Med Surg Exam 3

A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

ANS: A, B, E (ALL ANSWERS HAVE "IV" IN IT)

A young adult male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of a. recent kidney trauma. b. gonococcal urethritis. c. recurrent bladder infection. d. benign prostatic hyperplasia.

ANS: B The patient's clinical manifestations are consistent with urethral strictures,

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

ANS: C The patient's clinical manifestations are consistent with appendicitis.

Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective? a. "I will drink more liquids with my meals." b. "I should choose high carbohydrate foods." c. "Vitamin supplements may prevent anemia." d. "Persistent heartburn is common after surgery."

C

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives.

C - for renal vein thrombosis

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hour.

A

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can accommodate larger needles. d. A fistula can be used sooner after surgery.

A

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Cloudy urine b.Urinary Hesitancy C. Post voiding dribbling d. Weak urinary stream

ANS: A Cloudy urine could indicate infection due to possible urine retention and should be a priority action. Common symptoms of benign prostatic hyperplasia are urinary hesitancy, post-void dribbling, and a weak urinary stream due to the enlarged prostate causing bladder outlet obstruction.

A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding? a. Client who has had two saturated perineal pads in the last 2 hours b. Client with a temperature of 99 F and blood pressure of 115/73 mm Hg c. Client who has pain of 4 on a scale of 0 to 10 d. Client with a urinary catheter output of 150 mL in the last 3 hours

ANS: A Normal vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first.

A patient who has elevated blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient? a. Fleet enema c. Senna/docusate (Senokot-S) b. Tap-water enema d. Bisacodyl (Dulcolax) tablets

ANS: A High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate.

A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this clients risk factors? a. Do you smoke cigarettes? b. Do you use any alcohol? c. Do you use recreational drugs? d. Do you take any prescription drugs?

ANS: A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to increase the risk of developing bladder cancer.

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?a. Place the client on a cardiac monitor immediately.b. Teach the client to limit high-potassium foods.c. Continue to monitor the clients intake and output.d. Ask to have the laboratory redraw the blood specimen.

ANS: A The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias. The other choices are logical nursing interventions for acute kidney injury but not the best immediate action.

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a. Family history of prostate cancer b. Smoking c. Obesity d. Advanced age e. Eating too much red meat f. Race

ANS: A, D, E, F Advanced family history of prostate cancer, age, a diet high in animal fat, and race are all risk factors for prostate cancer. Smoking and obesity are not known risk factors.

A client has recently been diagnosed with stage III endometrial cancer and asks the nurse for an explanation. What response by the nurse is correct about the staging of the cancer? a. The cancer has spread to the mucosa of the bowel and bladder. b. It has reached the vagina or lymph nodes. c. The cancer now involves the cervix. d. It is contained in the endometrium of the cervix.

ANS: B Stage III of endometrial cancer reaches the vagina or lymph nodes. Stage I is confined to the endometrium. Stage II involves the cervix, and stage IV spreads to the bowel or bladder mucosa and/or beyond the pelvis.

A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. Do you have family or friends for support? b. Id like to know what you are feeling now. c. Well, we knew this would probably happen. d. Would you like me to refer you to hospice?

ANS: B The nurse assesses the clients emotional state with open-ended questions and statements and shows a willingness to listen to the clients concerns. Asking about support people is very limited in nature, and yes-or-no questions are not therapeutic. Stating that this was expected dismisses the clients concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)a. I can continue to take antacids to relieve heartburn.b. I need to ask for an antibiotic when scheduling a dental appointment.c. Ill need to check my blood sugar often to prevent hypoglycemia.d. The dose of my pain medication may have to be adjusted.e. I should watch for bleeding when taking my anticoagulants.

ANS: B, C, D, E

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

ANS: C A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

The nurse is reviewing discharge plans with a client who is recovering from a cervical biopsy. Which statements indicate good understanding by the client? (Select all that apply.) a. I can return to work this afternoon. BAD b. There should be no problem lifting my 2-year-old toddler when I get home. BAD c. I cannot douche until the biopsy site is healed. d. I need to wait for about 2 weeks to have intercourse with my husband. e. If I have some bleeding, I can use a regular tampon this evening. BAD

ANS: C, D The client should not douche, have intercourse, or use tampons until the biopsy site is healed. The client should rest for 24 hours after the procedure and should not lift heavy objects.

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The patient denies pain with voiding. b. The urine dipstick is negative for nitrites. c. The antistreptolysin-O (ASO) titer has decreased. d. The periorbital and peripheral edema are resolved.

ANS: D Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action?a. Calculate the mean arterial pressure (MAP).b. Ask for insertion of a pulmonary artery catheter.c. Take the clients pulse.d. Slow down the normal saline infusion.

ANS: D The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion.

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

B

A 68-yr-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Barrier products for skin protection c. Catheterization technique and schedule d. Analgesic use before emptying the pouch

C

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider? a. The patient is voiding every 4 hours. b. The patient is using opioids for pain. c. The patient has seen clots in the urine. d. The patient is anxious about the cancer.

C

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?a. Position the client to lay on the surgical incision.b. Measure the specific gravity of the clients urine.c. Administer intravenous pain medications.d. Assess the rate and quality of the clients pulse.

D

A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the clients record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the clients abdomen and vital signs.

The nephrostomy tube should continue to have a consistent amount of drainage. If the drainage slows or stops, it may be obstructed. The nurse must notify the provider, but first should carefully assess the clients abdomen for pain and distention and check vital signs so that this information can be reported as well. The other interventions are not appropriate.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine.

A

A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily. a.2 c.4 b.3 d.5

A

After change-of-shift report, which patient should the nurse assess first? a. Patient with a urethral stricture who has not voided for 12 hours b. Patient who has cloudy urine after orthotopic bladder reconstruction c. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg d. Patient who voided bright red urine immediately after returning from lithotripsy

A

The nurse is caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy. In which order will the nurse take actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

ANS: D, B, A, C -> Place on contact precautions, Assess BP/HR, contact HCP, give tylenol

A patient complains of gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the prescribed IV morphine sulfate. d. Offer the prescribed promethazine (Phenergan).

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this clients teaching? a. Drink plenty of fluids to prevent dehydration. b. You should only drink 1 liter of fluids daily. c. Increase your protein intake by drinking more milk. d. Sips of cola or tea may help to relieve your nausea.

ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

ANS: A The initial action for the nurse is to assess anxiety, coping styles, and the clients acceptance of the required treatment for CKD. The client may be in denial of the diagnosis. While rescheduling hemodialysis appointments may help, and referral to a mental health practitioner and the possibility of peritoneal dialysis are all viable options, assessment of the clients acceptance of the treatment should come first.

A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.

ANS: A, B, E After gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse should provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition.

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce

ANS: A, C, D, E (Everything EXCEPT Decaf coffee- ok) Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided.

A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this groups teaching? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. To prevent E. coli infection, dont drink water when swimming. d. Clients who have botulism should be quarantined within their home. e. Parasitic diseases may not show up for 1 to 2 weeks after infection

ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals.

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output

ANS: AThe nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the excess gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

ANS: B Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

A patient who has diabetes and reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline ? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

ANS: B Tricyclic antidepressants (TCAs) decrease the transmission of pain impulses to the spinal cord and brain. TCAs also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by TCAs.

Which action for a patient receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient's nutritional status weekly b. Providing skin care to the area around the tube site c. Teaching the patient how to administer tube feedings d. Determining the need for adding water to the feedings

B

A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best? a. Arrange an intensive care unit tour. b. Assess the clients psychosocial status. c. Document the teaching and response. d. Have the client begin nutritional supplements.

ANS: B Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the clients psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope.

After teaching a client who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I must change the ostomy appliance daily and as needed. b. I will use warm water and a soft washcloth to clean around the stoma. c. I might start bicycling and swimming again once my incision has healed. d. Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown. e. I will check the stoma regularly to make sure that it stays a deep red color. f. I must avoid dairy products to reduce gas and odor in the pouch.

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the clients skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the clients skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Clear drainage b. Bloody drainage at site c. Client reports headache d. Foul-smelling drainage e. Urine draining from site

ANS: B, D, E After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if drainage decreases or stops, drainage is cloudy or foul-smelling, the nephrostomy sites leaks blood or urine, or the client has back pain. Clear drainage is normal. A headache would be an unrelated finding.

After teaching a client who has a new colostomy, the nurse provides feedback based on the clients ability to complete self-care activities. Which statement should the nurse include in this feedback? a. I realize that you had a tough time today, but it will get easier with practice. b. You cleaned the stoma well. Now you need to practice putting on the appliance. c. You seem to understand what I taught you today. What else can I help you with? d. You seem uncomfortable. Do you want your daughter to care for your ostomy?

ANS: BThe nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider?a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

ANS: C A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix)

ANS: C The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

B

A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. Aspirin must be avoided. b. Do not worry about black stools. c. Report diarrhea to your provider. d. Take 1 hour before meals.

ANS: C Maalox can cause hypermagnesemia, which causes diarrhea, so the client should be taught to report this to the provider. Aspirin is avoided with bismuth sulfate (Pepto-Bismol). Black stools can be caused by Pepto-Bismol. Maalox should be taken after meals.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon

ANS: CAfter a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the clients creatinine level. d. Increase the clients fluid intake.

ANS: D Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the clients fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

B

The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states a. "The cobalamin injections will prevent gastric inflammation." b. "The cobalamin injections will prevent me from becoming anemic." c. "These injections will increase the hydrochloric acid in my stomach." d. "These injections will decrease my risk for developing stomach cancer."

B- Cobalamin supplementation prevents the development of pernicious anemia

A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

B- recent weight gain

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

C

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

C

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

C

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.

D

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a. iron dextran infusions b. oral ferrous sulfate tablets. c. routine blood transfusions. d. cobalamin (B12) supplements.

D

A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

c. breath sounds. (@ risk for aspiration pneumonia)

A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present based on these findings? a. Activity intolerance b. Excess fluid volume c. Disturbed body image d. Altered nutrition: less than required

B - excess fluid vol.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

A

A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds

ANS: A Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple sexual partners c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse

ANS: A, B, C, E Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer.

The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria-(production of hydrochloric acid is absent or low) b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia

ANS: A, B, C, E Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

ANS: B Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction. Pyelonephritis is an intrinsic or intrarenal cause of AKI related to kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI related to urine flow obstruction.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care?a. Edema and painb. Electrolyte and fluid imbalancec. Cardiac and respiratory statusd. Mental health status

ANS: B This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential. Edema and pain are not usually a problem with fluid loss. There could be changes in the clients cardiac, respiratory, and mental health status if the electrolyte imbalance is not treated.

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a. Complete blood count b. Culture and sensitivity c. Prostate-specific antigen d. Cystoscopy

ANS: C The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy would be performed to assess the effect of a bladder neck obstruction.

A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye examination was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.

ANS: C The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye examination and addressing the questions about diet, but the area for prompt intervention is the patient's decreased renal function.

The nurse is developing a teaching plan for a client who is scheduled for her first Papanicolaou test. What instruction by the nurse is the most accurate? a. The timing of the Pap smear does not matter. b. Sexual intercourse will not interfere with the results. c. Results can be interpreted immediately in the office. d. Results are best if you do not douche 24 hours before the test.

ANS: D In order to prevent false interpretation, the client must not douche or have sexual intercourse for at least 24 hours before the Pap smear. Timing is important, with the test scheduled between the clients menstrual periods so that the menstrual flow does not interfere with laboratory analysis. The specimens are placed on a glass slide and sent to the laboratory for examination and cannot be interpreted immediately.

A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which item will the nurse need to obtain? a. Urinary catheter c. Cleansing towelettes b. Sterile specimen cup d. Large urine container

ANS: D Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2

ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.

A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this clients teaching?a. Since you only have one kidney, a salt and fluid restriction is required.b. Your therapy will include hemodialysis while you recover.c. Medication will be prescribed to control your high blood pressure.d. You need to avoid participating in contact sports like football.

ANS: D Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? a. A 25-year-old female with a history of sexually transmitted diseases b. A 42-year-old male who has worked in a lumber yard for 10 years c. A 55-year-old female who has had numerous episodes of bacterial cystitis d. An 86-year-old male with a 50 pack-year cigarette smoking history

ANS: D The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

A young woman who has Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Bacteria in the perianal area can enter the urethra. b. Fistulas can form between the bowel and bladder. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

B

To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot

BP, SERUM CREAT, MICROALBUMIN, FOOT B, C, D, F

A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond?a. Lets talk to the ostomy nurse to help you and your husband work through this. b. You could try to wear longer lingerie that will better hide the ostomy appliance. c. You should empty the pouch first so it will be less noticeable for your husband. d. If you are not careful, you can hurt the stoma if you engage in sexual activity.

ANS: AThe nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of a. anxiety related to effects of procedure on lifestyle. b. disturbed body image related to change in function. c. readiness for enhanced coping related to need for information. d. self-care deficit (toileting) related to denial of altered body function.

B

A young adult with extensive facial injuries from a motor vehicle crash is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned on the left side. b. Check the gastric residual volume every 4 to 6 hours. c. Avoid giving bolus tube feedings through the PEG tube. d. Obtain a daily abdominal radiographs to verify tube placement.

B

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first? a. Check blood pressure and heart rate. b. Administer morphine sulfate 4 mg IV. c. Transport to radiology for an intravenous pyelogram. d. Insert a urethral catheter and obtain a urine specimen.

ANS: A Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions are also important after the patient's cardiovascular status has been determined and stabilized.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion or return to surgery are needed (or both). Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action.

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert a urinary retention catheter. b. Draw blood for a serum creatinine level. c. Schedule an intravenous pyelogram (IVP). d. Administer lorazepam (Ativan) 0.5 mg PO..

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve after the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP may be used as a diagnostic test but does not need to be done urgently

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

ANS: B The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

ANS: A, B, C Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI. Severe burns would be a pre-renal cause. Lupus would be an intrarenal cause for AKI.

The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years

ANS: A, C The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds (WOULD BE HIGH PITCHED NOT LOW) e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the clients dietary habits. b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. Hold the clients metformin (Glucophage). d. Contact the health care provider immediately.

ANS: AAn elevated BUN/creatinine ratio is often indicative of dehydration, urinary obstruction, catabolism, or a high-protein diet. The nurse should inquire about the clients dietary habits. Kidney damage related to NSAID use most likely would manifest with elevations in both BUN and creatinine, but no change in the ratio. The nurse should obtain more assessment data before holding any medications or contacting the provider.

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, The stool in my pouch is still liquid. How should the nurse respond?a. The stool will always be liquid with this type of colostomy.b. Eating additional fiber will bulk up your stool and decrease diarrhea.c. Your stool will become firmer over the next couple of weeks.d. This is abnormal. I will contact your health care provider.

ANS: AThe stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the clients diet or with the passage of time.

A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client? a. Enteral tube feeding b. Esophageal dilation c. Nissen fundoplication d. Photodynamic therapy

ANS: B Esophageal dilation can provide immediate relief of esophageal strictures that impair swallowing. Enteral tube feeding is a method of providing nutrition when dysphagia is severe, but esophageal dilation would be attempted before this measure is taken. Nissen fundoplication is performed for severe gastroesophageal reflux disease. Photodynamic therapy is performed for esophageal cancer.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent Helicobacterpylori infection

A nurse cares for a client with a new ileostomy. The client states, I dont think my friends will accept me with this ostomy. How should the nurse respond? a. Your friends will be happy that you are alive. b. Tell me more about your concerns. c. A therapist can help you resolve your concerns. d. With time you will accept your new body

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the clients concerns or provide false reassurance.

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. Ill rinse my rectal area with warm water after each stool and apply zinc oxide ointment. b. I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel. c. I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry. d. I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment.

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. I must decrease my intake of fat. b. I will increase my intake of protein. c. A decreased intake of carbohydrates will be required. d. An increased intake of vitamin C is necessary.

ANS: BIn nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by increased intake of protein. The client would not need to adjust fat, carbohydrates, or vitamins based on this disorder.

A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? a. Client having a radial neck dissection tomorrow who is asking questions b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning c. Client who is 1 day postoperative for an oral tumor resection who is reporting pain d. Client waiting for discharge instructions after a small tumor resection

ANS: BThe client who needs frequent suctioning should be seen first to ensure that his or her airway is patent. The client waiting for pain medication should be seen next. The nurse may need to call the surgeon to see the client who is asking questions. The client waiting for discharge instructions can be seen last.

A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

ANS: C, D The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.

A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac)

ANS: C Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid.

A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago:Sodium 136 mEq/LPotassium 5 mEq/LBlood urea nitrogen (BUN) 44 mg/dL (Norm: 7-20)Serum creatinine 2.5 mg/dL (Norm: 0.5-1.1)What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

ANS: CThe client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels. This increased dose may reverse the possible acute rejection of the transplanted kidney. The client does not need hemodialysis, peritoneal dialysis, or further surgery at this point.

After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best? a. Bacteria can often cause ulcers. b. This operation often causes ulcers. c. The medication keeps your blood pH low. d. It prevents stress-related ulcers.

ANS: D After surgery, anti-ulcer medications such as pantoprazole are often given to prevent stress-related ulcers. The other responses are incorrect.

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

ANS: D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient.

B

An older patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place. The health care provider prescribes 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.

B

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."

B - elevate head

Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation? a. Paresthesias c. Dry, scaly skin b. Ecchymoses d. Gingival swelling

A

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

D- PPI

A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL (Norm: 7-20) b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

ANS: A Shock leads to decreased renal perfusion. An elevated BUN accompanies this condition. The creatinine should be normal because no kidney damage occurred. A low BUN signifies overhydration, malnutrition, or liver damage. A low BUN/creatinine ratio indicates fluid volume excess or acute renal tubular acidosis.

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)? a. Change the ostomy appliance. b. Choose the appropriate ostomy bag. c. Monitor the appearance of the stoma. d. Assess for possible urinary tract infection (UTI).

A

A patient complains of gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the prescribed IV morphine sulfate. d. Offer the prescribed promethazine (Phenergan).

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL (LOW norm: 3.4-5.4) b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

ANS: A Albumin level of 2.5 g/dL (LOW norm: 3.4-5.4) Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the clients metabolic needs. The electrolyte values are not related to the protein-restricted diet.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment?a. The client has lost 11 pounds in the past 10 days. b. The clients urine specific gravity is 1.048. c. No blood is observed in the clients urine. d. The clients blood pressure is 152/88 mm Hg.

ANS: A Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.

A nurse contacts the health care provider after reviewing a clients laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

ANS: A Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This clients creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate.

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

ANS: A Right lower quadrant pain, specifically at McBurneys point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. Its a good thing I love orange and cherry gelatin. b. My spouse will be here to drive me home. c. I should refrigerate the GoLYTELY before use. d. I will buy a case of Gatorade before the prep.

ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease.

The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections

ANS: A, B, C, D Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is.

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) a. I just joined a gym, so I hope that helps me lose weight. b. I sure hate to give up my coffee, but I guess I have to. c. I will eat three small meals and three small snacks a day. d. Sitting upright and not lying down after meals will help. e. Smoking a pipe is not a problem and I dont have to stop.

ANS: A, B, C, D (Everything except smoking obvi) Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate, caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals. Tobacco is a risk factor for GERD and should be avoided in all forms.

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness

ANS: A, B, D Nephrotic syndrome is caused by glomerular damage and is characterized by proteinuria (protein level higher than 3.5 g/24 hr), hypoalbuminemia, edema, and lipiduria. Fluid overload leading to edema and hypertension is common with nephrotic syndrome; dehydration does not occur. Dysuria is present with cystitis. CVA tenderness is present with inflammatory changes in the kidney.

After teaching a client with an anal fissure, a nurse assesses the clients understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning

ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil)

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurses first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. My sodium level changes by movement from the blood into the dialysate. b. Dialysis works by movement of wastes from lower to higher concentration. c. Extra fluid can be pulled from the blood by osmosis. d. The dialysate is similar to blood but without any toxins.

ANS: B Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the clients gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure will depress the clients gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the clients readiness for them.

A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: BProtecting the clients skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohns disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment Vital Signs Physician Orders Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best? a. Administer the prescribed pain medication. b. Consult the surgeon about a different antibiotic. c. Consult the surgeon about increased IV fluids. d. Have respiratory therapy reduce the respiratory rate.

ANS: C This clients vital signs, cardiac output, dry skin, and urine output indicate hypovolemia or possible hypotension resulting from pressure placed on the posterior heart during surgery. The client needs more fluids, so the nurse should consult with the surgeon about increasing the fluid intake. The client may be restless as a result of the hypotension and may not need pain medication at this time. There is no reason to request a different antibiotic. The respiratory rate does not need to be adjusted.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would like to cancel it. How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.

ANS: C a negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

ANS: C The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? a. Delegate oral care every 4 hours. b. Monitor and record the clients intake. c. Place the client in a high-Fowlers position. d. Remove the inner cannula for cleaning.

ANS: C To promote airway clearance, this client should be placed in a semi- or high-Fowlers position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would like to cancel it. How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.

ANS: C a negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.

A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration

ANS: C, D The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid

A nurse cares for a client with colon cancer who has a new colostomy. The client states, I think it would be helpful to talk with someone who has had a similar experience. How should the nurse respond? a. I have a good friend with a colostomy who would be willing to talk with you. b. The enterostomal therapist will be able to answer all of your questions. c. I will make a referral to the United Ostomy Associations of America. d. Youll find that most people with colostomies dont want to talk about them.

ANS: CNurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the clients request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

A nurse cares for a teenage girl with a new ileostomy. The client states, I cannot go to prom with an ostomy. How should the nurse respond? a. Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance. b. The pouch wont be as noticeable if you avoid broccoli and carbonated drinks prior to the prom c. Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles. d. You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable.

ANS: CThe ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

A nurse cares for a client who has a family history of colon cancer. The client states, My father and my brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond? a. If you eat a low-fat and low-fiber diet, your chances decrease significantly. b. You are safe. This is an autosomal dominant disorder that skips generations. c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer. d. You should have a colonoscopy more frequently to identify abnormal polyps early.

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the clients diet, preemptive chemotherapy, and removal of polyps will decrease the clients risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet.

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

D

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will begin sitting in a chair at the bedside on the first postoperative day. b. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. c. An additional surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. The site where the stoma will be located will be marked on the abdomen preoperatively.

D

3. When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency.

D- The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption