Exam 2: GI & integumentary

A client has been recovering for 18 months from burns that affected 60% total body surface area. For which problems will the nurse anticipate providing continuing care to this client? Select all that apply. a. Depression b. Post-traumatic stress disorder (PTSD) c. Grief and loss d. Anxiety e. Body image disorder

a. Depression b. Post-traumatic stress disorder (PTSD) c. Grief and loss d. Anxiety e. Body image disorder

A client is diagnosed with atrial fibrillation and the physician orders warfarin. For what skin lesion will the nurse monitor this client? a. Ulcer b. Scar c. Erosion d. Ecchymosis

d. Ecchymosis

A nurse assists the wound care nurse assess a patient prior to ileostomy surgery. Which assessments will the nurse complete before marking the placement for the ostomy? Select all that apply. a. Avoidance of skin folds b. The stoma lies below the waist c. Avoidance of previous scars d. Avoidance of bony prominences e. The stoma is visible to the client

a. Avoidance of skin folds b. The stoma lies below the waist c. Avoidance of previous scars d. Avoidance of bony prominences e. The stoma is visible to the client

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis? a. Grouped vesicles in linear patches along a dermatome b. Grouped vesicles occurring on the genitalia c. Grouped vesicles occurring on lips and oral mucous membranes d. Rough, fresh, or gray skin protrusions

a. Grouped vesicles in linear patches along a dermatome

A client has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance will have what effect on the client's gastrointestinal function? Select all that apply. a. Inhibition of secretions b. Increased peristalsis c. Decreased motility d. Increased enzyme release e. Increased sphincter tone

a. Inhibition of secretions c. Decreased motility e. Increased sphincter tone

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse will initiate therapy by performing which of the following actions? a. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance b. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible c. Changing the rate of administration every 2 hours based on serum electrolyte values d. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

a. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance

A nurse is preparing to discharge a client home on parenteral nutrition. What will an effective home care teaching program address? Select all that apply. a. Teaching the client and family strict aseptic technique b. Preparing the client to troubleshoot for problems c. Teaching the client when it is safe to leave the access site open to air d. Teaching the client to flush the line with clean tap water e. Teaching the client and family how to set up the infusion

a. Teaching the client and family strict aseptic technique b. Preparing the client to troubleshoot for problems e. Teaching the client and family how to set up the infusion

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). The nurse will address which of the following topics when providing health education? Select all that apply. a. The procedure carries a risk for dumping syndrome b. Part of the client's stomach and colon will be removed c. The client is likely to require long-term total parenteral nutrition (TPN) d. The client can resume a usual diet in 3 to 5 weeks e. Diarrhea f. A feeling of fullness

a. The procedure carries a risk for dumping syndrome e. Diarrhea f. A feeling of fullness

A nurse is caring for a client who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply. a. To remove gas from the stomach b. To remove toxins from the stomach c. To administer clotting factors to treat a GI bleed d. To open sphincters that are closed e. To diagnose GI motility disorders

a. To remove gas from the stomach b. To remove toxins from the stomach e. To diagnose GI motility disorders

A new client presents at the clinic and the nurse performs a comprehensive health assessment. The nurse notes that the client's fingernail surfaces are pitted. The nurse will suspect the presence of what health problem? a. Systemic lupus erythematosus (SLE) b. Psoriasis c. Eczema d. Chronic obstructive pulmonary disease (COPD)

b. Psoriasis

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? a. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. b. Report signs and symptoms of obstruction to the health care provider. c. Contact the physician and obtain a swab of the stoma for culture. d. Encourage the client to mobilize in order to enhance motility.

b. Report signs and symptoms of obstruction to the health care provider.

After teaching a client with an anal fissure, a nurse assesses the patient's understanding. Which patient actions indicate that the patient correctly understands the teaching? Select all that apply. a. Taking a laxative each morning b. Taking a warm sitz bath several times each day c. Increased water intake d. Utilizing a daily enema to prevent constipation e. Using bulk-producing agents to aid elimination

b. Taking a warm sitz bath several times each day c. Increased water intake e. Using bulk-producing agents to aid elimination

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? a. To prevent heterotopic ossification b. To prevent contractures c. To prevent wound breakdown d. To prevent neuropathies

b. To prevent contractures

A nurse caring for a client with colorectal cancer is preparing the client for upcoming surgery. The nurse administers antibiotics to the client and explains what rationale? a. To reduce abdominal distention postoperatively b. To reduce intestinal bacteria levels c. To reduce bowel motility d. To treat any undiagnosed infections

b. To reduce intestinal bacteria levels

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter related bloodstream infections? a. Irrigate the insertion site with sterile water during each dressing change. b. Apply antibiotic ointment around the site with each dressing change. c. Change the dressing no more than weekly. d. Use clean technique and wear a mask during dressing changes.

c. Change the dressing no more than weekly.

A client with human immune deficiency virus (HIV) has sought care because of the recent development of new skin lesions. The nurse will interpret these lesions as most likely suggestive of what? a. A reduction in the client's CD4+ count b. A reduction in the client's viral load c. An adverse effect of antiretroviral therapy d. Virus-induced changes in allergy status

a. A reduction in the client's CD4+ count

A client requires a full-thickness graft to cover a chronic wound. How is the donor site selected? a. An area matching the color and texture of the skin at the surgical site is selected. b. An area matching the sensory capability of the skin at the surgical site is selected. c. Any area that is not normally visible can be used. d. The largest area of the body without hair is selected.

a. An area matching the color and texture of the skin at the surgical site is selected.

A nurse cares for a patient who is recovering from a colonoscopy. Which actions would the nurse take? Select all that apply. a. Assess the patient for rectal bleeding. b. Confirm the patient has a ride home. c. Administer prescribed pain medications. d. Obtain vital signs every 15 to 30 minutes. e. Monitor the patient's glucose level.

a. Assess the patient for rectal bleeding. b. Confirm the patient has a ride home. d. Obtain vital signs every 15 to 30 minutes.

An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education will include what guidelines? Select all that apply. a. Avoid non-steroidal anti-inflammatories b. Avoid drinking alcohol c. Adopt a low-residue diet d. Prepare for the possibility of surgery e. Take calcium gluconate as prescribed

a. Avoid non-steroidal anti-inflammatories b. Avoid drinking alcohol

A client's enteral feedings have been determined to be too concentrated based on the client's development of dumping syndrome. What physiologic phenomenon caused this client's complication of enteral feeding? a. Entry of large amounts of water into the small intestine because of osmotic pressure b. Increased gastric secretion of HCl and gastrin because of high osmolality of feeds c. Mucosal irritation of the stomach and small intestine by the high concentration of the feed d. Acid-base imbalance resulting from the high volume of solutes in the feed

a. Entry of large amounts of water into the small intestine

The nurse is developing a plan of care for a client with an active bleeding peptic ulcer disease. What nursing interventions will be included in the care plan? Select all that apply. a. Frequently monitoring hemoglobin and hematocrit levels b. Making neurovascular checks every 4 hours c. Inserting an indwelling catheter for incontinence d. Observing stools and vomitus for color, consistency, and volume e. Checking the blood pressure and pulse rate every 15 to 20 minutes

a. Frequently monitoring hemoglobin and hematocrit levels d. Observing stools and vomitus for color, consistency, and volume e. Checking the blood pressure and pulse rate every 15 to 20 minutes

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? Select all that apply. a. Fruit juice b. Smoking c. Alcohol d. Nonsteroidal anti-inflammatory drugs (NSAIDs) e. Caffeine

b. Smoking c. Alcohol d. Nonsteroidal anti-inflammatory drugs (NSAIDs) e. Caffeine

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment will the nurse anticipate? Select all that apply. a. Increased fiber intake b. Enemas on alternating days c. Reduced fat intake d. Anticholinergic medications e. Fluid reduction

a. Increased fiber intake c. Reduced fat intake

A nurse is caring for a client admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. a. Lipase b. Amylase c. Trypsin d. Pepsin e. Ptyalin

a. Lipase b. Amylase c. Trypsin

The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these patients? Select all that apply a. Peptic ulcer disease b. Inflammatory bowel disease c. Chronic alcohol abuse d. Colon cancer e. Diverticulitis

a. Peptic ulcer disease b. Inflammatory bowel disease c. Chronic alcohol abuse d. Colon cancer e. Diverticulitis

The nurse documenting an acute open wound will include which characteristic(s)? Select all that apply. a. Periwound skin b. Pattern of eruption c. Wound bed d. Wound edges e. Wound size

a. Periwound skin c. Wound bed d. Wound edges e. Wound size

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse will prioritize what finding? a. Potassium level b. White blood cell level c. Creatinine level d. Hemoglobin level

a. Potassium level

A nurse is admitting a client to the postsurgical unit following a gastrostomy. When planning assessments, the nurse will be aware of what potential postoperative complication of a gastrostomy? a. Premature removal of the G tube b. Constipation c. Bowel perforation d. Development of peptic ulcer disease (PUD)

a. Premature removal of the G tube

A client with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction will the nurse include in home care instructions? a. Protect the graft from direct sunlight and temperature extremes. b. Apply antibiotic ointment to the graft and donor sites daily. c. Protect the graft site from any form of moisture for at least 12 weeks. d. Gently massage the graft site daily to promote perfusion.

a. Protect the graft from direct sunlight and temperature extremes.

A nurse is caring for a client whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the client is performing active range-of-motion (ROM) exercises with the affected hand. How will the nurse best respond? a. Remind the client of the need to immobilize the graft to facilitate healing. b. Remind the client that ROM exercises should be passive, not active. c. Validate the client's efforts to increase blood perfusion to the graft site. d. Consult with the physical therapist to ensure that the client is performing exercises safely

a. Remind the client of the need to immobilize the graft to facilitate healing.

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. a. Skin turgor b. Oxygen saturation c. Percentage of meals eaten d. Daily weights e. Hourly urine output

a. Skin turgor d. Daily weights e. Hourly urine output

A client with squamous cell carcinoma has been scheduled for treatment of this malignancy. The nurse will anticipate that treatment for this type of cancer will primarily consist of what intervention? a. Surgical excision b. Biopsy of sample tissue c. Chemotherapy d. Radiation therapy

a. Surgical excision

A patient who has a history of ulcerative colitis has been hospitalized for repair of a fractured humerus. A combination of which findings would prompt the nurse to collaborate with the healthcare provider regarding a transfer to the ICU? Select all that apply. a. The client is tachycardic b. The client's stool is hemacult positive c. The client's BUN drops d. The client vomits coffee ground material e. The client is hypotensive

a. The client is tachycardic b. The client's stool is hemacult positive d. The client vomits coffee ground material e. The client is hypotensive

The nurse is planning the care of a client who has burns to the face, neck, upper chest, and both upper arms. To prevent complications of immobility, the nurse will include which interventions in the patient's plan of care? Select all that apply. a. Turning and proper positioning of the patient b. Use a bed cradle over the burned areas c. Get the patient out of bed as soon as medically feasible. d. Passive and active range of motion e. Assess splinted areas for proper joint alignment

a. Turning and proper positioning of the patient c. Get the patient out of bed as soon as medically feasible. d. Passive and active range of motion e. Assess splinted areas for proper joint alignment

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings will the nurse correlate with this diagnosis? Select all that apply. a. Vomiting b. Abdominal distension c. Hypokalemia d. Hyponatremia e. Low-pitched bowel sounds

a. Vomiting b. Abdominal distension c. Hypokalemia d. Hyponatremia

What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. a. abdominal distention b. Fever c. sudden drop in body temperature d. sudden, sustained abdominal pain e. intermittent, severe pain

a. abdominal distention b. Fever d. sudden, sustained abdominal pain

A 30-year-old male client has just returned from the operating room after having a "flap" done following a motorcycle accident. The client's wife asks the nurse about the major complications following this type of surgery. What will be the nurse's best response? a. "The major complication is when the pedicle tears loose and the flap dies." b. "The major complication is when the blood supply fails and the tissue in the flap dies." c. "The major complication is when the client loses sensation in the flap." d. "The major complication is when the client develops chronic pain."

b. "The major complication is when the blood supply fails and the tissue in the flap dies."

A client admitted for treatment of a gastric ulcer is being prepared for discharge. The client will follow a regimen of antacid therapy. Discharge teaching will include which instructions? Select all that apply. a. "Be sure to take antacids with meals." b. "You may be prescribed H2-receptor antagonists for up to 1 year." c. "Continue to take antacids even if your symptoms subside." d. "You may take antacids with other medications." e. "The antacids will make you sleepy, so do not operate machinery while taking them."

b. "You may be prescribed H2-receptor antagonists for up to 1 year." c. "Continue to take antacids even if your symptoms subside."

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? a. Distraction and relaxation techniques supplemented by NSAIDs b. A patient-controlled analgesia (PCA) system c. A combination of benzodiazepines and topical anesthetics d. Oral opioids supplemented by NSAIDs

b. A patient-controlled analgesia (PCA) system

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? a. Pain b. Airway management c. Anxiety and fear d. Fluid balance

b. Airway management

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. a. Malignant hyperthermia b. Atelectasis c. Pneumonia d. Hemorrhage e. Chronic gastritis

b. Atelectasis c. Pneumonia d. Hemorrhage

A nurse is preparing to administer a client's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that small amounts of white precipitate are present in the bag. What is the nurse's best action? a. Recognize this as an expected finding. b. Contact the pharmacy to obtain a new bag of PN. c. Place the bag in a warm environment for 30 minutes. d. Shake the bag vigorously for 10 to 20 seconds

b. Contact the pharmacy to obtain a new bag of PN.

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse will emphasize that ultraviolet light helps to synthesize what vitamin? a. C b. D c. E d. A

b. D

A nurse cares for a patient who has a nasogastric (NG) tube. Which actions will the nurse take? Select all that apply. a. Secure the NG tube to the patient's upper lip. b. Disconnect suction when auscultating bowel peristalsis. c. Flush the tube with water every hour to ensure patency. d. Monitor the patient's skin around the tube site for irritation. e. Assess for proper placement of the tube every 4 hours.

b. Disconnect suction when auscultating bowel peristalsis. d. Monitor the patient's skin around the tube site for irritation. e. Assess for proper placement of the tube every 4 hours.

A client with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment will the nurse prioritize? a. Assessment of hemoglobin, hematocrit, and red blood cell levels b. Frequent abdominal auscultation c. Close monitoring of temperature d. Palpation of peripheral pulses and leg girth

b. Frequent abdominal auscultation

A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse will recognize an increased need for what form of health promotion? a. Annual screening colonoscopies b. Frequent screening for osteoporosis c. Regular blood pressure monitoring d. Adherence to recommended immunization schedules

b. Frequent screening for osteoporosis

A 35-year-old male client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary provider, what intervention will the nurse prioritize? a. Administration of a glycerin suppository and an oral laxative b. Insertion of a nasogastric tube c. Insertion of a central venous catheter d. Administration of a mineral oil enema

b. Insertion of a nasogastric tube

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? a. Administration of proton pump inhibitors as prescribed b. Insertion of an NG tube for decompression c. Infusion of hypotonic IV solution d. Administration of antiemetics

b. Insertion of an NG tube for decompression

A client experienced surgical resection of a tumor of the esophagus via a thoracotomy approach. After recovery from the anesthesia, what will the nurse include in the postoperative care plans? Select all that apply. a. Maintain the client in a side-lying position. b. Monitor drainage in the closed chest drainage system. c. Assess lung sounds every 4 hours and prn. d. Replace the nasogastric tube if the tube becomes dislodged. e. Verify rhythm on the cardiac monitoring system.

b. Monitor drainage in the closed chest drainage system. c. Assess lung sounds every 4 hours and prn. e. Verify rhythm on the cardiac monitoring system.

A nurse is caring for a client in the late stages of esophageal cancer. The nurse will plan to prevent or address what characteristics of this stage of the disease? Select all that apply. a. Painful swallowing b. Perforation into the mediastinum c. Obstruction of the esophagus d. Erosion into the great vessels e. Development of an esophageal lesion

b. Perforation into the mediastinum c. Obstruction of the esophagus d. Erosion into the great vessels

After teaching a patient who had an ileostomy, a nurse assesses the patient's understanding. Which dietary items chosen indicate that the client needs additional teaching? Select all that apply. a. Squash b. Popcorn c. Apple sauce d. Carrots e. Corn

b. Popcorn e. Corn

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following will most likely be included in the client's medication regimen? a. Beta adrenergic blockers to reduce bowel motility b. Vitamin B12 injections to prevent pernicious anemia c. Antidiarrheal medications 30 minutes before a meal d. Antiemetics on a PRN basis

c. Antidiarrheal medications 30 minutes before a meal

A client has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. What intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? a. Administration of stool softeners b. Administration of prophylactic antibiotics c. Early enteral feeding d. Bowel-cleansing procedures

c. Early enteral feeding

The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation will the nurse make to the client? a. Drink a minimum of 12 ounces of fluid with each meal. b. Choose foods that are high in simple carbohydrates. c. Eat several small meals daily spaced at equal intervals. d. Sit upright when eating and for 30 minutes afterward.

c. Eat several small meals daily spaced at equal intervals.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what will be the nurse's immediate, priority concern when planning this client's care? a. Nutritional status b. Risk of infection c. Fluid status d. Psychosocial coping

c. Fluid status

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what? a. Hypokalemia, hyponatremia, elevated hematocrit b. Hypokalemia, hypernatremia, decreased hematocrit c. Hyperkalemia, hyponatremia, elevated hematocrit d. Hyperkalemia, hypernatremia, decreased hematocrit

c. Hyperkalemia, hyponatremia, elevated hematocrit

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse will anticipate the administration of what fluid? a. 0.45% NaCl with 40 mEq/L KCl b. Normal saline c. Lactated Ringer's d. 0.45% NaCl with 20 mEq/L KCl

c. Lactated Ringer's

A nurse is caring for a client who is in the acute phase of a burn injury. What interventions will be appropriate to assist the client to strengthen their coping strategies. Select all that apply. a. Avoid asking the client to make decisions b. Administer benzodiazepines as prescribed c. Provide positive reinforcement d. Teach the client coping strategies e. Promote truthful communication

c. Provide positive reinforcement d. Teach the client coping strategies e. Promote truthful communication

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How will the nurse best respond to this finding? a. Obtain an order to reduce the rate of the client's IV fluid infusion b. Report the client's early signs of acute kidney injury (AKI) c. Recognize that the client is experiencing an expected onset of diuresis d. Administer sodium chloride as prescribed to compensate for this fluid loss

c. Recognize that the client is experiencing an expected onset of diuresis

A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? a. Reposition the client into a prone or semi-Fowler position and apply supplementary oxygen by nasal cannula. b. Encourage the client to perform deep breathing and coughing exercises hourly. c. Report this finding promptly to the health care provider and remain with the client. d. Activate the emergency response system.

c. Report this finding promptly to the health care provider and remain with the client.

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? a. The client has abdominal bloating that developed rapidly. b. The client is experiencing dizziness and confusion with no apparent hemodynamic changes. c. The client has a rigid, "boardlike" abdomen that is tender. d. The client is experiencing intense lower right quadrant pain.

c. The client has a rigid, "boardlike" abdomen that is tender.

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? a. The effect of laxatives on electrolyte levels b. The risk of fecal incontinence c. The risk of becoming laxative-dependent d. The underlying causes of constipation

c. The risk of becoming laxative-dependent

A nurse is doing a shift assessment on a group of clients after first taking report. An elderly client is having her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's chest. The nurse will ask what priority question regarding the presence of a reddened rash? a. "Is the rash worse at a particular time or season?" b. "Is your rash painful?" c. "Are you having any loss of sensation in that area?" d. "Are you allergic to any foods or medication?"

d. "Are you allergic to any foods or medication?"

A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What will the nurse do next? a. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration. b. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. c. Remove the NG tube promptly and obtain an order for reinsertion from the primary provider. d. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

d. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse will monitor the client closely for what signs of the onset of burn shock? a. High fever b. Sudden agitation c. Confusion d. Decreased blood pressure

d. Decreased blood pressure

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse will identify what comorbidity as increasing the client's vulnerability to skin infections? a. Chronic obstructive pulmonary disease b. Rheumatoid arthritis c. Gout d. Diabetes

d. Diabetes

A client has received a diagnosis of irritant contact dermatitis. What action will the nurse prioritize in the client's subsequent care? a. Teaching the client how to maintain meticulous skin hygiene b. Helping the client perform wound care in the home environment c. Teaching the client to safely and effectively administer immunosuppressants d. Helping the client identify and avoid the offending agent

d. Helping the client identify and avoid the offending agent

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? a. Changes in the character and quantity of bacterial skin flora b. Increased vascular supply to superficial skin layers c. Increased thickness of the subcutaneous skin layer d. Increased time required for wound healing

d. Increased time required for wound healing

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? a. Document this finding as an expected phase of graft healing. b. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. c. Perform mechanical debridement to remove the exudate and prevent further infection. d. Inform the primary provider promptly because the graft may need to be removed.

d. Inform the primary provider promptly because the graft may need to be removed.

A client is admitted to the burn unit after being transported from a facility a large distance away. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse will be cognizant of the risk of what complication? a. Venous thromboembolism (VTE) b. Referred pain c. Cellulitis d. Ischemia

d. Ischemia

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information will be included in this plan? a. Wash skin frequently to prevent infection. b. Liberally apply corticosteroids as needed. c. Avoid public places until symptoms subside. d. Lifelong management is likely needed.

d. Lifelong management is likely needed.

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what will be a priority nursing action for this client? a. Place the client in a prone position. b. Prepare for the insertion of an NG tube. c. Provide the client with ice water to slow any GI bleeding. d. Notify the health care provider

d. Notify the health care provider

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? a. Gastritis b. Acute pancreatitis c. Gastroesophageal reflux d. Peritonitis

d. Peritonitis

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action? a. Perform chest physiotherapy. b. Reduce the height of the client's bed and remove the NG tube. c. Consult with the dietitian to obtain a feeding solution with lower osmolarity. d. Report possible signs of aspiration pneumonia to the primary provider.

d. Report possible signs of aspiration pneumonia to the primary provider.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? a. The source of the burn b. The length of time since the burn c. The location of burned skin surfaces d. The total body surface area (TBSA) affected by the burn

d. The total body surface area (TBSA) affected by the burn