PDM: Chapter 5

The client 2 days postoperative from a laparoscopic cholecystectomy tells the office nurse, "My right shoulder hurts so bad I can't stand it." Which statement is the nurse's best response? 1. "This is a result of the carbon dioxide gas used in surgery." 2. "Call 911 and go to the emergency department immediately." 3. "Increase the pain medication the surgeon ordered." 4. "You need to ambulate in the hall to walk off the gas pains."

1. "This is a result of the carbon dioxide gas used in surgery."

The client tells the nurse in the bariatric clinic, "I have tried to lose weight on just about every diet out there but nothing works." Which statement is the nurse's best response? 1. "Which diets and modifications have you tried?" 2. "How much weight are you trying to lose?" 3. "This must be difficult. Would you like to talk?" 4. "You may need to get used to being overweight."

1. "Which diets and modifications have you tried?"

The client is diagnosed with gastroenteritis. Which laboratory data warrants immediate intervention by the nurse? 1. A serum sodium level of 152 mEq/L. 2. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 4.8 mEq/L. 4. A stool sample that is positive for fecal leukocytes.

1. A serum sodium level of 152 mEq/L.

The staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. Which action should be taken by the nurse? 1. Ask the supervisor to come to the unit. 2. Determine what is bothering the nurse. 3. Suggest the nurse go home. 4. Smell the nurse's breath for alcohol.

1. Ask the supervisor to come to the unit.

The nurse is caring for a client 1 day postoperative sigmoid resection. There is a large amount of bright red blood on the dressing. Which intervention should the nurse implement first? 1. Assess the client's apical pulse and blood pressure. 2. Auscultate the client's bowel sounds. 3. Notify the healthcare provider immediately. 4. Reinforce the dressing with a sterile gauze pad

1. Assess the client's apical pulse and blood pressure.

The LPN tells the nurse the client diagnosed with liver failure is getting more confused. Which intervention should the nurse implement first? 1. Assess the client's neurological status. 2. Notify the client's healthcare provider. 3. Request a STAT ammonia serum level. 4. Tell the LPN to obtain the client's vital signs.

1. Assess the client's neurological status.

Which task should the nurse in the long-term care facility delegate to the unlicensed assistive personnel (UAP)? 1. Assist the resident up in a wheelchair for meals. 2. Assess the incontinent client's perianal area. 3. Discuss requirements with the client for going out on a pass. 4. Explain how to care for the client's colostomy to the family.

1. Assist the resident up in a wheelchair for meals.

The male Mexican American client, who is terminally ill, refuses hospice services because he says it is "giving up" and he is not going to die. Which is the most appropriate action by the nurse? 1. Discuss the philosophy and services of palliative care with the client. 2. Take no other action and support the client's decision. 3. Contact the client's healthcare provider to discuss the prognosis. 4. Talk to the client's family members about his choice to refuse hospice.

1. Discuss the philosophy and services of palliative care with the client.

The unlicensed assistive personnel (UAP) tells the nurse angrily, "You are the worst nurse I have ever worked with and I really hate working with you." Which action should the nurse implement first? 1. Don't respond to the comment and appraise the situation. 2. Tell the UAP to leave the unit immediately. 3. Report this comment and behavior to the charge nurse. 4. Explain to the UAP that he or she cannot talk to the primary nurse like this.

1. Don't respond to the comment and appraise the situation.

Which nursing problem is the highest priority for the client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid and electrolyte imbalance. 2. Alteration in bowel elimination. 3. Nutrition, altered: less than body requirements. 4. Oral mucous membrane, altered.

1. Fluid and electrolyte imbalance.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia. 2. Request the UAP change the linens for the 89-year-old client with fecal incontinence. 3. Tell the UAP to assist the 54-year-old client with a bowel management program. 4. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis.

1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia.

The client who is morbidly obese is 8 hours postoperative gastric bypass surgery. Which nursing intervention is of the greatest priority? 1. Instruct the client to use the incentive spirometer. 2. Weigh the client daily in the same clothes and at the same time. 3. Apply sequential compression devices to the client's lower extremities. 4. Assist the client to sit in the bedside chair.

1. Instruct the client to use the incentive spirometer.

The nurse is transcribing the HCP's orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first? 1. Obtain the client's informed consent. 2. Administer 2 mg of IV morphine, every 4 hours, PRN. 3. Shave the lower right abdominal quadrant. 4. Administer the on-call IVPB antibiotic.

1. Obtain the client's informed consent.

The client 1 day postoperative abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first? 1. Place sterile normal saline gauze on the eviscerated area. 2. Reinforce the abdominal dressing with an ABD pad. 3. Assess the client's abdominal bowel sounds. 4. Place the client in the left lateral position.

1. Place sterile normal saline gauze on the eviscerated area.

. The nurse is caring for a client who is hemorrhaging from a duodenal ulcer. Which collaborative interventions should the nurse implement? Select all that apply. 1. Prepare to administer a Sengstaken-Blakemore tube. 2. Assess the client's vital signs. 3. Administer a proton-pump intravenously. 4. Obtain a type and crossmatch for four units of blood. 5. Monitor the client's intake and output.

1. Prepare to administer a Sengstaken-Blakemore tube. 3. Administer a proton-pump intravenously. 4. Obtain a type and crossmatch for four units of blood.

The client with a sigmoid colostomy has an excoriated area around the stoma that has not improved for more than 2 weeks. Which intervention is most appropriate for the home health nurse (HH) to implement? 1. Refer the client to the wound care nurse. 2. Notify the client's healthcare provider. 3. Continue to monitor the stoma site. 4. Place Karaya paste over the excoriated area.

1. Refer the client to the wound care nurse.

The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the unlicensed assistive personnel (UAP) to assist the client to the bathroom. Which action should the charge nurse implement? 1. Take no action because this is appropriate delegation. 2. Tell the UAP to obtain a bedside commode for the client. 3. Discuss the inappropriate delegation of the nursing task. 4. Document the situation in an adverse occurrence report.

1. Take no action because this is appropriate delegation.

Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the long-term care nurse? 1. The UAP is giving the client with a gastrostomy tube a glass of water. 2. The UAP is ambulating the client outside using a safety belt. 3. The UAP is assisting the client with putting a jigsaw puzzle together. 4. The UAP is giving a back rub to the client who is on bed rest.

1. The UAP is giving the client with a gastrostomy tube a glass of water.

The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone? 1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm. 2. The client who is 1 day postoperative total colectomy with creation of an ileal conduit who has a hemoglobin and hematocrit level of 12/36. 3. The client who is 4 days postoperative for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL. 4. The client who is 8 hours postoperative for exploratory laparotomy who has a serum potassium level of 4.5 mEq/L.

1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm.

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The client with peptic ulcer disease who is complaining of acute epigastric pain. 2. The client with acute gastroenteritis who is upset and wants to go home. 3. The client with inflammatory bowel disease who is receiving total parental nutrition. 4. The client with hepatitis B who is complaining and who is jaundiced and anorexic.

1. The client with peptic ulcer disease who is complaining of acute epigastric pain.

The nurse is discussing end-of-life care (EOL) with the client diagnosed with pancreatic cancer. Which statements are the goals for end-of-life care? Select all that apply. 1. To provide comfort and supportive care during the dying process. 2. To plan and arrange the funeral for the client. 3. To improve the client's quality of life for the remaining time. 4. To help ensure a dignified death for the client and family. 5. To assist with the financial cost of the dying process.

1. To provide comfort and supportive care during the dying process. 3. To improve the client's quality of life for the remaining time. 4. To help ensure a dignified death for the client and family.

The nurse is preparing to hang a new bag of total parental nutrition on a client who has had an abdominal perineal resection. The bag has 2,000 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?

106 gtt/min

The significant other of a client diagnosed with liver cancer and who is dying asks the nurse, "What is bereavement counseling?" Which statement is the nurse's best response? 1. "Bereavement counseling helps the client accept the terminal illness." 2. "It provides support to you and your family in the transition to a life without your loved one." 3. "We provide counseling to you and your loved one during the dying process." 4. "It is group counseling for family members whose loved ones have died."

2. "It provides support to you and your family in the transition to a life without your loved one."

The client with hepatitis asks the nurse, "Is there any herb I can take to help my liver get better?" Which statement is the nurse's best response? 1. "You should ask your healthcare provider about taking herbs." 2. "Milk thistle is a powerful oxidant and promotes liver cell growth." 3. "You should not take any medication that is not prescribed." 4. "Why would you want to take any herbs?"

2. "Milk thistle is a powerful oxidant and promotes liver cell growth."

The client, who is terminally ill, tells the nurse, "I just want to live to see my grandson graduate in 2 months." Which stage of grief is the client experiencing? 1. Anger. 2. Bargaining. 3. Depression. 4. Acceptance.

2. Bargaining.

The unlicensed assistive personnel (UAP) notifies the charge nurse that the male client is angry with the care he is receiving and is packing to leave the hospital. Which intervention should the charge nurse implement first? 1. Ask the client's nurse why the client is upset. 2. Discuss the problem with the client. 3. Notify the healthcare provider (HCP). 4. Have the client sign the against medical advice (AMA) form.

2. Discuss the problem with the client.

The client admitted to the critical care unit tells the nurse, "I have an advance directive (AD) and I do not want to have cardiopulmonary resuscitation (CPR)." Which intervention should the nurse implement first? 1. Ask the client for a copy of the AD so that it can be placed in the chart. 2. Inform the healthcare provider of the client's request as soon as possible. 3. Determine whether the client has a durable power of attorney for healthcare. 4. Request the hospital chaplain to come and talk to the client about this request.

2. Inform the healthcare provider of the client's request as soon as possible.

The administrative supervisor is staffing the hospital's medical-surgical units during an ice storm and has received many calls from staff members who are unable to get to the hospital. Which action should the supervisor implement first? 1. Inform the chief nursing officer. 2. Notify the on-duty staff to stay. 3. Call staff members who live close to the facility. 4. Implement the emergency disaster protocol.

2. Notify the on-duty staff to stay.

The charge nurse notices a nurse recapping a needle in a client's room. Which action should the charge nurse take first? 1. Tell the nurse not to recap the needle. 2. Quietly ask the nurse to step into the hall. 3. Reprimand the nurse for not following procedure. 4. Notify the house supervisor of the nurse's behavior

2. Quietly ask the nurse to step into the hall.

The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? 1. The client who has received three units of packed red blood cells (RBCs). 2. The client scheduled for an esophagogastroduodenoscopy in the morning. 3. The client with short bowel syndrome who has diarrhea and a K+ level of 3.3 mEq/L. 4. The client who has just returned from surgery for a sigmoid colostomy.

2. The client scheduled for an esophagogastroduodenoscopy in the morning.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PaCO2 44, HCO3 30. 2. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10. 3. The client who is 12 hours postoperative abdominal surgery and has dark green bile draining in the nasogastric tube. 4. The client who is 2 days postoperative for hiatal hernia repair and is complaining of feeling constipated.

2. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10.

The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first? 1. The client with an inguinal hernia repair who has a urine output of 160 mL in 4 hours. 2. The client with an emergency appendectomy who was transferred from PACU. 3. The client who is 4 hours postoperative abdominal surgery who has flatulence. 4. The client who is 6 hours post-procedure colonoscopy and is being discharged.

2. The client with an emergency appendectomy who was transferred from PACU.

The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure? 1. The cardiac catheterization department. 2. The dietary department. 3. The nuclear medicine department. 4. The hospital laboratory department

2. The dietary department.

The nurse is changing the client's colostomy bag. Which interventions should the nurse implement? Rank in the order of priority. 1. Remove the client's colostomy bag. 2. Apply the client's new colostomy bag. 3. Don non-sterile gloves. 4. Assess the client's stoma site. 5. Cleanse the area around the client's stoma.

3, 1, 4, 5, 2

The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority. 1. Cleanse the stomal site with mild soap and water. 2. Assess the stoma for a pink, moist appearance. 3. Monitor the drainage in the ostomy drainage bag. 4. Apply stoma adhesive paste to the skin around the stoma. 5. Attach the ostomy drainage bag to the abdomen.

3, 2, 1, 4, 5

The nurse and the unlicensed assistive personnel (UAP) are caring for a client on a medical unit who has difficulty swallowing and is incontinent of urine and feces. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the client's PEG feeding tube for patency. 2. Place DuoDERM wound care patches on the client's coccyx. 3. Apply non-medicated ointment to the client's perineum. 4. Suction the client during feeding to prevent aspiration.

3. Apply non-medicated ointment to the client's perineum.

The nurse is working in a community health clinic. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to take the client's history. 2. Request the UAP to document the client's complaints. 3. Ask the UAP to obtain the client's weight and height. 4. Tell the UAP to complete the client's follow-up care.

3. Ask the UAP to obtain the client's weight and height.

The nurse is preparing to teach the male client how to irrigate his sigmoid colostomy. Which intervention should the nurse implement first? 1. Demonstrate the procedure on a model. 2. Provide the client with written instructions. 3. Ask the client whether he has any questions. 4. Show the client all of the equipment needed.

3. Ask the client whether he has any questions.

The unlicensed assistive personnel (UAP) tells the nurse a female client, who had a laparoscopic cholecystectomy, is complaining of abdominal pain. Which intervention should the nurse implement first? 1. Check the medication administration record for the last pain medication the client received. 2. Instruct the UAP to ask the client to rate her pain on a 1 to 10 pain scale. 3. Assess the client to rule out any postoperative surgical complications. 4. Tell the UAP to obtain the client's vital signs and pulse oximeter reading

3. Assess the client to rule out any postoperative surgical complications.

The client who has had abdominal surgery is complaining of pain and tells the nurse, "I felt something pop in my stomach." Which intervention should the nurse implement first? 1. Check the client's apical pulse and blood pressure. 2. Determine the client's pain on a 1 to 10 pain scale. 3. Assess the client's surgical wound site. 4. Administer pain medication intravenously.

3. Assess the client's surgical wound site.

The nurse is caring for clients on a medical unit. Which task should the nurse implement first? 1. Change the abdominal surgical dressing for a client who has ambulated in the hall. 2. Discuss the correct method of placing Montgomery straps on the client with the UAP. 3. Assess the male client who called the desk to say he is nauseated and just vomited. 4. Place a call to the extended care facility to give the report on a discharged client.

3. Assess the male client who called the desk to say he is nauseated and just vomited.

The nurse is working in a digestive disease disorder clinic. Which nursing action is an example of evidence-based practice (EBP)? 1. Turn on the tap water to help a client urinate. 2. Use two identifiers to identify a client before a procedure. 3. Educate a client based on current published information. 4. Read nursing journals about the latest procedures.

3. Educate a client based on current published information.

Which behavior by the UAP warrants intervention by the home health (HH) nurse? The client tells the HH nurse the UAP: 1. Would not accept a birthday gift from the client. 2. Gave the client a vase of flowers from the UAP's garden. 3. Picked up the client's prescriptions from the pharmacy. 4. Cleaned the client's bathroom, including scrubbing the commode.

3. Picked up the client's prescriptions from the pharmacy.

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice and is scratching the upper extremities. Which intervention should the nurse implement first? 1. Request the UAP to assist the client to take a hot, soapy shower. 2. Apply an emollient to the client's upper extremities. 3. Place mittens on both hands of the client. 4. Administer Benadryl 25mg PO to the client.

3. Place mittens on both hands of the client.

The client is experiencing severe diarrhea and a serum potassium level of 3.3 mEq/L. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Assess the client for leg cramps. 3. Place the client on cardiac telemetry. 4. Prepare to administer intravenous potassium.

3. Place the client on cardiac telemetry.

The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first? 1. Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn's disease. 2. Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia. 3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease. 4. Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery.

3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease.

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate to assign/delegate? 1. Instruct the UAP to discontinue the client's total parenteral nutrition. 2. Ask the UAP to give the client 30 mL of Maalox for heartburn. 3. Tell the LPN to administer a bulk laxative to a client diagnosed with constipation. 4. Request the LPN to assess the abdomen of a client who has had complaints of pain.

3. Tell the LPN to administer a bulk laxative to a client diagnosed with constipation.

Which task would be most appropriate for the nurse on the GI unit to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to draw the serum liver function test. 2. Ask the UAP to remove the nasogastric tube. 3. Tell the UAP to empty the client's colostomy bag. 4. Instruct the UAP to assist the unit secretary to transcribe HCP orders.

3. Tell the UAP to empty the client's colostomy bag.

The female client, diagnosed with diverticulosis, called the home healthcare agency and told the nurse, "I am having really bad pain in my left lower stomach and I think I have a fever." Which action should the nurse take? 1. Recommend the client take an antacid and lie flat in the bed. 2. Instruct one of the nurses to visit the client immediately. 3. Tell the client to have someone drive them to the emergency room. 4. Ask the client what she has had to eat in the last 8 hours.

3. Tell the client to have someone drive them to the emergency room.

Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse? 1. The UAP is refusing to feed the client diagnosed with acute diverticulitis. 2. The UAP would not place the client on the bedside commode who was on bed rest. 3. The UAP placed the client with a continuous feeding tube in the supine position. 4. The UAP placed sequential compression devices on the client who is on strict bed rest.

3. The UAP placed the client with a continuous feeding tube in the supine position.

The male client is 30 minutes post-procedure liver biopsy. Which action by the unlicensed assistive personnel (UAP) requires the nurse to intervene? 1. The UAP offered the client a urinal to void. 2. The UAP gave the client a glass of water. 3. The UAP turned the client on the left side. 4. The UAP took the client's vital signs.

3. The UAP turned the client on the left side.

The charge nurse is making assignments on a medical-surgical unit. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with lower esophageal dysfunction who is experiencing regurgitation. 2. The client diagnosed with Barrett's esophagitis who is scheduled for an endoscopy. 3. The client diagnosed with gastroesophageal reflux disease who has bilateral wheezes. 4. The client diagnosed with 1 day post-op hiatal hernia who has pain rated a 4 on a pain scale of 1 to 10.

3. The client diagnosed with gastroesophageal reflux disease who has bilateral wheezes

The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications? 1. The client scheduled for removal of an abdominal mass who is overweight. 2. The client scheduled for a gastrectomy who has arterial hypertension. 3. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day. 4. The client scheduled for an emergency appendectomy who smokes marijuana on a daily basis.

3. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day.

The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? 1. The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants. 2. The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset. 3. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen. 4. The client who is 2 days postoperative for an emergency appendectomy and is complaining of abdominal pain, rating it as an 8 on a pain scale of 1 to 10.

3. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen.

The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first? 1. The client who has a paralytic ileus and has absent bowel sounds. 2. The client who is 2 days post-op abdominal surgery and has a soft, tender abdomen. 3. The client who is 6 hours postoperative and has an abdominal wound dehiscence. 4. The client who had a liver transplant and is being transferred to the rehabilitation unit.

3. The client who is 6 hours postoperative and has an abdominal wound dehiscence.

The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with ulcerative colitis who had five loose stools the previous shift. 2. The elderly client admitted from another facility who is refusing to be seen by the nurse. 3. The client with intractable vomiting who has tented skin turgor and dry mucous membranes. 4. The client with hemorrhoids who had spotting of bright red blood on the toilet tissue.

3. The client with intractable vomiting who has tented skin turgor and dry mucous membranes.

The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse? 1. The client's hemoglobin/hematocrit is 11.4/32. 2. The client's abdomen is soft to touch and non-tender. 3. The client's vital signs are T 99, AP 114, RR 18, B/P 88/60. 4. The client's nasogastric tube has coffee ground drainage.

3. The client's vital signs are T 99, AP 114, RR 18, B/P 88/60.

The client is admitted to the critical care unit after a motor vehicle accident. The client asks the nurse, "Do you know if the person in the other car is all right?" The nurse knows the person died. Which statement supports the ethical principle of veracity? 1. "I am not sure how the other person is doing." 2. "I will try to find out how the other person is doing." 3. "You should rest now and try not worry about it." 4. "I am sorry to have to tell you, but the person died."

4. "I am sorry to have to tell you, but the person died."

The nurse is discussing end-of-life issues with a client. The nurse is explaining about a document used for listing the person the client will allow to make healthcare decisions should he or she become unable to make informed decisions for him- or herself. Which document is the nurse discussing with the client? 1. Advance directive. 2. Directive to physicians. 3. Living will. 4. Durable power of attorney for healthcare.

4. Durable power of attorney for healthcare.

The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority? 1. Altered nutrition. 2. Self-care deficit. 3. Impaired body image. 4. Fluid and electrolyte imbalance.

4. Fluid and electrolyte imbalance.

The nurse is caring for a 14-year-old female client diagnosed with bulimia. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Talk with the parents about setting goals for the client. 2. Stay with the client for 15 to 20 minutes after each meal. 3. Encourage the client to verbalize low self-esteem. 4. List for the dietician the amount of food the client consumed.

4. List for the dietician the amount of food the client consumed.

Which task is most appropriate for the home healthcare nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to give the herb ginkgo biloba to the client with Alzheimer's. 2. Ask the UAP to perform the tube feedings for a client with a gastrostomy tube. 3. Request the UAP to perform the daily colostomy irrigation for the client. 4. Tell the UAP to wash and dry the client's hair.

4. Tell the UAP to wash and dry the client's hair.

The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? 1. Obtain informed consent from the client for the diagnostic procedure. 2. Discuss the need to increase oral fluid intake after the procedure. 3. Explain to the client that he or she will have to drink a white, chalky substance. 4. Tell the client not to eat or drink anything prior to the procedure.

4. Tell the client not to eat or drink anything prior to the procedure.

The nurse is caring for a client diagnosed with peptic ulcer disease. Which assessment data would cause the client to require an immediate intervention by the nurse? 1. The client has hypoactive bowel sounds. 2. The client's output is 480 mL for 12-hour shift. 3. The client has T 98.6, AP 98, RR 22, B/P 102/78. 4. The client has coffee ground emesis.

4. The client has coffee ground emesis.

Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with dyspepsia who has eructation and bloating. 2. The client diagnosed with pancreatitis who has steatorrhea and pyrexia. 3. The client with diverticulitis who has left lower quadrant pain and fever. 4. The client with Crohn's disease who has right lower abdominal pain and diarrhea

4. The client with Crohn's disease who has right lower abdominal pain and diarrhea

Which client should the nurse assess first after receiving the p.m. shift assessment? 1. The client with Barrett's esophagus who has dysphagia and pyrosis. 2. The client with proctitis who has tenesmus and passage of mucus through the rectum. 3. The client with liver failure who is jaundiced and has ascites. 4. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr.

4. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr.

The client who is 2 days postoperative abdominal surgery has a hemovac drainage tube. Which assessment data indicates the Jackson-Pratt (JP) is functioning appropriately? 1. The hemovac is round and has 40 mL of fluid. 2. The drainage tube is pinned to the dressing. 3. The hemovac insertion site is pink and has no drainage. 4. The hemovac has suction and is compressed.

4. The hemovac has suction and is compressed.

The nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised. Which action is most appropriate for the nurse to implement first? 1. Discuss the blood administration flow sheet with the chief nursing officer. 2. Contact an individual to help design a new blood transfusion flow sheet. 3. Learn to adapt to the present form and do not take any further action. 4. Volunteer to be on an ad hoc committee to research alternate flow sheets.

4. Volunteer to be on an ad hoc committee to research alternate flow sheets.