Nurs 327 Exam #3
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by
Assessing lung sounds
The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient?
Assisting client to turn, cough, and deep breath every 2hrs
Which of the following is the most common presenting symptom of colon cancer?
Change in bowel habits
A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unitwith signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?
Third-spacing
A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:
Troussaui's sign
An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:
Exhibiting hemoglobin AIC 8.2
Patients diagnosed with hypervolemia should avoid sweet or dry food because
It increases the patients desire to consume fluid
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?
Test all stools for occult blood
A client experienced extensive burns and 72 hours later has developed an ulcer. Which of the following types of ulcer is most likely in this client?
Curling's Ulcer
Which of the following ulcers is associated with extensive burn injury?
Curling's Ulcer
The nurse is performing a community screening for colorectal cancer. Which of the following characteristics should the nurse include in the screening?
Familial polyposis
Which of the following conditions in a patient with pancreatitis makes it necessary for the nurse to check fluid intake and output, hourly urine output, and monitor electrolyte levels?
Frequent vomiting leading to loss of fluid volume
Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
Hemoglobin and hematocrit
Diet therapy for patients diagnosed with IBS include what?
High-fiber diet
Patient's medications is digitalis (digoxin [Lanoxin]), the nurse monitors the patient closely for which of the following?
Hypokalemia
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
Hypothalamus
To confirm an acid-base imbalance, it is necessary to assess which of the following findings from the results of a client's arterial blood gas (ABG) results?
pH , PaCO2, HCO3
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
positioning patient on the side with knees flexed
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find:
severe abdominal pain with direct palpation or rebound tenderness
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
yellow sclerae
Which of the following is considered an isotonic solution?
0.9% normal saline
A nurse is caring for a client diagnosed with cholelithiasis. Which of the following would be most appropriate for a client who is experiencing biliary colic?
Administer analgesic to the client
A longitudinal tear or ulceration in the lining of the anal canal is termed a (an
Anal Fissure
A patient with acute pancreatitis has been started on total parenteral nutrition (TPN). Following the administration of the TPN, which of the following should the nurse plan to monitor?
Blood glucose every 4 to 6 hours
A patient with acute pancreatitis has been started on total parenteral nutrition (TPN). Following the administration of the TPN, which of the following should the nurse plan to monitor?
Blood glucose levels every 4 to 6 hours
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the patient then experiences diarrhea, the nurse documents the presence of which of the following?
Borborygmus
In women, which of the following types of cancer exceeds colorectal cancer?
Breast Cancer
What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
Deficient fluid volume
A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?
Increases arterial pH
The client has been taking famotidine (Pepcid) at home. The nurse prepares a teaching plan for the client indicating that the medication acts primarily to achieve which of the following?
Inhibit gastric acid secretions
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
Maintain a high-carbohydrate, low-fat diet
Which of the following is the major cause of morbidity and mortality in patients with acute pancreatitis?
Pancreatic necrosis
The nurse knows that the client with cholelithiasis can have a nutritional deficiency. The obstruction of bile flow due to cholelitiasis can interfere with the absorption of
Vitamin A
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
light-headedness or paresthesia
Semi-Fowler's position is maintained for at least which time frame following completion of an intermittent tube feeding?
1 hour
Morbid obesity is defined as being how many pounds over the person's ideal body weight?
100
A nursing student is preparing a teaching plan about peptic ulcer disease. The student knows to include teaching about the percentage of clients with peptic ulcers who experience bleeding. The percentage is
15%
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?
30mL
Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve?
6 to 12
Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones?
6 to 12 months
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?
At first the stoma may bleed a little when touched
The primary source of microorganisms for catheter-related infections are the skin and which of the following?
Catheter Hub
Which foods should be avoided following acute gallbladder inflammation?
Cheese
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?
Chest Pain
The nurse is irrigating a patient's colostomy when the patient begins to complain of cramping. What is the appropriate action by the nurse?
Clamp the tubing and allow the patient to rest
Which of the following is clinical manifestation of cholelithiasis?
Clay-colored stools
Which of the following laxatives should be used by a cardiac patient who should avoid straining?
Colace
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for:
Diaphoresis, vomiting, diarrhea
What is one of the primary symptoms of irritable bowel syndrome (IBS)?
Diarrhea
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?
Dysfunction of pancreatic islet cells
A nurse has admitted a client suspected of having acute pancreatitis. The nurse knows that mild acute pancreatitis is characterized by:
Edema and inflammation
A physician suspects that a client has peptic ulcer disease. With which of the following diagnostic procedures would the nurse most likely prepare to assist?
Endoscopy
A patient with an ileostomy should avoid which of the following?
Enteric-coated products
Which nerve is implicated in the Chvostek's sign?
Facial
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
Jugular vein distention
Which of the following enzymes aids in the digestion of fats?
Lipase
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
Metoclopramide(Reglan)
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications
Celiac sprue is an example of which category of malabsorption?
Mucosal disorders causing generalized malabsorption
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?
Neurological (because that would indicate hypocalcemia)
Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit?
Pancreatitis
Which of the following are classified as a histamine-2 receptor antagonist?
Pepcid
The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?
Peritonitis
Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances?
Positron emission tomography (PET)
A client with a history of peptic ulcer disease is admitted for hematemesis associated with gastric bleeding. Which is the most appropriate action of the nurse?
Prepare for nasogastric irrigations
he nurse is scheduling gastrointestinal (GI) diagnostic testing for a client. Which GI test should be scheduled first?
Radiography of the Gallbladder
When interviewing a client with internal hemorrhoids, which of the following would the nurse expect the client to report?
Rectal Bleeding
Which of the following is the most common symptom of a polyp?
Rectal Bleeding
Which type of diarrhea is caused by increased production and secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen?
Secretory Diarrhea
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
Serum antibodies for H.pylori
The nurse is caring for patient scheduled to undergo radical neck dissection. During preoperative teaching, the nurse includes that which of the following as associated complications?
Shoulder drop
Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?
Sialolithiasis
A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?
Sigmoidoscopy
The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be
Solid
The nurse is reviewing the laboratory test results of a client with Crohn's disease. Which of the following would the nurse most likely find?
Stool cultures negative for microorganisms or parasite
A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?
Suggest fluid intake of 2L per day
To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?
Tachycardia
Hickman and Groshong are examples of which type of central venous access device?
Tunneled central catheters
The digestion of carbohydrates is aided by what?
amylase
Cancer of the esophagus is most often diagnosed by which of the following?
Esophagogastroduodenoscopy (EGD) with biopsy and brushing
A patient underwent a continent ileostomy. Within which timeframe should the patient expect to empty the reservoir?
Every 4 to 6 hours