final part 5

41. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. The nurse explains to the patient that a. this type of colostomy is usually temporary. b. soft, formed stool can be expected as drainage. c. the drainage is liquid at this site but less odorous than at higher sites. d. colostomy irrigations can help regulate the drainage from the proximal stoma.

Answer: A Rationale: A loop or double-barrel stoma is usually temporary. Cognitive Level: Application Text Reference: p. 1069 Nursing Process: Implementation NCLEX: Physiological Integrity

16. While obtaining a nursing history from a patient with IBD, the nurse recognizes that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing a. weight loss. b. bloody stools. c. abdominal pain and cramping. d. disease onset at age 20.

Answer: B Rationale: Because ulcerative colitis affects the colon, blood in the stools is more common with this form of IBD. Weight loss, abdominal pain and cramping, and onset at age 20 are consistent with both Crohn's disease and ulcerative colitis. Cognitive Level: Comprehension Text Reference: p. 1051 Nursing Process: Assessment NCLEX: Physiological Integrity

The health care provider prescribes finasteride (Proscar) for a 56-year-old male patient who has a BPH symptom score of 12 on the AUA Symptom Index. When teaching the patient about the drug, the nurse informs him that a. his interest in sexual activity may decrease while he is taking the medication. b. he should change position from lying to standing slowly to avoid dizziness. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

Correct Answer: A Rationale: A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Orthostatic hypotension is a side effect of the α-blocking agents. Improvement in symptoms of obstruction takes 3 to 6 months. The medication does not cause hypertension. Cognitive Level: Application Text Reference: p. 1417 Nursing Process: Implementation NCLEX: Physiological Integrity

30. When the nurse is caring for the patient with pancreatic cancer, which nursing diagnosis is a priority? a. Chronic pain related to tumor pressure on abdominal structures b. Imbalanced nutrition: less than required related to anorexia c. Impaired skin integrity related to itching secondary to jaundice d. Grieving related to potentially terminal diagnosis

A Rationale: All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating the patient's pain is the priority because the patient will be unable to meet outcomes for the other nursing diagnoses unless the pain is controlled. Cognitive Level: Application Text Reference: pp. 1122, 1126 Nursing Process: Diagnosis NCLEX: Physiological Integrity

4. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Teach the patient that the HCV will resolve in 2 to 4 months. c. Administer immune globulin and the HCV vaccine. d. Instruct the patient on self-administration of -interferon.

A Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with -interferon or other medications is started. HCV has a high percentage of conversion to the chronic state so the nurse should not teach the patient that the HCV will resolve in 2 to 4 months. Immune globulin or vaccine is not available for HCV. Cognitive Level: Application Text Reference: p. 1092 Nursing Process: Planning NCLEX: Physiological Integrity

27. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with acute pancreatitis include a. muscle twitching and finger numbness. b. paralytic ileus and abdominal distention. c. hypotension. d. hyperglycemia.

A Rationale: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance. Cognitive Level: Analysis Text Reference: p. 1122 Nursing Process: Assessment NCLEX: Physiological Integrity

32. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to a. turn, cough, and deep breathe every 2 hours. b. choose low-fat foods from the menu. c. perform leg exercises hourly while awake. d. ambulate the evening of the operative day.

A Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation. Cognitive Level: Application Text Reference: p. 1131 Nursing Process: Planning NCLEX: Physiological Integrity

5. A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority to the patient outcome of a. maintaining adequate nutrition. b. establishing a stable home environment. c. increasing activity level. d. identifying the source of exposure to hepatitis.

A Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as having adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis. Cognitive Level: Application Text Reference: p. 1097 Nursing Process: Planning NCLEX: Physiological Integrity

22. A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse a. asks the patient to empty the bladder. b. positions the patient on the right side. c. obtains informed consent for the procedure. d. assists the patient to lie flat in bed.

A Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. The health care provider is responsible for obtaining informed consent. Cognitive Level: Application Text Reference: p. 1111 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

29. The health care provider prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse teaches the patient that the drug is considered effective if the patient experiences a. normal-appearing stools. b. decreased jaundice. c. improved appetite. d. reduced abdominal pain.

A Rationale: The patient's steatorrhea should improve if the pancreatic enzymes are effective. The pancreatin will not decrease jaundice, improve appetite, or reduce abdominal pain. Cognitive Level: Application Text Reference: p. 1125 Nursing Process: Evaluation NCLEX: Physiological Integrity

6. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The nurse explains to the patient that a. because no medication is available to treat acute viral hepatitis, adequate nutrition and rest are the most important treatments. b. lamivudine (Epivir) can decrease viral load and liver damage in patients with acute hepatitis B, but it must be taken for at least 1 year. c. patients with acute hepatitis B can be given HBIG to help reduce the symptoms. d. various antiviral drugs are available to treat acute hepatitis B, but serious side effects limit their use.

A Rationale: There are no drug therapies to treat acute hepatitis, although -interferon and nucleoside analogs (i.e., lamivudine) may be used to treat chronic hepatitis B. Immune globulin may be given within 24 hours after exposure to prevent hepatitis B, but it is not used to decrease symptoms for patients with acute hepatitis. Cognitive Level: Application Text Reference: p. 1093 Nursing Process: Implementation NCLEX: Physiological Integrity

37. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will a. administer IV fluids. b. order a diet high in fiber and fluids. c. give stool softeners. d. prepare the patient for colonoscopy.

Answer: A Rationale: A patient with acute diverticulitis will be NPO with parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have colonoscopy because of the risk for perforation and peritonitis. Cognitive Level: Application Text Reference: p. 1077 Nursing Process: Implementation NCLEX: Physiological Integrity

8. Two days following an exploratory laparotomy with a resection of a short segment of small bowel, the patient complains of gas pains and abdominal distention. Which nursing action is most appropriate to take at this time? a. Assisting the patient to ambulate b. Administering the ordered IV morphine sulfate c. Giving a return-flow enema d. Inserting the ordered promethazine (Phenergan) suppository

Answer: A Rationale: Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patient's symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention. Cognitive Level: Application Text Reference: p. 1046 Nursing Process: Implementation NCLEX: Physiological Integrity

15. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to a. place the patient on NPO status. b. administer Cobalamin (vitamin B12) injections. c. start bowel preparation for colonoscopy. d. administer IV metoclopramide (Reglan).

Answer: A Rationale: An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. It is not appropriate to administer laxatives needed for colonoscopy to a patient with diarrhea. Metoclopramide increases peristalsis and will worsen symptoms. Cognitive Level: Application Text Reference: p. 1058 Nursing Process: Planning NCLEX: Physiological Integrity

40. In providing discharge teaching for a patient who has undergone a hemorrhoidectomy at an outpatient surgical center, the nurse instructs the patient to a. take prescribed pain medications before a bowel movement is expected. b. delay having a bowel movement for several days until healing has occurred. c. maintain a low-residue diet until the surgical area is healed. d. use ice packs on the perianal area to relieve pain and swelling.

Answer: A Rationale: Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. Delay of bowel movements is likely to lead to constipation. A high-residue diet will increase stool bulk and prevent constipation. Sitz baths are used to relieve pain and keep the surgical area clean. Cognitive Level: Application Text Reference: p. 1083 Nursing Process: Implementation NCLEX: Physiological Integrity

24. A patient newly diagnosed with Crohn's disease asks the nurse what to expect in the future. The best response by the nurse is, a. "You need to know that there is the probability of lifelong, unpredictable periods of remissions and recurrences." b. "You can expect to lead a normal life and may have long periods without episodes of diarrhea or other symptoms." c. "Most patients with Crohn's disease require an ostomy to control the disease, but you can adjust to that." d. "After about 10 years, patients with Crohn's disease have a high risk for colon cancer unless the colon is removed."

Answer: A Rationale: Crohn's disease has recurrent acute exacerbations that occur at unpredictable intervals. There are many lifestyle changes that patients need to make with regard to diet and medication use. The preference is to treat Crohn's disease with medications rather than with surgery. Patients with Crohn's disease are at high risk for cancer of the small intestine, but the risk for colon cancer is lower. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Physiological Integrity

27. In the immediate postoperative period, the nurse caring for a patient who is a recipient of a kidney transplant would expect that fluid therapy would involve administration of IV fluids a. to be determined hourly, based on every milliliter of urine output. b. at a minimum rate of 100 ml/hr to perfuse the kidney. c. titrated to keep blood pressure within a normal range. d. at a rate to keep urine clear and without blood clots.

Answer: A Rationale: Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. Fluid infusion rate is titrated rather than being at a set rate. Blood pressure and urine appearance are not the major parameters considered when titrating fluid infusion. Cognitive Level: Comprehension Text Reference: p. 1228 Nursing Process: Implementation NCLEX: Physiological Integrity

18. Before administration of calcitriol (Rocaltrol) to a patient with CKD, the nurse should check the laboratory value for a. serum phosphate. b. total cholesterol. c. creatinine. d. potassium.

Answer: A Rationale: If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcitriol should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not impact whether calcitriol should be administered. Cognitive Level: Application Text Reference: p. 1210 Nursing Process: Implementation NCLEX: Physiological Integrity

35. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. fills the irrigating container with 1000 to 2000 ml of lukewarm tap water. d. inserts the irrigation tubing no further than 4 to 6 inches into the stoma.

Answer: A Rationale: Irrigating container should be hung 18 to 24 inches above the stoma. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

31. A patient with CKD brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? a. Milk of magnesia 30 ml administered orally b. Oral acetaminophen (Tylenol) 650 mg c. Multivitamin with iron d. Calcium phosphate (PhosLo)

Answer: A Rationale: Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD. Cognitive Level: Application Text Reference: p. 1207 Nursing Process: Assessment NCLEX: Physiological Integrity

28. A recent colonoscopy revealed an increased number of polyps in a 22-year-old patient with a history of moderately severe familial adenomatous polyposis (FAP). In planning care for the patient, the nurse recognizes that the medical recommendation for patients with familial adenomatous polyposis includes a. a total colectomy with ileostomy. b. annual colonoscopy until age 40. c. routine periodic polypectomies via colonoscope to remove these abnormal growths. d. biannual colonoscopy for life because of a 50% chance of developing colon cancer.

Answer: A Rationale: Patients with FAP have a high likelihood of developing colorectal cancer by age 40; therefore, total colectomy with ileostomy is recommended for these patients. Frequent colonoscopy is required, but patients are encouraged to have a colectomy. Patients with FAP have too many polyps to be removed by polypectomy. The patient has an 80% chance of developing colorectal cancer. Cognitive Level: Application Text Reference: p. 1063 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

24. A patient with diabetes who has chronic kidney disease (CKD) is considering using continuous ambulatory peritoneal dialysis (CAPD). In discussing this treatment option with the patient, the nurse informs the patient that a. patients with diabetes who use CAPD have fewer dialysis-related complications than those on hemodialysis. b. home CAPD requires more extensive equipment than does home hemodialysis. c. CAPD is contraindicated for patients who might eventually want a kidney transplant. d. dietary restrictions are stricter for patients using CAPD than for those having hemodialysis.

Answer: A Rationale: Patients with diabetes have better control of blood pressure, less hemodynamic instability, and fewer problems with retinal hemorrhages when using peritoneal dialysis than when using hemodialysis. CAPD is less expensive and has fewer dietary restrictions than hemodialysis. CAPD is not a contraindication for a kidney transplant. Cognitive Level: Application Text Reference: p. 1220 Nursing Process: Implementation NCLEX: Physiological Integrity

11. A diabetic patient is admitted for evaluation of renal function because of recent fatigue, weakness, and elevated BUN and serum creatinine levels. While obtaining a nursing history, the nurse identifies an early symptom of renal insufficiency when the patient states, a. "I get up several times every night to urinate." b. "I wake up in the night feeling short of breath." c. "My memory is not as good as it used to be." d. "My mouth and throat are always dry and sore."

Answer: A Rationale: Polyuria occurs early in chronic kidney disease (CKD) as a result of the inability of the kidneys to concentrate urine. The other symptoms would be expected later in the progression of CKD. Cognitive Level: Application Text Reference: p. 1206 Nursing Process: Assessment NCLEX: Physiological Integrity

17. The nurse has instructed a patient who is receiving hemodialysis about dietary management. Which diet choices by the patient indicate that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Cheese sandwich, tomato soup, and cranberry juice c. Split-pea soup, whole-wheat toast, and nonfat milk d. Oatmeal with cream, half a banana, and herbal tea

Answer: A Rationale: Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate. Cognitive Level: Application Text Reference: pp. 1211-1212 Nursing Process: Evaluation NCLEX: Physiological Integrity

10. A patient with renal insufficiency is scheduled for an intravenous pyelogram (IVP). Which of the following orders for the patient will the nurse question? a. Ibuprofen (Advil) 400 mg PO PRN for pain b. Dulcolax suppository 4 hours before IVP procedure c. Normal saline 500 ml IV before procedure d. NPO for 6 hours before IVP procedure

Answer: A Rationale: The contrast dye used in IVPs is nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure that adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure. Cognitive Level: Application Text Reference: p. 1203 Nursing Process: Implementation NCLEX: Physiological Integrity

11. A patient is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the patient, it is important for the nurse to a. assess the BP and pulse. b. remove the knife to assess the wound. c. determine the presence of Rovsing's sign. d. insert a urinary catheter and assess for hematuria.

Answer: A Rationale: The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing's sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Assessment NCLEX: Physiological Integrity

1. A patient with acute diarrhea of 24 hours' duration calls the clinic to ask for directions for care. In talking with the patient, the nurse should a. ask the patient to describe the character of the stools and any associated symptoms. b. advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility. c. inform the patient that laboratory testing of blood and stool specimens will be necessary. d. advise the patient to drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.

Answer: A Rationale: The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment. Cognitive Level: Application Text Reference: p. 1037 Nursing Process: Assessment NCLEX: Physiological Integrity

12. A patient is diagnosed with stage 3 CKD. The patient is treated with conservative management, including erythropoietin injections. After teaching the patient about management of CKD, the nurse determines teaching has been effective when the patient states, a. "I will measure my urinary output each day to help calculate the amount I can drink." b. "I need to take the erythropoietin to boost my immune system and help prevent infection." c. "I need to try to get more protein from dairy products." d. "I will try to increase my intake of fruits and vegetables."

Answer: A Rationale: The patient with CKD who is not receiving dialysis is generally taught to restrict fluids. The patient would need to measure urine output and then add 600 ml for insensible losses to calculate an appropriate oral intake. Erythropoietin is given to increase red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD. Cognitive Level: Application Text Reference: p. 1212 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

21. In preparation for hemodialysis, a patient has an AV native fistula created in the left forearm. When caring for the fistula postoperatively, the nurse should a. check the fistula site for a bruit and thrill. b. assess the rate and quality of the left radial pulse. c. compare blood pressures in the left and right arms. d. irrigate the fistula site daily with low-dose heparin.

Answer: A Rationale: The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula. Cognitive Level: Comprehension Text Reference: p. 1221 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness, anorexia, and chills. The vital signs include temperature 101° F (38.3° C), pulse 130, respirations 34, and blood pressure (BP) 82/50. Of the following collaborative interventions, which one should the nurse implement first? a. Infuse 1000 ml of lactated Ringer's solution over 30 minutes. b. Administer IV ketorolac (Toradol) 15 mg. c. Give IV ceftriaxone (Rocephin) 1 g. d. Obtain a computed tomography (CT) scan of the abdomen with and without contrast.

Answer: A Rationale: The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. Cognitive Level: Application Text Reference: pp. 1044-1045 Nursing Process: Implementation NCLEX: Physiological Integrity

33. During the initial postoperative assessment of a patient's stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The nurse should a. document the stoma assessment. b. notify the surgeon about the stoma appearance. c. monitor the stoma every 30 minutes. d. place an ice pack on the stoma to reduce swelling.

Answer: A Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. Cognitive Level: Application Text Reference: p. 1071 Nursing Process: Implementation NCLEX: Physiological Integrity

7. A 23-year-old woman is being evaluated in the emergency department for acute lower abdominal pain and vomiting. During the nursing history, the most helpful question by the nurse to obtain information regarding the patient's condition is a. "What type of foods do you usually eat?" b. "Can you tell me about your pain?" c. "What is your usual elimination pattern?" d. "Is it possible that you are pregnant?"

Answer: B Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most. Cognitive Level: Application Text Reference: p. 1044 Nursing Process: Assessment NCLEX: Physiological Integrity

22. The nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements for a patient who is hospitalized with an acute exacerbation of Crohn's disease, based on the finding of a. complaints of fatigue and weakness. b. hemoglobin of 10 g/dl (120 g/L). c. weight loss of 2 pounds (0.9 kg) in 2 days. d. a 1500-calorie intake over the last day.

Answer: B Rationale: A hemoglobin count of 10 g/dl indicates that the patient's iron and possibly protein intake are low. Fatigue and weakness may be due to the acute inflammatory response and to lack of rest because of frequent stools. A 2-pound weight loss over 2 days is not unusual in patients who are well nourished. A 1500-calorie diet may be sufficient to meet patient needs, depending on the patient's size. Cognitive Level: Application Text Reference: pp. 1053, 1059 Nursing Process: Diagnosis NCLEX: Physiological Integrity

5. Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the patient about the use of the drug, the nurse stresses that a. the use of this type of laxative is safe and adverse effects are very minimal. b. large amounts of fluid should be taken to prevent impaction or bowel obstruction. c. dietary sources of fiber should be eliminated to prevent excessive gas formation. d. fat-soluble vitamins must be taken because the drug blocks absorption of these vitamins.

Answer: B Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives. Cognitive Level: Comprehension Text Reference: pp. 1042, 1044 Nursing Process: Implementation NCLEX: Physiological Integrity

21. A total proctocolectomy with a permanent ileostomy is performed for a patient with ulcerative colitis. The patient is very upset and tells the nurse, "I can not bear to even look at the stoma. I do not think I can manage all these changes." The nurse's best approach to the patient's remarks is to a. reassure the patient that care for the ileostomy will become easier. b. ask the patient if a member of an ostomy support group may visit. c. develop a detailed written plan for ostomy care for the patient. d. wait to intervene until the patient adjusts to the body image change.

Answer: B Rationale: A visitor from an ostomy support group who has had similar experiences may be helpful to the patient. In the response beginning, "reassure the patient," the nurse does not acknowledge the patient's feelings. The response beginning "develop a detailed written plan" also fails to acknowledge the patient's emotional response to the ostomy. The nurse should act to assist the patient with body image changes, not just wait for the patient to adjust as in the remaining response. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Implementation NCLEX: Psychosocial Integrity

25. A patient who has been on continuous ambulatory peritoneal dialysis (CAPD) is hospitalized and is receiving CAPD with four exchanges a day. During the dialysate inflow, the patient complains of having abdominal pain and pain in the right shoulder. The nurse should a. massage the patient's abdomen and back. b. decrease the rate of dialysate infusion. c. stop the infusion and notify the health care provider. d. administer the PRN acetaminophen (Tylenol).

Answer: B Rationale: Abdominal pain and referred shoulder pain can be caused by a rapid infusion of dialysate; the nurse should slow the rate of the infusion. Massage and administration of acetaminophen (Tylenol) would not address the reason for the pain. There is no need to notify the health care provider. Cognitive Level: Application Text Reference: p. 1219 Nursing Process: Implementation NCLEX: Physiological Integrity

36. The nurse explains to a patient with a new ileostomy that after the bowel adjusts to the ileostomy, the usual drainage will be about a. 1 cup. b. 2 cups. c. 3 cups. d. 1 quart.

Answer: B Rationale: After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 ml daily. Cognitive Level: Comprehension Text Reference: p. 1073 Nursing Process: Implementation NCLEX: Physiological Integrity

39. A 42-year-old patient recently developed abdominal distention, weight loss, steatorrhea, and flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The nurse determines that teaching about the treatment of the disease has been effective when the patient says, a. "I must take folic acid for the rest of my life." b. "I will avoid dietary wheat, rye, barley, and oats." c. "I will be sure to take all of the ordered antibiotics." d. "I should eat only very low-fat or fat-free foods."

Answer: B Rationale: Avoidance of gluten-containing foods is the only treatment for celiac disease. Folic acid deficiency may occur, but once the inflammatory process is resolved, the patient will not need to take folic acid. Antibiotics are not helpful in the treatment of the inflammatory process. Avoidance of dietary fat is not necessary. Cognitive Level: Application Text Reference: p. 1081 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

2. A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will a. order a diet with no dairy products for the patient. b. place the patient in a private room with contact isolation. c. explain to the patient why antibiotics are not being used. d. teach the patient about proper food handling and storage.

Answer: B Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile. Cognitive Level: Application Text Reference: p. 1038 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

26. The nurse is assessing a patient who is receiving peritoneal dialysis with 2-L inflows. Which information should be reported immediately to the health care provider? a. The patient complains of feeling bloated after the inflow. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient has an outflow volume of 1600 ml.

Answer: B Rationale: Cloudy-appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient. Cognitive Level: Application Text Reference: p. 1219 Nursing Process: Assessment NCLEX: Physiological Integrity

19. To determine glomerular filtration rate (GFR) for a patient with chronic kidney disease, the nurse will plan to a. schedule frequent blood urea nitrogen (BUN) tests. b. initiate a 24-hour collection of the patient's urine. c. check the specific gravity on serial urine specimens. d. use a bladder scanner to check for residual urine.

Answer: B Rationale: Creatinine clearance testing, the most accurate way to assess GFR, requires a 24-hour urine collection. BUN levels may increase for other reasons, such as dehydration, and are not as accurate in determining glomerular filtration. Urine-specific gravity testing and monitoring residual urine would not be useful in determining the GFR. Cognitive Level: Application Text Reference: p. 1206 Nursing Process: Planning NCLEX: Physiological Integrity

43. A patient with Crohn's disease has a megaloblastic anemia. The nurse will anticipate teaching the patient about the ongoing need for a. oral ferrous sulfate tablets. b. cobalamin (B12) injections. c. iron dextran (Imferon) injections. d. regular blood transfusions.

Answer: B Rationale: Crohn's disease frequently affects the ileum, where absorption of vitamin B12 occurs and the B12 must be administered regularly by the IM route to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions. Cognitive Level: Application Text Reference: pp. 1052-1053, 1056-1057 Nursing Process: Planning NCLEX: Physiological Integrity

25. A patient with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, foul-smelling urine. The nurse will teach the patient a. to clean the perianal carefully after any stools. b. about fistula formation between the bowel and bladder. c. to empty the bladder before and after sexual intercourse. d. about the effects of corticosteroid use on immune function.

Answer: B Rationale: Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. There is no information indicating that the patient's risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient's urine indicate that a fistula has occurred. Cognitive Level: Application Text Reference: p. 1052 Nursing Process: Implementation NCLEX: Physiological Integrity

36. A patient complains of leg cramps during hemodialysis. The nurse should a. give acetaminophen (Tylenol). b. infuse a bolus of normal saline. c. massage the patient's legs. d. reposition the patient.

Answer: B Rationale: Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps. Cognitive Level: Application Text Reference: p. 1223 Nursing Process: Implementation NCLEX: Physiological Integrity

34. A patient receiving peritoneal dialysis using 2 L of dialysate per exchange has an outflow of 1200 ml. Which action should the nurse take first? a. Infuse 1200 ml of dialysate during the inflow. b. Assist the patient in changing position. c. Administer a laxative to the patient. d. Notify the health care provider about the outflow problem.

Answer: B Rationale: Outflow problems may occur because the peritoneal catheter is collapsed by a portion of the intestine, and repositioning the patient will move the catheter and allow outflow to occur. If less than the ordered 2 L of dialysate is infused, the dialysis will be less effective. Administration of a laxative may also help if the patient's colon is full, but this should be tried after repositioning the patient. If the problem with outflow persists after the patient is repositioned, the health care provider should be notified. Cognitive Level: Application Text Reference: p. 1219 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient with acute renal failure (ARF) has an arterial blood pH of 7.30. The nurse will assess the patient for a. tachycardia. b. rapid respirations. c. poor skin turgor. d. vasodilation.

Answer: B Rationale: Patients with metabolic acidosis caused by ARF may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Tachycardia and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in ARF. Cognitive Level: Application Text Reference: pp. 1200-1201 Nursing Process: Assessment NCLEX: Physiological Integrity

17. Sulfasalazine (Azulfidine) is prescribed for a patient who has been diagnosed with ulcerative colitis. The nurse recognizes that teaching about this drug has been effective when the patient says, a. "The medication will prevent infections that cause the diarrhea." b. "The medication suppresses the inflammation in my large intestine." c. "I will need lab tests to be sure that I can still fight infections." d. "I will take the sulfasalazine as an enema or suppository."

Answer: B Rationale: Sulfasalazine suppresses the inflammatory process that causes the symptoms of ulcerative colitis. It is not used to treat infections. Laboratory tests for immune suppression are needed for the immunosuppressant medications used for ulcerative colitis. Sulfasalazine is an oral medication, although the active portion of the medication (5-ASA) may be given rectally. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Evaluation NCLEX: Physiological Integrity

4. When reviewing the laboratory values for a patient admitted with a severe crushing injury after an industrial accident, the nurse will be most concerned about levels of a. creatinine. b. potassium. c. white blood cells (WBCs). d. BUN.

Answer: B Rationale: The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse will also review the other laboratory values, but abnormalities in these are not immediately life threatening. Cognitive Level: Application Text Reference: p. 1200 Nursing Process: Assessment NCLEX: Physiological Integrity

9. After noting increasing QRS intervals in a patient with ARF, which action should the nurse take first? a. Notify the patient's health care provider. b. Check the chart for the most recent blood potassium level. c. Look at the patient's current BUN and creatinine levels. d. Document the QRS interval.

Answer: B Rationale: The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with ARF, but these would not directly affect the ECG. Documentation of the QRS interval is also appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia. Cognitive Level: Application Text Reference: p. 1200 Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient is admitted to the emergency department for evaluation of right lower-quadrant abdominal pain with nausea and vomiting. The patient has a white blood cell count (WBC) of 14,000/μl with a shift to the left. Which of these actions is appropriate for the nurse to take? a. Encouraging the patient to take sips of clear liquids b. Applying an ice pack to the right lower quadrant c. Checking for rebound tenderness every 30 minutes d. Teaching the patient how to cough and deep breathe

Answer: B Rationale: The patient's clinical manifestations are consistent appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain and the patient is not likely to retain information at this point. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Implementation NCLEX: Physiological Integrity

30. Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? a. The blood glucose is 144 mg/dl. b. The patient has a round, moonlike face. c. There is a nontender lump in the axilla. d. The patient's blood pressure is 150/92.

Answer: C Rationale: A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy. Cognitive Level: Application Text Reference: p. 1230 Nursing Process: Assessment NCLEX: Physiological Integrity

20. A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. can accommodate larger needles. b. increases patient mobility. c. is much less likely to clot. d. can be used sooner after surgery.

Answer: C Rationale: AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not impact on needle size or patient mobility. Cognitive Level: Application Text Reference: p. 1221 Nursing Process: Implementation NCLEX: Physiological Integrity

28. To monitor for corticosteroid-related complications after a kidney transplant, the nurse teaches the patient to report a. pain at the donor kidney site. b. dizziness with position change. c. pain in the hips, knees, and other joints. d. changes in the character of the urine.

Answer: C Rationale: Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Pain at the site, orthostatic dizziness, and changes in the urine appearance are not associated with corticosteroid use. Cognitive Level: Comprehension Text Reference: p. 1230 Nursing Process: Implementation NCLEX: Physiological Integrity

38. The nurse identifies a nursing diagnosis of acute pain related to edema and surgical incision for a patient who has had a herniorrhaphy performed for an incarcerated inguinal hernia. An appropriate nursing intervention for this problem is to a. administer stool softeners as ordered. b. provide warm sitz baths several times a day. c. apply a scrotal support with application of ice. d. apply moist heat to the abdomen.

Answer: C Rationale: Because swelling is likely to affect the scrotum, a scrotal support and ice are used to reduce edema. Stool softeners will not decrease pain or swelling. Sitz baths or moist heat application will not reduce swelling or edema in the scrotal area. Cognitive Level: Application Text Reference: p. 1078 Nursing Process: Implementation NCLEX: Physiological Integrity

32. A patient returns from surgery following an abdominal-perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. On the first postoperative day, the nurse gives the highest priority to a. teaching about a low-residue diet. b. monitoring drainage from the stoma. c. assessing the perineal drainage and incision. d. encouraging acceptance of the colostomy site.

Answer: C Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. Cognitive Level: Application Text Reference: p. 1068 Nursing Process: Planning NCLEX: Physiological Integrity

31. Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to a. identify the extent of cancer spread or metastasis. b. confirm the diagnosis of colon cancer. c. monitor the tumor status after surgery. d. determine the need for postoperative chemotherapy.

Answer: C Rationale: CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on other factors than CEA. Cognitive Level: Comprehension Text Reference: p. 1066 Nursing Process: Implementation NCLEX: Physiological Integrity

7. The health care provider orders IV glucose and insulin to be given to a patient in ARF whose serum potassium level is 6.3 mEq/L. To best evaluate the effectiveness of the medications, the nurse will a. monitor the patient's electrocardiograph (ECG). b. check the blood glucose level. c. obtain serum potassium levels. d. assess BUN and creatinine levels.

Answer: C Rationale: Changes in potassium will impact on the ECG and muscle strength, but the nurse should expect to recheck the serum potassium level during the infusion of glucose and insulin to determine the effectiveness of the therapy. The blood glucose level should be monitored during the infusion to assess for hypoglycemia or hyperglycemia. The BUN and creatinine levels will not change with administration of glucose and insulin. Cognitive Level: Application Text Reference: pp. 1201-1202 Nursing Process: Evaluation NCLEX: Physiological Integrity

23. A 26-year-old patient is diagnosed with Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach the patient about a. activity restrictions. b. fluid restriction. c. oral corticosteroids. d. enteral feedings.

Answer: C Rationale: Corticosteroids are used to achieve remission in IBD, and systemic corticosteroids will be used in Crohn's disease to affect the small intestine. Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Planning NCLEX: Physiological Integrity

8. A patient in ARF has a gradual increase in urinary output to 3400 ml a day with a BUN of 92 mg/dl (33 mmol/L) and a serum creatinine of 4.2 mg (371 μmol/L). The nurse should plan to a. use a urine dipstick to monitor for proteinuria. b. auscultate the lungs to assess for pulmonary edema. c. take the blood pressure to check for hypotension. d. draw blood to monitor for hyperkalemia.

Answer: C Rationale: During the diuretic phase of ARF, fluid and electrolyte losses may cause hypovolemia, hypotension, hyponatremia, and hypokalemia. Proteinuria, pulmonary edema, and hyperkalemia occur during the oliguric phase. Cognitive Level: Application Text Reference: p. 1201 Nursing Process: Planning NCLEX: Physiological Integrity

34. A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of the ileostomy, the nurse informs the patient about the need to a. restrict fluid intake to prevent constant liquid drainage from the stoma. b. change the pouch every day to prevent leakage of contents onto the skin. c. use care when eating high-fiber foods to avoid obstruction of the ileum. d. irrigate the ileostomy daily to avoid having to wear a drainage appliance.

Answer: C Rationale: High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. Cognitive Level: Application Text Reference: p. 1073 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

45. The RN and nursing assistant (NA) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to the NA? a. Irrigation of the NG tube with saline b. Retaping the NG tube c. Applying petroleum jelly to the lips d. Auscultation for bowel sounds

Answer: C Rationale: NA education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN. Cognitive Level: Comprehension Text Reference: p. 1062 Nursing Process: Implementation NCLEX: Physiological Integrity

22. A patient begins hemodialysis after having had conservative management of chronic kidney disease. The nurse explains that one dietary regulation that will be changed when hemodialysis is started is that a. unlimited fluids are allowed since retained fluid is removed during dialysis. b. increased calories are needed because glucose is lost during hemodialysis. c. more protein will be allowed because of the removal of urea and creatinine by dialysis. d. dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

Answer: C Rationale: Once the patient is started on dialysis and nitrogenous wastes are removed, more protein in the diet is allowed. Fluids are still restricted to avoid excessive weight gain and complications such as shortness of breath. Glucose is not lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid the complications associated with high levels of these electrolytes. Cognitive Level: Application Text Reference: p. 1211 Nursing Process: Implementation NCLEX: Physiological Integrity

9. Following an exploratory laparotomy and bowel resection, a patient has an NG tube to suction but complains of nausea and stomach distention. The nurse irrigates the tube PRN as ordered, but the irrigating fluid does not return. The first action by the nurse should be to a. notify the patient's health care provider. b. auscultate for bowel sounds. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

Answer: C Rationale: Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence of absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient. Cognitive Level: Application Text Reference: p. 1045 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

46. When performing an admission assessment for a patient with abdominal pain, the nurse palpates the left lower quadrant and the patient complains of right lower quadrant pain. The nurse will document this as a. McBurney's point. b. rebound pain. c. Rovsing's sign. d. Cullen's sign.

Answer: C Rationale: Rovsing's sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. McBurney's point, rebound pain, and Cullen's sign are used to describe other aspects of the abdominal assessment. Cognitive Level: Application Text Reference: pp. 1047-1049 Nursing Process: Assessment NCLEX: Physiological Integrity

16. Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess a. the BUN and creatinine. b. the blood glucose level. c. the patient's bowel sounds. d. the level of consciousness (LOC).

Answer: C Rationale: Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not impact on the nurse's decision to give the medication. Cognitive Level: Application Text Reference: pp. 1202, 1210 Nursing Process: Assessment NCLEX: Physiological Integrity

29. Two hours after a kidney transplant, the nurse obtains all these data when assessing the patient. Which information is most important to communicate to the health care provider? a. The BUN and creatinine levels are elevated. b. The urine output is 900 to 1100 ml/hr. c. The patient's central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incision pain when coughing.

Answer: C Rationale: The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant. Cognitive Level: Application Text Reference: p. 1228 Nursing Process: Assessment NCLEX: Physiological Integrity

13. The nurse identifies the collaborative problem of potential complication: hypovolemic shock related to loss of circulatory volume for a patient with bacterial peritonitis resulting from a ruptured appendix. The nurse recognizes that the major loss of circulating fluid volume occurs as a result of a. prolonged nasogastric (NG) suctioning. b. increased production of stress hormones. c. extracellular fluid shift into the peritoneal cavity. d. loss of purulent drainage into the peritoneal cavity.

Answer: C Rationale: The inflammatory process causes the shift of fluids into the peritoneal space. Patients with NG suctioning receive IV fluids to compensate for fluid loss. Stress hormone production causes retention of fluids. Purulent drainage is not usually a significant source of fluid loss. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Diagnosis NCLEX: Physiological Integrity

4. A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." The most appropriate nursing action at this time is to a. encourage the patient to drink at least 3000 ml of fluid a day. b. inform the patient that a daily bowel movement is not necessary. c. perform a focused nursing assessment to identify risk factors for constipation. d. suggest that the patient increase dietary intake of foods that are high in fiber.

Answer: C Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment. Cognitive Level: Application Text Reference: pp. 1042-1043 Nursing Process: Implementation NCLEX: Physiological Integrity

35. A patient with acute renal failure (ARF) requires hemodialysis and temporary vascular access is obtained by placing a catheter in the left femoral vein. The nurse will plan to a. restrict the patient's oral protein intake. b. discontinue the retention catheter. c. place the patient on bed rest. d. start continuous pulse oximetry.

Answer: C Rationale: The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry. Cognitive Level: Application Text Reference: p. 1221 Nursing Process: Planning NCLEX: Physiological Integrity

42. After being treated for a respiratory tract infection with a 10-day course of antibiotics, a 69-year-old patient calls the clinic and tells the nurse about developing frequent, watery diarrhea. The nurse anticipates that the patient will need to a. prepare for colonoscopy by taking laxatives. b. have blood drawn for blood cultures. c. bring a stool specimen in to be tested for C. difficile. d. schedule a barium enema to check for inflammation.

Answer: C Rationale: The patient's age and history of antibiotic use suggest a C. difficile infection. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. Cognitive Level: Application Text Reference: pp. 1036-1037 Nursing Process: Planning NCLEX: Physiological Integrity

1. A patient admitted with severe dehydration has a urine output of 380 ml over the next 24 hours and elevated blood urea nitrogen (BUN) and creatinine levels. A finding that the nurse would expect when reviewing the patient's urinalysis is a. proteinuria. b. bacteriuria. c. high specific gravity. d. tubular casts.

Answer: C Rationale: The patient's renal failure has been caused by the prerenal problem of hypovolemia. Prerenal oliguria is characterized by the ability of the kidneys to concentrate urine, resulting in a high urine specific gravity. The urinalysis in intrarenal failure would show proteins and tubular casts. Bacteriuria would be typical of a urinary tract infection (UTI), not renal failure. Cognitive Level: Application Text Reference: pp. 1198-1199 Nursing Process: Assessment NCLEX: Physiological Integrity

14. As the nurse reviews a diet plan with a patient with diabetes and renal insufficiency, the patient states that with diabetes and kidney failure there is nothing that is good to eat. The patient says, "I am going to eat what I want; I'm going to die anyway!" The best nursing diagnosis for this patient is a. imbalanced nutrition: more than required related to knowledge deficit about appropriate diet. b. risk for noncompliance related to feelings of anger. c. grieving related to actual and perceived losses. d. risk for ineffective health maintenance related to complexity of therapeutic regimen.

Answer: C Rationale: The patient's statements that there is nothing that is good to eat and that death is unavoidable indicate grieving about the losses being experienced as a result of the diabetes and chronic kidney disease (CKD). The patient data do not indicate knowledge deficit, anger, or the complexity of the therapeutic program as being issues for this patient. Cognitive Level: Application Text Reference: p. 1215 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

19. Surgery is recommended by the health care provider for a patient with severe ulcerative colitis. The patient asks the nurse for clarification about the various procedures and the associated advantages and disadvantages. In responding to the patient's concerns, the nurse explains that a. surgery for ulcerative colitis involves the formation of a temporary ileostomy to divert fecal contents until the large bowel heals. b. in a total proctocolectomy with a continent ileostomy, a pouch is created that holds bowel contents and is emptied once a day with the use of a catheter. c. a total colectomy and ileal reservoir provide the most normal elimination function, but this surgery consists of two procedures, requiring a temporary ileostomy for 8 to 12 weeks. d. any proposed surgery for treatment of ulcerative colitis should be given serious consideration because the disease often recurs in previously unaffected parts of the bowel.

Answer: C Rationale: The total colectomy and ileal reservoir enable the patient to pass stool rectally but require two procedures 8 to 12 weeks apart. Although a temporary ileostomy may be needed, the large bowel is removed rather than being allowed to heal. The pouch formed during total proctocolectomy with continent ileostomy is drained more often than once daily. Surgical treatment for ulcerative colitis is curative because the colon is removed. Cognitive Level: Application Text Reference: p. 1055 Nursing Process: Implementation NCLEX: Physiological Integrity

13. A patient with CKD has a nursing diagnosis of disturbed sensory perception related to central nervous system changes induced by uremic toxins. An appropriate nursing intervention for this problem is to a. convey a caring attitude and foster the nurse-patient relationship. b. keep the patient on bed rest to avoid possible falls or other injuries. c. ensure restricted protein intake to prevent nitrogenous product accumulation. d. provide an opportunity for the patient to discuss concerns about the condition.

Answer: C Rationale: Uremia is caused by the products of protein breakdown, and protein restriction is used to decrease uremia. Because the primary cause of the patient's disturbed sensory perception is the uremia, conveying a caring attitude and providing opportunities for the patient to discuss concerns will not be as helpful as protein restriction. Although safety is a concern for the patient, bed rest is likely to promote weakness. The patient should be supervised when out of bed. Cognitive Level: Application Text Reference: p. 1211 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 ml emesis and 250 ml urine. The nurse plans a fluid replacement for the following day of ___ ml. a. 400 b. 800 c. 1000 d. 1400

Answer: C Rationale: Usually fluid replacement should be based on the patient's measured output plus 600 ml/day for insensible losses. Cognitive Level: Application Text Reference: pp. 1201-1202 Nursing Process: Implementation NCLEX: Physiological Integrity

33. A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's a. blood glucose. b. serum potassium. c. BUN and creatinine. d. urine osmolality.

Answer: C Rationale: When a patient at risk for CKD receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin. Cognitive Level: Application Text Reference: p. 1213 Nursing Process: Evaluation NCLEX: Physiological Integrity

18. The nurse identifies a nursing diagnosis of impaired skin integrity related to having 15 to 20 daily episodes of diarrhea for a patient with ulcerative colitis. The nurse recognizes that teaching regarding perianal care has been effective when the patient a. takes a sitz bath for 40 minutes following each stool. b. asks for antidiarrheal medication after each diarrhea stool. c. uses witch hazel compresses to provide relief from anal irritation. d. cleans the perianal area with soap and water after each stool.

Answer: C Rationale: Witch hazel compresses are suggested to reduce anal irritation and discomfort. Sitz baths may be helpful but should be limited to 15 or 20 minutes. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with water after each stool. Cognitive Level: Application Text Reference: p. 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity

30. During preoperative preparation for a patient scheduled for an abdominal-perineal resection, the nurse will a. give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria. b. teach the patient that activities such as sitting at the bedside will be started the first postoperative day. c. instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. administer enemas and laxatives to ensure that the bowel is empty before the surgery.

Answer: D Rationale: A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery. Cognitive Level: Application Text Reference: p. 1066 Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient has a large bowel obstruction that occurred as a result of a fecal impaction. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes a. metabolic alkalosis. b. referred pain to the back. c. bile colored vomiting. d. abdominal distension.

Answer: D Rationale: Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction. Cognitive Level: Comprehension Text Reference: pp. 1061-1062 Nursing Process: Assessment NCLEX: Physiological Integrity

3. A patient who is hospitalized with a diagnosis of Giardia lamblia infection frequently has uncontrollable explosive diarrhea. The patient closes the eyes and will not talk to the nurse when the linens are changed and skin care is performed. To help maintain the patient's self-esteem, the nurse should a. use incontinence briefs for the patient so that the cleaning is less cumbersome and embarrassing. b. request an order for an antidiarrheal drug from the health care provider to help control the diarrhea episodes. c. ensure the patient that the lack of control is temporary and will resolve after about a week of treatment. d. acknowledge the behavior as reflective of a difficult situation and provide privacy during hygiene.

Answer: D Rationale: Acknowledging the difficulty of the situation and providing privacy will decrease the patient's embarrassment about the incontinence. Incontinence briefs are usually perceived as humiliating for patients. Use of antidiarrheal medications prolongs the exposure to the Giardia by slowing GI motility. Giardia may take several months to resolve. Cognitive Level: Application Text Reference: pp. 1039-1040 Nursing Process: Implementation NCLEX: Psychosocial Integrity

32. A patient with hypertension and stage 2 chronic kidney disease is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient's a. creatinine. b. glucose. c. phosphate. d. potassium.

Answer: D Rationale: Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention; therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values would also be monitored in patients with CKD but would not impact whether the captopril was given or not. Cognitive Level: Application Text Reference: p. 1210 Nursing Process: Assessment NCLEX: Physiological Integrity

14. A patient diagnosed with irritable bowel syndrome (IBS) tells the nurse, "My friends tell me this problem is all in my head." In caring for the patient, the nurse should a. discuss the new medications that are available to treat the condition. b. inform the patient that IBS has a specific, identifiable cause. c. explain that modifications to increase dietary fiber can control the symptoms. d. encourage the patient to express feelings and ask questions about IBS.

Answer: D Rationale: Because psychologic and emotional factors can impact on the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Although new medications are available, discussion of these medications does not address the patient's concerns with what friends think or say. There is no specific cause for IBS. Modifications in fiber intake may help some patients but might also increase bloating and gas pain. In addition, discussion of fiber does not address the patient's feelings. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Psychosocial Integrity

26. A patient is hospitalized with severe vomiting and colicky abdominal pain that is somewhat relieved with the vomiting. The health care provider orders an IV infusion of lactated Ringer's solution and placement of an NG tube. An appropriate collaborative problem for the nurse to identify for the patient at this time is a. potential complication: volvulus. b. potential complication: thromboembolism. c. potential complication: renal insufficiency. d. potential complication: metabolic alkalosis.

Answer: D Rationale: Metabolic alkalosis is a complication of NG suction resulting from loss of HCl from the stomach. Volvulus and thromboembolism are not associated with NG placement. The patient is hydrated with IV fluids to avoid renal insufficiency or failure. Cognitive Level: Application Text Reference: pp. 1061-1062 Nursing Process: Diagnosis NCLEX: Physiological Integrity

15. The RN observes an LPN/LVN carrying out all these actions while caring for a patient with renal insufficiency. Which action requires the RN to intervene? a. The LPN/LVN carries a tray containing low-protein foods into the patient's room. b. The LPN/LVN assists the patient to ambulate in the hallway. c. The LPN/LVN administers erythropoietin subcutaneously. d. The LPN/LVN gives the iron supplement and phosphate binder with lunch.

Answer: D Rationale: Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency. Cognitive Level: Application Text Reference: p. 1211 Nursing Process: Implementation NCLEX: Psychosocial Integrity

29. While obtaining a nursing history from a 55-year-old patient scheduled for a colonoscopy, the nurse will be most concerned about a. lifelong constipation. b. nausea and vomiting. c. history of an appendectomy. d. recent blood in the stools.

Answer: D Rationale: Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a clinical manifestation of colorectal cancer, but lifelong constipation is not an indication. Nausea and vomiting are not common clinical manifestations of problems with the distal GI tract. An appendectomy is not a risk factor for cancer of the colon. Cognitive Level: Application Text Reference: pp. 1064-1065 Nursing Process: Assessment NCLEX: Physiological Integrity

10. A patient is brought to the emergency department following an automobile accident in which blunt trauma to the abdomen occurred. The patient is splinting the abdomen and complaining of pain, and bowel sounds are decreased. Peritoneal lavage returns brown drainage. Based on the results of the lavage, the nurse plans for a. preparation for a paracentesis. b. administration of pain medications. c. continued monitoring of the patient's condition. d. immediate preparation of the patient for surgery.

Answer: D Rationale: Return of brown drainage suggests perforation of the bowel and the need for immediate surgery. Paracentesis is not a treatment for abdominal trauma and may spread infection. Administration of pain medication and/or continued monitoring may be indicated for a negative finding with peritoneal lavage. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Planning NCLEX: Physiological Integrity

23. A patient with chronic kidney disease (CKD) is started on hemodialysis, and after the first treatment, the patient complains of nausea and a headache. The nurse notes mild jerking and twitching of the patient's extremities. The nurse will anticipate the need to a. increase the time for the next dialysis to remove wastes more completely. b. switch to continuous renal replacement therapy (CRRT) to improve dialysis efficiency. c. administer medications to control these symptoms before the next dialysis. d. slow the rate for the next dialysis to decrease the speed of solute removal.

Answer: D Rationale: The patient has symptoms of disequilibrium syndrome, which can be prevented by slowing the rate of dialysis so that fewer solutes are removed during the dialysis. Increasing the time of the dialysis to remove wastes more completely will increase the risk for disequilibrium syndrome. CRRT is a less efficient means of removing wastes and, because it is continuous, would not be used for a patient with CKD. Administration of medications to control the symptoms is not an appropriate action; rather, the disequilibrium syndrome should be avoided. Cognitive Level: Application Text Reference: p. 1224 Nursing Process: Planning NCLEX: Physiological Integrity

20. After teaching a patient with IBD about recommended dietary modifications, the nurse identifies a need for further instruction when the patient chooses from the menu a. spaghetti with tomato sauce. b. poached eggs and crisp bacon. c. boiled shrimp and white rice. d. ham hocks and beans.

Answer: D Rationale: The patient is taught to avoid high-fiber foods such as beans. In addition, high-fat foods such as ham may trigger diarrhea in some patients. The other choices are appropriate for a patient with IBD. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

3. A patient with severe heart failure develops elevated BUN and creatinine levels. The nurse plans care for the patient based on the knowledge that collaborative care of the patient will be directed toward the goal of a. preventing hypertension. b. replacing fluid volume. c. diluting nephrotoxic substances. d. maintaining cardiac output.

Answer: D Rationale: The primary goal of treatment for ARF is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing ARF, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct. Cognitive Level: Application Text Reference: pp. 1201-1202 Nursing Process: Planning NCLEX: Physiological Integrity

5. A patient admitted with sepsis has had several episodes of severe hypotension. Laboratory results indicate a BUN 50 mg/dl (10.7 mmol/L), serum creatinine 2.0 mg/dl (177 µmol/L), urine sodium 70 mEq/L (70 mmol/L), urine specific gravity 1.010, and cellular casts and debris in the urine. The nurse knows these findings are consistent with a. chronic renal insufficiency. b. prerenal failure. c. postrenal failure. d. acute tubular necrosis.

Answer: D Rationale: The specific gravity and presence of casts and debris in the urinalysis suggest intrarenal failure and acute tubular necrosis. The sudden onset indicates that the renal failure is acute, not chronic. In prerenal failure, there would not be casts or debris in the urine. The patient does not have risk factors for postrenal failure. Cognitive Level: Application Text Reference: pp. 1198-1199 Nursing Process: Assessment NCLEX: Physiological Integrity

44. After a patient with IBD has had dietary teaching, which food choice by the patient indicates that the teaching has been successful? a. Oatmeal with cream, whole wheat toast, and a banana b. Corn tortilla taco with chicken, lettuce, tomato, and cheese c. Roast beef, mashed potatoes, and a tossed green salad d. Chicken sandwich with mayonnaise on white bread

Answer: D Rationale: This choice is consistent with the appropriate high-protein, low-residue diet. Oatmeal, whole wheat toast, green salad, corn tacos, lettuce, and tomato are all high-fiber choices and likely to worsen symptoms. Cognitive Level: Application Text Reference: pp. 1056-1057, 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity

28. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of a. cigarette smoking. b. alcohol use. c. diabetes mellitus. d. high-protein diet.

B Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors. Cognitive Level: Comprehension Text Reference: p. 1118 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

8. When taking a health history for a new patient, which information given by the patient would indicate that screening for hepatitis C is appropriate? a. The patient had a blood transfusion after surgery in 1998. b. The patient reports a one-time use of IV drugs 20 years ago. c. The patient eats frequent meals in fast-food restaurants. d. The patient recently traveled to an undeveloped country.

B Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries. Cognitive Level: Application Text Reference: pp. 1090, 1098 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

17. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the nurse gives the highest priority to the goal of a. controlling bleeding. b. maintenance of the airway. c. maintenance of fluid volume. d. relieving the patient's anxiety.

B Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important for this patient, but they are not as high a priority as airway maintenance. Cognitive Level: Application Text Reference: pp. 1107, 1114 Nursing Process: Planning NCLEX: Physiological Integrity

40. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse is the best indicator that these therapies have been effective? a. Bowel sounds are present. b. Abdominal pain is decreased. c. Electrolyte levels are normal. d. Grey Turner sign resolves.

B Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective. Cognitive Level: Application Text Reference: p. 1120 Nursing Process: Evaluation NCLEX: Physiological Integrity

25. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the patient outcome of a. developing no acute complications. b. maintenance of normal respiratory function. c. expressing satisfaction with pain control. d. having adequate fluid and electrolyte balance.

B Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient. Cognitive Level: Application Text Reference: p. 1122 Nursing Process: Planning NCLEX: Physiological Integrity

12. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning patient teaching, the priority information for the nurse to include is the need for a. vitamin B supplements. b. abstinence from alcohol. c. maintenance of a nutritious diet. d. long-term, low-dose corticosteroids.

B Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease. Cognitive Level: Application Text Reference: pp. 1114-1115 Nursing Process: Planning NCLEX: Physiological Integrity

11. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data indicate that it is most important for the nurse to monitor the patient's a. temperature. b. albumin level. c. hemoglobin. d. activity level.

B Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema. The other parameters should also be monitored, but they are not contributing factors to the patient's current symptoms. Cognitive Level: Application Text Reference: p. 1104 Nursing Process: Assessment NCLEX: Physiological Integrity

16. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate diet. The nurse determines that the teaching has been effective when the patient's choice of foods from the menu includes a. an omelet with cheese and mushrooms and milk. b. pancakes with butter and honey and orange juice. c. baked beans with ham, cornbread, potatoes, and coffee. d. baked chicken with french-fries, low-fiber bread, and tea.

B Rationale: The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia levels. The other choices are all higher in protein and would not be as appropriate for this patient. In addition, the patient's ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium. Cognitive Level: Application Text Reference: p. 1110 Nursing Process: Evaluation NCLEX: Physiological Integrity

9. A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Have you been around anyone with jaundice?" b. "Do you use any prescription or over-the-counter (OTC) drugs?" c. "Are you taking corticosteroids for any reason?" d. "Is there any history of IV drug use?"

B Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Exposure to a jaundiced individual and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed. Cognitive Level: Application Text Reference: pp. 1099-1100 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

3. During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B vaccine has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgM. d. anti-HBc IgG

B Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV. Cognitive Level: Application Text Reference: pp. 1089, 1093 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

20. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to a. restrict dietary protein intake. b. arrange for a pressure-relieving mattress. c. perform passive range of motion QID. d. turn the patient every 4 hours.

B Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Dietary protein intake may be increased in patients with ascites to improve oncotic pressure. Turning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown. Cognitive Level: Application Text Reference: p. 1111 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

21. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding esophageal varices. The nurse plans to teach the patient that this procedure a. is likely to improve the patient's life expectancy. b. will increase the risk of hepatic encephalopathy. c. will help to decrease the incidence of peritonitis. d. is a first-line therapy for portal hypertension.

B Rationale: The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses the portal system and ammonia is diverted past the liver and into the systemic circulation. Life expectancy is not improved. The risk for peritonitis is not decreased by a surgical procedure, which will increase infection risk. First-line procedures for portal hypertension are medications such as diuretics and albumin. Cognitive Level: Application Text Reference: p. 1108 Nursing Process: Planning NCLEX: Physiological Integrity

37. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate? a. The medication will inhibit the development of gastric ulcers. b. The medication will prevent irritation to the esophageal varices. c. The medication will decrease nausea and anorexia. d. The medication will reduce the risk for aspiration.

B Rationale: The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient. Cognitive Level: Application Text Reference: p. 1108 Nursing Process: Implementation NCLEX: Physiological Integrity

7. Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient with human immunodeficiency virus (HIV). The nurse will plan to monitor a. blood glucose. b. lymphocyte count. c. potassium level. d. serum creatinine.

B Rationale: Therapy with ribavirin and -interferon may decrease lymphocyte counts. The other laboratory values should not be changed by the drug therapy. Cognitive Level: Application Text Reference: p. 1095 Nursing Process: Planning NCLEX: Physiological Integrity

36. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will teach the patient that the medication is ordered to a. decrease systemic BP. b. prevent the development of ischemia. c. lower the risk for bleeding varices. d. reduce fluid retention and edema.

C Rationale: -blockers have been shown to decrease the risk for bleeding in esophageal varices. Although propranolol will decrease BP and prevent cardiac ischemia, these are not the purposes for this patient. Propranolol will not decrease fluid retention or edema. Cognitive Level: Application Text Reference: p. 1107 Nursing Process: Implementation NCLEX: Physiological Integrity

34. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient surgical center, the nurse recognizes that teaching has been effective when the patient states, a. "I should plan to limit my activities and not return to work for 4 to 6 weeks." b. "I can expect some reddish yellow drainage from the incisions for a few days." c. "I can remove the bandages on my incisions tomorrow and take a shower." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

C Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions; patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement. Cognitive Level: Application Text Reference: p. 1132 Nursing Process: Evaluation NCLEX: Physiological Integrity

10. When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that additional teaching is needed when the patient says a. "I should not drink alcohol for at least the next year." b. "My family members should be tested for hepatitis B." c. "When the jaundice is gone, I have recovered from my illness and the infection is cured." d. "Until my tests for the virus are negative, I should use a condom for sexual intercourse."

C Rationale: After the acute (icteric) phase, there is a convalescent phase lasting several months. The other patient statements are correct and indicate that teaching has been effective. Cognitive Level: Application Text Reference: pp. 1091, 1098 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

24. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum a. calcium. b. bilirubin. c. amylase. d. potassium.

C Rationale: Amylase is elevated early in acute pancreatitis. Changes in bilirubin, calcium, and potassium levels are not diagnostic for pancreatitis. Cognitive Level: Comprehension Text Reference: pp. 1120-1121 Nursing Process: Assessment NCLEX: Physiological Integrity

14. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient to a. stand on one foot. b. ambulate with the eyes closed. c. extend both arms. d. perform the Valsalva maneuver.

C Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy. Cognitive Level: Comprehension Text Reference: p. 1106 Nursing Process: Assessment NCLEX: Physiological Integrity

26. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse explains to the patient that the major purpose of this treatment is a. control of fluid and electrolyte imbalance. b. relief from nausea and vomiting. c. reduction of pancreatic enzymes. d. removal of the precipitating irritants.

C Rationale: Pancreatic enzymes are released when the patient eats. NG suction and NPO status decrease the release of these enzymes. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive IV fluids to prevent this. The patient's nausea and vomiting may decrease, but this is not the major reason for these treatments. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction. Cognitive Level: Application Text Reference: p. 1120 Nursing Process: Implementation NCLEX: Physiological Integrity

13. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before notifying the health care provider, the nurse should a. administer the furosemide and withhold the spironolactone. b. give both drugs as scheduled. c. administer the spironolactone. d. withhold both drugs until talking with the health care provider.

C Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider. Cognitive Level: Application Text Reference: p. 1107 Nursing Process: Implementation NCLEX: Physiological Integrity

19. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor a. prothrombin time. b. bilirubin levels. c. ammonia levels. d. potassium levels.

C Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but these will not be affected by the bleeding episode. Cognitive Level: Application Text Reference: p. 1113 Nursing Process: Assessment NCLEX: Physiological Integrity

31. A patient who is admitted to the hospital with a sudden onset of severe right upper-quadrant pain that radiates to the right shoulder is diagnosed with cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider? a. The patient has an increase in pain after eating. b. The patient needs 4 mg of morphine for pain relief. c. The patient's stools are clay colored. d. The patient's urine is bright yellow.

C Rationale: The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider. Cognitive Level: Application Text Reference: p. 1128 Nursing Process: Assessment NCLEX: Physiological Integrity

23. A patient with end-stage liver disease who is to undergo a liver transplant tells the nurse, "I have a friend who has already rejected two kidney transplants. I am concerned that I will reject this liver." The nurse's best response to the patient is a. "Perhaps your friend did not have a good tissue match with the kidney transplants." b. "You would not be scheduled for a transplant if there was a concern about rejection." c. "The problem of rejection is not as common in liver transplants as in kidney transplants." d. "It is easier to get a good tissue match with liver transplants than with kidney transplants."

C Rationale: The liver is less susceptible to rejection than the kidney. The other statements are inaccurate or will not decrease the patient's anxiety. Cognitive Level: Application Text Reference: p. 1118 Nursing Process: Implementation NCLEX: Physiological Integrity

18. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which nursing action will be included in the plan of care? a. Encourage the patient to cough and deep breathe. b. Insert the tube and verify its position q4hr. c. Monitor the patient for shortness of breath. d. Deflate the gastric balloon q8-12hr.

C Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway. Cognitive Level: Application Text Reference: p. 1114 Nursing Process: Implementation NCLEX: Physiological Integrity

39. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient's hand. Which action should the nurse take next? a. Notify the health care provider immediately. b. Retake the patient's blood pressure. c. Check the calcium level on the chart. d. Ask the patient about any arm pain.

C Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse learns the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain. Cognitive Level: Analysis Text Reference: p. 1122 Nursing Process: Assessment NCLEX: Physiological Integrity

Trimethoprim and sulfamethoxazole (Bactrim) BID for 7 days is ordered for a patient who has a recurrent relapse of an Escherichia coli UTI. The nurse instructs the patient to a. take the antibiotic for the full 7 days, even if symptoms improve in a few days. b. return to the clinic in 3 days so that a urine culture can be done to evaluate the effectiveness of the drug. c. increase the effectiveness of the drug by taking it with cranberry juice to acidify the urine. d. take two of the pills a day for 5 days, and reserve the rest of the pills to take if the symptoms reappear.

Correct Answer: A Rationale: Although an initial infection may be treated with a shorter course of antibiotics, the patient with a recurrent infection should take the antibiotic for 7 days. Success of treatment is evaluated by resolution of symptoms rather than by a repeat culture. Acidifying the urine when a patient is taking sulfa antibiotics may lead to stone formation. The patient is instructed to take all the antibiotics.

A patient in the hospital has a history of urinary incontinence. Which nursing action will be included in the plan of care? a. Place a bedside commode near the patient's bed. b. Use an ultrasound scanner to check urine residual after the patient voids. c. Demonstrate the use of the Credé maneuver to the patient. d. Teach the use of Kegel exercises to strengthen the pelvic floor.

Correct Answer: A Rationale: Environmental changes can make it easier for the patient to avoid incontinence for patients with urinary incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. Cognitive Level: Application Text Reference: p. 1181 Nursing Process: Planning NCLEX: Physiological Integrity

A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. d. sterility will not be a problem after surgery because sperm production will not be affected.

Correct Answer: A Rationale: Erectile problems are rare, but retrograde ejaculation may occur after TURP. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. Cognitive Level: Application Text Reference: p. 1418 Nursing Process: Implementation NCLEX: Physiological Integrity

After her bath, a 62-year-old patient asks the nurse for a perineal pad, saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient? a. Teach the patient how to perform Kegel exercises. b. Demonstrate how to perform Credé's maneuver. c. Place commode at the patient's bedside. d. Assist the patient to the bathroom q3hr.

Correct Answer: A Rationale: Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence. Cognitive Level: Application Text Reference: pp. 1181-1184 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

A patient with bladder cancer is scheduled for intravesical chemotherapy. In preparation for the treatment the nurse will teach the patient about a. the need to empty the bladder prior to treatment. b. premedicating to prevent nausea. c. the importance of oral care during treatment. d. where to obtain wigs and scarves.

Correct Answer: A Rationale: The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not experienced with intravesical chemotherapy. Cognitive Level: Application Text Reference: p. 1180 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with symptomatic BPH is scheduled for visual laser ablation of the prostate (VLAP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. to expect an immediate improvement in urinary force. d. that an intraprostatic urethral stent will be placed.

Correct Answer: A Rationale: The patient will have indwelling catheter for up to a week and will need to be instructed on catheter care to avoid problems such as infection. There is minimal bleeding with this procedure. It will take several weeks before the full benefits of the procedure take effect. Stent placement is not included in the procedure. Cognitive Level: Application Text Reference: pp. 1420-1422 Nursing Process: Planning NCLEX: Physiological Integrity

The nurse determines that instruction regarding prevention of future UTIs for a patient with cystitis has been effective when the patient states, a. "I will empty my bladder every 3 to 4 hours during the day." b. "I can use vaginal sprays to reduce bacteria." c. "I will wash with soap and water before sexual intercourse." d. "I will drink a quart of water or other fluids every day."

Correct Answer: A Rationale: Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenanc

A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "The prostate gland normally changes slightly in size from day to day, and this may be making your symptoms worse." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate?" d. "I will talk to the doctor about ordering a prostate specific antigen test."

Correct Answer: B Rationale: Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer and is not indicated in this patient, who has already been diagnosed with BPH. Cognitive Level: Application Text Reference: p. 1421 Nursing Process: Assessment NCLEX: Physiological Integrity

Following discharge teaching for a patient who has had a transurethral prostatectomy for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will increase fiber and fluids in my diet to prevent constipation." b. "I should call the doctor if I have any incontinence at home." c. "I will avoid heavy lifting or driving until I get approval from my health care provider." d. "I should continue to schedule yearly appointments for prostate exams."

Correct Answer: B Rationale: Incontinence is common for several weeks after a TURP. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. Cognitive Level: Application Text Reference: p. 1422 Nursing Process: Evaluation NCLEX: Physiological Integrity

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about a. flank pain. b. pain with urination. c. poor urine output. d. nausea.

Correct Answer: B Rationale: Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI. Cognitive Level: Application Text Reference: p. 1157 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient has a cystectomy and a Kock continent diversion created for treatment of bladder cancer. During postoperative teaching of the patient, it is important that the nurse include instructions regarding a. application of ostomy appliances. b. catheterization technique and schedule. c. use of barrier products for skin protection. d. analgesic use before emptying the pouch.

Correct Answer: B Rationale: The Kock pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful. Cognitive Level: Application Text Reference: p. 1190 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with acute urinary retention associated with BPH is admitted to the emergency department. The patient has had no urine output for 16 hours, and the laboratory work shows a blood urea nitrogen (BUN) level of 50 mg/dl and a creatinine of 3.0 mg/dl. The nurse will anticipate a health care provider order to a. schedule the patient for inpatient hemodialysis. b. insert a retention catheter. c. start an IV line for fluid administration. d. administer furosemide (Lasix).

Correct Answer: B Rationale: The patient data indicate that the patient may have hydronephrosis and acute renal failure caused by the BPH; the initial therapy will be to insert a catheter. Hemodialysis may be needed if the elevation in BUN and creatinine persists, but it will not be ordered initially. Fluid administration and furosemide administration will increase the bladder distension. Cognitive Level: Application Text Reference: p. 1415 Nursing Process: Planning NCLEX: Physiological Integrity

Following a cystectomy, a patient has an ileal conduit created. The nurse identifies the nursing diagnosis of risk for infection related to altered urinary structures. An appropriate nursing intervention for this problem is to a. clamp the drainage bag while the patient sleeps. b. empty the drainage appliance every 2 to 3 hours or when it is one-third full. c. use liquid antiseptic in the appliance to decrease bacterial colonization. d. drain the conduit every 4 hours using a sterile catheter.

Correct Answer: B Rationale: The patient with an ileal conduit will have an appliance to hold urine, which should be emptied to avoid reflux of urine back into the conduit. The drainage bag should not be clamped. The use of a liquid antiseptic will not decrease risk for infection. Unlike a continent pouch, the ileal conduit will drain continuously and is not drained with a catheter. Cognitive Level: Application Text Reference: p. 1193

Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the c cnurse specialist care for the stoma. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in body function. c. ineffective health maintenance related to refusal to participate in care. d. self-care deficit, toileting, related to denial of altered body function.

Correct Answer: B Rationale: The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. There are no data suggesting that the impact on lifestyle is a concern for the patient. The patient may be at risk for ineffective health maintenance if the lack of participation in care continues, but the patient's behavior is normal 2 days after surgery. The patient does not appear to be in denial. Cognitive Level: Application Text Reference: p. 1191 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

Two days after surgery for an ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialist care for the stoma. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in body function. c. ineffective health maintenance related to refusal to participate in care. d. self-care deficit, toileting, related to denial of altered body function.

Correct Answer: B Rationale: The patient's unwillingness to look at the stoma or participate in care indicates that disturbed body image is the best diagnosis. There are no data suggesting that the impact on lifestyle is a concern for the patient. The patient may be at risk for ineffective health maintenance if the lack of participation in care continues, but the patient's behavior is normal 2 days after surgery. The patient does not appear to be in denial. Cognitive Level: Application Text Reference: p. 1191 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

The wife of a patient who has undergone a TURP and has continuous bladder irrigation asks the nurse about the purpose of the continuous bladder irrigation. Which response by the nurse is appropriate? a. "The bladder irrigation is needed to stop the postoperative bleeding in the bladder." b. "The irrigation is needed to keep the catheter from being occluded by blood clots." c. "Normal production of urine is maintained with the irrigations until healing occurs." d. "Antibiotics are being administered into the bladder with the irrigation solution."

Correct Answer: B Rationale: The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or maintain urine production. Antibiotics are given by the IV route, not through the bladder irrigation. Cognitive Level: Comprehension Text Reference: pp. 1420-1421 Nursing Process: Implementation NCLEX: Physiological Integrity

A 41-year-old man asks the nurse what he can do to decrease the risk of BPH. The nurse explains that a. riding a bicycle raises prostate specific antigen levels and may increase BPH risk. b. prevention is not possible because prostatic enlargement occurs with normal aging. c. decreasing butter and margarine and increasing fruits in the diet may help. d. taking a daily vitamin E supplement has reduced prostate size in some men.

Correct Answer: C Rationale: A diet high in saturated fats, found in foods like butter, is associated with an increased risk for BPH. Individuals who eat more fruits and vegetables may be at lower risk. Riding a bicycle does increase prostate-specific antigen (PSA) levels, but this is not associated with development of BPH. Dietary changes and increased exercise do appear to help prevent BPH. Vitamin E supplements do not decrease prostate size. Cognitive Level: Comprehension Text Reference: p. 1415 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with a. antibiotics. b. antihypertensives. c. anticoagulants. d. corticosteroids.

Correct Answer: C Rationale: Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis. Cognitive Level: Application Text Reference: p. 1175 Nursing Process: Planning NCLEX: Physiological Integrity

A 78-year-old patient is admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. In developing a plan of care for the patient, an appropriate nursing intervention for the patient's incontinence is to a. insert an indwelling catheter. b. apply absorbent incontinent pads. c. assist the patient to the bathroom q2hr. d. restrict fluids after the evening meal.

Correct Answer: C Rationale: In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for UTI. Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration. Cognitive Level: Application Text Reference: pp. 1183-1185 Nursing Process: Planning NCLEX: Physiological Integrity

To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests that the patient use the OTC urinary analgesic phenazopyridine (Pyridium) but cautions the patient that this preparation a. contains methylene blue, which turns the urine blue or green. b. should be taken on an empty stomach for maximum effect. c. causes the urine to turn reddish orange and can stain underclothing. d. frequently causes allergic reactions and should be stopped if a rash occurs.

Correct Answer: C Rationale: Patients should be taught that Pyridium will color the urine deep orange and stain underclothing. Urised may turn the urine blue or green. The medication can cause gastrointestinal distress and should be taken with food. Although an allergic reaction may occur, this is not common. Cognitive Level: Comprehension Text Reference: p. 1158 Nursing Process: Implementation NCLEX: Physiological Integrity

A 72-year-old patient with benign prostatic hyperplasia and a history of frequent UTIs is admitted to the hospital with chills, fever, and nausea and vomiting. To determine whether the patient has an upper UTI, the nurse will assess for a. suprapubic pain. b. foul-smelling urine. c. bladder distension. d. costovertebral angle (CVA) tenderness.

Correct Answer: D Rationale: CVA tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI. Cognitive Level: Application Text Reference: p. 1161 Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse working in a urology clinic receives a call from a patient who had a transurethral resection with fulguration for bladder cancer 3 days previously. Which information given by the patient is of most concern to the nurse? a. The patient is voiding every 4 hours at night. b. The patient is using opioids for pain. c. The patient is very anxious about the cancer. d. There are clots in the urine.

Correct Answer: D Rationale: Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure. Cognitive Level: Application Text Reference: p. 1179 Nursing Process: Assessment NCLEX: Physiological Integrity

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective? a. "I will need to buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will need to take prophylactic antibiotics to prevent any urinary tract infections." d. "I will wash the catheter with soap and water before and after each catheterization."

Correct Answer: D Rationale: Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics. Cognitive Level: Application Text Reference: p. 1188 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to a. administer the ordered IV morphine sulfate, 4 mg. b. increase the flow rate of the continuous bladder irrigation. c. give the ordered the belladonna and opium suppository. d. manually instill 50 ml of saline and try to remove the clots.

Correct Answer: D Rationale: The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot.

41. When the nurse is caring for a patient with acute pancreatitis, which of these assessment data should be of most concern? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

D Rationale: A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications. Cognitive Level: Application Text Reference: p. 1119 Nursing Process: Assessment NCLEX: Physiological Integrity

2. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. hepatitis B surface antigen (HBsAg). b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

D Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would indicate past infection and lifelong immunity. Cognitive Level: Application Text Reference: p. 1089 Nursing Process: Assessment NCLEX: Physiological Integrity

38. Which of these nursing actions included in the plan of care for a patient with cirrhosis can the nurse delegate to a nursing assistant? a. Assessing the patient for jaundice b. Assisting the patient in choosing the diet c. Palpating the abdomen for distention d. Providing oral hygiene before meals

D Rationale: Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs. Cognitive Level: Application Text Reference: pp. 1110-1115 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

35. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern? a. The patient's skin has multiple spider-shaped blood vessels on the abdomen. b. The patient has ascites and a 2-kg weight gain from the previous day. c. The patient complains of right upper-quadrant pain with abdominal palpation. d. The patient's hands flap back and forth when the arms are extended.

D Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper-quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status. Cognitive Level: Application Text Reference: p. 1106 Nursing Process: Assessment NCLEX: Physiological Integrity

15. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the patient complains that it causes diarrhea. The nurse explains to the patient that it is still important to take the drug because the lactulose will a. promote fluid loss. b. prevent constipation. c. prevent gastrointestinal (GI) bleeding. d. improve nervous system function.

D Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not ordered for these purposes for this patient. Cognitive Level: Application Text Reference: p. 1109 Nursing Process: Implementation NCLEX: Physiological Integrity

1. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include a. baseline hepatitis B antibody testing now and in 2 months. b. active immunization with hepatitis B vaccine. c. hepatitis B immune globulin (HBIG) injection. d. both the hepatitis B vaccine and HBIG injection.

D Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure. Cognitive Level: Application Text Reference: p. 1096 Nursing Process: Implementation NCLEX: Physiological Integrity

33. An appropriate collaborative problem for the nurse to include in the care plan for a patient with cholelithiasis and obstruction of the common bile duct is a. potential complication: bleeding. b. potential complication: gastritis. c. potential complication: thromboembolism. d. potential complication: biliary cirrhosis.

D Rationale: With obstruction of the common bile duct, bile will back up into the liver and damage liver cells. Bleeding, gastritis, and thromboembolism are not common complications of biliary obstruction. Cognitive Level: Comprehension Text Reference: pp. 1128-1129 Nursing Process: Planning NCLEX: Physiological Integrity

to determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. the presence of blood in the urine. b. any erectile dysfunction (ED). c. occurrence of a weak urinary stream. d. lower back and hip pain.

correct Answer: C Rationale: The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms with BPH. Cognitive Level: Application Text Reference: pp. 1415-1416 Nursing Process: Assessment NCLEX: Physiological Integrity