Passpoint 2

When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. A. epigastric pain at night B. relief of epigastric pain after eating C. vomiting D. weight loss E. melena

C. vomiting D. weightloss E. melena

The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby's anomaly. Which approach by the nurse would best support the parents? A. helping the parents accept their feelings as a normal reaction B. explaining that the parents did nothing to cause the newborn's defect C. encouraging the parents to concentrate on planning their baby's care D. urging the parents to visit their newborn as often as possible

A. helping parents accept their feelings as a normal reaction

As part of the treatment plan, a client is prescribed steroids to treat ulcerative colitis. The nurse should assess the client for which of the following? A. Peptic ulcer. B. Hypoglycemia. C. Tachycardia. D. Renal failure.

A. peptic ulcer

When caring for a client with ulcerative colitis the nurse should: encourage the use of stool softeners. A. suggest sitz baths as needed. B. arrange for the client to have a private bathroom. C. wear a gown to provide direct care.

A. suggest a sitz bath as needed

The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The healthcare provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply. A. vital signs B. enemas until clear C. CBC D. morphine E. regular diet

B. enemas until clear E. regular diet

What manifestations are important for the nurse to assess in a 43-year-old client who has developed thrombocytopenia after undergoing colon cancer treatment? Select all that apply. A. diarrhea B. hematuria C. ecchymosis D. melena E. epistaxis

B. hematuria C. ecchymosis D. melena E. epistaxis

An adolescent who has had an appendectomy and developed peritonitis has nausea. Which intervention should the nurse do first? A. Administer an antiemetic. B. Irrigate the nasogastric (NG) tube. C. Notify the surgeon. D. Take the blood pressure.

B. irrigate the NG tube

An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate? A. administering digestive enzymes before meals as ordered B. providing small, frequent meals C. administering antibiotics with meals as ordered D. providing high-fiber snacks

B. providing small, frequent meals

When reviewing the chart of a client recently diagnosed with AIDS, the nurse should expect to find which assessment data? Select all that apply. A. CD4+ count below 200 cells per microliter B. infection with HIV C. an alternative lifestyle D. opportunistic infection E. T-cell count above 400 cells per microliter

A. CD4+ count below 200 cells per microliter B. infection with HIV D. opportunistic infection

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? A. "I will be able to eat most things as long as I eat small amounts." B. "I'll lie down for 30 minutes after I eat to promote digestion." C. "I'll gradually increase the amount of heavy lifting I do." D. "I'll eat frequent, small, bland meals that are high in fiber."

D. I'll eat frequent, small, bland meals that are high in fiber

Which finding would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning? A. barking cough B. substernal retractions C. decreased activity level D. increased respiratory rate

B. Substernal Retractions

Which diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply. A. "Limit your caloric intake so that you don't become overweight." B. "An adequate intake of protein is important to your health." C. "I encourage you to eat small, frequent meals." D. "Restrict your fluid intake to 1,000 mL/day." E. "Limit your alcohol intake to one glass of wine daily."

B. "An adequate intake of protein is important to your health." C. "I encourage you to eat small, frequent meals."

The nurse is teaching the client with cirrhosis about taking lactulose. The nurse should tell the client that which type of bowel movement is an expected outcome of taking this drug? A. one regular bowel movement a day B. two to three soft stools per day C. four to five loose stools per day D. five to six loose stools per day

B. 2 to 3 stools a day

An adolescent with ulcerative colitis who is taking corticosteroids is at risk for which complication? A. jaundice B. decreased bowel sounds C. perianal lesions D. delayed sexual maturation

D. delayed sexual maturation

The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? A. peripheral edema B. ascites C. anorexia D. jaundice

C. anorexia

The client is being monitored by the healthcare provider for ulcerative colitis (UC). The healthcare provider orders hydrocortisone therapy. What information should the nurse include in the teaching of a client receiving hydrocortisone therapy? Select all that apply. A. "Do not abruptly stop taking the medication." B. "Avoid exposure to infections." C. "Wear a medical alert." D. "Consume foods low in potassium." E. "Take medications in the evening."

A. "Do not abruptly stop taking the medication." B. "Avoid exposure to infections." C. "Wear a medical alert."

A client, diagnosed with heart failure, suddenly develops dyspnea at rest, disorientation, confusion, and crackles in the lung bases on auscultation. What are the important nursing interventions? Select all that apply. A. Insert a Foley catheter B. Monitor urinary output C. Administer nasal oxygen D. Administer a prescribed rapid-acting diuretic E. Place the client in a modified Trendelenburg position F. Administer the ordered 500-ml IV bolus of normal saline solution

A. Insert a Foley catheter B. Monitor urinary output C. Administer nasal oxygen D. Administer a prescribed rapid-acting diuretic

Which finding will the nurse assess in a client diagnosed with peritonitis? A. abdominal wall rigidity B. absence of bowel sounds C. positive Cullen's sign D. Battle's sign

A. abdominal wall rigidity

The client with an exacerbation of ulcerative colitis is to be on bed rest with bathroom privileges. What will indicate to the nurse that being on bed rest has had the desired outcome? A. The client has not fallen. B. The client has slowed intestinal peristalsis. C. The client has slept through the night. D. The client has minimized stress.

B. The client has slowed intestinal peristalsis

Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol? A. "I'll take the medication whenever my joints hurt." B. "I must take this drug on an empty stomach." C. "I should drink plenty of fluids when taking allopurinol." D. "I shouldn't take aspirin when taking allopurinol."

C. I should drink plenty of fluids when taking allopurinol

The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the health care provider of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? A. aldosterone B. creatinine C. potassium D. protein

C. Potassium

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do? A. Institute range-of-motion (ROM) exercise every 4 hours. B. Massage the abdomen once a shift. C. Use an alternating air pressure mattress. D. Elevate the lower extremities.

use an alternating air pressure mattress

A client with ulcerative colitis is scheduled for a bowel resection. The client is receiving parenteral nutrition prior to surgery. Which is the best explanation for the nurse to give the client about the need for parenteral nutrition? A. The client has lost 15% of body weight and has prolonged diarrhea. B. It will help the client have surgery as soon as possible. C. The client cannot absorb nutrients through the colon. D. It will help restore fluid and electrolyte imbalances.

A. The client has lost 15% of body weight and has prolonged diarrhea.

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which complications? Select all that apply. A. copious frothy mucus B. episodes of cyanosis C. several loose stools D. distended abdomen E. poor gag reflex

A. copious frothy mucus B. Episodes of cyanosis D. Distended abdomen

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? A. decreased mental status B. elevated blood pressure C. decreased urine output D. labored respirations

A. decreased mental status

What diet should be implemented for a client who is in the early stages of cirrhosis? A. high-calorie, high-carbohydrate B. high-protein, low-fat C. low-fat, low-protein D. high-carbohydrate, low-sodium

A. high calorie, high carbohydrate