nur 290 exam 4 practice Qs
the nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). which statement(s) by the client indicates effective knowledge of the procedure? SATA. a. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating" b. "it is likely that I will need to receive nutrition directly into my veins" c. "one of my nerves, the vagus nerve, may be cut during the surgery" d. "I can eat a normal diet again after 3 to 5 weeks" e. "this surgery will remove part of my stomach and colon"
A. "I WILL BE AT RISK OF DEVELOPING DIARRHEA, NAUSEA, AND FEELING LIGHT-HEADED AFTER EATING" C. "ONE OF MY NERVES, THE VAGUS NERVE, MAY BE CUT DURING THE SURGERY"
A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? a. "make sure you don't bring your knees close together" b. "try to lie as still as possible for the first few days" c. "try to avoid bending your knees until next week" d. "keep your legs higher than your chest whenever you can"
A. "MAKE SURE YOU DON'T BRING YOUR KNEES CLOSE TOGETHER"
a client comes to the clinic reporting pain in the epigastric region. what statement by the client is specific to the presence of a duodenal ulcer? a. "my pain resolves when I have something to eat" b. "the pain begins right after I eat" c. "I know that my father and grandfather both had ulcers" d. "I seem to have bowel movements more often than I usually do"
A. "MY PAIN RESOLVES WHEN I HAVE SOMETHING TO EAT"
a client is undergoing diagnostic testing to determine the etiology of recent joint pain. the client asks the nurse about the different between osteoarthritis (OA) and rheumatoid arthritis (RA). what is the best response by the nurse? a. "OA is considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints" b. "OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the larger, weight-bearing joints like the knees" c. "OA originates with an infection. RA is a result of your body's cells attacking one another" d. "OA is associated with impaired immune function; RA is a consequence of physical damage"
A. "OA IS CONSIDERED A NONINFLAMMATORY JOINT DISEASE. RA IS CHARACTERIZED BY INFLAMED, SWOLLEN JOINTS"
a client with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on a medical unit. the nurse observes that the client expresses anger and irritation when the call bell isn't answered immediately. which response would be the most appropriate? a. "you seem like you're feeling angry. is that something that we could talk about?" b. "try to remember that stress can make your symptoms worse" c. "would you like to talk about the problem with the nursing supervisor?" d. "I can see you're angry. I'll come back when you've calmed down"
A. "YOU SEEM LIKE YOU'RE FEELING ANGRY. IS THAT SOMETHING THAT WE COULD TALK ABOUT?"
a client has come to the clinic reporting pain just above her umbilicus. when assessing the client, the nurse notes sister Mary Joseph nodules. the nurse should refer the client to the primary provider to be assessed for what health problem? a. a GI malignancy b. dumping syndrome c. peptic ulcer disease d. esophageal/gastric obstruction
A. A GI MALIGNANCY
the nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. which of the following would most likely be included in the client's medication regimen? a. antidiarrheal medications 30 minutes before a meal b. antiemetics on a PRN basis c. vitamin b12 injections to prevent pernicious anemia d. beta adrenergic blockers to reduce bowel motility
A. ANTIDIARRHEAL MEDICATIONS 30 MINUTES BEFORE A MEAL
a client has a diagnosis of rheumatoid arthritis, and the primary provider has now prescribed cyclophosphamide. the nurse's subsequent assessments should address which potential adverse effect? a. bone marrow suppression b. acute confusion c. sedation d. malignant hyperthermia
A. BONE MARROW SUPPRESSION
the nurse is administering total parenteral nutrition to a client who underwent surgery for gastric cancer. which of the nurse's assessments most directly addresses a major complication of TPN? a. checking the client's capillary blood glucose levels regularly b. having the client frequently rate his or her hunger on a 10 point scale c. measuring the client's heart rhythm at least every 6 hours d. monitoring the client's level of consciousness after each shift
A. CHECKING THE CLIENT'S CAPILLARY BLOOD GLUCOSE LEVELS REGULARLY
a client with gastric cancer has been scheduled for a total gastrectomy. during the preoperative assessment, the client confides in the nurse feeling the surgery will "mutilate" the client's body. the nurse should plan interventions that address what nursing diagnosis? a. disturbed body image b. deficient knowledge related to the risks of surgery c. anxiety about the surgery d. low self-esteem
A. DISTURBED BODY IMAGE
during a health education session, a participant has asked about the hepatitis E virus. what prevention measure should the nurse recommend for preventing infection with this virus? a. following proper hand-washing techniques b. avoiding chemicals that are toxic to the liver c. wearing a condom during sexual contact d. limiting alcohol intake
A. FOLLOWING PROPER HAND-WASHING TECHNIQUES
a nurse is presenting an educational event to a local community group. when speaking about colorectal cancer, what risk factor should the nurse cite? a. high levels of alcohol consumption b. history of bowel obstruction c. history of diverticulitis d. long-standing psychosocial stress
A. HIGH LEVELS OF ALCOHOL CONSUMPTION
a nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. what preventative measures should the nurse educator promote? SATA. a. immunization b. use of standard precautions c. consumption of a vitamin-rich diet d. annual vitamin K injections e. annual vitamin b12 injections
A. IMMUNIZATION B. USE OF STANDARD PRECAUTIONS
a client is admitted to the medical unit with a diagnosis of intestinal obstruction. when planning this client's care, which of the following nursing diagnoses should the nurse prioritize? a. ineffective tissue perfusion related to bowel ischemia b. imbalanced nutrition: less than body requirements related to impaired absorption c. anxiety related to bowel obstruction and subsequent hospitalization d. impaired skin integrity related to bowel obstruction
A. INEFFECTIVE TISSUE PERFUSION RELATED TO BOWEL ISCHEMIA
a client presents to the clinic reporting vomiting and burning in the mid-epigastria. the nurse knows that in the process of confirming peptic ulcer disease, the healthcare provider is likely to order a diagnostic test to detect the presence of what? a. infection with helicobacter pylori b. excessive stomach acid secretion c. an incompetent pyloric sphincter d. a metabolic acid-base imbalance
A. INFECTION WITH HELICOBACTER PYLORI
a nurse is preparing to place a client's prescribed nasogastric tube. what anticipatory guidance should the nurse provide to the client? a. insertion is likely to cause some gagging b. insertion will cause some short-term pain c. a narrow-gauge tube will be inserted before being replaced with a larger-gauge tube d. topical anesthetics will be used to reduce discomfort during insertion
A. INSERTION IS LIKELY TO CAUSE SOME GAGGING
a 35 year old client presents at the emergency department with symptoms of a small bowel obstruction. in collaboration with the primary care provider, what intervention should the nurse prioritize? a. insertion of a nasogastric tube b. insertion of a central venous catheter c. administration of a mineral oil enema d. administration of a glycerin suppository and an oral laxative
A. INSERTION OF A NASOGASTRIC TUBE
a client has a gastronomy tube that has been placed to drain stomach contents by low intermittent suction. what is the nurse's priority during this aspect of the client's care? a. measure and record drainage b. monitor drainage for change in color c. titrate the suction every hour d. feed the client via the G tube as prescribed
A. MEASURE AND RECORD DRAINAGE
a client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. the nurse should anticipate that the client may be prescribed what drug? a. metoclopramide b. omeprazole c. lansoprazole d. calcium carbonate
A. METOCLOPRAMIDE
a nurse is caring for a client in the late stages of esophageal cancer. the nurse should plan to prevent or address what characteristic(s) of this stage of the disease? SATA. a. perforation into the mediastinum b. development of an esophageal lesion c. erosion into the great vessels d. painful swallowing e. obstruction of the esophagus
A. PERFORATION INTO THE MEDIASTINUM C. EROSION INTO THE GREAT VESSELS E. OBSTRUCTION OF THE ESOPHAGUS
diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. the nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? a. peritonitis b. gastritis c. gastroesophageal reflux d. acute pancreatitis
A. PERITONITIS
a nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. how should the nurse position the client? a. place a pillow between the legs b. turn the client on the surgical side c. avoid flexion of the right hip d. keep the right hip abducted at all times
A. PLACE A PILLOW BETWEEN THE LEGS
a client is involved in a motorcycle accident and injures an arm. the health care provider diagnoses the man with an intra-articular fracture and splints the injury. the nurse implements the teaching plan developed for this client. what sequela of intra-articular fractures should the nurse describe regarding this client? a. posttraumatic arthritis b. fat embolism syndrome (FES) c. osteomyelitis d. compartment syndrome
A. POSTTRAUMATIC ARTHRITIS
a client was fitted with an arm cast after fracturing the humerus. twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. analgesics do not relieve the pain. what would be the most appropriate nursing action? a. prepare the client for opening or bivalving of the cast b. obtain a prescription for a different analgesic c. encourage the client to wiggle and move the fingers d. petal the edges of the client's cast
A. PREPARE THE CLIENT FOR OPENING OR BIVALVING OF THE CAST
a client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. this client has been diagnosed with which health problem? a. rheumatoid arthritis (RA) b. systemic lupus erythematosus (SLE) c. osteoporosis d. polymyositis
A. RHEUMATOID ARTHRITIS (RA)
a nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. the nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? a. risk for infection b. risk for ineffective role performance c. risk for preoperative positioning injury d. risk for powerlessness
A. RISK FOR INFECTION
a client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? a. the client will be monitored closely to detect malignant changes b. liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage c. small amounts of blood are likely to be present in the stools and are not cause for concern d. antacids may be discontinued when symptoms of heartburn subside
A. THE CLIENT WILL BE MONITORED CLOSELY TO DETECT MALIGNANT CHANGES
a nurse is caring for a 78 year old client with a history of osteoarthritis (OA). when planning the patient's care, what goal should the nurse prioritize? a. the client will express satisfaction with the ability to perform ADLs b. the client will recover from OA within 6 months. c. the client will adhere to the prescribed plan of care d. the client will deny signs or symptoms of OA
A. THE CLIENT WILL EXPRESS SATISFACTION WITH ABILITY TO PERFORM ADLS
diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. the nurse's anticipatory guidance should include what information? a. the possibility of surgery, chemotherapy, and radiotherapy b. the possibility of needing a short-term or long-term colostomy c. the benefits of weight loss and exercise as tolerated during recovery d. the good prognosis for clients who are treated for gastric cancer
A. THE POSSIBILITY OF SURGERY, CHEMOTHERAPY, AND RADIOTHERAPY
a client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. the client's current medication regimen includes lactulose four times daily. what desired outcome should the nurse relate to this pharmacologic intervention? a. two to three soft bowel movements daily b. significant increase in appetite and food intake c. absence of nausea and vomiting d. absence of blood or mucus in stool
A. TWO TO THREE SOFT BOWEL MOVEMENTS DAILY
a nurse is providing care for a client who has just been diagnosed with early-stage rheumatoid arthritis (RA). the nurse should anticipate the administration of which medication? a. hydromorphone b. methotrexate c. allopurinol d. prednisone
B. METHOTREXATE
a client with a right tibial fracture is being discharged home after having a cast applied. what instruction should the nurse provide in relationship to the client's cast care? a. "cover the cast with a blanket until the cast dries" b. "keep your right leg elevated above heart level" c. "use a clean object to scratch itches inside the cast" d. "a foul smell from the cast is normal after the first few days"
B. "KEEP YOUR RIGHT LEG ELEVATED ABOVE HEART FAILURES"
what health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? a. finish all prescribed courses of antibiotics, regardless of symptom resolution b. adhere to dosing recommendations of over-the-counter antibiotics c. ensure that expired medications are disposed of safely d. ensure that pharmacists regularly review drug regimens for potential interactions
B. ADHERE TO DOSING RECOMMENDATIONS OF OVER-THE-COUNTER ANTIBIOTICS
the nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. what are these nursing actions attempting to prevent? a. gastric ulcers b. aspiration c. abdominal distention d. diarrhea
B. ASPIRATION
a nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. what assessment should the nurse prioritize in this client's plan of care? a. measurement of abdominal girth and body weight b. assessment for variceal bleeding c. assessment for signs and symptoms of jaundice d. monitoring of results of liver function testing
B. ASSESSMENT FOR VARICEAL BLEEDING
a client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. the nurse has attempted to aspirate with a large-bore syringe, with no success. what should the nurse do next? a. withdraw the NG tube 2 inches (5 cm) and reattempt aspiration b. attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating c. withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers d. remove the NG tube promptly and obtain an order for reinsertion from the primary care provider
B. ATTACH A SYRINGE FILLED WITH WARM WATER AND ATTEMPT AN IN-AND-OUT MOTION OF INSTILLING AND ASPIRATING
an older client has fallen int eh home and is brought to the emergency department by ambulance with a suspected fractured hip. x-rays confirm a fracture of the left femoral neck. when planning assessments during the client's pre surgical care, the nurse should be aware of the client's heightened risk of what complication? a. osteomyelitis b. avascular necrosis c. phantom pain d. septicemia
B. AVASCULAR NECROSIS
a nurse is caring for an older adult client who is preparing for discharge following recovery from a total hop replacement. what outcome must be met prior to discharge? a. client is able to perform ADLs independently b. client is able to perform transfers safely c. client is able to weight bear equally on both legs d. client is able to demonstrate full ROM on the affected hip
B. CLIENT IS ABLE TO PERFORM TRANSFERS SAFELY
Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture? A. Open B. Comminuted C. Intra-articular D. Greenstick
B. COMMINUTED
a nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. the orthopedic nurse should plan to care for what type of fracture? a. compression b. compound c. impacted d. transverse
B. COMPOUND
a client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. the nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. what is the nurse's best response? a. administer a fleet enema as prescribed and remain with the client b. contact the primary care provider promptly and report these signs of perforation c. position the client supine and insert an NG tube d. page the primary provider and report that the client may be obstructed
B. CONTACT THE PRIMARY CARE PROVIDER PROMPTLY AND REPORT THESE SIGNS OF PERFORATION
the nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. the nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. what is the nurse's best action? a. contact the care provider to have the client's hemoglobin and hematocrit measured b. document these expected assessment findings c. apply barrier ointment to the stoma as prescribed d. cleanse the stoma with alcohol or chlorhexidine
B. DOCUMENT THESE EXPECTED ASSESSMENT FINDINGS
a client has been prescribed cimetidine for the treatment of peptic ulcer disease. when providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? a. bowel incontinence b. drug-drug interaction c. abdominal pain d. heat intolerance
B. DRUG-DRUG INTERACTION
a client with a simple arm fracture is receiving discharge education from the nurse. what would the nurse instruct the client to do? a. elevate the affected extremity to shoulder level when at rest b. engage in exercises that strengthen the unaffected muscles c. apply topical anesthetics to accessible skin surfaces as needed d. avoid using analgesics so that further damage is not masked
B. ENGAGE IN EXERCISES THAT STRENGTHEN THE UNAFFECTED MUSCLES
a nurse is caring for a client who has just been diagnosed with a peptic ulcer. when teaching the client about his new diagnosis, how should the nurse best describe it? a. inflammation of the lining of the stomach b. erosion of the lining of the stomach or intestine c. bleeding from the mucosa in the stomach d. viral invasion of the stomach wall
B. EROSION OF THE LINING OF THE STOMACH OR INTESTINE
a nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus eryhthromatosus (SLE). which skin manifestation would the nurse expect to observe on inspection? a. petechiae b. erythematous rash c. jaundice d. skin sloughing
B. ERYTHEMATOUS RASH
a client with a. diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. the nurse has planned the client's care in the knowledge of potential complications. what assessment should the nurse prioritize? a. close monitoring of temperature b. frequent abdominal auscultation c. assessment of hemoglobin, hematocrit, and red blood cell levels d. palpation of peripheral pulses and leg girth
B. FREQUENT ABDOMINAL AUSCULATION
The orthopedic nurse should assess for signs and symptoms of Volkmann's contracture if a patient has fractured which of the following bones? A) Femur B) Humerus C) Radial head D) Clavicle
B. HUMERUS
an adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. the client will be treated on an outpatient basis. what components of treatment should the nurse anticipate? SATA. a. anticholinergic medications b. increased fiber intake c. enemas on alternating days d. reduced fat intake e. fluid reduction
B. INCREASED FIBER INTAKE D. REDUCED FAT INTAKE
a nurse is assessing a client with peptic ulcer disease. the client requests more information about the typical causes of helicobacter pylori infection. what would it be appropriate for the nurse to instruct the client? a. most affected clients acquired the infection during international travel b. infection typically occurs due to ingestion of contaminated food and water c. many people possess genetic factors causing a predisposition to H. pylori infection d. the h. pylori microorganism is endemic in warm, moist climates
B. INFECTION TYPICALLY OCCURS DUE TO INGESTION OF CONTAMINATED FOOD AND WATER
a nurse is caring for a client who has suffered an unstable thoracolumbar fracture. what goal should the nurse prioritize during nursing care? a. preventing skin breakdown b. maintaining spinal alignment c. maximizing function d. preventing increased intracranial pressure
B. MAINTAINING SPINAL ALIGNMENT
what nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? a. administer analgesics as required b. place a pillow between the client's legs when turning c. maintain prone positioning at all times d. encourage internal and external rotation of the affected leg
B. PLACE A PILLOW BETWEEN THE CLIENT'S LEGS WHEN TURNING
a client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. when taking the health history, the nurse should expect the client to describe what sign or symptom? a. burning pain on swallowing b. regurgitation of undigested food c. symptoms mimicking a myocardial infarction d. chronic parotid abscesses
B. REGURGITATION OF UNDIGESTED FOOD
a nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. the client also reports worsening nausea. what is the nurse's priority action? a. facilitate a referral to the wound-ostomy-continence nurse b. report signs and symptoms of obstruction to the healthcare provider c. encourage the client to mobilize in order to enhance motility d. contact the healthcare provider and obtain a swab of the stoma for culture
B. REPORT SIGNS AND SYMPTOMS OF OBSTRUCTION TO THE HEALTHCARE PROVIDER
a client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually discharged with gout. when planning teaching for this client, what management technique should the nurse emphasize? a. take OTC calcium supplements consistently b. restrict consumption of foods high in purines c. ensure fluid intake of at least 4 L per day d. restrict weight-bearing on right foot
B. RESTRICT CONSUMPTION OF FOODS HIGH IN PURINES
a 16 year old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. when planning this client's nursing care, the nurse should prioritize what nursing diagnosis? a. imbalanced nutrition: less than body requirements related to decreased oral intake b. risk for infection related to possible rupture of appendix c. constipation related to decreased bowel motility and decreased fluid intake d. chronic pain related to appendicitis
B. RISK FOR INFECTION RELATED TO POSSIBLE RUPTURE OF APPENDIX
a nurse is providing care for a client who has a rheumatic disorder. the nurse's focused assessment includes the client's mood, behavior, level of consciousness, and neurologic status. which diagnosis is most likely for this client? a. osteoarthiritis (OA) b. systemic lupus erythematosus (SLE) c. rheumatoid arthritis (RA) d. gout
B. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
a client with a history of peptic ulcer disease has presented to the emergency department in distress. what assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? a. the client has abdominal bloating that developed rapidly b. the client has a rigid, "board-like" abdomen that is tender c. the client is experiencing intense lower right quadrant pain d. the client is experiencing dizziness and confusion with no apparent hemodynamic changes
B. THE CLIENT HAS A RIGID, "BOARD-LIKE" ABDOMEN THAT IS TENDER
a client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the client's level of anxiety. which of the following actions is most likely to accomplish this? a. the nurse gauges the client's response to hypothetical outcomes b. the client is encouraged to express fears openly c. the nurse provides detailed and accurate information about the disease d. the nurse closely observes the client's body language
B. THE CLIENT IS ENCOURAGED TO EXPRESS FEARS OPENLY
a nurse is assessing a client for risk factors known to contribute to osteoarthritis. what assessment finding should the nurse interpret as a risk factor? a. the client has a 30 pack year smoking history b. the client's body mass index is 34 (obese) c. the client has primary hypertension d. the client is 58 years old
B. THE CLIENT'S BODY MASS INDEX IS 34 (OBESE)
a nurse is planning client education for a client being discharged home for a diagnosis of rheumatoid arthritis. the client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect? a. tinnitus b. visual changes c. stomatitis d. hirsutism
B. VISUAL CHANGES
a client with systemic lupus erythematosus (SLE) is preparing for discharge. the nurse knows that the client has understood health education when the client makes what statement? a. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels" b. "I'll try to be as physically active between flare-ups" c. "I'll make sure to monitor my body temperature on a regular basis" d. "I'll stop taking my steroids when I get relief from my symptoms"
C. "I'LL MAKE SURE TO MONITOR MY BODY TEMPERATURE ON A REGULAR BASIS"
the client who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. the client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastronomy tube. what is the nurse's best response? a. "it eliminates the risk for infection" b. "feeds can be infused at a faster rate" c. "regurgitation and aspiration are less likely" d. "it allows caregivers to provide personal hygiene more easily"
C. "REGURGITATION AND ASPIRATION ARE LESS LIKELY"
a client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. which explanation should the nurse give to the client about skeletal traction? a. "skeletal traction temporarily stabilizes the fracture before surgery" b. "weights are attached to the leg using a boot" c. "traction involves passing a pin through the bone" d. "light weights must be used with skeletal traction"
C. "TRACTION INVOLVES PASSING A PIN THROUGH THE BONE"
A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? a. ensure that the client knows that he or she will be responsible for care after discharge b. reassure the client that many people are fearful after the creation of an ostomy c. acknowledge the client's reluctance and initiate discussion of the factors underlying it d. arrange for the client to be seen by a social worker or spiritual advisor
C. ACKNOWLEDGE THE CLIENT'S RELUCTANCE AND INITIATE DISCUSSION OF THE FACTORS UNDERLYING IT
the nurse is administering medications to a client through a feeding tube. which action should the nurse take? a. flush the tube with 5 mL of water before administering medication b. turn the tube feeding off for 1 hour before administering the medication c. administer each medication separately d. flush with 50 mL of water between each medication
C. ADMINISTER EACH MEDICATION SEPARATELY
a client's health history is suggestive of inflammatory bowel disease. which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms. a. a pattern of distinct exacerbations and remissions b. severe diarrhea c. an absence of blood in stool d. involvement of the rectal mucosa
C. AN ABSENCE OF BLOOD IN STOOL
a 68 year old client with a history of rheumatic disease has persistent swelling, no stiffness, and full range of motion to his left knee after an injury sustained several months ago. x-rays reveal no fracture of the extremity. which factor is the most likely cause of this client's continued swelling? a. degradation of cartilage b. aging c. an inflammation process d. reinjury not seen on x-ray results
C. AN INFLAMMATION PROCESS
a client with rheumatoid arthritis comes into the clinic for a routine check-up. on assessment, the nurse notes that the client appears to have lost some ability to function since the last office visit. what is the nurse's most appropriate action? a. arrange a family meeting in order to explore assisted living options b. refer the client to a support group c. arrange for the client to be assessed in the home environment d. refer the client to social work
C. ARRANGE FOR THE CLIENT TO BE ASSESSED IN THE HOME ENVIRONMENT
the nurse is caring for a c client who had a low-profile gastrostomy device placed. which instruction should the nurse give the client and family? a. wear the tubing outside of clothing b. use tape to secure the device c. bring the connection tubing if going to the hospital d. change the wet-to-dry dressing daily
C. BRING THE CONNECTION TUBING IF GOING TO THE HOSPITAL
a client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. the client has been placed in traction until eh femur can be rodded in surgery. for what early complication(s) should the nurse monitor this client? SATA. a. systemic infection b. complex regional pain syndrome c. deep vein thrombosis d. compartment syndrome e. fat embolism
C. DEEP VEIN THROMBOSIS D. COMPARTMENT SYNDROME E. FAT EMBOLISM
a nurse is assessing a client's stoma on postoperative day 3. the nurse notes that the stoma has a shiny appearance and a bright red color. how should the nurse best respond to this assessment finding? a. irrigate the ostomy to clear a possible obstruction b. contact the primary care provider to report this finding c. document that the stoma appears healthy and well perfused d. document a nursing diagnosis of impaired skin integrity
C. DOCUMENT THAT THE STOMA APPEARS HEALTHY AND WELL PERFUSED
a nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. what action should the nurse recommend as having the greatest potential to prevent esophageal cancer? a. promotion of a nutrient-dense, low-fat diet b. annual screening endoscopy for clients over 50 with a family history of esophageal cancer c. early diagnosis and treatment of gastroesophageal reflux disease d. adequate fluid intake and avoidance of spicy foods
C. EARLY DIAGNOSIS AND TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE
a client with a total hip replacement has developed decreased breath sounds. what is the nurse's best action? a. place the client on bed rest b. request an antitussive medication form the healthcare provider c. encourage use of the incentive spirometer d. assess for signs and symptoms of systemic infection
C. ENCOURAGE USE OF THE INCENTIVE SPIROMETER
a client is scheduled for the creation of a continent ileostomy. what dietary guidelines should the nurse encourage during the weeks following surgery? a. a minimum of 30 g of soluble fiber daily b. increased intake of free water and clear juices c. high intake of strained fruits and vegetables d. a high-calorie, high-residue diet
C. HIGH INTAKE OF STRAINED FRUITS AND VEGETABLES
a clinic nurse is caring for a client with suspected gout. while describing the pathophysiology of gout to the client, what should the nurse explain? a. autoimmune processes in the joints b. chronic metabolic acidosis c. increased uric acid levels d. unstable serum calcium levels
C. INCREASED URIC ACID LEVELS
a client is undergoing diagnostic testing for a tumor of the small intestine. what are the most likely symptoms that prompted the client to first seek care? a. hematemesis and persistent sensation of fullness b. abdominal bloating and recurrent constipation c. intermittent pain and bloody stool d. unexplained bowel incontinence and fatty stools
C. INTERMITTENT PAIN AND BLOODY STOOL
a nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. the client has recently been prescribed misoprostol. what would the nurse be most accurate in informing the client about the drug? a. it reduces the stomach's volume of hydrochloric acid b. it increases the speed of gastric emptying c. it protects the stomach's lining d. it increases lower esophageal sphincter pressure
C. IT PROTECTS THE STOMACH'S LINING
a nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). what assessment finding is most consistent with the clinical presentation of RA? a. cool joints with decreased range of motion b. signs of systemic infection c. joint stiffness lasting longer than 1 hour, especially in the morning d. visible atrophy of the knee and shoulder joints
C. JOINT STIFFNESS LASTING LONGER THAN 1 HOUR, ESPECIALLY IN THE MORNING
a nurse is educating a client with gout about lifestyle modifications that can help control the signs and symptoms of the disease. what recommendation should the nurse make? a. ensuring adequate rest b. limiting exposure to sunlight c. limiting intake of alcohol d. smoking cessation
C. LIMITING INTAKE OF ALCOHOL
a client with systemic lupus erythematosus (SLE) asks the nurse why the client has to come to the office so often for check-ups. which rationale for frequent office visits would be best for the nurse to mention? a. seeing the client face to face b. ensuring that the client is taking medications as prescribed c. monitoring the disease process and how well the prescribed treatment is working d. drawing blood work every month
C. MONITORING THE DISEASE PROCESS AND HOW WELL THE PRESCRIBED TREATMENT IS WORKING
a nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. what technique should the nurse use to palpate the client's liver? a. place hand under the right lower abdominal quadrant and press down lightly with the other hand b. place the left hand over the abdomen and behind the left side at the 11th rib c. place hand under the right lower rib cage and press down lightly with the other hand d. hold hand 90 degrees to the right side of the abdomen and push down firmly
C. PLACE HAND UNDER THE RIGHT LOWER RIB CAGE AND PRESS DOWN LIGHTLY WITH THE OTHER HAND
a client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. what should the nurse include in the client's immediate postoperative plan of care? a. teaching the client to self-suction b. performing chest physiotherapy to promote oxygenation c. positioning the client to prevent gastric reflux d. providing a regular diet as tolerated
C. POSITIONING THE CLIENT TO PREVENT GASTRIC REFLUX
a nurse is caring for a client who has had a total hip replacement. the nurse is reviewing health education prior to discharge. which of the client's statements would indicate to the nurse that the client requires further teaching? a. "I'll need to keep several pillows between my legs at night" b. "I need to remember not to cross my legs. it's such a habit" c. "the occupational therapist is showing me how to use a 'sock ruler' to help me get dressed" d. "I will need my husband to assist me in getting off the low toilet seat at home"
D. "I WILL NEED MY HUSBAND TO ASSIST ME IN GETTING OFF THE LOW TOILET SEAT AT HOME"
a community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. what would the nurse anticipate that the plan of care is most likely to include? a. enteral feeding via gastrostomy tube (G tube) b. gastrointestinal decompression by nasogastric tube c. periodic assessment for esophageal distention d. administration of injections of vitamin B12
D. ADMINISTRATION OF INJECTIONS OF VITAMIN B12
a local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. what should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? a. the hepatitis A vaccine b. albumin infusion c. the hepatitis A and B vaccines d. an immune globulin injection
D. AN IMMUNE GLOBULIN INJECTION
a client with peptic ulcer disease has had metronidazole added to their current medication regimen. what health education related to this medication should the nurse provide? a. take the medication on an empty stomach b. take up to one extra dose per day if stomach pain persists c. take at bedtime to mitigate the effects of drowsiness d. avoid drinking alcohol while taking the drug
D. AVOID DRINKING ALCOHOL WHILE TAKING THE DRUG
allopurinol has been prescribed for a client receiving treatment for gout. the nurse caring for this client knows to assesss the client for bone marrow suppression, which may be manifested by what diagnostic finding? a. hyperuricemia b. increased erythrocyte sedimentation rate c. elevated serum creatinine d. decreased platelets
D. DECREASED PLATELETS
a community health nurse is performing a visit to the home of a client who has a history of rheumatoid arthritis (RA). on which aspect of the client's health should the nurse focus most closely during the visit? a. understanding of rheumatoid arthritis b. risk for cardiopulmonary complications c. social support system d. functional status
D. FUNCTIONAL STATUS
which of the following is the most plausible nursing diagnosis for a client whose treatment for colon cancer has necessitated a colostomy? a. risk for unstable blood glucose due to changes in digestion and absorption b. unilateral neglect related to decreased physical mobility c. risk for excess fluid volume related to dietary changes and changes in absorption d. ineffective sexuality patterns related to changes in self-concept
D. INEFFECTIVE SEXUALITY PATTERNS RELATED TO CHANGES IN SELF-CONCEPT
a nurse is talking with a. client who is scheduled to have a hemicolectomy with the creation of a colostomy. the client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. what nursing action is most appropriate? a. reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy b. provide the client with educational materials that match the client's learning style c. encourage the client to write down these concerns and questions to bring forward to the surgeon d. maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse
D. MAINTAIN AN OPEN DIALOGUE WITH THE CLIENT AND FACILITATE A REFERRAL TO THE WOUND-OSTOMY-CONTINENCE (WOC) NURSE
a client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. the nurse's care should prioritize which of the following outcomes? a. preventing infection b. maintaining skin and tissue integrity c. preventing nausea and vomiting d. maintaining fluid and electrolyte balance
D. MAINTAINING FLUID AND ELECTROLYTE BALANCE
a nurse is assessing a client with rheumatoid arthritis. the client expresses the intent to pursue complementary and alternative medicine (CAM) therapies. which fact should underlie the nurse's response to the client? a. new evidence shows CAM to be as effective as medical treatment b. CAM therapies negate many of the benefits of medications c. CAM therapies typically do more harm than good d. Most CAM therapies lack sufficient evidence to support them
D. MOST CAM THERAPIES LACK SUFFICIENT EVIDENCE TO SUPPORT THEM
a client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. which action should the nurse take? a. administer pain medication b. massage the client's calf c. apply anitembolic stockings d. notify the health care provider
D. NOTIFY THE HEALTHCARE PROVIDER
a nurse's plan of care for a client with rheumatoid arthritis includes several exercise-based interventions. what goal should the nurse prioritize? a. maximize range of motion while minimizing exertion b. increase joint size and strength c. limit energy output in order to preserve strength for healing d. preserve or increase range of motion while limiting joint stress
D. PRESERVE OR INCREASE RANGE OF MOTION WHILE LIMITING JOINT STRESS
a client's rheumatoid arthritis has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. what principle will guide this aspect of the client's treatment? a. the client will need daily blood testing for the duration of treatment b. the client must stop all other drugs 72 hours before starting prednisone c. the drug should be sued at the highest dose the client can tolerate d. the drug should be used for as short a time as possible
D. THE DRUG SHOULD BE USED FOR AS SHORT A TIME AS POSSIBLE
a nurse is admitting a client diagnosed with late-stage gastric cancer. the client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. what factor most likely contributed to the client's late diagnosis? a. gastric cancer does not cause signs or symptoms until metastasis has occurred b. adherence to screening recommendations for gastric cancer is exceptionally low c. early symptoms of gastric cancer are usually attributed to constipation d. the early symptoms of gastric cancer are usually not alarming or highly unusual
D. THE EARLY SYMPTOMS OF GASTRIC CANCER ARE USUALLY NOT ALARMING OR HIGHLY UNUSUAL
an orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. what nursing intervention should be included in the client's subsequent care? a. dressing changes should not be performed unless there are clear signs of infection b. the surgical site can be soaked in warm bath water for up to 5 minutes c. the surgical site should be cleansed with hydrogen peroxide once daily d. the foot should be elevated in order to prevent edema
D. THE FOOT SHOULD BE ELEVATED IN ORDER TO PREVENT EDEMA
a nurse is creating a care plan for a client receiving nasogastric tube feedings. which intervention should the nurse include? a. check the gastric residual volume every 4 hours b. hold the tube feeding if the gastric residual volume is greater than 200 mL: c. position client flat in bed during feedings d. use client assessment findings to determine tolerance of feedings
D. USE CLIENT ASSESSMENT FINDINGS TO DETERMINE TOLERANCE OF FEEDINGS
a nasogastric tube is being inserted in a client with the COVID virus. which action should the nurse take? a. place the client in a prone position b. administer bolus feedings c. place a mask over the client's nose d. wear personal protective equipment
D. WEAR PERSONAL PROTECTIVE EQUIPMENT
