessment finding does the nurse anticipate may be present? Select all that apply. A. Psychosis B. Bacteria in urine C. Temperature 101.9°F D. Oxygen saturation 89% E. Has been present for 6 months

A. Psychosis B. Bacteria in urine C. Temperature 101.9°F D. Oxygen saturation 89% Delirium is condition with an acute and fluctuating onset (not a long-term condition) that is characterized by inattentiveness, disorganized thinking, and an altered level of consciousness. Psychosis may be present. Infections and poor oxygenation often contribute to delirium. Therefore, psychosis, bacteria in the urine, a fever, and low oxygen saturation may all be anticipated.

Which assessment finding alerts the nurse to determine that inflammation has progressed to the cellular level? A. Pus B. Warmth C. Redness D. Swelling

A. Pus Responses at the tissue level cause the five cardinal symptoms of inflammation: warmth, redness, swelling, pain, and decreased function. Stage II is the cellular exudate part of the response. In this stage, neutrophilia (an increased number of circulating neutrophils) occurs. Exudate in the form of pus occurs, containing dead WBCs, necrotic tissue, and fluids that escape from damaged cells.

A nursing assistant in a nursing home reports to the nurse that an 87-year-old nursing home client has a 6-inch reddened wound with pus draining from it on his shin where he scratched it open yesterday. After directly assessing the client's wound, what are the most relevant priority actions for the nurse to take? Select all that apply. A. Take a photo of the wound to show the primary health care provider when rounds are made 2 days from now. B. Assess the client for signs and symptoms of systemic infection, including temperature elevation. C. Notify the primary health care provider now and request a prescription for antibiotic therapy. D. Ask the primary health care provider to prescribe a tetanus booster vaccination. E. Immediately obtain a specimen for culture and sensitivity testing. F. Cleanse the wound and apply a dry dressing to it.

A. Take a photo of the wound to show the primary health care provider when rounds are made 2 days from now. B. Assess the client for signs and symptoms of systemic infection, including temperature elevation. C. Notify the primary health care provider now and request a prescription for antibiotic therapy. F. Cleanse the wound and apply a dry dressing to it.

How do plasma cells provide immune protection? A. They actively secrete immunoglobulins against specific antigens. B. They interact with virgin B lymphocytes at first exposure to an antigen, enhancing B-lymphocyte sensitization. C. They regulate the function of natural killer cells, preventing unnecessary damage or death to normal healthy body cells. D. They are responsible for balancing helper cell activity with regulator T-cell activity, ensuring that an immunologic response can be mounted whenever the body is invaded by pathologic microorganisms but limiting the response when the body receives antigens as drugs or food.

A. They actively secrete immunoglobulins against specific antigens.

Which factor does the nurse identify that impacts clinical judgment? Select all that apply. A.State legislation about marijuana B.Socioeconomic status of the client C.Age of technology in the health care agency D.The number of a client's co-existing conditions E.Access to a database of clinical best practices F.Availability of members of the interprofessional team

A.State legislation about marijuana B.Socioeconomic status of the client C.Age of technology in the health care agency D.The number of a client's co-existing conditions E.Access to a database of clinical best practices F.Availability of members of the interprofessional team The nurse recognizes that there are 7 key influencers that impact clinical judgment: •Complexity of care •Interprofessional practice •Evidence-based practice •Determinants of health •Population health •Emerging technology •Health policy Six of the seven are influencers are included in the answers to this question. •Complexity of care - answer D •Interprofessional practice - answer F •Evidence-based practice - answer E •Determinants of health - answer B •Population health - (not reflected in this question) •Emerging technology - answer C •Health policy - answer A

The nurse is caring for a client who has experienced numerous recent hospital admissions due to chronic obstructive pulmonary disease (COPD). Which client statement required nursing intervention? A. "I use an incentive spirometer often." B. "I will avoid getting a flu shot." C. "I quit smoking two months ago." D. "I know it is important to use my home oxygen."

B. "I will avoid getting a flu shot." The nurse will need to intervene if the client expresses that he or she is not getting a flu shot. It is important for clients with gas exchange problems to adhere to vaccinations, particularly for flu and pneumonia, since these are respiratory problems.

When caring for four clients, which client does the nurse identify at highest risk for infection? A. 20-year-old with stomach pain B. 31-year-old with chronic kidney disease C. 44-year-old using a 10-day steroid taper D. 62-year-old with history of prostate hyperplasia

B. 31-year-old with chronic kidney disease The client's immune status plays a large role in determining risk for infection. Congenital abnormalities, acquired health problems (for example, kidney injury, steroid dependence, cancer, AIDS) and advancing age can increase a client's risk of developing immunologic deficiencies. Chronic physical and psychological stress can also depress the immune system, making the client more susceptible to infection.

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? A. Asking about the use of sugar substitutes B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease

B. Determining what drugs are taken daily

The nurse observes that numerous clients on a medical-surgical respiratory unit seem to have increasingly frequent readmissions. What quality improvement step could the nurse implement to explore the readmission rate? A. Inform the unit manager of the concern. B. Evaluate trends and develop a plan for improvement. C. Contact the hospital quality improvement nurse to create an improvement strategy. D. Post a journal article on the unit that addresses national readmission rates for respiratory disorders.

B. Evaluate trends and develop a plan for improvement. To meet the quality improvement competency, nurses are expected to "use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems" (www.qsen.org). Options A and D transfer the nurse's direct involvement in quality improvement processes. Option C may be an appropriate intervention at a later time, but the nurse should first evaluate the problem using data prior to developing a strategy for improvement.

The medical-surgical nurse notices that many clients return often for readmission for heart failure. What is the nurse's appropriate action? A. Inform the unit manager of the concern. B. Evaluate trends and develop a plan for improvement. C. Contact the hospital quality improvement nurse to ask what to do about readmissions. D. Give other nurses a journal article that addresses national readmission rates for heart failure.

B. Evaluate trends and develop a plan for improvement. To meet the quality improvement competency, nurses are expected to "use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems" (www.qsen.org). Options A, C, and D transfer the nurse's direct involvement in quality improvement processes to other people. The medical-surgical nurse should evaluate trends and develop a plan for improvement, and then share this information with others.

Which dietary item will the nurse remove from the client's nutrition tray? A. Applesauce B. Granola cereal C. Scrambled eggs D. Toast with butter

B. Granola cereal Based on his symptoms, the client needs to be on a soft diet. The client's ill-fitting dentures would also make it difficult to eat granola. Granola is not a part of a soft diet plan. All other items reflect soft diet items that the client could have.

What priority laboratory analysis will the nurse review when caring for a client with Crohn's disease? A. Potassium B. Hemoglobin C. Serum albumin D. C-reactive protein

B. Hemoglobin Crohn's disease presents as transmural inflammation that causes a thickened bowel wall, strictures, and deep ulcerations that result in severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues. C-reactive protein may be monitored as a marker of inflammation, albumin to assess nutritional status, and potassium related to losses from diarrhea.

A 23-year-old client admitted and just diagnosed with ulcerative colitis (UC) reports approximately 5 bloody stools daily. Vital signs show a pulse of 80 bpm, respiration rate of 18 breaths per minute, blood pressure of 124/88, and temperature of 97.6ºF. Mild abdominal tenderness on palpation is noted. The ESR is mildly elevated. 1. How is the severity of the client's ulcerative colitis documented? A. Mild B. Moderate C. Severe D. Fulminant

B. Moderate In moderate UC, vital signs are often normal and there are less than 6 blood stools daily. C-reactive protein and/or EST may be elevated.

A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A. Provide meticulous skin care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Encourage the client to drink extra fluids.

B. Place the client on Contact Precautions.

A client has a new diagnosis of irritable bowel syndrome (IBS) with diarrhea. What health teaching by the nurse is appropriate for this client? A. "Take a stool softener every day to ease defecation." B. "Avoid high-fiber foods in your diet." C. "Avoid dairy products and caffeinated beverages." D. "Ask your primary health care provider for an antidepressant."

C. "Avoid dairy products and caffeinated beverages."

The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? A. "It is important to provide care consistent with the client's expectation." B. "I will always consider my client's cultural preferences when delivering care." C. "I have been comparing our rates of infection with other units in the hospital." D. "I will look for the policy about family visitation to show my client."

C. "I have been comparing our rates of infection with other units in the hospital."

Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."

C. "It is important to keep my skin very moist, so I will use lotion."

The client is preparing for discharge. She asks what is the best way to take care of her skin. Which teaching will the nurse provide? A. "Add high-fiber or high-cellulose foods to your diet." B. "Apply a pectin-based skin barrier after each bowel movement." C. "Wash with mild soap and warm water after each bowel movement." D. "Take a laxative bedtime to facilitate morning bowel movements."

C. "Wash with mild soap and warm water after each bowel movement." Good skin care after each bowel movement is the best way to protect from excoriation or irritation due to frequent bowel movements. Pectin skin barriers are only used for ostomies; not UC. High-fiber or high-cellulose foods should be avoided, as should laxatives.

Which client does the nurse identify whose immune function is most efficient? A. 12 month old infant B. 18 year old adolescent C. 32 year old adult D. 49 year old adult

C. 32 year old adult Immune function is most efficient when people are in their 20s and 30s and slowly declines with increasing age. The immune system is developing and changing during infancy and teen years.

The nurse is conducting a handwashing refresher session. For which situation will the the nurse remind all staff that cleansing hands with an alcohol-based hand rub is appropriate? A. After using the bathroom B. To cleanse visibly soiled hands C. After handing oral medications to a client D. After caring for a client with Clostridium difficile

C. After handing oral medications to a client Alcohol-based hand rubs (ABHRs) are not appropriate if one's hands are visibly dirty, soiled, or feel sticky, or after toileting. In these cases, the nurse will teach to wash hands instead of using ABHRs. ABHRs are also ineffective against spore-forming organisms such as C. difficile. The only situation where using an ABHR is appropriate is after handing an oral medication to a client.

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test D. Increase the IV flow rate of the normal saline infusion

C. Assess the client's response to the Chvostek test

How do macrophages contribute to the neutrophilia that occurs in response to an acute bacterial infection? A. When invasion occurs, macrophages mature into neutrophils, increasing their circulating numbers. B. Macrophages have only an indirect role in neutrophilia by secreting substances that reduce bone marrow production of erythrocytes and platelets. C. At the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils. D. Inflammatory damage to macrophages allows release of proteolytic enzymes that enhance liver production of all white blood cell types, including mature segmented neutrophils.

C. At the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils.

Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action? A. No action is necessary at this time. B. Notify the health care provider of a possible wound infection. C. Clean the wound and reassess for presence of infection. D. Culture the wound and anticipate an order for antibiotics.

C. Clean the wound and reassess for presence of infection. Wound fluid and debris often interact with the dressing and may result in an odor when the dressing is removed. Gently clean the wound and reassess. Signs of infection are most frequently stalled wound healing, presence of purulent exudate, increased wound size or depth, fever, elevated WBC count, and increased pain. Cultures are not usually obtained.

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus

C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours

Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood

C. Continuous metabolic production of free hydrogen ions

A nurse conducts an assessment of an older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? A. Vitamin D B. Losartan C. Nortriptyline D. Hydrochlorothiazide (HCTZ)

C. Nortriptyline

The nurse is reviewing the orders for a client with COPD who was admitted for chest pain. Laboratory results indicate reveal mild respiratory acidosis. Which order will the nurse question? A. Encourage oral fluids B. Keep head of bed elevated C. Oxygen therapy at 4 L/min as needed D. Bedrest with bathroom privileges only

C. Oxygen therapy at 4 L/min as needed •The bedrest order will help the client conserve energy. The upright position (mid-Fowler's to high-Fowler's position) helps increase lung expansion. Increasing fluid intake may reduce the thickness of lung secretions and assist in their removal. Oxygen therapy helps promote gas exchange for clients with respiratory acidosis. However, use caution when giving oxygen to clients with COPD and CO2 retention as evidenced by a high Paco2 level. The only breathing trigger for these clients is a decreased arterial oxygen level. Giving too much oxygen to these clients decreases their respiratory drive and may lead to respiratory arrest.

The nurse is caring for a client with abdominal pain. Which documentation reflects the QSEN competency of Teamwork and Collaboration? A. Pain is rated as 7 on 1-10 scale B. Maintained on NPO status at this time C. Paged for consultation from surgical team D. Reviewed nursing literature for best practices

C. Paged for consultation from surgical team The nurse practicing with Teamwork and Collaboration has paged for a consultation from the surgical team; this nurse is working with other members of the health care team to provide quality care for the patient. Evaluating the client's pain on a 1-10 scale reflects providing Patient-Centered Care. Maintaining the client on NPO status in case surgery is needed reflects providing Safety. Reviewing nursing literature for best practices reflects Evidence-Based Practice.

The nurse reviews the client's admission laboratory results. 3. Which result does the nurse anticipate, given the earlier assessment findings of undernutrition? A. Hematocrit 37% B. Hemoglobin 12 g/dL C. Prealbumin 13 mg/dL D. Serum albumin 3.5 g/dL

C. Prealbumin 13 mg/dL Serum albumin, hematocrit, and hemoglobin are all low normal values that could indicate undernutrition. A serum albumin value of 3.5 g/dL is low and reflects nutritional status a few weeks before testing, so it is not the most sensitive protein study. A 13 mg/dL prealbumin level is low and is a more sensitive indicator of protein deficiency because of its short half-life of 2 days.

A client with a history of COPD is brought to the ED with respiratory depression. What acid-base imbalance does the nurse anticipate? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis •Respiratory acidosis results when respiratory function is impaired and the exchange of oxygen (O2) and carbon dioxide (CO2) is reduced. This problem causes CO2 retention, which leads to the same increase in hydrogen ion levels and acidosis.

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? A. Foot and ankle B. Forehead C. Sacrum D. Chest

C. Sacrum

The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates a total count of 5000 cells per cubic millimeter (mm3) of blood. Which of the follow differential counts or percentages does the nurse report to the surgeon to prevent harm? A. Eosinophils 300/mm3 B. Monocytes 600/mm3 C. Segmented neutrophils 2000/mm3 D. Lymphocytes 2100/mm3

C. Segmented neutrophils 2000/mm3

An older adult with anemia requests help with menu choices. What type of food will the nurse encourage the client to eat? A. Prunes B. Oranges C. Skim milk D. Wheat bread

C. Skim milk Vitamin B12 deficiency in a client's diet can result in anemia. Older adults are at risk for several nutritional concerns including anemia from vitamin B12 and iron deficiencies. Vitamin B12 can be found in meats, fish, dairy, and egg food products. Prunes and oranges can assist with adding fiber and vitamins to the diet. Encouraging complex carbohydrates such as wheat bread is also important for good nutrition.

Which nursing statement reflects an awareness of systems thinking?A."My client values spirituality when receiving care." B."I looked at our unit policy to be sure it was evidence-based." C."The care we provide to prevent pressure injuries should work on other units." D. "Appropriate documentation enhances continuity of care."

C."The care we provide to prevent pressure injuries should work on other units." The nurse who has an awareness of systems thinking looks at the care given to an individual that generates favorable outcomes, and translates that into how it could favorably affect others in a system. The nurse could also look at care that generated favorable outcomes at a systems level, and think about how adopting that into individual care could improve individual outcomes. •Recognizing that a client values spirituality is important at the individual point of care. •Looking at a unit policy to be sure it is evidence-based is practicing evidence-based care. •Documenting appropriately enhances continuity of care at the individual level.

A 40-year-old client with polycystic kidney disease is to receive a kidney transplant. When the nurse begins to administer 2 units of leukocyte-poor packed red blood cells to treat a low hemoglobin, the client asks why this has been prescribed. What is the appropriate nursing response? A. "It causes fewer blood reactions for pre-transplant patients." B. "It is less likely to causes hemolysis, or destruction of the blood cells, after transfusion." C. "All pre-transplant patients receive leukocyte-poor blood because it is absorbed better by the body." D. "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."

D. "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function." •Human leukocyte antigens (HLAs) are found on the surface of all body cells and serve as a "cellular fingerprint" recognizing self and non-self cells. When the HLAs of the immune system encounter a cell that is foreign, the immune system cell then takes action to neutralize, destroy, or eliminate this foreign invader. Transfusion of blood that contains leukocytes increases the number of HLAs introduced to the body. Evidence shows that leukocytes present in cellular blood products are the main component involved in the occurrence of HLA immunization, and several studies show that leukocyte-poor blood products are less able to induce it. HLA immunization through blood transfusion will make it harder to find an acceptable kidney transplant match for the patient (for example, HLA match for kidney transplant).

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia to prevent harm? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hr C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

A 21-year-old client presents to the student health center reporting vomiting and diarrhea all night. She has not eaten or drunk in the past 24 hours. Which prescription does the nurse anticipate the health care provider will recommend? A. IV fluid replacement B. Drink8 glasses of water C. No fluid replacement is needed at this time D. Oral rehydration therapy with a solution containing glucose and electrolytes

D. Oral rehydration therapy with a solution containing glucose and electrolytes •Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life threatening, or the client is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy (ORT) is a cost-effective way to replace fluids for the client with dehydration. Specifically formulated solutions containing glucose and electrolytes are absorbed even when the client is vomiting or has diarrhea.

Which nursing action reflects implementation of systems level thinking? A. Conducting a skin assessment on a newly admitted client B. Documenting a pressure injury in the electronic health record C. Notifying the health care provider of a 2″ × 1″ pressure injury on the coccyx D. Participating in a quality improvement project about eliminating pressure injury occurrences

D. Participating in a quality improvement project about eliminating pressure injury occurrences

The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A. Dementia B. Relocation stress C. Urinary incontinence D. Presbyopia E. Obesity

D. Presbyopia

While monitoring a client with fluid overload, which assessment findings requires immediate nursing intervention? A. Bounding pulse B. Neck vein distention C. Pitting edema in the feet D. Presence of crackles in the lungs

D. Presence of crackles in the lungs •Fluid overload may lead to pulmonary edema and heart failure. Any client with fluid overload, regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in clients with fluid overload.

The client's stool is positive for occult blood. He is admitted to the inpatient oncology unit, and soon passes bright red blood from the rectum. Where does the nurse anticipate that the client's tumor is located? A. Ascending colon B. Transverse colon C. Descending colon D. Rectosigmoid colon

D. Rectosigmoid colon Tumors of the rectosigmoid colon are associated with hematochezia (the passing of red blood via the rectum). This tumor location is also associated with straining to pass stools and narrowing of stools. Additionally, the client may report dull pain.

The client reports vomiting, fatigue, and weight loss of about 15 pounds over the past month. (CRC) What is the priority diagnostic test that the nurse anticipates the health care provider will order? A. Esophagogastroduodenoscopy (EGD) B. Colonoscopy C. Serum electrolytes D. Stool for fecal occult blood

D. Stool for fecal occult blood The most common signs of colorectal cancer are rectal bleeding and anemia. BUT COLONOSCOPIES ARE DEFINITIVE

A client received one positive fecal occult blood test. Which response is most appropriate? A. The client has colon cancer B. The client has bleeding in the GI tract C. The client may be taking Aspirin D. The client will need two samples on three consecutive days.

D. The client will need two samples on three consecutive days. •Two to three fecal occult blood tests on 3 consecutive days are needed to fully assess for blood in the stool. While a positive result may mean that the client has cancer, or bleeding in the GI tract, or has been taking medication, one test could be a false positive. The most appropriate response is to obtain additional samples for testing.

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%.

D. The hematocrit is 52%.

How will the experienced nurse explain systems thinking to a new nurse? A. Reading a journal article to enhance one's understanding of a specific disorder B. Providing patient-centered care to each individual, recognizing his or her uniqueness C. Engaging in a professional development activity to earn continuing education credit D. Using information from individual client care to improve outcomes at a macro level

D. Using information from individual client care to improve outcomes at a macro level

Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; Pao2 92 mm Hg; CO2 41 mm Hg; HCO3 − 28 mEq/L (mmol/L) B. pH 7.46; Pao2 98 mm Hg; CO2 38 mm Hg; HCO3 − 30 mEq/L (mmol/L) C. pH 7.22; Pao2 60 mm Hg; CO2 80 mm Hg; HCO3 − 22 mEq/L (mmol/L) D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)

D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)

When assessing a client who smells of alcohol, which question will the nurse ask? Select all that apply. A."Do you drink like this often?" B. "Why were you out drinking tonight?" C."Are you telling the truth about drinking?" D."Do people annoy you by criticizing your drinking?" E."Have you ever tried to cut down on your drinking?" F."Have you ever had a drink in the morning to settle your nerves?"

D."Do people annoy you by criticizing your drinking?" E."Have you ever tried to cut down on your drinking?" F."Have you ever had a drink in the morning to settle your nerves?" These three answers are part of the CAGE questionnaire (seen below). Options A, B, and C do not provide useful nor constructive information that can contribute to the proper care of the client. Have you ever tried to cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to settle your nerves? (eye-opener)

The nurse recognizes that which ethnic group has a higher incidence of colorectal cancer? A. Asian B. Caucasian C. Hispanic/Latino D. African-American

D.African-American African-American men and women are diagnosed with and die from colorectal cancer at higher rates than men and women of any other U.S. racial or ethnic group. The possible reasons for this difference include less use of diagnostic testing (especially colonoscopy), increased biological susceptibilities, decreased access to health care, lack of health insurance, cultural or spiritual beliefs, and lack of education about the need for early cancer detection (Tammana & Laiyemo, 2014; Haddad & You, 2016).