NCLEX Review Quiz 4 Saunder's Questions (Ch. 39, 40, 54-57)

411. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

1 Celiac disease also is known as gluten enteropathy or celiac sprue and refers to an intolerance to gluten, the protein component of wheat, barley, rye, and oats. The important factor to remember is that all wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements - especially the fat-soluble vitamins, iron, and folic acid - may be needed to correct deficiencies. Dietary restrictions are likely to be lifelong.

638. The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? 1. Protruding stoma 2. Sunken and hidden stoma 3. Narrowed and flattened stoma 4. Dark and bluish-colored stoma

1 A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.

639. A client has a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. Which is the correct interpretation by the nurse? 1. This is a normal, expected event 2. The client is experiencing early signs of ischemic bowel 3. The client should not have the nasogastric tube removed 4. This indicates inadequate preoperative bowel preparation

1 As peristalsis returns following creation of a colostomy, the chest begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect

607. The community health nurse visits a client at home. Prednisone, 10 mg orally daily, has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? 1. "I can take aspirin or my antihistamine if I need it" 2. "I need to take the medication every day at the same time" 3. "I need to avoid coffee, tea, cola, and chocolate in my diet" 4. "If I gain more than 5 pounds a week, I will call my health care provider"

1 Aspirin and other over the counter medications should not be taken unless the client consults with the HCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected, but after the dosage is stabilized, a weight gain of 5 pounds or more weekly should be reported to the HCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

635. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammnoia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet

1 Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the GI tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed.

578. The nurse is monitoring a client newly diagnosed with DM for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? 1. Polyuria 2. Diaphoresis 3. Hypertension 4. Increased pulse rate

1 Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Options 2, 3, and 4 are not signs of hyperglycemia.

633. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stool constantly oozing from the rectum

1 Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 to 5 stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.

587. The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? 1. Laryngeal stridor 2. Abdominal cramps 3. Difficulty in voiding 4. Mild to moderate incisional pain

1 During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration; stridor is caused by compression of the trachea, leading to respiratory distress. Stridor is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway. Options 2, 3 and 4 do not identify signs of a life-threatening complication.

642. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

1 Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

604. The HCP prescribed exenatide for a client with type 1 DM who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP, questioning the prescription for the client 2. Administer the medication within 60 minutes before the morning and evening meal 3. Monitor the client for GI side effects after administering the medication 4. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration

1 Exenatide (Byetta) is an incretin mimetic used for type 2 DM only. It is not recommended for clients taking insulin. Hence, the nurse should withhold the medication and question the HCP regarding this prescription. Although options 2 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

626. The HCP has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

1 Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

621. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort

1 Hepatitis causes GI symptoms such as anorexia, nausea, right upper quadrant discomfort and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

617. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is sceduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? 1. Notify the HCP 2. Administer the prescribed pain medication 3. Call and ask the operating room team to perform the surgery as soon as possible 4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

1 On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.

596. The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

1 Pheochromocytoma is a catecholamine-producing tumor. HTN is the hallmark of pheochromocytoma. Severe HTN can precipitate a stroke or sudden blindness. Although all the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the BP.

616. A client with DM visits a health care clinic. The client's DM previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dl. Which medication if added to the client's regimen, may have contributed to the hyperglycemia? 1. Prednisone 2. Phenelzine 3. Atenolol 4. Allopurinol

1 Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a monoamine oxidase inhibitor, and option 3, a beta-blocker, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

623. The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1, 2, 3, 5 Foods that decrease lower esophagela sphincter pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.

580. The home health nurse visits a client with a diagnosis of type I DM. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin" 2. "I need to increase my fluid intake" 3. "I need to monitor my blood glucose every 3-4 hours" 4. "I need to call the HCP because of these symptoms"

1 When a client with DM is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client shold consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones.

602. Glimepiride is prescribed for a client with DM. The nurse instructs the client to avoid consuming which food while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages

1 When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided.

600. The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into each vial

1 When preparing a mixture of short-acting insulin suc as regular insulin with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3 and 4 identify correct actions for preparing NPH and short-acting insulin

637. A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Consuming small, frequent, bland meals 3. Raising the head of the bed on 6-inch blocks 4. Taking H2-receptor antagonist medication

1 Hiatal hernial is caused by protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2 receptor antagonists and antacids, and elevation of the thorax following meals and during sleep.

606. The home health care nurse is visiting a client who was recently diagnosed with type 2 DM. The client is prescribed repaglinide and metformin and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply. 1. Diarrhea may occur secondary to the metformin 2. The repaglinide is not taken if a meal is skipped 3. The repaglinide is taken 30 minutes before eating 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes 5. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide 6. Muscle pain is an expected effect of metformin and may be treated with acetaminophen

1, 2, 3, 4 Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants HCP notification, not the use of acetaminophen.

632. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which intervention would the nurse expect to be prescribed for the client? Select all that apply. 1. Administer antacids as prescribed 2. Encourage coughing and deep breathing 3. Administer anticholinergics as prescribed 4. Give small, frequent high-calorie feedings 5. Maintain the client in a supine and flat position 6. Give meperidine as prescribed for pain

1, 2, 3, 6 The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

599. A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1, 2, 4, 5 Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia.

413. Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet 2. Teaching the child effective hand-washing techniques 3. Scheduling playtime in the playroom with other children 4. Notifying the HCP if jaundice is present 5. Instructing the parents to avoid administration of medications unless prescribed 6. Arranging for indefinite home schooling because the child will not be able to return to school

1, 2, 5 Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications can become dangerous owing to the liver's inability to detoxify and excrete them. Hand-washing is the most effective measure for control of hepatitis in any setting, and effective hand-washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

609. The nurse is monitoring a client receiving levothyroxine for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance

1, 2, 5 Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine. Bradycardia and constipation are not side effects associated with this medication and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

605. A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1. Hypoglycemia may be experienced before dinnertime 2. The insulin dose should be decreased if illness occurs 3. The insulin should be administered at room temperature 4. The insulin vial needs to be shaken vigorously to break up the precipitates 5. The NPH insulin should be drawn into the syringe first, then the regular insulin

1, 3 Humulin NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 0.5 hours, it peaks in 2 to 5.5 hours, and its duration is 5 to 8 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.

608. A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply. 1. Administer methimazole with food 2. Place the client on a low-calorie, low-protein diet 3. Assess the client for unexplained bruising or bleeding 4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches 5. Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration

1, 3, 4 Common side effects of methimazole include nausea, vomiting, and diarrhea. To address these side effects, this medication should be taken with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high calorie diet. Antithyroid medications can cause agranulocytosis and the HCP should be notified immediately. Methimazole is not radioactive and should not be stopped abruptly, due to the risk of thyroid storm.

589. The nurse is monitoring a client who was diagnosed with type 1 DM and is being treated with NPH and regular insulin. Which client complaint(s) would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

1, 3, 4 Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the signs of hypoglycemia. In hypoglycemia, usually the client feels hunger.

622. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed 2. Instruct the client to limit fluid intake to avoid urinary retention 3. Instruct the client to avoid activities that will initiate vasovagal responses 4. Encourage a high-fiber diet to promote bowel movements without straining 5. Apply cold packs to the anal-rectal area over the dressing until the packing is removed 6. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

1, 4, 5 Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and increase bleeding. Options 2, 3, and 6 are incorrect interventions.

594. The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1. "I will need to limit the amount of protein in my diet" 2. "I should eat foods that have a lot of potassium in them" 3. "I am fortunate that I can eat all the salty food I enjoy" 4. "I am fortunate that I do not need to follow any special diet"

2 A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and HTN, control of hypokalemia, and rebuilding of wasted tissue.

581. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed 2. Test the drainage for glucose 3. Obtain a culture of the drainage 4. Continue to observe the drainage

2 After hypophysectomy, the client sould be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

620. A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat 2. Increase intake of fluids, including juices 3. Eat a good supper when anorexia is not as severe 4. Eat less often, preferably only three large meals daily

2 Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500-3000 mL/day that includes nutritional juices is also important.

579. The nurse is preparing a plan of care for a client with DM who has hyperglycemia. The nurse places highest priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

2 An increased blood glucos level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the subject of the question.

627. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2 Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading tot he loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, and E deficiency.

595. The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of DM and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? 1. Call a code to obtain needed assistance immediately 2. Obtain a capillary blood glucose level and perform a focused assessment 3. Ask the unlicensed assistive personnel to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat 4. Stay with the client and ask the UAP to call the health care provider for a prescription for intravenous 50% dextrose

2 Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client's change on condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the unlicensed assistive personnel to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

611. The nurse provides medication instructions to a client who is taking levothyroxine and should tell the client to notify the HCP if which problem occurs? 1. Fatigue 2. Tremors 3. Cold intolerance 4. Excessively dry skin

2 Excessive doses of levothyroxine can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. The client should be instructed to notify the HCP if these occur. Options 1, 3, and 4 are signs of hypothyroidism.

586. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain

2 Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Options 1, 3 and 4 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

410. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

2 In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration including a decrease in urine output.

601. The home care nurse visits a client recently diagnosed with DM who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? 1. Freeze the insulin 2. Refrigerate the insulin 3. Store the insulin in a dark, dry place 4. Keep the insulin at room temperature

2 Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.

650. A client has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation

2 Omeprazole (Prilosec) is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

399. A mother brings her 3 week old infant to a clinic for a phenylketonuria rescreening blood test, The test indicates a serum phenylalanine level of 1 mg/dL. The nurse reviews this result and makes which interpretation? 1. It is positive 2. It is negative 3. It is inconclusive 4. It requires rescreening at the age of 6 weeks

2 Phenylketonuria is a genetic (autosomal recessive) disorder that results in CNS damage from toxic levels of phenylalanine (an essential AA) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (normal level is 1.2-3.4 mg/dL in newborns and 0.8-1.8 thereafter). A result of 1 mg/dL is a negative result.

612. The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition? 1. Myxedema 2. Graves' disease 3. Addison's disease 4. Cushing's syndrome

2 Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

575. A client with DM demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? 1. Administer a sedative 2. Convey empathy, trust, and respect toward the client 3. Ignore the signs and symptoms of anxiety so that they will soon disappear 4. Make sure that the client knows all the correct medical terms to understand what is happening

2 The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

649. A client who chronically uses NSAIDs has been taking misoprostol. The nurse determines that the medication is having the intended therapeutic effect if which finding is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count

2 The client who chronically uses NSAIDs is prone to gastric mucosal injury. Misoprostol (Cytotec) is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of this medication but is not an intended effect. Options 3 and 4 are incorrect.

583. A client is admitted to an emergency department and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? 1. Warm the client 2. Maintain a patent airway 3. Administer thyroid hormone 4. Administer fluid replacement

2 The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

618. A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin

2 The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.

643. A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed

2 The principle manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.

574. The nurse teaches a client with DM about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2, 3, 5 Shakiness, palpitations, and lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are signs of hyperglycemia.

614. A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication? 1. At noon 2. At bedtime 3. Early mornings 4. Any time at the same time, each day

3 Corticosteroids (glucocorticoids) should be administered before 9AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally be the adrenal glands each morning. Options 1, 2, and 4 are incorrect.

641. The nurse is doing preoperative teaching with a client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement? 1. "I will be able to pass stool by the rectum eventually" 2. "The drainage from this type of ostomy will be formed" 3. "I will need to drain the pouch regularly with a catheter" 4. "I will need to wear a drainage bag for the rest of my life"

3 A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bad but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool from the rectum only if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

405. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? 1. Prone position 2. On the stomach 3. Left lateral position 4. Right lateral position

3 A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.

636. The nurse us doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for for which symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm

3 A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

585. A client with type I DM calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH and exercise? 1. "The best time for me to exercise is after I eat" 2. "The best time for me to exercise is after breakfast" 3. "The best time for me to exercise is mid- to late afternoon" 4. "The best time for me to exercise is after my morning snack"

3 A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 1, 2, and 4 do not address peak action times.

592. The nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting blood glucose level of 120 mg/dl, temperature of 101F, pulse of 88 beats/minute, respirations of 22 breaths/minute, and blood pressure of 100/72 mm Hg. Which finding would be of most concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

3 An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemia hyperosmolar nonketotic syndrome or DKA. The other findings noted in the question are within normal limits.

634. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot 2. Measure the abdominal girth 3. Moderate-fate diet 4. High carbohydrate diet

3 Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

647. An older client recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations

3 Cimetidine (Tagamet) is a histamine H2-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

582. After several diagnostic tests, a client is diagnosed with DI. The nurse performs an assessment on the client, knowing that which symptoms is most indicative of this disorder? 1. Fatigue 2. Diarrhea 3. Polydipsia 4. Weight gain

3 DI is characterized by hyposecretion of ADH, and the kidney tubules fail to reabsorb water. Polydispsia and polyuria are classic symptoms of DI. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur. Option 1 is a vague symptom. Option 2 and 4 are not specific to this disorder.

613. The nurse is instructing a client regarding intranasal desmopressin. The nurse should tell the client that which occurrence is a side effect of the medication? 1. Headache 2. Vulval pain 3. Runny nose 4. Flushed skin

3 Desmopressin administered by the intranasal route can cause a runny nose. Options 1, 2, and 4 are side effects if the medication is administered by the intravenous route.

631. The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal 2. Eat high-carbohydrate foods 3. Limit the fluids taken with meals 4. Sit in a high fowler's position during meals

3 Dumping syndrome is a term refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed

577. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dl. A continuous intravenous infusion of short-acting insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dl. The nurse would next prepare to administer which item? 1. Ampule of 50% dextrose 2. NPH insulin subcutaneously 3. Intravenous fluids containing dextrose 4. Phenytoin (Dilantin) for the prevention of seizures

3 During management of DKA, when the blood glucose level falls to 250 - 300 mg/dl, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin (DIlantin) is not a usual treatment measure for DKA.

628. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T tube 2. Irrigate the T tube 3. Document the findings 4. Notify the HCP

3 Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml/day. The nurse would document the output.

615. Prednisone is prescribed for a client with DM who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with the prednisone? 1. An additional dose of prednisone daily 2. A decreased amount of daily Humulin NPH insulin 3. An increased amount of daily Humulin NPH insulin 4. The addition of an oral hypoglycemic medication daily

3 Glucocorticoids can elevate blood glucose levels. Clients with DM may need their dosages of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. Therefore, options 1, 2, and 4 are incorrect.

409. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? 1. Bile-stained fecal emesis 2. The passage of currant jelly-like stools 3. Failure to pass meconium stool in the first 24 hrs after birth 4. Sausage-shaped mass palpated in the upper right abdominal quadrant

3 Imperforate anus is the incomplete development of absence of the anus in its normal position in the perineum. During the newborn assessment, this defect should be identified easily on sight. A rectal thermometer or tube may be necessary, however to determine patency if meconium is not passed in the first 24 hrs after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options 1, 2, and 4 are findings noted in intussusception.

630. The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

3 In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the HCP. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

406. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

3 In esophageal atresia and tracheoesophageal fistula, the esophagus terminated before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the 3 C's (coughing, choking with feedings, and unexplained cyanosis) should be suspected to have tracheoesophageal fistula. Options 1, 2, and 4 are not specifically associated with tracheoesophageal fistula.

644. A client has a PRN prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage

3 Loperamide (Imodium) is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.

610. The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication at which time? 1. With food 2. At lunch time 3. On an empty stomach 4. At bedtime with a snack

3 Oral doses of levothyroxine should be take on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast.

646. A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain

3 Pancrelipase (Pancrease, Creon) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.

603. Sildenafil is prescribed to treat a client with erectile dysfunction. The nurse reviews the client's medical record and should question the prescription if which data is noted in the client's history? 1. Insomnia 2. Neuralgia 3. Use of nitroglycerin 4. Use of multivitamins

3 Sildenafil (Viagra) enhances the vasodilating effects of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Sildenafil is not contraindicated with the use of vitamins. Insomnia and neuralgia are side effects of the medication.

625. The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form" 2. "I hope the throat spray keeps me from gagging" 3. "I'm glad I don;t have to lie still for this procedure" 4. "I'm glad some IV medication will be given to relax me"

3 The client does have t lie still for endoscopic retrograde cholangiopancreatography, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

571. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketonic syndrome is made. The nurse would immediately prepare to initiate which anticipated HCP prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

3 The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS.

598. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

3 Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status as any swelling to the surgical site could cause respiratory distress. Although all the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.

651. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and moxicillin. Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria" 2. "These medications are only taken when I have pain from my ulcer" 3. "The medication will kill the bacteria and stop the acid production" 4. "These medications will coat the ulcer and decrease the acid production in my stomach"

3 Triple therapy for Helicobacter pylori infection usually includes two antibacterial medications and a proton pump inhibitor. Clarithromycin (Biaxin) and amoxicillin (Amoxil) are antibacterials. Esomeprazole (Nexium) is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

408. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problems? 1. Diarrhea 2. Metabolic acidosis 3. Metabolic alkalosis 4. Hyperactive bowel sounds

3 Vomiting causes the loss of HCl and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might/might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

396. The mother of a 6 y/o child has type I DM calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin 2. Come to the clinic immediately 3. Encourage the child to drink liquids 4. Administer an additional dose of regular insulin

3 When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

597. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3, 4, 5, 6 Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.

573. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level 6. Low plasma bicarbonate level

3, 5, 6 In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dl, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul's respirations (deep and regular breathing pattern) would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.

403. The nurse should implement which interventions for a child older than 2 years with type I DM who has a blood glucose level of 60 mg/dL. Select all that apply. 1. Administer regular insulin 2. Encourage the child to ambulate 3. Give the child a teaspoon of honey 4. Provide electrolyte replacement therapy intravenously 5. Wait 30 minutes and confirm the blood glucose reading 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs

3, 6 Hypoglycemia is defined as a blood glucose level <70 mg/dl. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose lvl is retested in 15 mins; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy IV is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

640. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance

4 A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the post operative period.

401. The nurse has just administered ibuprofen to a child with a temperature of 38.8C (102F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours 2. Sponge the child with cold water 3. Plan to administer salicylate (aspirin) in 4 hours 4. Remove excess clothing and blankets from the child

4 After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

572. An external insulin pump is prescribed for a client with DM and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? 1. Is timed to release programmed doses of short-duration or NPH insulin into the blood stream at specific intervals 2. Continuously infuses small amounts of NPH insulin into the blood stream while regularly monitoring blood glucose levels 3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

4 An insulin pump provides a small continuous dose of short duration (rapid or short-acting) insulin subcutaneously throughout the day and night, and the client can self administer a bolus with an additional dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

593. The nurse is interviewing a client with type 2 DM. Which statement by the client indicates an understanding of the treatment for this disorder? 1. "I take oral insulin instead of shots" 2. "By taking these medications, I am able to eat more" 3. "When I become ill, I need to increase the number of pills I take" 4. "The medications I'm taking help release the insulin I already make"

4 Clients with type 2 DM have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of insulin by digestion. Options 1, 2, and 3 are incorrect.

591. The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease results from an oversecretion of insulin" 2. "Cushing's disease results from an undersecretion of corticotropic hormones" 3. "Cushing's disease results from an undersecretion of mineralocorticoid hormones" 4. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone"

4 Cushing's disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison's disease is characterized by the hyposecretion of adrenal cortex hormones (glucocorticoids and mineralcorticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones. Options 1, 2, and 3 are inaccurate regarding Cushing's disease.

400. A child with type I DM is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of IV infusion? 1. Potassium infusion 2. NPH infusion 3. 5% dextrose infusion 4. Normal saline infusion

4 Diabetic ketoacidosis is a complication for DM that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the K level, but would not be part of the initial Tx.

398. An adolescent client with type I DM is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

4 Diabetic ketoacidosis is a complication for DM that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing LOC. Hunger can be a sign of hypoglycemia or hyperglycemia, but HTN is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood vol related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

619. The nurse us assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of pain? 1. Right lower quadrant, radiating to the back 2. Right lower quadrant, radiating to the umbilicus 3. Right upper quadrant, radiating to the left scapula and shoulder 4. Right upper quadrant, radiating to the right scapula and shoulder

4 During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect.

576. The nurse provides instructions to a client newly diagnosed with type I DM. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat" 2/ "I will decrease my insulin dose during times of illness" 3. "I will adjust my insulin dose according to the level of glucose in my urine" 4. "I will notify my HCP if my blood glucose level is higher than 250 mg/dl"

4 During illness, the client should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dl. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should ot be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings.

407. The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? 1. Provide less frequent, larger feedings 2. Burp the infant less frequently during feedings 3. Thin the feedings by adding water to the formula 4. Thicken the feedings by adding rice cereal to the formula

4 Gastroesophageal reflux is a backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required.

404. The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected HIrschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptoms most likely led the mother to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. Regurgitation of feedings 4. Foul-smelling ribbon-like stools

4 Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other area of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.

395. A school-age child with type 1 DM has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1. Eat twice the amount of normally eaten at lunchtime 2. Take half the amount of prescribed insulin on practice 3. Take the prescribed insulin at noontime rather than in the morning 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice

4 Hypoglycemia is a blood glucose level less than 70 mg/dL and results from too much insulin, not enough food, or excessive activity. An extra snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice would prevent hypoglycemia. A small box of raisins or a cup of orange juice provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to adjust the amount of time of insulin administration. Meal amounts should not be doubled.

397. A health care provider prescribes an intravenous solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtain a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4 In hypotonic dehydration, electrolyte loss exceeds water loss. The primary assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, KCl should not be administered. Although options 1, 2, and 3 are appropriate for a child with dehydration, these assessments are not related specifically to the IV administration of KCl.

402. A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears 2. Urine specific gravity is 1.030 3. Urine output is less than 1 mL/kg/hour 4. Capillary refill is less than 2 seconds

4 Indicators that fluid vol deficit is resolving would be capillary refill < 2 secs, specific gravity of 1.002-1.025, urine output of at least 1 mg/kg/hr, and adequate tear production. A cap refill <2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hr, a specific gravity of 1.030 and no tears would indicate that the deficit is not resolving.

412. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom if this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stool

4 Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder

584. The nurse is caring for a client admitted tot he emergency department with diabetic ketoacidosis. In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis 2. Administer 5% dextrose intravenously 3. Apply a monitor for an electrocardiogram 4. Administer short-duration insulin intravenously

4 Lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (short or rapid-acting), intravenous fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not the priority action.

645. A client has a PRN prescription for ondansetron. For which condition should the nurse administer this medication to the postoperative client? 1. Paralytic ileus 2. Incisional pain 3. Urinary retention 4. Nausea and vomiting

4 Ondansetron (Zofran) is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect.

629. The nurse is monitoring a client with a diagnosis of peptic ulcer. which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, boardlike abdomen

4 Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mild-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

588. A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic? 1. Caused profound hypotension 2. Is manifested by severe hypoglycemia 3. Is not curable and is treated symptomatically 4. Causes the release of excessive amounts of catecholamines

4 Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. HTN is the prinicple manifestation and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral.

648. A client with a gastric ulcer has a prescription for sucralfate 1 g by mouth four times daily. The nurse should schedule the medication for which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime

4 Sucralfate (Carafate) is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.

590. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A coagulation time of 5 minutes 2. A urinary output of 50 mL/hr 3. A blood urea nitrogen level of 20 mg/dL 4. A heart rate that is 90 beats/minute and irregular

4 The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hr is an adequate output. A blood urea nitrogen level of 20 mg/dl is a normal finding.

624. A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex

4 The nurse places highest priority on assessing the return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the GI tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for a sore throat and heartburn are also important; however, the client's airway is the priority.