Exam 2 - Theory Study

During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care? - Body image - Ostomy care - Sexual concerns - Skin care

Ostomy care

A patient with chronic cholecystitis asks the nurse whether she will need to continue a low-fat diet after the patient has a cholecystectomy. What is the best response by the nurse? - "A low-fat diet will prevent the development of further gallstones and should be continued." - "Yes, because you will not have a gallbladder to store bile, you will not be able to digest fats adequately." - "A low-fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile." - "Removal of the gallbladder will eliminate the source of your pain that was associated with fat intake, so you may eat whatever you like."

"A low-fat diet is recommended for a few weeks after surgery until the intestine adjusts to receiving a continuous flow of bile." After removal of the gallbladder, bile drains directly from the liver into the duodenum and a low-fat diet is recommended until adjustment to this change occurs. Most patients tolerate a regular diet with moderate fat intake but should avoid excessive fat intake, as large volumes of bile previously stored in the gallbladder are not available. Steatorrhea could occur with large fat intake.

The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that more patient education about GERD is needed? - "I take antacids between meals and at bedtime each night." - "I sleep with the head of the bed elevated on 4-6 inch blocks." - "I quit smoking several years ago, but I still chew a lot of gum." - "I eat small meals throughout the day and have a bedtime snack."

"I eat small meals throughout the day and have a bedtime snack." GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

When teaching a community group about measures to prevent colon cancer, which instruction should the nurse include? - "Limit fat intake to 20% to 25% of your total daily calories." - "Include 15 to 20 grams of fiber into your daily diet." - "Get an annual rectal examination after age 35." - "Undergo sigmoidoscopy annually after age 50."

"Limit fat intake to 20% to 25% of your total daily calories." To help prevent colon cancer, fats should account for no more than 20% to 25% of total daily calories and the diet should include 25 to 30 grams of fiber per day. A digital rectal examination isn't recommended as a stand-alone test for colorectal cancer. For colorectal cancer screening, the American Cancer society advises clients over age 50 to have a flexible sigmoidoscopy every 5 years, yearly fecal occult blood tests, yearly fecal occult blood tests PLUS a flexible sigmoidoscopy every 5 years, a double-contrast barium enema every 5 years, or a colonoscopy every 10 years.

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? - "The tube will help to drain the stomach contents and prevent further vomiting." - "The tube will push past the area that is blocked and help to stop the vomiting." - "The tube is just a standard procedure before many types of surgery to the abdomen." - "The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."

"The tube will help to drain the stomach contents and prevent further vomiting." The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume? - polyuria - bradycardia - restlessness - difficulty breathing

- Restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

You are caring for a patient admitted with diabetes, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient? (Select all that apply.) - The potassium level may be increased if the patient has nephropathy. - The patient has been eating excessive amounts of foods that increase potassium levels. - The patient may be excreting extra sodium and retaining potassium secondary to malnutrition. - There may be excess potassium being released into the blood as a result of massive blood transfusion. - The potassium level may be increased because of dehydration that accompanies high blood glucose levels.

- The potassium level may be increased if the patient has nephropathy. - There may be excess potassium being released into the blood as a result of massive blood transfusion. - The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have a nasogastric tube and not be eating.

The nurse is caring for a patient admitted to the medical until with hypokalemia. The best food to offer the patient are? (select all that apply) - apple - banana - orange juice - chocolate milk - cooked broccoli

- banana - orange juice - chocolate milk - cooked broccoli Milk products, oranges, and bananas are all high in potassium. Cooked broccoli is high in potassium. Apples are low in potassium.

A nurse is assigned to care for a client with an infection. The nurse is required to identify and record signs and symptoms of the infection. The nurse should closely monitor the client for the following symptoms.(Select all that apply) - localized pain - Fever - General Malaise - Diabetes Mellitus - Chills - Anemia

- localized pain - Fever - General Malaise (feeling of discomfort, illness, or uneasiness - general sense of unwell) - Chills

Always assess the patient with eye problems for a. visual acuity b. pupillary reactions c. intraocular pressure d. confrontation visual fields

A

During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as: - A normal finding - A conductive hearing loss in the right ear - A sensorineural or conductive loss - The presence of nystagmus

A sensorineural or conductive loss In the Weber tuning fork test the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard in equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear

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

A, C For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related to enteral nutrition, and teach the caregiver about feeding via the gastrostomy tube at home.

Which of the following tests is most commonly used to diagnose cholecystitis? - Abdominal CT scan - Abdominal ultrasound - Barium swallow - Endoscopy

Abdominal ultrasound An abdominal ultrasound can show if the gallbladder is enlarged, if gallstones are present, if the gallbladder wall is thickened, or if distention of the gallbladder lumen is present. An abdominal CT scan can be used to diagnose cholecystitis, but it usually isn't necessary. A barium swallow looks at the stomach and the duodenum. Endoscopy looks at the esophagus, stomach, and duodenum.

Which is a risk factor for gallbladder​ disease? A. Male gender B. Hypocalcemia C. Rapid weight loss D. Hypolipidemia

Answer: C​ Rationale: Rapid weight​ loss, hyperlipidemia​ (not hypolipidemia), and female​ (not male) gender are risk factors for gallbladder disease. Hypocalcemia is not a risk factor.

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient? (Select all that apply.) - Ataxia - itching - nausea - urinary retention - gastrointestinal bleeding

Ataxia nausea urinary retention

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? (Select all that apply.) - weakness - paresthesia - facial spasms - muscle tremors - depressed reflexes

weakness & depressed reflexes paresthesia is when you feel tingling in the hand

The nurse is providing dietary teaching to a client with a history of gallstones. Which diet should the nurse​ recommend? (Select all that​ apply.) A. High protein B. Low sodium C. Low fat D. High vitamin C E. High carbohydrate

Answer: A, C Rationale: A​ low-carbohydrate, low-fat,​ high-protein diet reduces symptoms of cholecystitis. While fasting and very​ low-calorie diets are​ contraindicated, a moderate reduction in caloric intake and increased activity levels promote weight loss.

A client scheduled for a cholecystectomy asks what caused the gallstones to develop. Which risk factor should the nurse list when responding to this​ client? (Select all that​ apply.) A. American Indian ethnicity B. Male sex C. Family history of gallstones D. Obesity E. Hyperlipidemia

Answer: A, C, D, E​ Rationale: The risk factors for developing gallbladder disorders include​ age, family history of​ gallstones, American Indian​ ethnicity, obesity,​ hyperlipidemia, female​ sex, pregnancy, diabetes​ mellitus, cirrhosis, ileal​ disease, and sickle cell disease. Men have a lower risk of developing gallbladder disorders.

A client who is morbidly obese is diagnosed with acute cholelithiasis. Which nonpharmacologic therapy should the nurse expect to be prescribed for this​ client? A. Parenteral nutrition B. ​Fat-soluble vitamins C. Bile salts D. Withholding all oral intakes and inserting a nasogastric tube

Answer: D​ Rationale: During an acute attack of​ cholecystitis, food should be eliminated and a nasogastric tube inserted to relieve nausea and vomiting. Parenteral nutrition is not indicated at this time. Once the client is eating​ again, dietary fat intake may be​ limited, especially if the client is obese. If bile flow is​ obstructed, fat-soluble vitamins​ (A, D,​ E, and​ K) and bile salts may need to be administered but this would be considered a pharmacologic therapy.

If a gastric acid perforates, which of the following actions should not be included in the immediate management of the client? - Blood replacement - Antacid administration - Nasogastric tube suction - Fluid and electrolyte replacement

Antacid administration Antacids aren't helpful in perforation. The client should be treated with antibiotics as well as fluid, electrolyte, and blood replacement. NG tube suction should also be performed to prevent further spillage of stomach contents into the peritoneal cavity.

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately? - Notify the physician - Irrigate the eye with cold water - Apply ice to the affected eye - Accompany the client to the emergency room

Apply ice to the affected eye Treatment for contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.

A nurse is caring for a client who is 1-day postoperative following a gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? - Determine the time the client last received pain medication. - Measure the client's vital signs, including temperature - Ask the client to rate her pain on a scale from 0 to 10. - Reposition the client and offer her a back rub.

Ask the client to rate her pain on a scale from 0 to 10. Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.

For which patients is it most important for the nurse to refer to a dietitian for a complete nutritional assessment? a. A 38-yr-old with diabetes who is undergoing laser eye surgery b. A 55-yr-old with a history of alcohol use disorder who is hospitalized with a fractured femur from a fall c. A 24-yr-old who has been taking a burst of corticosteroid therapy for 1 week for treatment of an asthma exacerbation d. A 45-yr-old hospitalized with nausea and abdominal pain who has had no oral intake and only IV fluids of D5 ½ NS for 6 days

B Alcoholics usually drink instead of eat, so very worried about malnutrition with these patients The person in Option 4 is at risk for malnutrition after 10 days of only receiving intravenous fluids.

Which nursing action will the nurse include in the plan of care when admitting a patient with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Increase dietary fiber intake. d. Ambulate four times daily.

B Since anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease? (Select all that apply) - Restricted to rectum - Strictures are common - Bloody, diarrhea stools - Cramping abdominal pain - Lesions penetrate intestine

Bloody, diarrhea stools Cramping abdominal pain Manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

The nurse should be alert for which manifestations n a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms

C

During the course of a health history to assess vision, a patient reports dry eyes. What should the nurse assess next? - Assess for contact lenses. - Suggest saline eyedrops. - Ask about eyeglass usage. - Check the medication list.

Check the medication list. The nurse should evaluate the patient's medication list to identify agents that can contribute to dry eyes so follow-up nursing care can be planned. Dry eyes aggravate wearing contact lenses, but contact lenses do not normally cause dry eyes. The nurse should not suggest saline eyedrops until the etiology of the dry eyes is determined. Eyeglasses do not cause dry eyes.

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate would drop down to or below which of the following parameters? a. 16 Breaths/min b. 14 Breaths/min c. 12 Breaths/min d. 10 Breaths/min

Correct: C To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths/min.

A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer? - Discharge planning - Correction of nutritional deficits - Prevention of DVT - Instruction regarding radiation treatment

Correction of nutritional deficits Client's with gastric cancer commonly have nutritional deficits and may be cachectic. Discharge planning before surgery is important, but correcting the nutrition deficit is a higher priority. At present, radiation therapy hasn't been proven effective for gastric cancer, and teaching about it preoperatively wouldn't be appropriate. Prevention of DVT also isn't a high priority to surgery, though it assumes greater importance after surgery.

During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because: a. older adults have an impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adults c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are more significant because body fluids account for 45% to 50% of body weight in older adults

D

Increased intraocular pressure may occur because of a. edema of the corneal stoma b. dilation of the retinal arterioles c. blockage of the lacrimal canals and ducts d. increased aqueous humor production by ciliary process

D

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? - Ineffective coping related to fear of diagnosis of chronic illness - Deficient knowledge related to unfamiliarity with significant signs and symptoms - Constipation related to decreased gastric motility - Imbalanced nutrition: Less than body requirements due to gastric bleeding

Deficient knowledge related to unfamiliarity with significant signs and symptoms

A patient working in a noisy factory reports being off balance when standing or walking but not while lying down. What term will the nurse use to document this patient's symptoms? - Vertigo - Syncope - Dizziness - Nystagmus

Dizziness Dizziness is a sensation of being off balance that occurs when standing or walking; it does not occur when lying down. Nystagmus is an abnormal eye movement that may be observed as a twitching of the eyeball or described by the patient as a blurring of vision with head or eye movement. Vertigo is a sense that the person or objects around the person are moving or spinning and is usually stimulated by movement of the head. Syncope is a brief lapse in consciousness accompanied by a loss in postural tone (fainting).

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

Edema, Anemia, Impaired wound healing Protein deficiency can cause complications such as edema, anemia, and impaired wound healing. Decreased albumin in the vascular space allows fluids to leak into the interstitial spaces causing edema. Without adequate protein, blood formation is impaired. Adequate protein is required for wound healing. Asthma does not develop due to protein deficiency. A malabsorption syndrome may affect the amount of nutrients that are absorbed causing protein deficiency. Gastrointestinal bleeding is not a complication of protein deficiency.

After an acoustic neuroma is removed from a patient, the nurse teaches the patient about tumor recurrence. What should the nurse instruct the patient to monitor? (Select all that apply.) - Lack of coordination - Episodes of dizziness - Worsening of hearing - Inability to close the eye - Clear drainage from the nose

Episodes of dizziness Worsening of hearing Inability to close the eye An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve [CN] VIII) enters the internal auditory canal. Clinical manifestations of tumor recurrence including facial nerve (CN VII) paralysis can be manifested by intermittent vertigo, hearing loss, and inability to close the eye. Lack of coordination and clear nasal drainage do not manifest with acoustic neuroma.

The client has developed an infection in the abdominal wound. When assessing the wound, the nurse observes for signs and symptoms of an infection: These include: (Select all that Apply) - Erythema - Tenderness or Pain - Granulation Tissue - Purulent exudate

Erythema (red area/skin) Tenderness or Pain Purulent exudate

The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? - Decrease fluid intake to control the intraocular pressure - Avoid overuse of the eyes - Decrease the amount of salt in the diet - Eye medications will need to be administered lifelong.

Eye medications will need to be administered lifelong. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life.

A nurse is caring for a 6-month old infant who is postoperative following a myringotomy. which of the following pain scales should the nurse use to determine the infant's pain level? - FLACC - Oucher - FACES - Visual Analog Scale

FLACC - The FLACC pain scale is appropriate to use with infants and children between the ages of 2 months and 7 years.

A client with gastric cancer may exhibit which of the following symptoms? - Abdominal cramping - Constant hunger - Feeling of fullness - Weight gain

Feeling of fullness wont have abdominal cramping

Which of the following factors is believed to be linked to Crohn's disease? - Constipation - Diet - Hereditary - Lack of exercise

Hereditary Although the definite cause of Crohn's disease is unknown, it's thought to be associated with infectious, immune, or psychological factors. Because it has a higher incidence in siblings, it may have a genetic cause.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs? - Initiate continuous enteral feedings - Encourage a high protein, high-calorie diet - Implement total parenteral nutrition - Provide six small meals a day

Implement total parenteral nutrition Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into 6 small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client's symptoms.

A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially? - Irrigation of the ear - Instillation of diluted alcohol - Instillation of antibiotic ear drops - Instillation of corticosteroids ear drops

Instillation of diluted alcohol Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which then is removed by using forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse

The patient with suspected gallbladder disease is scheduled for an ultrasound of the gallbladder. What should the nurse explain to the patient about this test? - It is noninvasive and is a very reliable method of detecting gallstones. - It is the only test to use when the patient allergic to contrast medium - It will outline the gallbladder and the ductal system to enable visualization of stones. - It is an adjunct to liver function tests to determine whether the gallbladder is inflamed.

It is noninvasive and is a very reliable method of detecting gallstones. Ultrasonongraphy is accurate in detecting gallstones and is a noninvasive procedure. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) may also be used when the patient is allergic to contrast medium. An IV cholangiogram uses radiopaque dye to outline the gallbladder and ducts. Liver function studies will be elevated if liver damage has occurred but do not indicate gallbladder disease.

The nurse is reviewing the physician's orders for a client with Meniere's disease. Which diet will most likely be prescribed? - Low-cholesterol diet - Low-sodium diet - Low-carbohydrate diet - Low-fat diet

Low-sodium diet Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid sometimes are prescribed.

Which goal of the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? - Promoting self-care and independence - Managing diarrhea - Maintaining adequate nutrition - Promoting rest and comfort

Managing diarrhea

The client with a duodenal ulcer may exhibit which of the following findings on assessment? - Hematemesis - Malnourishment - Melena - Pain with eating

Melena The client with a duodenal ulcer may have bleeding at the ulcer site, which shows up as melena (black tarry poop). The other findings are consistent with a gastric ulcer.

What treatment for acute cholecystitis will prevent further stimulation of the gallbladder? - NPO with NG suction - Incisional cholecycstectomy - Administration of antiemetics - Administration of anticholinergics

NPO with NG suction NPO status and nasogastric (NG) suction prevent gallbladder stimulation from food or fluids moving into the duodenum. Laparoscopic cholecystectomy is used more often than incisional cholecystectomy, but both remove the gallbladder, not is stimulation. Administration of antiemetics decreases nausea and vomiting but does not decrease gallbladder stimulation. Anticholinergics counteract the smooth muscle spasms of the bile ducts to decrease output.

Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit? - Jaundice, dark urine, and steatorrhea - Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration - Ecchymosis petechiae, and coffee-ground emesis - Nausea, vomiting, and anorexia

Nausea, vomiting, and anorexia Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy's sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis.

A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? - Irrigate the NG tube. - Obtain the vital signs. - Listen for bowel sounds. - Give the ordered antacid.

Obtain the vital signs. The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken.

A nurse is caring for a client who is postoperative following a cholecystectomy and report pain. Which of the following actions should the nurse take? (select all that apply) - Offer the client a back rub - Identify the client's pain level - Assist the client to ambulate - Change the client's position - Remind the client to use incisional splinting

Offer the client a back rub is correct: Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct: Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain Identify the client's pain level is correct: The nurse should use a standard scale to determine and document the severity of the client's pain. Assist the client to ambulate is incorrect: If the client reports pain, the nurse should implement interventions to manage the pain, such as administering analgesia and giving it time to take effect, before assisting the client to ambulate. Change the client's position is correct: Nonpharmacological measures for managing pain include repositioning, imagery, and distraction.

The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye, what is the initial nursing action? - Remove the piece of wood using a sterile eye clamp - Apply an eye patch - Perform visual acuity tests - Irrigate the eye with sterile saline

Perform visual acuity tests If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the sclera. (The only option that will prevent further disruption is to assess visual acuity.)

A labyrinthectomy can be performed to treat Meniere's syndrome. This procedure results in: - Anosmia - Absence of pain - Reduction in cerumen - Permanent irreversible deafness

Permanent irreversible deafness The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, utricle, saccule, cochlear duct, and membranous semicircular canals. A labyrinthectomy is performed to alleviate the symptoms of vertigo but results in deafness, because the organ of Corti and cochlear nerve are located in the inner ear.

A patient with a history of peptic ulcer disease presents to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? - Providing IV fluids and inserting a nasogastric (NG) tube - Administering oral bicarbonate and testing the patient's gastric pH level - Performing a fecal occult blood test and administering IV calcium gluconate - Starting parenteral nutrition and placing the patient in a high Fowler's position

Providing IV fluids and inserting a nasogastric (NG) tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.

Which of the following symptoms are associated with jaundice in the patient with acute cholelithiasis? - Headache - Pruritis - Shoulder pain - Nausea

Pruritis Jaundice occurs as a result of no bile flow into the duodenum and bilirubin accumulates in the blood. The mechanism of action that contributes to itching is not well understood but bile salts and histamine are thought to play a role. Headache is not a symptom of jaundice. Shoulder pain and nausea are symptoms of cholelithiasis.

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate? - Excess Fluid Volume - Risk for Imbalanced Fluid Volume - Imbalanced Nutrition - Ineffective Tissue Perfusion

Risk for Imbalanced Fluid Volume The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium. Excess Fluid Volume is not an issue for pts with diabetes insipidus

The nurse is providing care for a patient who is a strict vegetarian. Which would be the best dietary choices the nurse recommends to prevent iron deficiency? - Brown rice and kidney beans - Cauliflower and egg substitutesIncorrect Answer - Soybeans and hot breakfast cereal - Whole-grain bread and citrus fruits

Soybeans and hot breakfast cereal

The nurse is assessing a patient with a fever. Which of the following does the nurse anticipate to be abnormal? - Temperature, heart rate, and respirations - Temperature, sedation level and red blood cells - Red blood cells, white blood cells, and platelets - Bowel habits, blood pressure, and temperature

Temperature, heart rate, and respirations Signs and symptoms of an infection include rising body temperature, increased respirations, an increased heart rate, increased white blood cells, and pain. Depending on the type of infection, a patient may experience any combination of these symptoms depending on the severity of the infection.

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful? - The client passes formed stools at regular intervals - The client reports a decrease in stool frequency and liquidity - The client exhibits firm skin turgor - The client no longer experiences perianal burning

The client exhibits firm skin turgor A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous membranes, and urine output of at least 30 ml/hr. The client also has a nursing diagnosis of diarrhea, with expected outcomes of passage of formed stools at regular intervals and a decrease in stool frequency and liquidity. The client is at risk for impaired skin integrity related to irritation from diarrhea; expected outcomes for this diagnosis include absence of erythema in perianal skin and mucous membranes and absence of perianal tenderness or burning.

Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? - The patient has taken only sips of water. - The patient is lethargic and difficult to arouse. - The patient's chart indicates a recent resection of the small intestine. - The patient has been vomiting several times a day for the last 4 days.

The patient is lethargic and difficult to arouse A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration.

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? - Both eyes are assessed together, followed by the assessment of the right and then the left eye. - The right eye is tested followed by the left eye, and then both eyes are tested. - The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. - The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.

The right eye is tested followed by the left eye, and then both eyes are tested.

A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? - Eggs over easy, whole wheat toast, and orange juice with pulp - Chicken fried rice with stir fried vegetables and iced tea - Turkey meatloaf with white rice and apple juice - Fish sticks with macaroni and cheese and soda

Turkey meatloaf with white rice and apple juice During the first week or so after ostomy placement, the patient should consume easy -to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? - Initiate coping strategies to reduce stress. - Identify patient's strengths and support system. - Verbalize feelings related to visual impairment. - Transition successfully to the sudden vision loss.

Verbalize feelings related to visual impairment. The nurse's priority is to help the patient express his feelings about the vision loss resulting from the lack of coping effectively with the situation. Until the patient expresses how they feel, they will be unable to progress in the rehabilitation process.

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

Verifying NG tube placement with x-ray wanna make sure it's not in the lungs

A patient with oral cancer is not eating. A small-bore feeding tube was inserted, and the patient started on enteral feedings. Which patient goal would best indicate improvement? - Weight gain of 1 kg in 1 week - Tolerated the tube feeding without nausea - Consumed 50% of clear liquid tray this shift - The feeding tube remained in proper placement

Weight gain of 1 kg in 1 week

D.B. must undergo surgical intervention. Which comment indicates that additional instruction about the care of his new ileostomy is needed? a. "I should change the appliance daily to prevent odors." b. "When I change the appliance, I should check the skin for irritation." c. "I should clean around the stoma with mild soap and water and pat dry." d. "I'll need to alter the appliance opening when the stoma becomes smaller as the area heals."

a The appliance is changed every 4 to 7 days unless leakage occurs. Flatus is expelled from the bag through a charcoal filter that helps control odor. Skin around the stoma should be washed with plain water or mild soap, rinsed with warm water, and dried thoroughly before the barrier is applied. When the appliance is changed, the skin should be assessed for irritation. Mild to moderate Swelling of the stoma in the first 2 to 3 weeks after surgery is expected. Therefore, the size of the pouch opening that fits around the stoma needs to be adjusted to accommodate the stoma's changing size

A client with acute cholecystitis has severe pain. Which prescription will be most effective in relieving the pain? - 1.infusing normal saline solution at 100 mL/h - 2.administering morphine sulfate 10 mg IM every 3 to 4 hours - 3.receiving nothing by mouth (NPO) - 4.having a nasogastric tube connected to low intermittent suction

administering morphine sulfate 10 mg IM every 3 to 4 hours The client is in severe pain, and the nurse should administer the morphine to relieve the pain. The client will receive IV fluids to maintain fluid and electrolyte balance, but that will not relieve the pain. The client may be NPO and have a nasogastric tube to promote gastric decompression to prevent further gallbladder stimulation, but these are not sufficient to manage the pain. CN: Pharmacologic and parenteral therapies; CL: Synthesize

Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance? - skin turgor - intake and output - osmotic pressure - cardiac rate and rhythm

cardiac rate and rhythm Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important.

A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem? - Glucose - corticosteroid - opioid - muscle relaxer

corticosteroid Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.

A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication? - seizure activity - fluid volume deficit - fluid volume excess - liver failure

fluid volume excess Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system. Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system.

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question? - limit foods with potassium - calcium gluconate IV piggyback - give a potassium-sparing diuretic daily - admin IV insulin and glucose

give a potassium-sparing diuretic daily Potassium-sparing diuretics inhibit the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. A potassium-sparing diuretic is contraindicated in a patient with hyperkalemia. Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

Which of the following findings would the nurse exp[ect to assess in a patient with hypokalemia? - hypertension - pH below 7.35 - hypoglycemia - hyporeflexia

hyporeflexia muscles are less responsive to stimuli.

The most appropriate therapy for a patient with acute diarrhea caused by a viral infection is to - increase fluid intake - administer an antibiotic - administer an antimotility drug - quarantine the patient to prevent spread of the virus

increase fluid intake

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. You should hold a medication from which classification until you consult with the health care provider? - antibiotic - loop diuretic - bronchodialotor - antihypertensives

loop diuretic Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

Etiologies associated with hypocalcemia may include all of the following except: - renal failure - inadequate intake calcium - metastatic bone lesions - vitamin D deficiency

metastatic bone lesions Metastatic bone lesions are associated with hypercalcemia due to accelerated bone metabolism and release of calcium into the serum. Renal failure, inadequate calcium intake, and vitamin D deficiency may cause hypocalcemia.

When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt? - drug toxicity - hypertension - visual disturbances - other electrolyte disturbances

other electrolyte disturbances may also have high phosphorus or decreased magnesium levels. (hypocalcium = may have hypotension) Hypercalcemia is more commonly caused by drug toxicities.

Which of the following findings would the nurse expect to asses in hypercalcemia? - prolonged QRS complex - tetany - petechiae - urinary calculi

urinary calculi Urinary calculi may occur with hypercalcemia. Shortened, not prolonged QRS complex would be seen in hypercalcemia. Tetany and petechiae are signs of hypocalcemia.