Exam 5 Fundamentals

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

"I ate shellfish about 2 weeks ago at a local restaurant."

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome. Which statement by the client indicates a need for further teaching?

"I need to limit my intake of dietary fiber."

The nurse provides a list of instructions to a client being discharged to home with a peripheral inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?

"I need to restrict my activity while this catheter is in place."

The nurse is providing discharge teaching for a client with a newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

"I should increase the fiber in my diet."

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?

"I'm glad I don't have to lie still for this procedure."

A nurse is caring for a client who weighs 80 kg (176 lbs) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

1.6 x 1.6 = 2.56 80/2.56 = 31.25 obese

The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

10% dextrose in water

The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at 500 mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape?

375 mL

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that what intravenous (IV) solution will most likely be prescribed for this client?

5% dextrose in lactated Ringer's solution

The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? (SATA)

A client with extensive burns A client with cancer who is septic A client with severe exacerbation of Crohn's disease A client with persistent nausea and vomiting from chemotherapy

The nurse is monitoring a client with the diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?

A rigid, boardlike abdomen

The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The priority action for the nurse is to: (SATA)

Administer oxygen to the client Notify the health care provider and Rapid Response Team Stop dialysis, and turn the client on the left side with head lower than feet

A client has just had a hemorroidectomy. Which nursing interventions are appropriate for this client? (SATA)

Administer stool softeners as prescribed Encourage a high-fiber diet to promote bowel movements without straining Apply cold packs to the anal-rectal area over the dressing until the packing is removed.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse asses for its presence?

Ask the client to extend the arms

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan>

Assessing for the return of the gag reflex

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (SATA)

Auscultate bowel sounds Assist the client to an upright position Test the pH of gastric aspirate

The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?

Blood return shows in the backflash chamber of the catheter.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? (SATA)

Broth Coffee Gelatin

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body the most energy?

Carbs

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrise in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillan/tazobactam. The client has one IV site. The nurse should plan to take which action first?

Check compatibility of the medication and IV fluids.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? (SATA)

Check the level of the drainage bag Reposition the client to his or her side Place the client in good body alignment Check the peritoneal dialysis system for kinks

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

Check to see whether the catheter is patent

A client has just undergone insertion of a central venous catheter at bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour.

Chest radiology results

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Clamp the enema tubing

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item?

Client's temperature

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on the list? (SATA)

Coffee Chocolate Peppermint Fried chicken

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of complication should the nurse assess based in the previously known date?

Crackles in the lungs.

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lbs in 1 week. The nurse should next assess the client for the presence of which condition?

Crackles on auscultation of the lungs.

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands the dietary modifications if the client selects which items from the dietary menu?

Cream of wheat, blueberries, coffee

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?

Custard

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?

Decrease PN rate to 50 mL/hr

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (SATA)

Decrease or avoid caffeine Avoid drinking alcohol

The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia?

Decreased force in the stream of urine

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion to infuse at 50 mL/hr?

Determine whether the client has an allergy to eggs.

A nurse is caring for a client who has a prescription for a 24 hour urine collection. Which of the following actions should the nurse take?

Discard the first voiding

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing interventuon is most appropriate?

Document the findings

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder?

Dysuria and penile discharge

The nurse is preparing to hand the first bag of parenteral nutrition (PN) solution via central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?

Electronic infusion pump

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the lab results, the nurse most likely would expect which finding?

Elevated creatinine level

The nurse is monitoring the status of a client's fat emulsion infusion and notes that the infusion is 1 hour behind. Which action should the nurse take?

Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? (SATA)

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal

The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination?

Fever, nausea, vomiting, and painful scrotal edema

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

A nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTIs. Which of the following factos should the nurse include? (SATA)

Frequent sexual intercourse Location of the urethra closer to the anus Frequent catheterization

A client is admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (SATA)

Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (SATA)

Have the client record urination times Gradually increase the urination intervals Remind the client to hold urine until the next scheduled urination time

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? (SATA)

Hemodialysis Kidney transplant Bilateral nephrectomy Intense immunosuppression therapy

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?

Hypervolemia

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (SATA)

Hypotension Elevated temperature Poor skin turgor

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juices

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?

Instruct the client to tuck their chin when swallowing.

The nurse is caring for a client following a gastrojejunostomy. Which post-operative prescription should the nurse question and verify?

Irrigating the nasogastric tube

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

Legumes

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?

Limit the fluids taken with meals

The client with a hiatal hernia chronically experiences heartburn following meals. The nurse planc to teach the client to avoid which action because it is contraindicated with hiatal hernia?

Lying recumbent following meals

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (SATA)

Maintain NPO Encourage coughing and deep breathing Give hydromorphone intravenously as prescribed for pain

"A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following?

Malaise

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? (SATA)

Margarine Cream cheese Lunch meats

A client is admitted to the emergency department following a fall from a horse and the health care provider prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action?

Notify the HCP before performing catheterization

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5 degrees C (101.2 degrees F). Which nursing action is most appropriate?

Notify the health care provider

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Notify the health care provider

The nurse monitoring a client admitted to the hospital with the diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

Notify the health care provider

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet?(SATA)

Nuts Liver Lentils

The nurse is preparing to hang fat emulsion and notes that fat globules are visible at the top of the solution. The nurse should take which action?

Obtain a different bottle of solution.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Obtain new IV tubing

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following should the nurse include? (SATA)

Older adults are more prone to dehydration than younger adults Older adults need the same amount of most vitamins and minerals as younger adults do. Many older men and women need calcium supplements

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position?

On the left side, with the head lower than the feet

A nurse providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend?

One medium apple with skin

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Oranges

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark green leafy veggies

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which signs/symptoms of duodenal ulcer?

Pain relieved by food intake

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? (SATA)

Pallor and coolness Numbness and pain Edema and blanched skin

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication?

Pallor, diminished pulse, and pain in the left hand

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Palpation of a thrill over the fistula

The nurse is reviewing the lab results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL. Which dietary selection does the nurse suggest to the client?

Pasta with sauce

A client with acute kidney injury has a serum potassium level of 7.0 mEq. The nurse should plan which actions as a priority?(SATA)

Place the client on a cardiac monitor Notify the health care provider Review the client's medications to determine if any contain or retain potassium

A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider, and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials?

Prepare to send them to the lab for culture.

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider?

Purple discoloration of the stoma

A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.

Remove the IV catheter at that site. Apply warm moist packs to the site. Notify the health care provider. Document the occurrence, actions taken, and the client's response.

The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?

Remove the IV site and restart at another site.

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (SATA)

Review a signal the client can use if feeling any distress Lay a towel across the client's chest

The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?

Secure all connections in the PN system.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?

Slow the IV infusion.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

Smoked sausage

A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?

Sterile 2x2 gauze

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

Stop the feeding

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided by to the client?

Summer squash

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which finding indicate this occurrence?

Sweating and pallor

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?

Take a deep breath, hold it, and bear down

A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?

Temperature and weight

A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder?

Tender, indurated prostate gland that is warm ti the touch

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?

The specimen cannot be contaminated with urine

A client had a new colostomy created 2 days earlier and is beginning to pass maladorous flatus from the stoma. What is the correct interpretation by the nurse?

This is a normal, expected event

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition?

Trauma to the bladder or abdomen

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the clients meal tray?

Vanilla Custard

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure?

Verify the placement of the NG tube

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

Vitamin B12

A nurse is preparing to administer a cleansing enema to an adult client for a diagnostic procedure. Which of the following steps should the nurse take? (SATA)

Warm the enema solution prior to instillation Position the client on the left side with the right leg flexed forward Lubricate the rectal tube or nozzle

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make?

Water helps clear the tube so it doesn't get clogged.

The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia?

Weakness, thirst, and increased urine output