Test 4 MedSurg/Peds

Which of the following findings should the nurse expect in a client who has ulcerative colitis? A) Bloody diarrhea B) Hyperkalemia C) Weight gain D) Sharp epigastric pain

A) Bloody diarrhea

The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? A) Smoking cessation B) Reduction of alcohol intake C) Maintenance of a diet high in vitamins and nutrients D) Vitamin D supplementation

A) Smoking cessation

Which of the following findings should the nurse expect in a client who has a duodenal ulcer? Select all that apply. A) Client is malnourished B) Awakening with pain during he night C) Pain is relieved by ingestion of food or antacid D) Pain occurs 1.5 to 3 hours after a meal

B, C, D

Which condition manifests the symptoms of tachycardia, tachypnea, and inadequate perfusion? A) Severe sepsis B) Septic shock C) Septicemia D) Sepsis

Septic shock

The nurse is caring for a patient who had a brush biopsy 12 hours ago. The presence of what assessment finding should prompt the nurse to notify the physician? A) Scant hematuria B) Renal colic C) Temperature 100.2F orally D) Infiltration of the patients intravenous catheter

C) Temperature 100.2F orally.

A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patients admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply. A) Diarrhea B) High fever C) Hematuria D) Urinary frequency E) Acute pain

C, D, E

Which of the following stated by a client with ulcerative colitis indicates an understand of teaching? A) "I will limit fiber in my diet" B) "I will drink coffee with my breakfast" C) "I will limit restrict fluid intake during meals" D) "I will eat 3 moderate to large meals a day"

A) "I will limit fiber in my diet"

A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? A) "I will plan to limit fiber in my diet" B) "I will restrict fluid intake during meals" C) "I will switch to black tea instead of drinking coffee" D) "I will try to eat cold foods rather than warm when my stomach feels upset."

A) "I will plan to limit fiber in my diet"

A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patients urine output hourly and notifies the physician when the hourly output is less than what? A) 30 mL B) 50 mL C) 100 mL D) 125 mL

A) 30mL

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? A) A 65-year-old man with alcoholism who smokes. B) A 45-year-old woman who has type 1 diabetes and who wears dentures. C) A 32-year-old man who is obese and uses smokeless tobacco. D) A 57-year-old man with GERD and dental caries

A) A 65-year-old man with alcoholism who smokes. Feedback: Oral cancers are often associated with the use of alcohol and tobacco, which when used together have a synergistic carcinogenic effect. Most cases of oral cancers occur in people over the age of 60 and a disproportionate number of cases occur in men. Diabetes, dentures, dental caries, and GERD are not risk factors for oral cancer.

A patient has come to the clinic complaining of pain just above her umbilicus. When assessing the patient, the nurse notes Sister Mary Joseph's nodules. The nurse should refer the patient to the primary care 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 Feedback: Palpable nodules around the umbilicus, called Sister Mary Josephs nodules, are a sign of a GI malignancy, usually a gastric cancer. This would not be a sign of dumping syndrome, peptic ulcer disease, or esophageal/gastric obstruction.

The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula? A) A vein and an artery in your arm will be attached surgically. B) The arm should be immobilized for 4 to 6 days. C) One needle will be inserted into the fistula for each dialysis treatment. D) The fistula can be used 2 days after the surgery for dialysis treatment.

A) A vein and an artery in your arm will be attached surgically.

Which intervention for TPN should be included in the plan of care? Select all that apply. A) Accuchecks 4 times a day B) Change TPN IV tubing every 24 hours C) Obtain vital signs every 4 hours D) Administer meds through secondary port on TPN IV tubing.

A) Accuchecks 4 times a day B) Change TPN IV tubing every 24 hours C) Obtain vital signs every 4 hours

The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response? A) Assess the patient for signs of bleeding and inform the physician. B) Monitor the patients vital signs every 15 minutes for the next hour. C) Reposition the patient and reassess vital signs. D) Palpate the patients flanks for pain and inform the physician.

A) Assess the patient for signs of bleeding and inform the physician.

The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A) Assessment of the quantity of the patients urine output B) Assessment of the patients incision C) Assessment of the patients abdominal girth D) Assessment for flank or abdominal pain

A) Assessment of the quantity of the patients urine output

A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care? A) Confirm placement of the tube prior to each medication administration. B) Have the patient sip cool water to stimulate saliva production. C) Keep the patient in a low Fowlers position when at rest. D) Connect the tube to continuous wall suction when not in use.

A) Confirm placement of the tube prior to each medication administration. Feedback: Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a nasogastric tube the patient should be positioned in a Fowlers position. Oral fluid administration is contraindicated by the patients dysphagia.

A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patients continuing care in the home setting, what assessment question is most relevant? A) Does anyone in your family have experience at giving injections? B) Are you going to be anywhere with strong sunlight in the next few months? C) Are you aware of your blood type? D) Do any of your family members have training in first aid?

A) Does anyone in your family have experience at giving injections? Feedback: Patients with malabsorption of vitamin B12 need information about lifelong vitamin B12injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the patient to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant.

A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? A) Does your pain resolve when you have something to eat? B) Do over-the-counter pain medications help your pain? C) Does your pain get worse if you get up and do some exercise? D) Do you find that your pain is worse when you need to have a bowel movement?

A) Does your pain resolve when you have something to eat? Feedback: Pain relief after eating is associated with duodenal ulcers. The pain of peptic ulcers is generally unrelated to activity or bowel function and may or may not respond to analgesics.

A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines? A) Eat small, frequent meals with high calorie and vitamin content. B) Eat frequent meals with an equal balance of fat, carbohydrates, and protein. C) Eat frequent, low-fat meals with high protein content. D) Try to maintain the pre-diagnosis pattern of eating.

A) Eat small, frequent meals with high calorie and vitamin content. Feedback: The nurse encourages the patient to eat small, frequent portions of nonirritating foods to decrease gastric irritation. Food supplements should be high in calories, as well as vitamins A and C and iron, to enhance tissue repair.

A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having trouble swallowing for the past few days. What recommendation should the nurse make? A) Eating more slowly and chewing food more thoroughly. B) Taking an OTC antacid or drinking a glass of milk prior to each meal. C) Chewing gum to cause relaxation of the lower esophageal sphincter. D) Drinking at least 12 ounces of liquid with each meal

A) Eating more slowly and chewing food more thoroughly. Feedback: Dysphagia may be prevented by educating patients to eat slowly, to chew food thoroughly, and to avoid eating tough foods such as steak or dry chicken or doughy bread. After bariatric procedures, patients should normally not drink beverages with meals. Medications or chewing gum will not alleviate this problem.

A nurse is caring for a patient who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the patients appetite? A) Encourage the family to bring in the patients favored foods. B) Limit visitors at mealtimes so that the patient is not distracted. C) Avoid offering food unless the patient initiates. D) Provide thorough oral care immediately after the patient eats.

A) Encourage the family to bring in the patients favored foods. Rationale: Family involvement and home-cooked favorite foods may help the patient to eat. Having visitors at mealtimes may make eating more pleasant and increase the patients appetite. The nurse should not place the complete onus for initiating meals on the patient. Oral care after meals is necessary, but does not influence appetite.

A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients long-term needs, the nurse should prioritize interventions and referrals with what goal? A) Enhancement of verbal communication. B) Enhancement of immune function. C) Maintenance of adequate social support. D) Maintenance of fluid balance.

A) Enhancement of verbal communication. Rationale: Verbal communication may be impaired by radical surgery for oral cancer. Addressing this impairment often requires a long-term commitment. Immune function, social support, and fluid balance are all necessary, but communication is a priority issue for patients recovering from this type of surgery.

A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status? A) Ensure that none of the patients visitors has an infection. B) Arrange for a diet that is high in protein and low in fat. C) Administer colony stimulating factors (CSFs) as ordered. D) Prepare to administer chemotherapeutics as ordered.

A) Ensure that none of the patients visitors has an infection. Rationale: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the patients immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.

A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A) Esophageal or pyloric obstruction related to scarring. B) Uncontrolled proliferation of H. pylori. C) Gastric hyperacidity related to excessive gastrin secretion. D) Chronic referred pain in the lower abdomen.

A) Esophageal or pyloric obstruction related to scarring. Feedback: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a patient who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.

The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay? A) Organic fruit juice B) Roasted nuts C) Red meat that is high in fat D) Cheddar cheese

A) Organic fruit juice Feedback: Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Patients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.

A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? A) Examine ones own attitudes towards obesity in general and the patient in particular. B) Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. C) Describe ones own struggles with weight gain and weight loss to the patient. D) Elicit the patients short-term and long-term goals for weight loss.

A) Examine ones own attitudes towards obesity in general and the patient in particular. Feedback: Studies suggest that health care providers, including nurses, harbor negative attitudes towards obese patients. Nurses have a responsibility to examine these attitudes and change them accordingly. This is foundational to all other areas of assessing this patient.

A nurse in the post-anesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying? A) Fowlers B) Supine C) Left lateral D) Left Sims

A) Fowlers Feedback: Positioning the patient in a Fowlers position postoperatively promotes comfort and facilitates emptying of the stomach following gastric surgery. Any position that involves lying down delays stomach emptying and is not recommended for this type of patient. Supine positioning and the left lateral (left Sims) position do not achieve this goal.

Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? A) Heart failure B) Glomerulonephritis C) Ureterolithiasis D) Aminoglycoside toxicity

A) Heart failure

The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A) Hematuria B) Precipitous decrease in serum creatinine levels C) Hypotension unresolved by fluid administration D) Glucosuria

A) Hematuria

A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.

A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.

A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis? A) Hemodialysis is a treatment option that is usually required three times a week. B) Hemodialysis is a program that will require you to commit to daily treatment. C) This will require you to have surgery and a catheter will need to be inserted into your abdomen. D) Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again.

A) Hemodialysis is a treatment option that is usually required three times a week.

Which of the following is the most common cause of acute renal failure in children? A) Hemolytic uremic syndrome B) Nephrotic syndrome C) Glomerulonephritis

A) Hemolytic uremic syndrome

A patient is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what? A) Hydronephrosis B) Nephritic syndrome C) Pylonephritis D) Nephrotoxicity

A) Hydronephrosis

A nurse knows that specific areas in the ureters have a propensity for obstruction. Prompt management of renal calculi is most important when the stone is located where? A) In the ureteropelvic junction B) In the ureteral segment near the sacroiliac junction C) In the ureterovesical junction D) In the urethra

A) In the ureteropelvic junction. Feedback: The three narrowed areas of each ureter are the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovescial junction. These three areas of the ureters have a propensity for obstruction by renal calculi or stricture. Obstruction of the ureteropelvic junction is most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. The urethra is not part of the ureter.

A nurse is working with a patient who will undergo invasive urologic testing. The nurse has informed the patient that slight hematuria may occur after the testing is complete. The nurse should recommend what action to help resolve hematuria? A) Increased fluid intake following the test B) Use of an OTC diuretic after the test C) Gentle massage of the lower abdomen D) Activity limitation for the first 12 hours after the test

A) Increased fluid intake following the test

The nurse is providing pre-procedure teaching about an ultrasound. The nurse informs the patient that in preparation for an ultrasound of the lower urinary tract the patient will require what? A) Increased fluid intake to produce a full bladder B) IV administration of radiopaque contrast agent C) Sedation and intubation D) Injection of a radioisotope

A) Increased fluid intake to produce a full bladder Feedback: Ultrasonography requires a full bladder; therefore, fluid intake should be encouraged before the procedures. The administration of a radiopaque contrast agent is required to perform IV urography studies, such as an IV pyelogram. Ultrasonography is a quick and painless diagnostic test and does not require sedation or intubation. The injection of a radioisotope is required for nuclear scan and ultrasonography is not in this category of diagnostic studies.

A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (Select all that apply) A) Avoid sitting in a wet bathing suit B) Wipe the perineal area back to front following elimination C) Empty the bladder when there is an urge to void. D) Wear synthetic fabric underwear E) Take a shower daily

A, C, E

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection? A) Indicates acceptance of altered appearance and demonstrates positive self-image. B) Freely expresses needs and concerns related to postoperative pain management. C) Compensates effectively for alteration in ability to communicate related to dysarthria. D) Demonstrates effective stress management techniques to promote muscle relaxation.

A) Indicates acceptance of altered appearance and demonstrates positive self-image. Feedback: Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patients appearance is visibly altered. The face generally appears asymmetric, with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Patients who have had head and neck surgery generally report less pain as compared with other postoperative patients; however, the nurse must assess each individual patients level of pain and response to analgesics. Patients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation.

A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician 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 acidbase imbalance

A) Infection with Helicobacter pylori. Feedback: H. pylori infection may be determined by endoscopy and histologic examination of a tissue specimen obtained by biopsy, or a rapid urease test of the biopsy specimen. Excessive stomach acid secretion leads to gastritis; however, peptic ulcers are caused by colonization of the stomach by H. pylori. Sphincter dysfunction and acidbase imbalances do not cause peptic ulcer disease.

A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action? A) Inform the physician and assess the patient for signs of infection. B) Flush the peritoneal catheter with normal saline. C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered.

A) Inform the physician and assess the patient for signs of infection.

The nurse and urologist have both been unsuccessful in catheterizing a patient with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the physician using to drain the patients bladder? A) Insertion of a suprapubic catheter B) Scheduling the patient immediately for a prostatectomy C) Application of warm compresses to the perineum to assist with relaxation D) Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours

A) Insertion of a suprapubic catheter

A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurses priority during this aspect of the patients care? A) Measure and record drainage. B) Monitor drainage for change in color. C) Titrate the suction every hour. D) Feed the patient via the G tube as ordered.

A) Measure and record drainage. Feedback: This drainage should be measured and recorded because it is a significant indicator of GI function. The nurse should indeed monitor the color of the output, but fluid balance is normally the priority. Frequent titration of the suction should not be necessary and feeding is contraindicated if the G tube is in place for drainage.

A patient 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 patient may be prescribed what drug? A) Metoclopramide (Reglan) B) Omeprazole (Prilosec) C) Lansoprazole (Prevacid) D) Famotidine (Pepcid)

A) Metoclopramide (Reglan) Rationale: Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprozole are proton pump inhibitors that reduce gastric acid secretion. Famotidine (Pepcid) is an H2receptor antagonist, which has a similar effect.

The nurse has tested the pH of urine from a patients newly created ileal conduit and obtained a result of 6.8. What is the nurses best response to this assessment finding? A) Obtain an order to increase the patients dose of ascorbic acid. B) Administer IV sodium bicarbonate as ordered. C) Encourage the patient to drink at least 500 mL of water and retest in 3 hours. D) Irrigate the ileal conduit with a dilute citric acid solution as ordered.

A) Obtain an order to increase the patients dose of ascorbic acid

An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? A) Palpate the patients parotid glands to detect swelling and tenderness. B) Assess the temporomandibular joint for evidence of a malocclusion. C) Test the integrity of cranial nerve XII by asking the patient to protrude the tongue. D) Inspect the patients gums for bleeding and hyperpigmentation.

A) Palpate the patients parotid glands to detect swelling and tenderness. Feedback: Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

Diagnostic imaging and physical assessment have revealed that a patient 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 Feedback: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.

The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patients health education, what nutritional guidelines should the nurse provide? A) Restrict protein intake as ordered. B) Increase intake of potassium-rich foods. C) Follow a low-calcium diet. D) Encourage intake of food containing oxalates

A) Restrict protein intake as ordered

A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care? A) Risk for Aspiration Related to Inhalation of Gastric Contents B) Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption C) Risk for Decreased Cardiac Output Related to Vasovagal Response D) Risk for Impaired Verbal Communication Related to Oral Trauma

A) Risk for Aspiration Related to Inhalation of Gastric Contents Rationale: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the patients nutritional status and does not affect cardiac output or communication.

A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patients post-procedure care? A) Strain the patients urine following the procedure. B) Administer a bolus of 500 mL normal saline following the procedure. C) Monitor the patient for fluid overload following the procedure. D) Insert a urinary catheter for 24 to 48 hours after the procedure.

A) Strain the patients urine following the procedure.

A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence? A) Stress incontinence B) Reflex incontinence C) Overflow incontinence D) Functional incontinence

A) Stress incontinence

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patients condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence? A) Tachycardia, hypotension, and tachypnea B) Tarry, foul-smelling stools C) Diaphoresis and sudden onset of abdominal pain D) Sudden thirst, unrelieved by oral fluid administration

A) Tachycardia, hypotension, and tachypnea. Feedback: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Patients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A) The patient will require an upper endoscopy every 6 months 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 patient will require an upper endoscopy every 6 months to detect malignant changes. Feedback: In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

The nurse is assessing a patients bladder by percussion. The nurse elicits dullness after the patient has voided. How should the nurse interpret this assessment finding? A) The patients bladder is not completely empty. B) The patient has kidney enlargement. C) The patient has a ureteral obstruction. D) The patient has a fluid volume deficit.

A) The patients bladder is not completely empty. Feedback:Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying. Enlargement of the kidneys can be attributed to numerous conditions such as polycystic kidney disease or hydronephrosis and is not related to bladder fullness. Dehydration and ureteral obstruction are not related to bladder fullness; in fact, these conditions result in decreased flow of urine to the bladder.

The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment finding would suggest that the patient is experiencing retention? A) The patients suprapubic region is dull on percussion. B) The patient is uncharacteristically drowsy. C) The patient claims to void large amounts of urine 2 to 3 times daily. D) The patient takes a beta adrenergic blocker for the treatment of hypertension.

A) The patients suprapubic region is dull on percussion.

A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A) The patients swallowing ability B) The patients ability to speak C) The patients management of secretions D) The patients airway patency

A) The patients swallowing ability. Rationale: If the superior laryngeal nerve is damaged, the patient may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Damage to this particular nerve does not inhibit speech and only affects management of secretions and airway patency indirectly.

A patient asks the nurse why kidney problems can cause gastrointestinal disturbances. What relationship should the nurse describe? A) The right kidneys proximity to the pancreas, liver, and gallbladder. B) The indirect impact of digestive enzymes on renal function. C) That the peritoneum encapsulates the GI system and the kidneys. D) The left kidneys connection to the common bile duct.

A) The right kidneys proximity to the pancreas, liver, and gallbladder.

A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic? A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy B) The need to expect a heavy menstrual period following the course of antibiotics C) The risk of developing antibiotic resistance after the course of antibiotics D) The need to undergo a series of three urine cultures after the antibiotics have been completed

A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action? A) This medication will reduce the amount of acid secreted in your stomach. B) This medication will make the lining of your stomach more resistant to damage. C) This medication will specifically address the pain that accompanies peptic ulcer disease. D) This medication will help your stomach lining to repair itself.

A) This medication will reduce the amount of acid secreted in your stomach. Feedback: Proton pump inhibitors like Prilosec inhibit the synthesis of stomach acid. PPIs do not increase the durability of the stomach lining, relieve pain, or stimulate tissue repair.

A patient with elevated BUN and creatinine values has been referred by her primary physician for further evaluation. The nurse should anticipate the use of what initial diagnostic test? A) Ultrasound B) X-ray C) Computed tomography (CT) D) Nuclear scan

A) Ultrasound

A nurse is preparing a patient diagnosed with benign prostatic hypertrophy (BPH) for a lower urinary tract cystoscopic examination. The nurse informs the patient that the most common temporary complication experienced after this procedure is what? A) Urinary retention B) Bladder perforation C) Hemorrhage D) Nausea

A) Urinary retention Feedback: After a cystoscopic examination, the patient with obstructive pathology may experience urine retention if the instruments used during the examination caused edema. The nurse will carefully monitor the patient with prostatic hyperplasia for urine retention. Post-procedure, the patient will experience some hematuria, but is not at great risk for hemorrhage. Unless the condition is associated with another disorder, nausea is not commonly associated with this diagnostic study. Bladder perforation is rare.

A nurse is caring for a 73-year-old patient with a urethral obstruction related to prostatic enlargement. When planning this patients care, the nurse should be aware of the consequent risk of what complication? A) Urinary tract infection B) Enuresis C) Polyuria D) Proteinuria

A) Urinary tract infection

The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what? A) Wash hands carefully and frequently. B) Ensure immediate function of the donated kidney. C) Instruct the patient to wear a face mask. D) Bar visitors from the patients room.

A) Wash hands carefully and frequently.

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that apply) A) Take the medication 1 hour before a meal B) Limit NSAIDs when taking this medication C) Expect skin flushing when taking this medication D) Increase fiber intake when taking this medication E_) Chew the medication thoroughly before swallowing

A, B

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that apply) A) Take the medication 1 hr before a meal B) Limit NSAIDs when taking this medication C) Expect skin flushing when taking this medication. D) Increase fiber intake when taking this medication E) Chew the medication thoroughly before swallowing.

A, B

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? (Select all that apply) A) Provide a high-protein diet B) Assess the urine for blood C) Monitor for intermittent anuria D) Weight the client once per week E) Provide NSAIDs for pain

A, B, C

The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply. A) Dietary history B) Family history of renal stones C) Medication history D) Surgical history E) Vaccination history

A, B, C

The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply. A) Quantity of output B) Color of the output C) Visible characteristics of the output D) Odor of the output E) pH of the output

A, B, C

Which of the following findings should the nurse expect in a client with a gastric ulcer? Select all that apply. A) Pain most often occurring 30 to 60 min after a meal B) Less often pain at night C) Pain exacerbated by ingestion of food D) Patient is well-nourished

A, B, C

A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A) Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion D) Teaching the patient to flush the line with sterile water E) Teaching the patient when it is safe to leave the access site open to air

A, B, C Feedback: An effective home care teaching program prepares the patient to store solutions, set up the infusion, flush the line with heparin, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Sterile water is never used for flushes and the access site must never be left open to air.

The nurse is reviewing the electronic health record of a patient with a history of incontinence. The nurse reads that the physician assessed the patients deep tendon reflexes. What condition of the urinary/renal system does this assessment address? A) Renal calculi B) Bladder dysfunction C) Benign prostatic hyperplasia (BPH) D) Recurrent urinary tract infections (UTIs)

B) Bladder dysfunction

A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply. A) Specific lifestyle changes associated with each procedure. B) Implications of each procedure for eating habits. C) Effects of different surgeries on bowel function. D) Effects of various bariatric surgeries on fertility. E) Effects of different surgeries on safety of future immunizations.

A, B, C Feedback: Different bariatric surgical procedures entail different lifestyle modifications; patients must be well informed about the specific lifestyle changes, eating habits, and bowel habits that may result from a particular procedure. Bariatric surgeries do not influence the future use of immunizations or fertility, though pregnancy should be avoided for 18 months after bariatric surgery.

A client who is scheduled for kidney transplantation surgery is assessed by the nurse for risk factors of surgery. Which of the following findings increase the client's risk of surgery? (Select all that apply) A) Age older than 70 years B) BMI of 41 C) Administer NPH insulin each morning D) Past hx of lymphoma E) Blood pressure averaging 120/70 mmHg

A, B, C, D

A nurse is planning postprocedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply). A) Check BUN and blood creatinine. B) Administer medications the nurse withheld prior to dialysis C) Observe for findings of hypovolemia D) Assess the access site for bleeding E) Evaluate blood pressure on the arm with AV access.

A, B, C, D

A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply. A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms. E) The cuffs absorb dialysate

A, B, C, D

The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply. A) Providing emotional support for the family. B) Monitoring for complications. C) Participating in emergency treatment of fluid and electrolyte imbalances. D) Providing nursing care for primary disorder (trauma). E) Directing nutritional interventions.

A, B, C, D

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply) A) Anuria B) Marked azotemia C) Crackles in the lungs D) Increased calcium level E) Proteinuria

A, B, C, E

A nurse is caring for a client who has type 2 diabetes mellitus and will have excretory urography. Prior to the procedure, which of the following actions should the nurse take? (Select all that apply) A) Identify an allergy to seafood B) Withhold metformin for 24hrs C) Administer an enema D) Obtain a blood coagulation profile E) Assess for asthma

A, B, C, E

A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A) Assess for jugular vein distention B) Provide frequent mouth rinses C) Auscultate for a pleural friction rub D) Provide a high-sodium diet E) Monitor for dysrhythmias

A, B, C, E

A nurse is planning postoperative care for a client following a kidney transplant. Which of the following actions should the nurse include? (Select all that apply) A) Obtain daily weights B) Assess dressings for a bloody drainage C) Replace hourly urine output with IV fluids D) Expect oliguria in the first 4 hr E) Monitor blood electrolytes

A, B, C, E

A nurse is teaching a parent of an infant about GERD. Which of the following should the nurse include in the teaching? ( Select all that apply) A) Offer frequent feedings B) Thicken formula with rice cereal C) Use a bottle with a one-way valve D) Position baby upright after feedings E) Use a wide-based nipple for feedings

A, B, D

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply. A) Decreased protein intake B) Decreased sodium intake C) Increased potassium intake D) Fluid restriction

A, B, D

Which of the following is not an expected finding of appendicitis? A) Increased WBC B) Bloody diarrhea C) RLQ abdominal pain D) Nausea and vomiting

B) Bloody diarrhea

A patient has been discharged home on parenteral nutrition (PN). Much of the nurses discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply. A) Changes in lifestyle. B) Loss of eating as social behavior. C) Chronic bowel incontinence from GI changes. D) Sleep disturbances related to frequent urination during nighttime infusions. E) Stress of choosing the correct PN formulation.

A, B, D Feedback: Patients must cope with the loss of eating as a social behavior and with changes in lifestyle brought on by sleep disturbances related to frequent urination during night time infusions. PN is not associated with bowel incontinence and the patient does not select or adjust the formulation of PN.

A nurse is caring for a several clients. Which of the following clients are at risk for developing pyelonephritis? (Select all that apply) A) A client who is 32 weeks of gestation B) A client who has kidney calculi C) A client who has a urine pH of 4.2 D) A client who has a neurogenic bladder E) A client who has diabetes mellitus

A, B, D, E

A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? (Select all that apply) A) Monitor blood glucose levels B) Report cloudy dialysate return C) Warm the dialysate in a microwave oven D) Assess for SOB E) Check the access site dressing for wetness F) Maintain medical asepsis when accessing the catheter insertion site.

A, B, D, E

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply). A) Review the medications the client currently takes B) Assess the AV fistula for a bruit. C) Calculate the client's hourly urine output D) Measure the client's weight. E) Check blood electrolytes F) Use the access site area for venipuncture.

A, B, D, E

A nurse is reviewing discharge instructions with a client who had spontaneous passage of a calcium phosphate renal calculus. Which of the following instructions should the nurse include in the teaching? (Select all that apply) A) Limit intake of food high in animal protein B) Reduce sodium intake C) Strain urine for 48 hr D) Report burning with urination to the provider E) Increase fluid intake to 3L/day

A, B, D, E

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (Select all that apply) A) Rigid abdomen B) Tachycardia C) Elevated blood pressure D) Circumoral cyanosis E) Rebound tenderness

A, B, E

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to peptic ulcer. Which of the following findings should the nurse expect? (Select all that apply) A) Rigid abdomen B) Tachycardia C) Elevated blood pressure D) Circumoral cyanosis E) Rebound tenderness

A, B, E

A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? A) Projectile vomiting B) Dry mucus membranes C) Currant jelly stools D) Sausage-shaped abd. mass E) Constant hunger

A, B, E

A nurse is caring for a client who has a new diagnosis of GERD. The nurse should expect prescriptions for which of the following medications? A) Antacids B) Histamine2 receptor antagonists C) Opioid analgesics D) Fiber laxatives E) Proton pump inhibitors

A, B, E

A nurse is caring for a client who has a new diagnosis of GERD. The nurse should expect prescriptions for which of the following medications? (Select all that apply) A) Antacids B) Histamine2 receptor antagonists C) Opioid analgesics D) Fiber laxatives E) Proton pump inhibitors

A, B, E

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care? ( Select all that apply) A) Evaluate intake and output B) Monitor lab reports of electrolytes C) Provide three large meals a day D) Administer ibuprofen for pain E) Observe stool char.

A, B, E

A nurse is caring for a child who has Meckel's diverticulum. Which of the following manifestations should the nurse expect? (Select all that apply) A) Abd. pain B) Fever C) Mucus and blood in stools D) Vomiting E) Rapid, swallow breathing

A, C

A nurse is teaching a client who is scheduled for a kidney transplant about organ rejection. Which of the following statements should the nurse include? (Select all that apply) A) "Expect an immediate removal of the donor kidney for a hyperacute rejection" B) "You might need to begin dialysis to monitor your kidney function for a hyperacute rejection" C) "A fever is a manifestation of an acute rejection" D) "Fluid retention is a manifestations of an acute rejection" E) "Your provider will increase your immunosuppressive medications for a chronic rejection"

A, C, D

What would the diet consist of for a client undergoing hemodialysis? Select all that apply. A) Decreased protein intake B) Increased potassium intake C) Decreased sodium intake D) Fluid restriction

A, C, D

A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse plan to take? (Select all that apply) A) Provide a referral for nutrition counseling B) Encourage daily fluid intake of 1 L C) Palpate the costovertebral angle D) Monitor urinary output E) Administer antibiotics

A, C, D, E

A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? (Select all that apply) 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, C, E

A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply. A) To remove gas from the stomach. B) To administer clotting factors to treat a GI bleed. C) To remove toxins from the stomach. D) To open sphincters that are closed. E) To diagnose GI motility disorders.

A, C, E Feedback: GI intubation may be performed to decompress the stomach and remove gas and fluid, lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility and other disorders, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. GI intubation is not used for opening sphincters that are not functional or for administering clotting factors.

The nurse is preparing to collect an ordered urine sample for urinalysis. The nurse should be aware that this test will include what assessment parameters? Select all that apply. A) Specific gravity of the patients urine B) Testing for the presence of glucose in the patients urine. C) Microscopic examination of urine sediment for RBCs. D) Microscopic examination of urine sediment for casts. E) Testing for BUN and creatinine in the patients urine

A,B,C,D

A nurse is caring for a female patient whose urinary retention has not responded to conservative treatment. When educating this patient about self-catheterization, the nurse should encourage what practice? A) Assuming a supine position for self-catheterization B) Using clean technique at home to catheterize C) Inserting the catheter 1 to 2 inches into the urethral D) Self-catheterizing every 2 hours at home

B) Using clean technique at home to catheterize

The nurse is reviewing lab data of a client who has an acute exacerbation of Crohn's disease. Which of the following blood lab results should the nurse expect to be elevated? (Select all that apply) A) Hematocrit B) Erythrocyte sedimentation rate C) WBC D) Folic acid E) Albumin

B

A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient? A) A patient whose diagnosis of chronic kidney disease requires a fluid restriction B) A patient who has Alzheimers disease and who is acutely agitated C) A patient who is on bed rest following a recent episode of venous thromboembolism D) A patient who has decreased mobility following a transmetatarsal amputation

B) A patient who has Alzheimers disease and who is acutely agitated

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A) A patient with a history of polycystic kidney disease. B) A patient with diabetes mellitus and poorly controlled hypertension. C) A patient who is morbidly obese with a history of vascular disorders. D) A patient with severe chronic obstructive pulmonary disease

B) A patient with diabetes mellitus and poorly controlled hypertension.

A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching? A) "I can take my medications with soda" B) "Peppermint tea will increase my indigestion" C) "Wearing an abdominal binder will limit my manifestations" D) "I will drink hot chocolate at bedtime to help me sleep" E) "I can lift weights as a way to exercise"

B) "Peppermint tea will increase my indigestion"

A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching? A) "I can take my meds with soda" B) "Peppermint tea will increase my indigestion" C) "Wearing an abdominal binder will limit my manifestations" D) "I will drink hot chocolate at bedtime to help me sleep" E) "I can lift weights as a way to exercise"

B) "Peppermint tea will increase my indigestion"

A charge nurse is teaching a group of nurses about a client who has chronic gastritis and is scheduled for a selective vagotomy. Which of the following statements by a unit nurse indicates an understanding of the purpose of the procedure? A) "The client will have increased duodenal gastric emptying" B) "The client will have a reduction of gastric acid secretions" C) "The client will have an increase of gastric mucus secretions D) "The client will have an increased secretion of hydrogen/potassium ATPase enzymes"

B) "The client will have a reduction of gastric acid secretions"

The nurse caring for a patient with suspected renal dysfunction calculates that the patients weight has increased by 5 pounds in the past 24 hours. The nurse estimates that the patient has retained approximately how much fluid? A) 1,300 mL of fluid in 24 hours B) 2,300 mL of fluid in 24 hours C) 3,100 mL of fluid in 24 hours D) 5,000 mL of fluid in 24 hours

B) 2,300 mL of fluid in 24 hours Feedback: An increase in body weight commonly accompanies edema. To calculate the approximate weight gain from fluid retention, remember that 1 kg of weight gain equals approximately 1,000 mL of fluid. Five lbs = 2.27 kg = 2,270 mL.

The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day? A) 1,250 mL B) 2,000 mL C) 2,750 mL D) 3,500 mL

B) 2,750 mL

A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what? A) Presence of small blood clots in the drainage B) 60 mL of milky or cloudy drainage C) Spots of drainage on the dressings surrounding the drain D) 120 mL of serosanguinous drainage

B) 60 mL of milky or cloudy drainage. Rationale: Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Milky drainage is indicative of a chyle fistula, which requires prompt treatment.

A nurse is caring for a patient with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples? A) A fasting serum potassium level and a random urine sample B) A 24-hour urine specimen and a serum creatinine level midway through the urine collection process C) A BUN and serum creatinine level on three consecutive mornings D) A sterile urine specimen and an electrolyte panel, including sodium, potassium, calcium, and phosphorus values

B) A 24-hour urine specimen and a serum creatinine level midway through the urine collection process Feedback: To calculate creatinine clearance, a 24-hour urine specimen is collected. Midway through the collection, the serum creatinine level is measured.

The critical care nurse is monitoring the patients urine output and drains following renal surgery. What should the nurse promptly report to the physician? A) Increased pain on movement B) Absence of drain output C) Increased urine output D) Blood-tinged serosanguineous drain output

B) Absence of drain output.

A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what? A) Knowledge of the causes of obesity and its associated risks. B) Adequate understanding of required lifestyle changes. C) Positive body image and high self-esteem. D) Insight into why past weight loss efforts failed.

B) Adequate understanding of required lifestyle changes. Feedback: Patients seeking bariatric surgery should be free of serious mental disorders and motivated to comply with lifestyle changes related to eating patterns, dietary choices, and elimination. While assessment of knowledge about causes of obesity and its associated risks as well as insight into the reasons why previous diets have been ineffective are included in the clients plan of care, these do not predict positive client outcomes following bariatric surgery. Most obese patients have an impaired body image and alteration in self-esteem. An obese patient with a positive body image would be unlikely to seek this surgery unless he or she was experiencing significant comorbidities.

The nurse is caring for a patient scheduled for renal angiography following a motor vehicle accident. What patient preparation should the nurse most likely provide before this test? A) Administration of IV potassium chloride B) Administration of a laxative C) Administration of Gastrografin D) Administration of a 24-hour urine test

B) Administration of a laxative

A patient who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patient's priority need at this time? A) Emotional support from visitors and staff B) An effective means of communicating with the nurse C) Referral to a speech therapist D) Dietary teaching focused on the consistency of food and frequency of feedings

B) An effective means of communicating with the nurse. Feedback: Verbal communication may be impaired by radical surgery for oral cancer. It is therefore vital to assess the patients ability to communicate in writing before surgery. Emotional support and dietary teaching are critical aspects of the plan of care; however, the patients ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the patients rehabilitation; however, it is not a priority at this particular time. Communication with the nurse is crucial for the delivery of safe and effective care.

A patients 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 3 to 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. Feedback: When a tube is first noted to be clogged, a 30- to 60-mL syringe should be attached to the end of the tube and any contents aspirated and discarded. Then the syringe should be filled with warm water, attached to the tube again, and a back-and-forth motion initiated to help loosen the clog. Removal is not warranted at this early stage and a flicking motion is not recommended. The tube should not be withdrawn, even a few centimeters.

The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurses best response to this finding? A) Perform a straight catheterization on this patient. B) Avoid further interventions at this time, as this is an acceptable finding. C) Place an indwelling urinary catheter. D) Press on the patients bladder in an attempt to encourage complete emptying

B) Avoid further interventions at this time, as this is an acceptable finding.

A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include? A) Increasing calcium intake to promote bone healing B) Avoiding chewing food for the specified number of weeks after surgery C) Techniques for managing parenteral nutrition in the home setting D) Techniques for managing a gastrostomy

B) Avoiding chewing food for the specified number of weeks after surgery. Rationale: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. Increased calcium intake will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely necessary.

A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A) Use clean technique and wear a mask during dressing changes. B) Change the dressing no more than weekly. C) Apply antibiotic ointment around the site with each dressing change. D) Irrigate the insertion site with sterile water during each dressing change.

B) Change the dressing no more than weekly. Feedback: The CDC (2011) recommends changing CVAD dressings not more than every 7 days unless the dressing is damp, bloody, loose, or soiled. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not used.

A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery? A) Disturbed Body Image Related to Obesity. B) Deficient Knowledge Related to Risks and Expectations of Surgery. C) Anxiety Related to Surgery. D) Chronic Low Self-Esteem Related to Obesity.

B) Deficient Knowledge Related to Risks and Expectations of Surgery. Feedback: It is expected that patients seeking bariatric surgery may have challenges with body image and self-esteem related to their obesity. Anxiety is also expected when facing surgery. However, if the patients knowledge remains deficient regarding the risks and realistic expectations for surgery, this may show that the patient is not an appropriate surgical candidate.

A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patients discharge education, what is the most plausible nursing diagnosis that the nurse should address? A) Impaired mobility related to limitations posed by the ileal conduit. B) Deficient knowledge related to care of the ileal conduit. C) Risk for deficient fluid volume related to urinary diversion. D) Risk for autonomic dysreflexia related to disruption of the sacral plexus

B) Deficient knowledge related to care of the ileal conduit.

A nurse is completing the admission assessment of a client who has renal calculi. Which of the following findings should the nurse expect? A) Bradycardia B) Diaphoresis C) Nocturia D) Bradypnea

B) Diaphoresis

A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A) Decrease intake of calorie dense foods B) Drink canned protein supplements C) Increase intake of high fiber foods D) Eat high-residue foods.

B) Drink canned protein supplements

A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patients discharge. Which of the following is essential to include? A) Drink a minimum of 12 ounces of fluid with each meal. B) Eat several small meals daily spaced at equal intervals. C) Choose foods that are high in simple carbohydrates. D) Sit upright when eating and for 30 minutes afterward.

B) Eat several small meals daily spaced at equal intervals Feedback: Due to decreased stomach capacity, the patient must consume small meals at intervals to meet nutritional requirements while avoiding a feeling of fullness and complications such as dumping syndrome. The patient should not consume fluids with meals and low-Fowlers positioning is recommended during and after meals. Carbohydrates should be limited.

A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patients body image? A) Emphasize that the diversion is an integral part of successful cancer treatment. B) Encourage the patient to speak openly and frankly about the diversion. C) Allow the patient to initiate the process of providing care for the diversion. D) Provide the patient with detailed written materials about the diversion at the time of discharge.

B) Encourage the patient to speak openly and frankly about the diversion.

A patients enteral feedings have been determined to be too concentrated based on the patients development of dumping syndrome. What physiologic phenomenon caused this patients complication of enteral feeding? A) Increased gastric secretion of HCl and gastrin because of high osmolality of feeds B) Entry of large amounts of water into the small intestine because of osmotic pressure C) Mucosal irritation of the stomach and small intestine by the high concentration of the feed D) Acidbase imbalance resulting from the high volume of solutes in the feed

B) Entry of large amounts of water into the small intestine because of osmotic pressure. Feedback: When a concentrated solution of high osmolality entering the intestines is taken in quickly or in large amounts, water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. This results in dumping syndrome. Dumping syndrome is not the result of changes in HCl or gastrin levels. It is not caused by an acidbase imbalance or direct irritation of the GI mucosa.

A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? 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. Feedback: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.

A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? A) Imbalanced nutrition: More than body requirements B) Excess fluid volume C) Sedentary lifestyle D) Adult failure to thrive

B) Excess fluid volume

A nurse is teaching about pernicious anemia with a client who has chronic gastritis. Which of the following information should the nurse include in the teaching? A) Pernicious anemia is caused when the cells producing gastric acid are damaged. B) Expect a monthly injection of vitamin B12 C) Plan to take vitamin K supplements D) Pernicious anemia is caused by an increased production of intrinsic factor.

B) Expect a monthly injection of vitamin B12

A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment? A) Bowel incontinence B) Flatus with oily discharge C) Abdominal pain D) Heat intolerance

B) Flatus with oily discharge Feedback: Side effects of orlistat include increased frequency of bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance.

A nurse is reviewing client laboratory data. Which of the following findings is expected for a client who has Stage 4 chronic kidney disease? A) Blood urea nitrogen (BUN) 15 mg/dL B) Glomerular filtration rate 20mL/min C) Blood creatinine 1.1 mg/dL D) Blood potassium 5.0 mEq/L

B) Glomerular filtration rate 20mL/min

A patient with a history of progressively worsening fatigue is undergoing a comprehensive assessment which includes test of renal function relating to erythropoiesis. When assessing the oxygen transport ability of the blood, the nurse should prioritize the review of what blood value? A) Hematocrit B) Hemoglobin C) Erythrocyte sedimentation rate (ESR) D) Serum creatinine

B) Hemoglobin

A nurse is monitoring a client who had a kidney biopsy for postop complications. Which of the following complications should the nurse identify as causing the greatest risk to the client? A) Infection B) Hemorrhage C) Hematuria D) Pain

B) Hemorrhage

Resection of a patients bladder tumor has been incomplete and the patient is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the patient, the nurse should emphasize the need to do which of the following? A) Remain NPO for 12 hours prior to the treatment. B) Hold the solution in the bladder for 2 hours before voiding. C) Drink the intravesical solution quickly and on an empty stomach.. D) Avoid acidic foods and beverages until the full cycle of treatment is complete.

B) Hold the solution in the bladder for 2 hours before voiding.

A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patients discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt? A) Increasing intake of protein from plant sources B) Increasing fluid intake C) Adopting a high-calcium diet D) Eating several small meals each day

B) Increasing fluid intake

A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patients plan of care, which of the following nursing diagnoses should be included? A) Risk for Peripheral Neurovascular Dysfunction Related to Catheter Placement. B) Ineffective Role Performance Related to Parenteral Nutrition. C) Bowel Incontinence Related to Parenteral Nutrition. D) Chronic Pain Related to Catheter Placement.

B) Ineffective Role Performance Related to Parenteral Nutrition. Feedback: The limitations associated with PN can make it difficult for patients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction.

A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient? A) Most affected patients 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. Feedback: Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water. The organism is endemic to all areas of the United States. Genetic factors have not been identified.

A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurses priority intervention? A) Administration of antiemetics B) Insertion of an NG tube for decompression C) Infusion of hypotonic IV solution D) Administration of proton pump inhibitors as ordered

B) Insertion of an NG tube for decompression Feedback: In treating the patient with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration.

Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage? A) Eating several small meals daily rather than 3 larger meals B) Keeping the head of the bed slightly elevated C) Drinking carbonated mineral water rather than soft drinks D) Avoiding food or fluid intake after 6:00 p.m.

B) Keeping the head of the bed slightly elevated Rationale: The patient with GERD is encouraged to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks. Frequent meals are not specifically encouraged and the patient should avoid food and fluid within 2 hours of bedtime. All carbonated beverages should be avoided.

A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? A) The decision is certainly yours to make, but be sure not to make a mistake. B) Kidney transplants in patients your age are as successful as they are in younger patients. C) I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare. D) Have you talked this over with your family?

B) Kidney transplants in patients your age are as successful as they are in younger patients.

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population? A) Administer prophylactic antibiotics as ordered. B) Limit the use of indwelling urinary catheters. C) Encourage frequent mobility and repositioning. D) Toilet residents who are immobile on a scheduled basis

B) Limit the use of indwelling urinary catheters.

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? A) Pyloric sphincter B) Lower esophageal sphincter C) Hypopharyngeal sphincter D) Upper esophageal sphincter

B) Lower esophageal sphincter. Rationale: The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.

A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient? A) Increasing oral intake B) Managing postoperative pain C) Managing dialysis D) Increasing mobility

B) Managing dialysis

A nurse is completing a assessment of a client who has GERD. Which of the following is an expected finding? A) Absence of saliva B) Painful swallowing C) Sweet taste in mouth D) Absence of eructation

B) Painful swallowing

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? A) Absence of saliva B) Painful swallowing C) Sweet taste in mouth D) Absence of eructation

B) Painful swallowing

A nurse is caring for an infant who has just returned from PACU following a cleft lip and palate repair. Which of the following actions should the nurse take? A) Remove the packing in mouth B) Place the infant in an upright position C) Offer a pacifier with sucrose D) Assess the mouth with a tongue blade

B) Place the infant in an upright position

A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a UTI? A) Positive for hyaline casts B) Positive for leukocyte esterase C) Positive for ketones D) Positive for crystals

B) Positive for leukocyte esterase

A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? A) Encourage a high-fiber, low-protein, low-calorie diet B) Prepare the family for surgery C) Place an NG tube for decompression D) Initiate bed rest

B) Prepare the family for surgery.

A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders? A) Monitor the patients electrolyte values every hour before the procedure. B) Preprocedure hydration and administration of acetylcysteine C) Hemodialysis immediately prior to the CT scan D) Obtain a creatinine clearance by collecting a 24-hour urine specimen.

B) Preprocedure hydration and administration of acetylcysteine

The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? A) Dull pain radiating to the ears and teeth. B) Presence of a painless sore with raised edges. C) Areas of tenderness that make chewing difficult. D) Diffuse inflammation of the buccal mucosa.

B) Presence of a painless sore with raised edges. Feedback: Malignant lesions of the oral cavity are most often painless lumps or sores with raised borders. Because they do not bother the patient, delay in seeking treatment occurs frequently, and negatively affects prognosis. Dull pain radiating to the ears and teeth is characteristic of malocclusion. Inflammation of the buccal mucosa causes discomfort and often occurs as a side effect of chemotherapy. Tenderness resulting in pain on chewing may be associated with gingivitis, abscess, irritation from dentures, and other causes. Pain related to oral cancer is a late symptom.

A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action? A) Document the findings as being consistent with a viable graft. B) Promptly report these indications of venous congestion. C) Closely monitor the patient and reassess in 30 minutes. D) Reposition the patient to promote peripheral circulation.

B) Promptly report these indications of venous congestion. Feedback: A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.

A patient with recurrent urinary tract infections has just undergone a cystoscopy and complains of slight hematuria during the first void after the procedure. What is the nurses most appropriate action? A) Administer a STAT dose of vitamin K, as ordered. B) Reassure the patient that this is not unexpected and then monitor the patient for further bleeding. C) Promptly inform the physician of this assessment finding. D) Position the patient supine and insert a Foley catheter, as ordered.

B) Reassure the patient that this is not unexpected and then monitor the patient for further bleeding.

A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurses most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurses most appropriate response? A) Assess the patient for further signs or symptoms of rejection. B) Recognize this as an expected finding. C) Inform the primary care provider of this finding. D) Administer exogenous antidiuretic hormone as ordered.

B) Recognize this as an expected finding.

A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom? A) Burning pain on swallowing B) Regurgitation of undigested food C) Symptoms mimicking a heart attack D) Chronic parotid abscesses

B) Regurgitation of undigested food Feedback: An esophageal diverticulum is an outpouching of mucosa and submucosa that protrudes through the esophageal musculature. Food becomes trapped in the pouch and is frequently regurgitated when the patient assumes a recumbent position. The patient may experience difficulty swallowing; however, burning pain is not a typical finding. Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid abscesses are not associated with a diagnosis of esophageal diverticulum.

A patient is scheduled for a diagnostic MRI of the lower urinary system. What pre-procedure education should the nurse include? A) The need to be NPO for 12 hours prior to the test B) Relaxation techniques to apply during the test C) The need for conscious sedation prior to the test D) The need to limit fluid intake to 1 liter in the 24 hours before the test

B) Relaxation techniques to apply during the test

A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action? A) Advance the catheter 2 to 4 cm further into the peritoneal cavity. B) Reposition the patient to facilitate drainage. C) Aspirate from the catheter using a 60-mL syringe. D) Infuse 50 mL of additional dialysate.

B) Reposition the patient to facilitate drainage.

A patient with renal failure secondary to diabetic nephropathy has been admitted to the medical unit. What is the most life-threatening effect of renal failure for which the nurse should monitor the patient? A) Accumulation of wastes B) Retention of potassium C) Depletion of calcium D) Lack of BP control

B) Retention of potassium Feedback: Retention of potassium is the most life-threatening effect of renal failure. Aldosterone causes the kidney to excrete potassium, in contrast to aldosterones effects on sodium described previously. Acidbase balance, the amount of dietary potassium intake, and the flow rate of the filtrate in the distal tubule also influence the amount of potassium secreted into the urine. Hypocalcemia, the accumulation of wastes, and lack of BP control are complications associated with renal failure, but do not have same level of threat to the patients well-being as hyperkalemia.

A patient with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acidbase balance? A) Sequestering free hydrogen ions in the nephrons. B) Returning bicarbonate to the bodys circulation. C) Returning acid to the bodys circulation. D) Excreting bicarbonate in the urine.

B) Returning bicarbonate to the bodys circulation.

A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan? A) Risk for Excess Fluid Volume Related to Enteral Feedings B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube C) Risk for Unstable Blood Glucose Related to Enteral Feedings D) Risk for Impaired Verbal Communication Related to Presence of NG Tube

B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube Feedback: NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This patients NG tube is in place for decompression, so complications of enteral feeding do not apply.

A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patients plan of care? A) Impaired physical mobility related to presence of an indwelling urinary catheter. B) Risk for infection related to presence of an indwelling urinary catheter. C) Toileting self-care deficit related to urinary catheterization. D) Disturbed body image related to urinary catheterization.

B) Risk for infection related to presence of an indwelling urinary catheter.

The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? A) Provide medication teaching related to pseudoephedrine sulfate. B) Teach the patient to perform pelvic floor muscle exercises. C) Prepare the patient for an anterior vaginal repair procedure. D) Provide information on periurethral bulking.

B) Teach the patient to perform pelvic floor muscle exercises.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A) The patient has abdominal bloating that developed rapidly. B) The patient has a rigid, boardlike abdomen that is tender. C) The patient is experiencing intense lower right quadrant pain. D) The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.

B) The patient has a rigid, boardlike abdomen that is tender. Feedback: An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.

The nurse is preparing to insert a patients ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement? A) The patient is obese and has a short neck. B) The patient is agitated. C) The patient has a history of gastroesophageal reflux disease (GERD). D) The patient is being treated for pneumonia.

B) The patient is agitated. Feedback: Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion. A short neck, GERD, and pneumonia are not linked to incorrect placement.

A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patients level of anxiety. Which of the following actions is most likely to accomplish this? A) The nurse gauges the patients response to hypothetical outcomes. B) The patient is encouraged to express fears openly. C) The nurse provides detailed and accurate information about the disease. D) The nurse closely observes the patients body language.

B) The patient is encouraged to express fears openly. Feedback: Encouraging the patient to discuss his or her fears and anxieties is usually the best way to assess a patients anxiety. Presenting hypothetical situations is a surreptitious and possibly inaccurate way of assessing anxiety. Observing body language is part of assessment, but it is not the complete assessment. Presenting information may alleviate anxiety for some patients, but it is not an assessment.

A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient? A) The disease is self-limiting and cysts usually resolve spontaneously in the fifth or sixth decade of life. B) The patients disease is incurable and the nurses interventions will be supportive. C) The patient will eventually require surgical removal of his or her renal cysts. D) The patient is likely to respond favorably to lithotripsy treatment of the cysts.

B) The patients disease is incurable and the nurses interventions will be supportive.

The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite? A) Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group. C) Men of all ages are less prone to UTIs, but typically experience more severe symptoms. D)The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.

B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group.

The nurse is caring for a patient who describes changes in his voiding patterns. The patient states, I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesnt seem to be a great deal of urine flow. What would the nurse expect this patients physical assessment to reveal? A) Hematuria B) Urine retention C) Dehydration D) Renal failure

B) Urine retention

A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions? A) Rinse the mouth with alcohol before bedtime for the next 7 days. B) Use warm saline to rinse the mouth as needed. C) Brush around the area with a firm toothbrush to prevent infection. D) Use a toothpick to dislodge any debris that gets lodged in the socket.

B) Use warm saline to rinse the mouth as needed. Rationale: The patient should be assessed for bleeding after the tooth is extracted. The mouth can be rinsed with warm saline to keep the area clean. A firm toothbrush or toothpick could injure the tissues around the extracted area. Alcohol would injure tissues that are healing.

A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? A) Administer antibiotics via the tube as ordered. B) Wash the area around the tube with soap and water daily. C) Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. D) Irrigate the skin surrounding the insertion site with normal saline before each use.

B) Wash the area around the tube with soap and water daily. Feedback: Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not administered to prevent site infection.

Dipstick testing of an older adult patients urine indicates the presence of protein. Which of the following statements is true of this assessment finding? A) This finding needs to be considered in light of other forms of testing. B) This finding is a risk factor for urinary incontinence. C) This finding is likely the result of an age-related physiologic change. D) This result confirms that the patient has diabetes. Select all that apply.

B, C, D

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of potential complications? Select all that apply. A) Malignant hyperthermia B) Atelectasis C) Pneumonia D) Metabolic imbalances E) Chronic gastritis

B, C, D Feedback: After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as pneumonia, atelectasis, or metabolic imbalances resulting from the GI disruption. Malignant hyperthermia is an intra-operative complication. Chronic gastritis is not a surgical complication.

patient is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply. A) Petechiae B) Pain C) Gastrointestinal symptoms D) Changes in voiding E) Jaundice

B, C, D Feedback: Dysfunction of the kidney can produce a complex array of symptoms throughout the body. Pain, changes in voiding, and gastrointestinal symptoms are particularly suggestive of urinary tract disease. Jaundice and petechiae are not associated with genitourinary health problems.

A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patients care plan should include nursing actions relevant to what potential complications? Select all that apply. A) Dumping syndrome B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis

B, C, D, E Feedback: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. A) Percuss for pain in the right lower abdominal quadrant. B) Assess for the presence of peripheral edema. C) Auscultate the patients apical heart rate for dysrhythmias. D) Assess the patients BP. E) Assess the patients orientation and judgment.

B, D

A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate calculus. To decrease the chance of recurrence, the nurse should instruct the client avoid which of the following foods? (Select all that apply) A) Red meat B) Black tea C) Cheese D) Whole grains E) Spinach

B, E

A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment? A) Clearly explain the potential benefits of pelvic floor muscle exercises. B) Ensure the patient knows that surgery will be required if the exercises are unsuccessful. C) Arrange for biofeedback when the patient is learning to perform the exercises. D) Contact the patient weekly to ensure that she is performing the exercises consistently.

C) Arrange for biofeedback when the patient is learning to perform the exercises.

A nurse is assessing a patient who has just been admitted to the post-surgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A) Assess ability to clear oral secretions. B) Assess for signs of infection. C) Assess for a patent airway. D) Assess for ability to communicate.

C) Assess for patent airway

A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A) Administer an opioid medication B) Monitor for hypertension C) Assess level of consciousness D) Increase the dialysis exchange rate.

C) Assess level of consciousness

The nurse is performing a focused genitourinary and renal assessment of a patient. Where should the nurse assess for pain at the costovertebral angle? A) At the umbilicus and the right lower quadrant of the abdomen B) At the suprapubic region and the umbilicus C) At the lower border of the 12th rib and the spine D) At the 7th rib and the xyphoid process

C) At the lower border of the 12th rib and the spine Feedback: The costovertebral angle is the angle formed by the lower border of the 12th rib and the spine. Renal dysfunction may produce tenderness over the costovertebral angle.

A nurse is completing discharges teaching with a client who is post-op following fundoplication. Which of the following statements by the client indicates understanding of the teaching? A) "When sitting in my lounge chair after a meal, I will lower the back of it" B) "I will try to eat three large meals a day" C) "I will elevate the head of my bed on blocks" D) "I will avoid eating within 1 hour before bedtime"

C) "I will elevate the head of my bed on blocks"

A nurse is completing discharge teaching with a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching? A) "When sitting in my lounge chair after a meal, I will lower the back of it" B) "I will try to eat three large meals a day" C) "I will elevate the head of the bed on blocks" D) "I will avoid eating within 1 hour before bedtime"

C) "I will elevate the head of the bed on blocks"

A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori. Which of the following statements by the client indicates understanding of the teaching? A) "I will continue my prescription for corticosteriods" B) "I will schedule a CT scan to monitor improvement" C) "I will take a combination of medications for treatment" D) "I will have my throat swabbed to recheck for bacteria"

C) "I will take a combination of medications for treatment"

A nurse is teaching a client who has a new prescription for famotidine. Which of the following statements by the client indicate understanding of the teaching? A) "The medication coats the lining of my stomach" B) "The medication should stop the pain right away" C) "I will take my pill at bedtime" D) "I will monitor for bleeding from my nose"

C) "I will take my pill at bedtime"

A nurse is teaching a client who is postoperative following a kidney transplant and is taking cyclosporine. Which of the following instructions should the nurse include? A) "Decrease your intake of protein-rich foods" B) "Take this medication with a grapefruit juice" C) "Monitor for and report a sore throat to your provider" D) "Expect your skin to turn yellow"

C) "Monitor for and report a sore throat to your provider"

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching? A) "Take the medication 2 hours after eating" B) "Discontinue this medication if your skin turns yellow-orange C) "Notify the provider if you experience a sore throat" D) "Expect your stools to turn black"

C) "Notify the provider if you experience a sore throat"

You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed? A) 2 weeks B) 4 to 6 weeks C) 2 to 3 months D) 4 to 6 months

C) 2 to 3 months Feedback: An alternative to the PEG device is a low-profile gastrostomy device (LPGD). LPGDs may be inserted 2 to 3 months after initial gastrostomy tube placement.

The staff educator is giving a class for a group of nurses new to the renal unit. The educator is discussing renal biopsies. In what patient would the educator tell the new nurses that renal biopsies are contraindicated? A) A 64-year-old patient with chronic glomerulonephritis B) A 57-year-old patient with proteinuria C) A 42-year-old patient with morbid obesity D) A 16-year-old patient with signs of kidney transplant rejection

C) A 42-year-old patient with morbid obesity Feedback: There are several contraindications to a kidney biopsy, including bleeding tendencies, uncontrolled hypertension, a solitary kidney, and morbid obesity. Indications for a renal biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies.

A nurse is caring for a client who has left renal calculus and an indwelling urinary catheter. Which of the following assessments findings is the priority for the nurse to report to the provider? A) Flank pain that radiates to the lower abdomen B) Client report of nausea C) Absent urine output for 1 hr D) Blood WBC count 15,000/mm3

C) Absent urine output for 1 hr

A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis? A) A patient who is receiving intravenous antibiotic therapy in the home setting. B) A patient who has a chronic venous ulcer. C) An older adult whose medication regimen includes an anticholinergic. D) A patient with poorly controlled diabetes who receives weekly wound care

C) An older adult whose medication regimen includes an anticholinergic. Rationale: Elderly, acutely ill, or debilitated people with decreased salivary flow from general dehydration or medications are at high risk for parotitis. Anticholinergic medications inhibit saliva production. Antibiotics, diabetes, and wounds are not risk factors for parotitis.

A patient is complaining of genitourinary pain shortly after returning to the unit from a scheduled cystoscopy. What intervention should the nurse perform? A) Encourage mobilization. B) Apply topical lidocaine to the patients meatus, as ordered. C) Apply moist heat to the patients lower abdomen. D) Apply an ice pack to the patients perineum.

C) Apply moist heat to the patients lower abdomen.

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A) Keep the head of the bed lowered. B) Drink a cup of hot tea before bedtime. C) Avoid carbonated drinks. D) Eat a low-protein diet.

C) Avoid carbonated drinks. Rationale: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.

A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority? A) Client reports difficulty sleeping B) The client's urine is positive for glucose C) Client reports having an elevated body temp. D) Client reports gaining 4lbs in the last 6 months

C) Client reports having an elevated body temp.

What would be an expected finding for a client with acute kidney injury? A) Inability to initiate voiding B) Urine is cloudy with foul odor C) Client's average urine output is 10 mL/hr for several hours D) Client complains of acute flank pain

C) Client's average urine output is 10 mL/hr for several hours

A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patients hypervolemia and hyperkalemia. Which of the following therapies will the patients hemodynamic status best tolerate? A) Hemodialysis B) Peritoneal dialysis C) Continuous venovenous hemodialysis (CVVHD) D) Plasmapheresis

C) Continuous venovenous

A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase? A) Hypokalemia B) Hypocalcemia C) Dehydration D) Acute flank pain

C) Dehydration

Prior to a patients scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment? A) Determining the patients nutritional needs. B) Determining that the patient fully understands the postoperative care required. C) Determining the patients ability to understand and cooperate with the procedure. D) Determining the patients ability to cope with an altered body image.

C) Determining the patients ability to understand and cooperate with the procedure. Feedback: The major focus of the preoperative assessment is to determine the patients ability both to understand and cooperate with the procedure. Body image, nutritional needs, and postoperative care are all important variables, but they are not the main focuses of assessment during the immediate preoperative period.

Diagnostic testing of an adult patient reveals renal glycosuria. The nurse should recognize the need for the patient to be assessed for what health problem? A) Diabetes insipidus B) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) C) Diabetes mellitus D) Renal carcinoma

C) Diabetes mellitus

A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure? A) Persistent feelings of hunger and thirst B) Constipation or bowel incontinence C) Diarrhea and feelings of fullness D) Gastric reflux and belching

C) Diarrhea and feelings of fullness Feedback: Following a Billroth I, the patient may have problems with feelings of fullness, dumping syndrome, and diarrhea. Hunger and thirst, constipation, and gastric reflux are not adverse effects associated with this procedure.

A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient? A) Bathe daily and keep the perineal region clean. B) Avoid voiding immediately after sexual intercourse. C) Drink liberal amounts of fluids. D) Void at least every 6 to 8 hours.

C) Drink liberal amounts of fluids

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 has the greatest potential to prevent esophageal cancer? A) Promotion of a nutrient-dense, low-fat diet B) Annual screening endoscopy for patients 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. Rationale: There are numerous risk factors for esophageal cancer but chronic esophageal irritation or GERD is among the most significant. This is a more significant risk factor than dietary habits. Screening endoscopies are not recommended solely on the basis of family history.

The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter? A) Vigorously clean the meatus area daily. B) Apply powder to the perineal area twice daily. C) Empty the drainage bag at least every 8 hours. D) Irrigate the catheter every 8 hours with normal saline.

C) Empty the drainage bag at least every 8 hours.

The management of the patients gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly? A) I clean my stoma twice a day with alcohol. B) The only time I flush my tube is when I'm putting in medications. C) I flush my tube with water before and after each of my medications. D) I try to stay still most of the time to avoid dislodging my tube

C) I flush my tube with water before and after each of my medications. Feedback: Frequent flushing is needed to prevent occlusion, and should not just be limited to times of medication administration. Alcohol will irritate skin surrounding the insertion site and activity should be maintained as much as possible.

A nurse is providing anticipator guidance to a patient who is preparing for bariatric surgery. The nurse learns that the patient is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the patients anxiety? A) Emphasize the fact that bariatric surgery has a low risk of complications. B) Encourage the patient to focus on the benefits of the surgery. C) Facilitate the patient's contact with a support group. D) Obtain an order for a PRN benzodiazepine.

C) Facilitate the patient's contact with a support group. Feedback: Support groups can be highly beneficial in relieving preoperative and postoperative anxiety and in promoting healthy coping. This is preferable to anti-anxiety medications. Downplaying the risks of surgery or focusing solely on the benefits is a simplistic and patronizing approach.

What would be an expected finding for a client with stage 4 chronic kidney disease? A) GFR greater than 90 mL/min B) GFR 60 to 89 mL/min C) GFR 20 mL/min D) GFR less than 15 mL/min

C) GFR 20 mL/min

The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown? A) Verify tube placement. B) Loop adhesive tape around the tube and connect it securely to the abdomen. C) Gently rotate the tube. D) Change the wet-to-dry dressing.

C) Gently rotate the tube Feedback: The nurse verifies the tubes placement and gently rotates the tube once daily to prevent skin breakdown. Verifying tube placement and taping the tube to the abdomen do not prevent skin breakdown. A gastrostomy wound does not have a wet-to-dry dressing.

The nurse is caring for a patient suspected of having renal dysfunction. When reviewing laboratory results for this patient, the nurse interprets the presence of which substances in the urine as most suggestive of pathology? A) Potassium and sodium B) Bicarbonate and urea C) Glucose and protein D) Creatinine and chloride

C) Glucose and protein Feedback: The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. Within the tubule, some of these substances are selectively reabsorbed into the blood. Glucose is completely reabsorbed in the tubule and normally does not appear in the urine. However, glucose is found in the urine if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb. Protein molecules are also generally not found in the urine because amino acids are also filtered at the level of the glomerulus and reabsorbed so that it is not excreted in the urine.

The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia

C) Hyperkalemia

What complication will require polystyrene sulfonate in a client with acute kidney injury? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia

C) Hyperkalemia

Which statement by a client with a new diagnosis of celiac disease indicates understanding? A) I will need to avoid taking vitamin supplements B) I need to avoid drinking liquids with my meals C) I can eat beans to ensure I get enough fiber in my diet D) I can return to my regular diet when I am free of symptoms.

C) I can eat beans to ensure I get enough fiber in my diet

A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori. Which of the following statements by the client indicates an understanding of the teaching? A) I will continue my prescription for corticosteroids B) I will schedule a CT scan to monitor improvement C) I will take a combination of medications for treatment D) I will have my throat swabbed to recheck for this bacteria

C) I will take a combination of medications for treatment

A patient has had her indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the patient informs the nurse that she is experiencing urinary urgency resulting in several small-volume voids. What is the nurses best response? A) Inform the patient that urgency and occasional incontinence are expected for the first few weeks post-removal. B) Obtain an order for a loop diuretic in order to enhance urine output and bladder function. C) Inform the patient that this is not unexpected in the short term and scan the patients bladder following each void. D) Obtain an order to reinsert the patients urinary catheter and attempt removal in 24 to 48 hours.

C) Inform the patient that this is not unexpected in the short term and scan the patients bladder following each void.

The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurses assessment reveals that the stoma is a dark purplish color. What is the nurses most appropriate response? A) Document the presence of a healthy stoma. B) Assess the patient for further signs and symptoms of infection. C) Inform the primary care provider that the vascular supply may be compromised. D) Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.

C) Inform the primary care provider that the vascular supply may be compromised.

The nurse is creating an education plan for a patient who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan? A) The importance of increased fluid intake B) Signs and symptoms of rejection C) Inspection and care of the incision D) Techniques for preventing metastasis

C) Inspection and care of the incision

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient 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. Feedback: When the patient is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors.

A nurse is providing patient education for a patient with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient 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 lining. D) It increases lower esophageal sphincter pressure.

C) It protects the stomach lining. Feedback: Misoprostol is a synthetic prostaglandin that, like prostaglandin, protects the gastric mucosa. NSAIDs decrease prostaglandin production and predispose the patient to peptic ulceration. Misoprostol does not reduce gastric acidity, improve emptying of the stomach, or increase lower esophageal sphincter pressure.

The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurses most appropriate action? A) Inform the physician that the tube may be in the patients pleural space. B) Withdraw the tube 2 to 4 cm. C) Leave the tube in its present position. D) Advance the tube up to 8 cm.

C) Leave the tube in its present position. Feedback: The patients aspirate is from the gastric area when the nurse observes that the color of the aspirate is green. Further confirmation of placement is necessary, but there is likely no need for repositioning. Pleural secretions are pale yellow.

The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate? A) Oral intake B) Pain intensity C) Level of consciousness D) Radiation of pain

C) Level of consciousness

A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1F (38.4C). How should the nurse best respond to the patient? A) Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence. B) Remind the patient that occasional febrile episodes are expected following ESWL. C) Tell the patient to report to the ED for further assessment. D) Tell the patient to monitor his temperature for the next 24 hours and then contact his urologists office.

C) Tell the patient to report to the ED for further assessment.

A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity? A) Weight loss drugs have many side effects, and most doctors think they'll all be off the market in a few years. B) There used to be a lot of hope that medications would help people lose weight, but it been shown to be mostly a placebo effect. C) Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone. D) Medications have rapidly become the preferred method of weight loss in people for whom diet and exercise have not worked.

C) Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone. Feedback: Though anti-obesity drugs help some patients lose weight, their use rarely results in loss of more than 10% of total body weight. Patients are consequently unlikely to attain their desired weight through medication alone. They are not predicted to disappear from the market and results are not attributed to a placebo effect.

A nurse administered captopril to a client during a renal scan. Which of the following actions should the nurse take? A) Assess for hypertension B) Limit the client's fluid intake C) Monitor for orthostatic hypotension D) Encourage early ambulation.

C) Monitor for orthostatic hypotension

A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurses best action? A) Insert a nasogastric tube promptly. B) Reposition the patient supine. C) Monitor the patient closely for further signs of dumping syndrome. D) Assess the patient for signs and symptoms of aspiration.

C) Monitor the patient closely for further signs of dumping syndrome. Feedback: The patients symptoms are characteristic of dumping syndrome, which results in a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. Aspiration is a less likely cause for the patients symptoms. Supine positioning will likely exacerbate the symptoms and insertion of an NG tube is contraindicated due to the nature of the patients surgery.

Which of the following nursing interventions for acute gastritis is correct? A) Administer ibuprofen for pain B) Offer caffeinated beverages as tolerated C) No foods or fluids by mouth D) Provide regular diet with 3 meals a day

C) No foods or fluid by mouth

The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient? A) Limit oral fluid intake for 1 to 2 days. B) Report the presence of fine, sand like particles through the nephrostomy tube. C) Notify the physician about cloudy or foul-smelling urine. D) Report any pink-tinged urine within 24 hours after the procedure.

C) Notify the physician about cloudy or foul-smelling urine.

A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrites. Which of the following actions should the nurse take? A) Repeat the test early the next morning B) Start a 24-hr urine collection for creatinine clearance C) Obtain a clean-catch urine specimen for culture and sensitivity D) Insert an indwelling urinary catheter to collect a urine specimen.

C) Obtain a clean-catch urine specimen for culture and sensitivity

A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patients cardiopulmonary status is stable, what aspect of care should the nurse prioritize? A) IV fluid administration B) Insertion of an indwelling urinary catheter C) Pain management D) Assisting with aspiration of the stone

C) Pain management

A patient has undergone surgery for oral cancer and has just been extubated in post-anesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient? A) Placing the patient in a left lateral position B) Administering opioids as ordered C) Placing the patient in Fowlers position D) Teaching the patient to use the patient-controlled analgesia (PCA) system

C) Placing the patient in Fowlers position Rationale: After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in Fowlers position to facilitate breathing and promote comfort. Lateral positioning does not facilitate oxygenation or comfort. Medications do not facilitate spontaneous breathing.

A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following post-anesthetic recovery. Which of the following should be included in the patients immediate postoperative plan of care? A) Teaching the patient to self-suction. B) Performing chest physiotherapy to promote oxygenation. C) Positioning the patient to prevent gastric reflux. D) Providing a regular diet as tolerated.

C) Positioning the patient to prevent gastric reflux. Rationale: After recovering from the effects of anesthesia, the patient is placed in a low Fowlers position, and later in a Fowlers position, to help prevent reflux of gastric secretions. The patient is observed carefully for regurgitation and dyspnea because a common postoperative complication is aspiration pneumonia. In this period of recovery, self-suctioning is also not likely realistic or safe. Chest physiotherapy is contraindicated because of the risk of aspiration. Nutrition is prioritized, but a regular diet is contraindicated in the immediate recovery from esophageal surgery.

A nurse is planning care for a client who ha prerenal acute kidney injury following abdominal aortic aneurysm repair. Urinary output is 60mL in the past 2 hr, and BP is 92/58 mmHg. The nurse should expect which of the following interventions? A) Prepare the client for a CT scan with contrast dye B) Plan to administer nitroprusside C) Prepare to administer a fluid challenge D) Plan to position the client in Trendelenburg

C) Prepare to administer a fluid challenge

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include? A) Muscle training to relieve dysphagia B) Relieving nerve paralysis in the cervical plexus C) Promoting maximum shoulder function D) Alleviating achalasia by decreasing esophageal peristalsis

C) Promoting maximum shoulder function Rationale: Shoulder drop occurs as a result of radical neck dissection. Shoulder function can be improved by rehabilitation exercises. Rehabilitation would not be initiated until the patients neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech therapist rather than a physical therapist.

A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education? A) Resumption of activities of daily living B) Pain control C) Promotion of adequate nutrition D) Strategies for promoting communication

C) Promotion of adequate nutrition. Rationale: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. The nature of this surgery threatens the patients nutritional status; this physiologic need would likely supersede the resumption of ADLs. Pain should be under control prior to discharge and communication is not precluded by this surgery.

A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses 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. Feedback: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.

nurse is aware of the high incidence and prevalence of fluid volume deficit among older adults. What related health education should the nurse provide to an older adult? A) If possible, try to drink at least 4 liters of fluid daily. B) Ensure that you avoid replacing water with other beverages. C) Remember to drink frequently, even if you dont feel thirsty. D) Make sure you eat plenty of salt in order to stimulate thirst.

C) Remember to drink frequently, even if you don't feel thirsty.

The nurse is caring for a patient with a nursing diagnosis of deficient fluid volume. The nurses assessment reveals a BP of 98/52 mm Hg. The nurse should recognize that the patients kidneys will compensate by secreting what substance? A) Antidiuretic hormone (ADH) B) Aldosterone C) Renin D) Angiotensin

C) Renin

A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient? A) Presence of acute pain and anxiety. B) Tissue integrity and color of the operative site. C) Respiratory status and airway clearance. D) Self-esteem and body image.

C) Respiratory status and airway clearance. Rationale: Postoperatively, the patient is assessed for complications such as altered respiratory status, wound infection, and hemorrhage. The other assessments are part of the plan of care for a patient who has had a radical neck dissection, but are not the nurses chief priority.

A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patients health problem? A) Consumes one or more protein drinks daily. B) Takes over-the-counter antacids frequently throughout the day. C) Smokes one pack of cigarettes daily. D) Reports a history of social drinking on a weekly basis.

C) Smokes one pack of cigarettes daily. Feedback: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in patients with a history of consumption of alcohol on a daily basis.

The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma? A) Avoiding heavy alcohol use B) Control of sodium intake C) Smoking cessation D) Adherence to recommended immunization schedules

C) Smoking cessation

A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patients chronic kidney disease is at what stage? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C) Stage 3

The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? A) Using a stethoscope for auscultating the fistula is contraindicated. B) The patient feels best immediately after the dialysis treatment. C) Taking a BP reading on the affected arm can damage the fistula. D) The patient should not feel pain during initiation of dialysis.

C) Taking a BP reading on the affected arm can damage the fistula.

A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient? A) The patients bowel movements maintain a loose consistency. B) The patient is able to tolerate three large meals a day. C) The patient maintains or gains weight. D) The patient consumes a diet high in calcium.

C) The patient maintains or gains weight. Feedback: Expected outcomes for the patient following gastric surgery include ensuring that the patient is maintaining or gaining weight (patient should be weighed daily), experiencing no excessive diarrhea, and tolerating six small meals a day. Patients may require vitamin B12 supplementation by the intramuscular route and do not require a diet excessively rich in calcium.

The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? A) The patient is complains of an inability to initiate voiding. B) The patients urine is cloudy with a foul odor. C) The patients average urine output has been 10 mL/hr for several hours. D) The patient complains of acute flank pain.

C) The patients average urine output has been 10 mL/hr for several hours.

Results of a patients 24-hour urine sample indicate osmolality of 510 mOsm/kg, which is within reference range. What conclusion can the nurse draw from this assessment finding? A) The patients kidneys are capable of maintaining acidbase balance. B) The patients kidneys reabsorb most of the potassium that the patient ingests. C) The patients kidneys can produce sufficiently concentrated urine. D) The patients kidneys are producing sufficient erythropoietin.

C) The patients kidneys can produce sufficiently concentrated urine.

A patient has been admitted to the post-surgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? A) The circumference of the stoma B) The narrowest part of the stoma C) The widest part of the stoma D) Half the width of the stoma

C) The widest part of the stoma

A patient admitted to the medical unit with impaired renal function is complaining of severe, stabbing pain in the flank and lower abdomen. The patient is being assessed for renal calculi. The nurse recognizes that the stone is most likely in what anatomic location? A) Meatus B) Bladder C) Ureter D) Urethra

C) Ureter

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. Which of the following information should the nurse include in the teaching? A) Take the medication with food B) Monitor for diarrhea C) Wait 1 hr before taking other oral medications D) Maintain a low-fiber diet

C) Wait 1 hr before taking other oral medications

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply) A) Reduced BUN B) Elevated cardiac enzyme C) Reduced urine output D) Elevated blood creatinine E) Elevated blood calcium

C, D

An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply. A) Anxiety B) Low BMI C) Age-related physiologic changes D) Chronic systemic disease E) NPO status

C, D

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply) A) Client reports pain relieved by eating B) Client states that pain often occurs at night C) Client reports a sensation of bloating D) Client states that pain occurs 30 min to 1 hr after a meal E) Client experiences pain upon palpation of the epigastric region.

C, D, E

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply) A) Client reports pain relieved by eating B) Client states that pain often occurs at night C) Client reports sensations of bloating D) Client states that pain occurs 30 min to 1 hour after a meal E) Client experiences pain upon palpation of the epigastric region.

C, D, E

A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his 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. Feedback: Alcohol must be avoided when taking Flagyl and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the patient.

The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices? A) Empty the collection bag when it is between one-half and two-thirds full. B) Limit fluid intake to prevent production of large volumes of dilute urine. C) Reinforce the appliance with tape if small leaks are detected. D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area.

D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area.

A nurse is teaching a client who has chronic kidney disease an is to begin hemodialysis. Which of the following information should the nurse include in the teaching? A) Hemodialysis restores kidney function B) Hemodialysis replaces hormonal function of the renal system C) Hemodialysis allows an unrestricted diet D) Hemodialysis returns a balance to blood electrolytes.

D) Hemodialysis returns a balance to blood electrolytes.

A nurse is teaching client who is scheduled for extracorporeal shock wave lithotripsy. Which of the following statements by the client indicates understanding of the teaching? A) "I will be fully awake during the procedure" B) "Lithotripsy will reduce my chances of having stones in the future" C) "I will report any bruising that occurs to my doctor" D) "Straining my urine following the procedure is important"

D) "Straining my urine following the procedure is important"

A nurse is teaching a client who will have an x-ray of the kidneys, ureters, and bladder. Which of the following statements should the nurse include in the teaching? A) "You will receive contrast dye during the procedure" B) "An enema is necessary before the procedure" C) "You will need to lie in a prone position during the procedure." D) "The procedure determines whether you have a kidney stone"

D) "The procedure determines whether you have a kidney stone"

A kidney biopsy has been scheduled for a patient with a history of acute renal failure. The patient asks the nurse why this test has been scheduled. What is the nurses best response? A) A biopsy is routinely ordered for all patients with renal disorders. B) A biopsy is generally ordered following abnormal x-ray findings of the renal pelvis. C) A biopsy is often ordered for patients before they have a kidney transplant. D) A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease.

D) A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease. Feedback: Biopsy of the kidney is used in diagnosing and evaluating the extent of kidney disease. Indications for biopsy include unexplained acute renal failure, persistent proteinuria or hematuria, transplant rejection, and glomerulopathies.

Which of the following best describes hemodialysis? A) Hemodialysis restores kidney function B) Hemodialysis allows unrestricted diet C) Hemodialysis replaces hormone function D) Hemodialysis returns a balance to serum electrolytes

D) Hemodialysis returns a balance to serum electrolytes

A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Irritation of the phrenic nerve due to diaphragmatic pressure. B) Chronic malabsorption of iron and vitamins A and C. C) Reflux of bile into the distal esophagus. D) A sudden release of peptides

D) A sudden release of peptides Feedback: For many years, it had been theorized that the hypertonic gastric food boluses that quickly transit into the intestines drew extracellular fluid from the circulating blood volume into the small intestines to dilute the high concentration of electrolytes and sugars, resulting in symptoms. Now, it is thought that this rapid transit of the food bolus from the stomach into the small intestines instead causes a rapid and exuberant release of metabolic peptides that are responsible for the symptoms of dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux.

What finding in a client with renal calculi is priority to report to provider? A) Serum WBC count 15,000/mm3 B) Flank pain that radiates to lower abdomen C) Client reports nausea D) Absent urine for 1 hour

D) Absent urine for 1 hour

A nurse is caring for a client who has a urinary tract infection. Which of the following is the priority intervention by the nurse? A) Offer a warm sitz bath B) Recommend drinking cranberry juice C) Encourage increased fluids D) Administer an antibiotic

D) Administer an antibiotic

What is the priority intervention for a client with UTI? A) Warm sitz bath B) Recommend drinking cranberry juice C) Encourage increased fluids D) Administer antibiotics as prescribed

D) Administer antibiotics as prescribed

The nurse is caring for a patient who has a fluid volume deficit. When evaluating this patients urinalysis results, what should the nurse anticipate? A) A fluctuating urine specific gravity B) A fixed urine specific gravity C) A decreased urine specific gravity D) An increased urine specific gravity

D) An increased urine specific gravity Feedback: Urine specific gravity depends largely on hydration status. A decrease in fluid intake will lead to an increase in the urine specific gravity. With high fluid intake, specific gravity decreases. In patients with kidney disease, urine specific gravity does not vary with fluid intake, and the patients urine is said to have a fixed specific gravity.

A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurses best response? A) Adhesive holds a flange in place against the abdominal skin. B) A stitch holds the tube in place externally. C) The tube is stitched to the abdominal skin externally and the stomach wall internally. D) An internal retention disc secures the tube against the stomach wall.

D) An internal retention disc secures the tube against the stomach wall Feedback: A PEG tube is held in place by an internal retention disc (flange) that holds it against the stomach wall. It is not held in place by stitches or adhesives.

A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists. B) H2 antagonists, antibiotics, and bicarbonate salts. C) Bicarbonate salts, antibiotics, and ZES. D) Antibiotics, proton pump inhibitors, and bismuth salts

D) Antibiotics, proton pump inhibitors, and bismuth salts. Feedback: Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. H2 receptor antagonists are used to treat NSAID-induced ulcers and other ulcers not associated with H. pylori infection, but they are not the drug of choice. Bicarbonate salts are not used. ZES is the Zollinger-Ellison syndrome and not a drug.

A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? A) Ensure that the patient moves the extremity with the vascular access site as little as possible. B) Change the dressing over the vascular access site at least every 12 hours. C) Utilize the vascular access site for infusion of IV fluids. D) Assess for a thrill or bruit over the vascular access site each shift.

D) Assess for a thrill or bruit over the vascular access site each shift.

What nursing action should the nurse perform when caring for a patient undergoing diagnostic testing of the renal-urologic system? A) Withhold medications until 12 hours post-testing. B) Ensure that the patient knows the importance of temporary fluid restriction after testing. C) Inform the patient of his or her medical diagnosis after reviewing the results. D) Assess the patients understanding of the test results after their completion.

D) Assess the patients understanding of the test results after their completion.

A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery? A) Assessing function of cranial nerves V, VI, and IX B) Assessing for a history of GERD C) Assessing for signs or symptoms of atherosclerosis D) Assessing the patency of the ulnar artery

D) Assessing the patency of the ulnar artery Rationale: If a radial graft is to be performed, an Allen test on the donor arm must be performed to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. The success of this surgery is not primarily dependent on CN function or the absence of GERD and atherosclerosis.

Which of the following findings should a nurse expect in a client who has peritonitis? A) Bloody diarrhea B) Periumbilical cyanosis C) Bradycardia D) Board-like abdomen

D) Board-like abdomen

A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation? A) Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash B) Applying a water-soluble gel to the teeth and gums C) Wiping the teeth and gums clean with a gauze pad D) Brushing the patients teeth with a toothbrush and small amount of toothpaste

D) Brushing the patients teeth with a toothbrush and small amount of toothpaste Feedback: Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.

A nurse is preparing to administer a patients scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurses best action? A) Recognize this as an expected finding. B) Place the bag in a warm environment for 30 minutes. C) Shake the bag vigorously for 10 to 20 seconds. D) Contact the pharmacy to obtain a new bag of PN.

D) Contact the pharmacy to obtain a new bag of PN. Feedback: Before PN infusion is administered, the solution must be inspected for separation, oily appearance (also known as a cracked solution), or any precipitate (which appears as white crystals). If any of these are present, it is not used. Warming or shaking the bag is inappropriate and unsafe.

A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic? A) Typical diet B) Allergy status C) Psychosocial stressors D) Current medication use

D) Current medication use

A geriatric nurse is performing an assessment of body systems on an 85-year-old patient. The nurse should be aware of what age-related change affecting the renal or urinary system? A) Increased ability to concentrate urine B) Increased bladder capacity C) Urinary incontinence D) Decreased glomerular filtration rate

D) Decreased glomerular filtration rate Feedback: Many age-related changes in the renal and urinary systems should be taken into consideration when taking a health history of the older adult. One change includes a decreased glomerular surface area resulting in a decreased glomerular filtration rate. Other changes include the decreased ability to concentrate urine and a decreased bladder capacity. It also should be understood that urinary incontinence is not a normal age-related change, but is common in older adults, especially in women because of the loss of pelvic muscle tone.

A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patients high risk for urinary retention and should implement what intervention in the patients plan of care? A) Relaxation techniques B) Sodium restriction C) Lower abdominal massage D) Double voiding

D) Double voiding

An adult patient has been hospitalized with pyelonephritis. The nurses review of the patients intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? A) Supplement the patients fluid intake with a high-calorie diet. B) Emphasize the need to limit intake to 2 L of fluid daily. C) Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. D) Encourage the patient to continue this pattern of fluid intake.

D) Encourage the patient to continue this pattern of fluid intake.

A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A) Constipation related to immobility B) Risk for injury related to altered thought processes C) Hyperthermia related to the inflammatory process D) Excess fluid volume related to generalized edema

D) Excess fluid volume related to generalized edema

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? A) Haloperidol B) Prostigmine C) Epinephrine D) Glucagon

D) Glucagon Rationale: Glucagon is administered prior to removal of a foreign body because it relaxes the smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Prostigmine is prescribed for patients with myastheniagravis. It increases muscular contraction, an effect opposite that which is desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma attack and bronchospasm.

A patient with a history of incontinence will undergo urodynamic testing in the physicians office. Because voiding in the presence of others can cause situational anxiety, the nurse should perform what action? A) Administer diuretics as ordered. B) Push fluids for several hours prior to the test. C) Discuss possible test results as the patient voids. D) Help the patient to relax before and during the test.

D) Help the patient to relax before and during the test.

A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? A) Ineffective Tissue Perfusion B) Impaired Skin Integrity C) Aspiration D) Imbalanced Nutrition: Less Than Body Requirements

D) Imbalanced Nutrition: Less Than Body Requirements. Rationale: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a persons nutritional status. Dental caries do not typically affect the patients tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.

A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries? A) Hormonal changes brought on by the stress response cause an acidic oral environment. B) Systemic infections frequently migrate to the teeth. C) Hydration that is received intravenously lacks fluoride. D) Inadequate nutrition and decreased saliva production can cause cavities

D) Inadequate nutrition and decreased saliva production can cause cavities. Feedback: Many ill patients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the patient is not significant in the development of dental caries in the ill patient.

A nurse is teaching a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following information should the nurse include in the teaching? A) Eat three moderate-sized meals a day B) Drink at least one glass of water with each meal C) Eat a bedtime snack that contains milk products D) Increase protein in diet.

D) Increase protein in diet

A nurse is teaching a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following information should the nurse include in the teaching? A) Eat three moderate-sized meals a day B) Drink at least one glass of water with each meal C) Eat a bedtime snack that contains a milk product D) Increase protein in the diet

D) Increase protein in the diet

A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A) Risk for Disuse Syndrome B) Unilateral Neglect C) Risk for Trauma D) Ineffective Tissue Perfusion

D) Ineffective tissue perfusion. Rationale: Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site.

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A) Drinking beverages after your meal, rather than with your meal, may bring some relief. B) Its best to avoid dry foods, such as rice and chicken, because theyre harder to swallow. C) Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating. D) Instead of eating three meals a day, try eating smaller amounts more often.

D) Instead of eating three meals a day, try eating smaller amounts more often. Rationale: Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.

The nurse is caring for a patient who is going to have an open renal biopsy. What would be an important nursing action in preparing this patient for the procedure? A) Discuss the patients diagnosis with the family. B) Bathe the patient before the procedure with antiseptic skin wash. C) Administer antivirals before sending the patient for the procedure. D) Keep the patient NPO prior to the procedure.

D) Keep the patient NPO prior to the procedure.

A patient is recovering in the hospital following gastrectomy. The nurse notes that the patient has become increasingly difficult to engage and has had several angry outbursts at various staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A) Ask the patient's primary care provider to liaise between the nurse and the patient. B) Delegate care of the patient to a colleague. C) Limit contact with the patient in order to provide privacy. D) Make appropriate referrals to services that provide psychosocial support.

D) Make appropriate referrals to services that provide psychosocial support. Feedback: The nurse should enlist the services of clergy, psychiatric clinical nurse specialists, psychologists, social workers, and psychiatrists, if needed. This is preferable to delegating care, since the patient has become angry with other care providers as well. It is impractical and inappropriate to expect the primary care provider to act as a liaison. It would be inappropriate and unsafe to simply limit contact with the patient.

A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action? A) Perform chest physiotherapy. B) Reduce the height of the patients bed and remove the NG tube. C) Liaise with the dietitian to obtain a feeding solution with lower osmolarity. D) Report possible signs of aspiration pneumonia to the primary care provider.

D) Report possible signs of aspiration pneumonia to the primary care provider. Feedback: The patient should be assessed for further signs of aspiration pneumonia. It is unnecessary to remove the NG tube and chest physiotherapy is not indicated. A different feeding solution will not resolve this complication.

A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A) Radiation therapy often results in secondary brain tumors. B) Surgical complications are exceedingly common. C) Diagnosis rarely occurs until the cancer is endstage. D) Metastases are common and respond poorly to treatment.

D) Metastases are common and respond poorly to treatment. Rationale: Deaths from malignancies of the head and neck are primarily attributable to local-regional metastasis to the cervical lymph nodes in the neck. This often occurs by way of the lymphatics before the primary lesion has been treated. This local-regional metastasis is not amenable to surgical resection and responds poorly to chemotherapy and radiation therapy. This high mortality rate is not related to surgical complications, late diagnosis, or the development of brain tumors.

A community health nurse is preparing for an initial home visit to a patient 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 distension D) Monthly administration of injections of vitamin B12

D) Monthly administration of injections of vitamin B12. Feedback: Since vitamin B12 is absorbed in the stomach, the patient requires vitamin B12 replacement to prevent pernicious anemia. A gastrectomy precludes the use of a G tube. Since the stomach is absent, a nasogastric tube would not be indicated. As well, this is not possible in the home setting. Since there is no stomach to act as a reservoir and fluids and nutrients are passing directly into the jejunum, distension is unlikely.

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of consciousness, what would be a priority nursing action for this patient? A) Place the patient in a prone position. B) Provide the patient with ice water to slow any GI bleeding. C) Prepare for the insertion of an NG tube. D) Notify the physician.

D) Notify the physician Feedback: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patients vital signs are monitored as the patients condition warrants. Putting the patient in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.

A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube? A) Nasogastric tube B) Levin tube C) Gastric sump D) Orogastric tube

D) Orogastric tube Feedback: An orogastric tube is a large-bore tube inserted through the mouth with a wide outlet for removal of gastric contents; it is used primarily in the emergency department or an intensive care setting. Nasogastric, Levin, and gastric sump tubes are not used for this specific purpose.

Which of the following stated by a client with a hiatal hernia and GERD indicates an understanding of teaching? A) I can drink caffeine and carbonated beverages B) I will keep the head of my bed flat C) I will eat a snack right before bedtime. D) Peppermint tea will increase my indigestion.

D) Peppermint tea will increase my indigestion.

The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder? A) Nephritic syndrome B) Acute glomerulonephritis C) Nephrotic syndrome D) Polycystic kidney disease (PKD)

D) Polycystic kidney disease (PKD)

A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding? A) Use a slipper bedpan. B) Apply a cold compress to the perineum. C) Have the patient lie in a supine position. D) Provide privacy for the patient.

D) Provide privacy for the patient.

A patient has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the patient at this time? A) Teaching the patient about necessary nutritional modification. B) Helping the patient weigh treatment options. C) Teaching the patient about the etiology of gastritis. D) Providing the patient with physical and emotional support

D) Providing the patient with physical and emotional support. Feedback: For acute gastritis, the nurse provides physical and emotional support and helps the patient manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. The scenario describes a newly diagnosed patient; teaching about the etiology of the disease, lifestyle modifications, or various treatment options would be best provided at a later time.

A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurses most appropriate response? A) Report this finding promptly to the primary care provider. B) Obtain a sterile urine sample and send it for culture. C) Obtain a urine sample and check it for pH. D) Reassure the patient that this is an expected phenomenon

D) Reassure the patient that this is an expected phenomenon

A patient has experienced excessive losses of bicarbonate and has subsequently developed an acidbase imbalance. How will this lost bicarbonate be replaced? A) The kidneys will excrete increased quantities of acid. B) Bicarbonate will be released from the adrenal medulla. C) Alveoli in the lungs will synthesize new bicarbonate. D) Renal tubular cells will generate new bicarbonate.

D) Renal tubular cells will generate new bicarbonate.

A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action? A) Encourage the patient to perform deep breathing and coughing exercises hourly. B) Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula. C) Activate the emergency response system. D) Report this finding promptly to the physician and remain with the patient.

D) Report this finding promptly to the physician and remain with the patient. Rationale: In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patients current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.

A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action? A) Gently twist the tube before pulling. B) Instill a digestive enzyme solution and reattempt removal in 10 to 15 minutes. C) Flush the tube with hot tap water and reattempt removal. D) Report this finding to the patients primary care provider.

D) Report this finding to the patients primary care provider. Feedback: If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. Enzymes are used to resolve obstructions, not to aid removal. For safety reasons, hot water is never instilled into a tube. Twisting could cause damage to the mucosa.

An older adult has experienced a new onset of urinary incontinence and family members identify this problem as being unprecedented. When assessing the patient for factors that may have contributed to incontinence, the nurse should prioritize what assessment? A) Reviewing the patients 24-hour food recall for changes in diet B) Assessing for recent contact with individuals who have UTIs C) Assessing for changes in the patients level of psychosocial stress D) Reviewing the patients medication administration record for recent changes

D) Reviewing the patients medication administration record for recent changes

A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A) Strategies for maintaining an alkaline gastric environment B) Safe technique for self-suctioning C) Techniques for positioning correctly to promote gastric healing D) Strategies for avoiding irritating foods and beverages

D) Strategies for avoiding irritating foods and beverages. Feedback: Measures to help relieve pain include instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the patient about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing.

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A) Psychosocial stress B) Hypersensitivity to an immunization C) Menarche D) Streptococcal infection

D) Streptococcal infection

A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patient's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage? 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. Feedback: Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation.

A patients most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding? A) The patient is likely to have a decreased level of blood urea nitrogen (BUN). B) The patient is at risk for hypokalemia. C) The patient is likely to have irregular voiding patterns. D) The patient is likely to have increased serum creatinine levels.

D) The patient is likely to have increased serum creatinine levels.

A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply. A) Food cravings B) Upper abdominal pain C) Insatiable thirst D) Uncharacteristic fatigue E) New onset of confusion

D) Uncharacteristic fatigue

A nurses colleague has applied an incontinence pad to an older adult patient who has experienced occasional episodes of functional incontinence. What principle should guide the nurses management of urinary incontinence in older adults? A) Diuretics should be promptly discontinued when an older adult experiences incontinence. B) Restricting fluid intake is recommended for older adults experiencing incontinence. C) Urinary catheterization is a first-line treatment for incontinence in older adults with incontinence. D) Urinary incontinence is not considered a normal consequence of aging.

D) Urinary incontinence is not considered a normal consequence of aging.

A female patients most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurses data analysis should be informed by what principle? A) Most UTIs in female patients are caused by viruses and do not cause obvious symptoms. B) A diagnosis of bacteriuria requires three consecutive positive results. C) Urine contains varying levels of healthy bacterial flora. D) Urine samples are frequently contaminated by bacteria normally present in the urethral area.

D) Urine samples are frequently contaminated by bacteria normally present in the urethral area.

A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? A) Auscultate the patients abdomen after injecting air through the tube. B) Assess the color and pH of aspirate. C) Locate the marking made after the initial x-ray confirming placement. D) Use a combination of at least two accepted methods for confirming placement.

D) Use a combination of at least two accepted methods for confirming placement. Feedback: There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods.

A nurse is admitting a client who has a bleeding varices. The nurse should expect a prescription for which of the following medications? A) Propranolol B) Metoclopramide C) Ranitidine D) Vasopressin

D) Vasopressin

A nurse is admitting a client who has bleeding esophageal varices. The nurse should expect a prescription for which of the following medications? A) Propranolol B) Metoclopramide C) Ranitidine D) Vasopressin

D) Vasopressin

The care team is considering the use of dialysis in a patient whose renal function is progressively declining. Renal replacement therapy is indicated in which of the following situations? A) When the patients creatinine level drops below 1.2 mg/dL (110 mmol/L). B) When the patients blood urea nitrogen (BUN) is above 15 mg/dL. C) When approximately 40% of nephrons are not functioning. D) When about 80% of the nephrons are no longer functioning.

D) When about 80% of the nephrons are no longer functioning. Feedback: When the total number of functioning nephrons is less than 20%, renal replacement therapy needs to be considered. Dialysis is an example of a renal replacement therapy. Prior to the loss of about 80% of the nephron functioning ability, the patient may have mild symptoms of compromised renal function, but symptom management is often obtained through dietary modifications and drug therapy. The listed creatinine and BUN levels are within reference ranges.

he nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time? A) Only when needed B) Daily at bedtime C) First thing in the morning D) With each meal

D) With each meal

A child is undergoing hemodialysis. The child should be monitored closely for Select all that apply. 1. Shock. 2. Hypotension. 3. Infections. 4. Migraines. 5. Fluid overload.

1,2,3 Rationale: Rapid changes in fluid and electrolyte balance during hemodialysis may lead to shock and hypotension. Other complications to watch for are thromboses and infection. Migraines and fluid overload are not clinical manifestations associated with hemodialysis.

A child is admitted with a diagnosis of early localized Lyme disease. On initial assessment, the nurse would expect to see what signs/symptoms? Select all that apply. 1. Erythema 515 cm in diameter. 2. Hyperactivity. 3. Cranial nerve palsies. 4. Fever. 5 Headache.

1,4,5 Erythema, fever, and headache are signs/symptoms in the early localized stage of Lyme disease. Cranial nerve palsies are seen in the early disseminated stage of the disease. Malaise, rather than hyperactivity, is seen with this disease.

The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. To administer this injection safely, the nurse chooses which of the following needles, size and length, injection type, and injection site? 1. 25-gauge, -inch needle; IM (intramuscular); anterolateral thigh. 2. 22-gauge, -inch needle; IM (intramuscular); ventrogluteal. 3. 25-gauge, -inch needle; ID (intradermal); deltoid. 4. 25-gauge, -inch needle; SQ (subcutaneous); anterolateral thigh.

1. 25-gauge, -inch needle; IM (intramuscular); anterolateral thigh. Rationale 1: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, to -inch needle; IM (intramuscularly). The only safe intramuscular injection site for a 6-month-old infant is the anterolateral thigh.

A child had an appendectomy after a ruptured appendix. The nurse anticipates orders for which interventions? Select all that apply. 1. Antibiotics. 2. A clear liquid diet. 3. NG tube. 4. Vital signs every 4 hours. 5. Frequent bowel sounds.

1. Antibiotics. 3. NG tube. 4. Vital signs every 4 hours. 5. Frequent bowel sounds.

A child, in renal failure, has hyperkalemia. The nurse plans to instruct that the child should avoid the following foods: 1. Carrots and green, leafy vegetables. 2. Chips, cold cuts, and canned foods. 3. Spaghetti and meat sauce, breadsticks. 4. Hamburger on a bun, cherry gelatin.

1. Carrots and green, leafy vegetables. Rationale 1: Carrots and green, leafy vegetables are high in potassium. Chips, cold cuts, and canned foods are high in sodium but not necessarily potassium. Spaghetti and meat sauce with breadsticks and a hamburger on a bun with cherry gelatin would be acceptable choices for a low-potassium diet.

A 3-day-old preterm infant is diagnosed with necrotizing enterocolitis. The nurse plans care around the frequent radiographs. How frequently should the nurse anticipate that the radiology staff will bring the portable machine to the nursery? 1. Every 6 hours. 2. Every 12 hours. 3. Every 24 hours. 4. Every 48 hours

1. Every 6 hours. Rationale 1: Radiographs are done every 6 hours to evaluate for perforation.

A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. The equipment the nurse prepares is: 1. Intubation setup. 2. Appropriate bag and mask. 3. Sterile gauze and saline. 4. Soft arm restraints.

1. Intubation setup. Rationale 1: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so the newborns respiratory status can be stabilized. A bag and mask will not be adequate to ventilate a newborn with this condition. The defect is not external so sterile gauze and saline are not needed. Soft arm restraints are not immediately necessary.

A child with nephrotic syndrome has been placed on prednisone for several weeks. An important point of teaching with the parents should include: 1. Never stop the medication suddenly. 2. This drug is taken once a week on Sunday. 3. The child should always take the medication at night before bed. 4. This drug should be taken with meals.

1. Never stop the medication suddenly. Rationale 1: Prednisone, a corticosteroid with anti-inflammatory action, is frequently used to treat nephrotic syndrome. It should never be stopped suddenly. The drug is taken more than once a week and can be taken any time during the day, but should remain on a constant schedule. Taking with food is always appropriate for most medications, but it does not have to be with a meal.

A child experienced a lacerated spleen in a motor vehicle accident. The highest-priority nursing intervention on admission to the PICU following surgery is: 1. Observing for signs of hypovolemic shock. 2. Maintaining IV fluids. 3. Strict bedrest. 4. Administer blood products as ordered.

1. Observing for signs of hypovolemic shock. Rationale 1: The priority nursing intervention is observing for signs of hypovolemic shock due to bleeding from the lacerated spleen. The other interventions are appropriate but not the highest priority.

The nurse is administering several medications to an infant with neurologic impairment and delay. The medication that is a proton pump inhibitor administered for gastroesophageal reflux is: 1. Omeprazole. 2. Ranitidine. 3. Phenytoin. 4. Glycopyrrolate.

1. Omeprazole. Rationale 1: Omeprazole is the proton pump inhibitor that blocks the action of acid-producing cells and is used to treat gastroesophageal reflux. Ranitidine causes the stomach to produce less acid and may be used to treat gastroesophageal reflux, but it is a histamine-2 receptor blocker. Phenytoin is an anticonvulsant used to treat seizures, and glycopyrrolate is an anticholinergic agent used to inhibit excessive salivation.

A child with nephrotic syndrome is severely edematous. The primary health-care provider has placed the child on bed rest. An important nursing intervention for this child would be to: 1. Reposition the child every two hours. 2. Monitor B/P every 30 minutes. 3. Encourage fluids. 4. Limit visitors.

1. Reposition the child every two hours. Rationale 1: A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every two hours. Vital signs are taken every four hours, fluids need to be monitored and should not be encouraged, and the child needs social interaction, so visitors should not be limited.

An infant has been born with an esophageal atresia and tracheoesophageal fistula. What is a priority preoperative nursing diagnosis? 1. Risk for Aspiration Related to Regurgitation. 2. Acute Pain Related to Esophageal Defect. 3. Ineffective Infant Feeding Pattern Related to Uncoordinated Suck and Swallow. 4. Ineffective Tissue Perfusion: Gastrointestinal, Related to Decreased Circulation.

1. Risk for Aspiration Related to Regurgitation. Rationale 1: With the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Pain is not usually experienced preoperatively with this condition. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. Tissue perfusion is not a problem with this condition.

A 3-year-old child is lying in a fetal position. The child has pale skin, glassy eyes, and a flat affect. The child is irritable and refuses food and fluids. The child's vital signs are temperature 40.1 degrees C (104.2 degrees F), pulse 120/min, respirations 28/min. The best, most comprehensive description of this child's condition is: 1. Toxic. 2. Feverish. 3. Flushed. 4. Tired.

1. Toxic Rationale 1: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis. The child has a high fever, and the child may be tired, but these words are not the best, most comprehensive description of the childs condition. The term flushed is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.

An infant born with an omphalocele defect is being admitted to the intensive-care nursery. The nurse in charge should instruct the nursing technician to prepare a: 1. Warmer. 2. Crib. 3. Feeding of formula. 4. Bilirubin light.

1. Warmer Rationale 1: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant many lose heat through the viscera; a warmer is indicated to prevent hypothermia. The crib would not provide adequate maintenance of temperature control. The infant is NPO (nothing by mouth) preoperatively and may or may not need a bilirubin light before surgery.

A child is scheduled for a kidney transplant. The nurse has completed the preoperative teaching to prepare the child and parents for the surgery and postoperative considerations. The nurse will know the parents realistically understand the transplantation process that is involved with a kidney transplant if they state: 1. We know its important to see that our child takes prescribed medications after the transplant. 2. Well be glad we wont have to bring our child in to see the doctor again. 3. Were happy our child wont have to take any more medicine after the transplant. 4. We understand our child wont be at risk anymore for catching colds from other children at school.

1. We know its important to see that our child takes prescribed medications after the transplant. Rationale: It is important that the nurse emphasize compliance with treatments that will need to be followed after the transplant. Follow-up appointments will be necessary, as well as medications and general health promotion.

A neonate is being fed 20 ml every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 ml of gastric residual. The nurse should: 1. Withhold the feeding and notify the physician. 2. Replace the residual and continue with the full feeding. 3. Replace the residual but only give 5 ml of the feeding. 4. Withhold the feeding and check the residual in three hours.

1. Withhold the feeding and notify the physician. Rationale 1: Residual of more than half the amount of feeding indicates a feeding intolerance and could be a sign of necrotizing enterocolitis. Early detection of enterocolitis is essential, and aggressive management is required. Therefore, the physician should be notified of this finding. The amount of residual is too much to replace and continue with the feeding, and waiting for three hours to recheck the residual could delay treatment of a serious condition.

The nurse is teaching a prenatal class about infant care. The nurse emphasizes that parents should call their health-care provider immediately if their infant: Select all that apply. 1. Is 4 months old, received a DTaP immunization yesterday, and has a temperature of 38.0 degrees C (100.4 degrees F). 2. Is under 3 months old and has a temperature over 40.1 degrees C (104.2 degrees F). 3. Is difficult to awaken and has a pulsing fontanel. 4. Has purple spots on the skin and is lethargic. 5. Has a stiff neck and has been irritable for three days.

2,3,4,5 Rationale: Infants under 3 months of age have limited ability to develop antibodies to fight infection, and a fever as high as 40.1 degrees C indicates a serious infection. Difficulty to awaken and a pulsing fontanel, purple spots on the skin and lethargy, a stiff neck and irritability for three days in infants and children of any age may indicate meningitis. A mild fever of 38.0 degrees C (100.4 degrees F) in the 4-month-old who received a DTaP immunization yesterday is incorrect because the mild fever is expected as the body develops antibodies in response to antigens in the immunization.

A child is being treated for strep throat. The nurse tells the parent to report any abrupt onset of mid-abdominal pain along with malaise, irritability and fever. The nurse is teaching the parent signs of: 1. Sodium retention. 2. Acute post-streptococcal glomerulonephritis.3. Hemolytic-uremic syndrome. 4. Renal insufficiency.

2. Acute post-streptococcal glomerulonephritis Rationale 2: Acute post-streptococcal glomerulonephritis is an inflammation of the glomeruli of the kidneys and manifests 1021 days after a strep infection. Symptoms are not related to sodium retention, hemolytic-uremic syndrome, or renal insufficiency.

A nurse is preparing to admit a child with possible obstructive uropathy. What labs should the nurse expect to draw on this child? 1. Platelet count. 2. Blood urea nitrogen (BUN) and creatinine. 3. Partial thromboplastin time (PTT). 4. Blood culture.

2. Blood urea nitrogen (BUN) and creatinine. Rationale 2: The blood urea nitrogen (BUN) and creatinine are serum lab tests for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN and creatinine will be elevated. Platelet count and partial thromboplastin time (PTT) are drawn when a bleeding disorder is suspected. A blood culture is done when an infectious process is suspected.

A newborn has been diagnosed with Hirschsprung disease. The parents ask the nurse about the symptoms that led to this diagnosis. The nurse should explain that common symptoms are: 1. Acute diarrhea; dehydration. 2. Failure to pass meconium; abdominal distension. 3. Currant jelly; gelatinous stools; pain. 4. Projectile vomiting; altered electrolytes.

2. Failure to pass meconium; abdominal distension. Rationale 2: Hirschsprung disease is the absence of autonomic parasympathetic ganglion cells in the colon that prevent peristalsis at that portion of the intestine. In newborns the symptoms include failure to pass meconium and abdominal distension. Acute diarrhea and dehydration are symptoms characteristic of gastroenteritis. Currant jelly, gelatinous stools, and pain are symptoms of intussusception, and projectile vomiting and altered electrolytes are symptoms of pyloric stenosis.

A 4-year-old has acute glomerulonephritis and is admitted to the hospital. An appropriate nursing diagnosis for this child would be: 1. Risk for Injury Related to Loss of Blood in Urine. 2. Fluid-Volume Excess Related to Decreased Plasma Filtration. 3. Risk for Infection Related to Hypertension. 4. Altered Growth and Development Related to a Chronic Disease.

2. Fluid-Volume Excess Related to Decreased Plasma Filtration. Rationale 2: The fluid is excessive, and fluid and electrolyte balance should be monitored. There is no risk for injury because the blood loss in the urine is not such that it causes anemia. While a risk for infection may be present, it is not related to the hypertension. Growth and development is not normally affected because this is an acute process, not a chronic one.

A mother brings her 4-month-old infant in for a routine checkup and vaccinations. The mother reports that the 4-month-old was exposed to a brother who has the flu. In this case the nurse will: 1. Withhold the vaccinations. 2. Give the vaccinations as scheduled. 3. Withhold the DTaP vaccination but give the others as scheduled. 4. Give the infant the flu vaccination but withhold the others.

2. Give the vaccinations as scheduled. Rationale 2: Recent exposure to an infectious disease is not a reason to defer a vaccine. There is no reason to withhold any of the vaccinations due at this time. The flu vaccination would not routinely be given to a 4-month-old.

The nurse teaches parents that the anticholinergic drug oxybutynin is used to treat enuresis. The best response when the parents ask why the drug is being used is: 1. Its an antidepressant that is used to help the child relax. 2. It will help decrease the spasms sometimes associated with enuresis. 3. It has an antidiuretic effect, so your child can attend sleepovers. 4. It will slow the production of urine, so your child does not have to urinate as frequently.

2. It will help decrease the spasms sometimes associated with enuresis. Rationale 2: Oxybutynin (Ditropan) is an anticholinergic that relaxes the smooth muscle of the bladder and decreases spasms. Oxybutynin is not an antidepressant or an antidiuretic, and does not slow urine production.

A child with acute glomerulonephritis is in the playroom and experiences blurred vision and headache. Which of the following actions should be taken by the nurse? 1. Check the urine to see if hematuria has increased. 2. Obtain a B/P on the child; notify the physician. 3. Reassure the child, and encourage bed rest until the headache improves. 4. Obtain serum electrolytes, and send a urinalysis to the lab.

2. Obtain a B/P on the child; notify the physician. Rationale 2: Blurred vision and headache may be signs of encephalopathy, a complication of acute glomerulonephritis. A B/P should be obtained and the physician notified. The physician may decide to order an antihypertensive to bring down the B/P. This is a serious complication, and delay in treatment could mean lethargy and seizures. Therefore, the other options (checking urine for hematuria, encouraging bed rest, and obtaining serum electrolytes) do not directly address the potential problem of encephalopathy.

A child has undergone a kidney transplant and is receiving cyclosporine. The parents ask the nurse about the reason for the cyclosporine. The nurse should explain that the drug is given to: 1. Boost immunity. 2. Suppress rejection. 3. Decrease pain. 4. Improve circulation.

2. Suppress rejection. Rationale 2: Cyclosporine is given to suppress rejection. It doesnt boost immunity, decrease pain, or improve circulation.

A parent brings her 6-year-old child to the clinic because the child has a temperature of 100.2F. The child remains active without other symptoms. The nurse may appropriately tell the parent to: 1. Take the child's temperature every 2 hours and call the clinic if it reaches 102F or above. 2. Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection. 3. Keep the child warm, because shivering often occurs with fever. 4. Alternate acetaminophen and ibuprofen to help keep the fever down and keep the child comfortable.

2. Unless the fever bothers the child, it is best to let the natural body defenses respond to the infection. Rationale 2: Fever is the bodys response to an infection, and is not a disease. Allowing the bodys natural defenses (fever) to fight the infection is best. The fever is treated if the child is uncomfortable from effects of the fever, such as body aches, headache, etc. Taking the childs temperature more than every 46 hours is unnecessary. The child should be dressed for comfort. Light clothing is recommended. Alternating acetaminophen and ibuprofen is not recommended.

The school nurse is trying to prevent the spread of a flu virus through the school. Infection-control strategies that may be employed include Select all that apply. 1. Teaching parents safe food preparation and storage. 2. Withholding immunizations for children with compromised immune systems. 3. Sanitizing toys, telephones, and door knobs to kill pathogens. 4. Separating children with infections from children who are well. 5. Teaching children to wash their hands after using the bathroom.

3,4,5 Rationale: To prevent the spread of communicable diseases, microorganisms must be killed or their growth controlled. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms but is not related to the flu virus. Immunizations should not be withheld from immunocompromised children; this is not an infection-control strategy.

The nurse is preparing to ambulate an 11-year-old child who has had an appendectomy. In addition to pharmacological pain management, the nurse can use which non-pharmacological pain-management strategy for this client? 1. A heating pad. 2. A warm, moist pack. 3. A pillow on the abdomen. 4. An ice pack.

3. A pillow on the abdomen. Rationale 3: A pillow placed on the abdomen can be a nonpharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incisional area as they can impair the healing process of the wound.

A child with severe gastroenteritis is being admitted to a semiprivate room on the pediatric unit. The nurse in charge should place this client with which roommate? 1. An infant with meningitis. 2. A child with fever and neutropenia. 3. Another child with gastroenteritis. 4. A child recovering from an appendectomy

3. Another child with gastroenteritis. Rationale 3: Gastroenteritis may be viral or bacterial and can be infectious. It is best to cohort children with this infectious process. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be placed with another child with an infectious process.

Discharge instructions for care of a child who has just had an orchiopexy should include: 1. Information to the parents about the child's resuming normal vigorous activities. 2. Discussion with the parents about the low incidence of testicular malignancy and no further need for any follow-up. 3. Explanation to the parents about the need for loose, nonrestrictive clothing. 4. Reassurance to the parents that infertility is not a future risk.

3. Explanation to the parents about the need for loose, nonrestrictive clothing. Rationale 3: Orchiopexy is the surgical correction of cryptorchidism (failure of the testes to descend into the scrotal sac). Discharge instructions should include information about the need for loose, nonrestrictive clothing to avoid pressure on the postoperative site. The risk of testicular cancer is 35 to 50 times greater in men with a history of cryptorchidism. Long-term planning includes teaching the child to perform monthly testicular examinations once puberty has been reached. Vigorous activities such as straddling toys, riding bicycles, or rough play should be avoided for up to two weeks following surgery to promote healing and prevent injury. A discussion of fertility and the possible need for fertility testing is important, since cryptorchidism increases the risk of infertility.

A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 cc three times daily by mouth 10 days for otitis media. To guard against antibiotic resistance, the nurse instructs the parent to: 1. Administer a loading dose for the first dose. 2. Measure the prescribed dose in a household teaspoon. 3. Give the antibiotic for the full 10 days. 4. Stop the antibiotic if the child is afebrile.

3. Give the antibiotic for the full 10 days. Rationale 3: Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon may contain less than 5 cc, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. The absence of a fever is not an indication that all bacteria are killed or not reproducing.

A nurse is providing information to a group of new mothers. The nurse would explain that newborns and young infants are more susceptible to infection because they have: 1. High levels of maternal antibodies to diseases to which the mother has been exposed. 2. Passive transplacental immunity from maternal immunoglobulin G. 3. Immune systems that are not fully mature at birth. 4. Been exposed to microorganisms during the birth process.

3. Immune systems that are not fully mature at birth. Rationale 3: Newborns have a limited storage pool of neutrophils and plasma proteins to defend against infection. Newborns and young infants high levels of maternal antibodies, passive transplacental immunity, and exposure to microorganisms during the birth process are all true but are incorrect answers because they do not explain the susceptibility of newborns and young infants to infection.

A child has been admitted to the hospital unit with a diagnosis of minimal-change nephrotic syndrome (MCNS). The clinical manifestations will include which of the following? 1. Hematuria, bacteriuria, weight gain. 2. Gross hematuria, albuminuria, fever. 3. Massive proteinuria, hypoalbuminemia, edema. 4. Hypertension, weight loss, proteinuria.

3. Massive proteinuria, hypoalbuminemia, edema. Rationale 3: Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. While hematuria and hypertension may be present, they are not pronounced. Gross hematuria and hypertension are associated with glomerulonephritis. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen.

The hospital has just provided its nurses with information about biologic threats and terrorism. After completing the course, a group of nurses is discussing its responsibility in relation to bioterrorism. The nurse who correctly understood the presentation is the one who identifies her action to be: 1. Separating clients according to age and illness to prevent the spread of disease. 2. Disposing of blood-contaminated needles in the lead-lined container. 3. Notifying the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room. 4. Initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA).

3. Notifying the Centers for Disease Control (CDC) if a large number of persons with the same life-threatening infection present to the emergency room. Rationale 3: The CDC must be contacted to investigate the source of serious infections and to determine if a bioterrorist threat exists. Separating clients according to age and illness to prevent the spread of disease will do nothing to stop terrorism. Proper disposal of blood-contaminated needles in the sharps container and initiating isolation precautions for a hospitalized client with methicillin-resistant staphylococcus aureus (MRSA) are appropriate nursing actions but do not relate to bioterrorism.

The nurse is planning postoperative care for an infant after a cleft-lip repair. The plan should include: 1. Prone positioning. 2. Suctioning with a Yankauer device. 3. Supine or side-lying positioning. 4. Avoidance of soft elbow restraints.

3. Supine or side-lying positioning. Rationale 3: Integrity of the suture line is essential for postoperative care of cleft-lip repair. The infant should be placed in a supine or side-lying position to avoid rubbing the suture line on the bedding. The prone position should be avoided. A Yankauer suction device is made of hard plastic and, if used, could cause trauma to the suture line. Suctioning should be done with a small, soft suction catheter. Soft elbow restraints may be used to prevent the infant from touching the incisional area.

The parents have understood the nurses teaching with regard to colostomy stoma care for their infant if they state: 1. We will change the colostomy bag with each wet diaper. 2. We will use adhesive enhancers when we change the bag. 3. We will watch for skin irritation around the stoma. 4. We will expect a moderate amount of bleeding after cleansing the area around the stoma.

3. We will watch for skin irritation around the stoma. Rationale 3: Skin irritation around the stoma should be assessed; it may indicate leakage. Physical or chemical skin irritation may occur if the appliance is changed too frequently or with each wet diaper. Adhesive enhancers should be avoided on the skin of newborns. Their skin layers are thin, and removal of the appliance can strip off the skin. Also, adhesive contains latex, and its constant use is not advised due to risk of latex allergy development. Bleeding is usually attributable to excessive cleaning.

A 10-year-old had abdominal surgery. The nurse is planning care for return of bowel function. What intervention should be included in the plan of care? 1. Fowlers position three times per day for 30 minutes each time. 2. Assist the child in choosing a low-fat diet. 3. Commode at bedside. 4. Ambulate 34 times a day.

4. Ambulate 34 times a day. Rationale 4: The best data that indicate return of bowel sounds are flatus and passage of stool. Ambulation is the primary intervention to assist with both. A Fowlers position, bedside commode, and a low-fat diet will not assist with bowel function.

The nurse is evaluating an infants tolerance of a feeding postpyloromyotomy. Which finding indicates that the infant is not tolerating the feeding? 1. Need for frequent burping. 2. Irritability during feeding. 3. Passing of gas. 4. Emesis after two feedings.

4. Emesis after two feedings. Rationale 4: An infant is not tolerating feedings after a pyloromyotomy if emesis is present. Frequent burping, irritability, and the passing of gas would be expected findings following a pyloromyotomy and would indicate tolerance of the feeding.

A mother refuses to have her child be immunized with measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. The nurses most appropriate response to this mother is to: 1. Honor her request because she is the parent. 2. Explain that antibodies can fight many diseases. 3. Tell her that not immunizing her infant may protect pregnant women. 4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases.

4. Explain that if her child contracts measles, mumps, or rubella, there could be very serious and permanent complications from these diseases. Rationale 4: Explaining that if her child contracts measles, mumps, or rubella, he could have very serious and permanent complications from these diseases is correct because measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Honoring her request is not correct because the nurse has a professional duty to explain that the mothers belief about immunizations is erroneous and may result in harm to her infant. Explaining that antibodies can fight many diseases is not correct because the body makes antibodies that are specific to antigens of each disease. Antibodies for one disease cannot fight another disease. Telling her that not immunizing her infant may protect pregnant women is not correct because immunizing the infant with MMR vaccine will help protect pregnant women from contracting rubella by decreasing the transmission. If a pregnant woman contracts rubella, her fetus can be severely damaged with congenital rubella syndrome.

A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever one week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. The nurse recognizes that this child may have: 1. Chicken pox (varicella). 2. German measles (rubella). 3. Roseola (exanthem subitum). 4. Fifth disease (erythema infectiosum).

4. Fifth disease (erythema infectiosum). Rationale 4: Fifth disease manifests first with a flulike illness, followed by a red slapped-cheek sign. Then a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Varicella (chicken pox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. The rash of varicella progresses from papules to vesicles to pustules. The rash of rubella is a pink maculopapular rash that begins on the face and progresses downward to the trunk and extremities. Roseola typically occurs in infants and begins abruptly with a high fever followed by a pale pink rash starting on the trunk and spreading to the face, neck, and extremities.

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTaP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4 months old. The nurse also may give which of the following immunizations during the same well-child-care appointment? 1. Var (varicella). 2. TIV (influenza). 3. MMR (measles, mumps, rubella). 4. Haemophilus influenza type B (HIB).

4. Haemophilus influenza type B (HIB). Rationale 4: Haemophilus influenza type B (HIB) vaccine is given at 2, 4, 6, and 1215 months of age (four doses). None of the other vaccines can be given to a 4-month-old infant. Influenza (TIV) vaccine may be given yearly to infants between 6 months and 3 years of age. Measles, mumps, and rubella (MMR) vaccine is given at 1215 months and 46 years of age (two doses). Varicella (Var) is given at 1218 months or any time up to 12 years for one dose; for 13 years and older two doses are given, 48 weeks apart.

Reducing the number of preventable childhood illnesses is a major national goal in Healthy People 2020. To reach this goal, the school nurse can teach families that: 1. A minor illness with a low-grade fever is a contraindication to receiving an immunization according to Healthy People 2020. 2. Vaccines should be given one at a time for optimum active immunity in the prevention of illness and disease. 3. Premature infants and low-birth-weight infants should receive half doses of vaccines for protection from communicable diseases. 4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten.

4. It is important to maintain vaccination coverage for recommended vaccines in early childhood and to maintain them through kindergarten. Rationale 4: The benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. A minor illness is not a contraindication to immunization. Giving vaccines one at a time will result in many missed opportunities. Half doses of vaccines should not be given routinely to premature and low-birth-weight infants.

The hospital admitting nurse is taking a history of a child's illness from the parents. The nurse concludes that the parents treated their 6-year-old child appropriately for a fever related to otitis media when they reported that they: 1. Used aspirin every four hours to reduce the fever. 2. Alternated acetaminophen with ibuprofen every two hours. 3. Put the child in a tub of cold water to reduce the fever. 4. Offered generous amounts of fluids frequently.

4. Offered generous amounts of fluids frequently. Rationale 4: The body's need for fluids increases during a febrile illness. Aspirin has been associated with Reyes syndrome and should not be given to children with a febrile illness. Alternating acetaminophen with ibuprofen every two hours may result in an overdose. Pediatric medication doses are more accurately calculated using the childs weight, not age. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature.

Which of the following symptoms is characteristic of a preschool child with a urinary tract infection? 1. Foul-smelling urine, elevated B/P, and hematuria. 2. Severe flank pain, nausea, headache. 3. Headache, hematuria, vertigo. 4. Urgency, dysuria, fever.

4. Urgency, dysuria, fever. Rationale 4: Clinical manifestations of a urinary tract infection (UTI) in a preschool-age child include fever, urgency, and dysuria. While hematuria may be present, there is no elevated B/P, headache, or vertigo.

A child with inflammatory bowel disease is taking prednisone daily. The family should be taught to administer the prednisone: 1. Between meals. 2. One hour before meals. 3. At bedtime. 4. With meals.

4. With meals. Rationale 4: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

A nurse is promoting increased protein intake to enhance a patients wound healing. The nurse knows that enzymes are essential in the digestion of nutrients such as protein. What is the enzyme that initiates the digestion of protein? A) Pepsin B) Intrinsic factor C)Lipase D)Amylase

A Feedback: The enzyme that initiates the digestion of protein is pepsin. Intrinsic factor combines with vitamin B12 for absorption by the ileum. Lipase aids in the digestion of fats and amylase aids in the digestion of starch.

A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient? A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B) Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C) Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D) Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN

A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. Feedback: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is administered for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN? A) Checking the patients capillary blood glucose levels regularly B) Having the patient frequently rate his or her hunger on a 10-point scale C) Measuring the patients heart rhythm at least every 6 hours D) Monitoring the patients level of consciousness each shift

A) Checking the patients capillary blood glucose levels regularly. Feedback: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.

A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication? A) Chemical phlebitis B) Hyperglycemia C) Dumping syndrome D) Line sepsis

A) Chemical phlebitis Feedback: Formulations with dextrose concentrations of more than 10% should not be administered through peripheral veins because they irritate the intima (innermost walls) of small veins, causing chemical phlebitis. Hyperglycemia and line sepsis are risks with both peripheral and central administration of PN. PN is not associated with dumping syndrome.

The nurse is preparing to perform a patients abdominal assessment. What examination sequence should the nurse follow? A) Inspection, auscultation, percussion, and palpation. B) Inspection, palpation, auscultation, and percussion. C) Inspection, percussion, palpation, and auscultation. D) Inspection, palpation, percussion, and auscultation.

A) Inspection, auscultation, percussion, and palpation. Feedback: When performing a focused assessment of the patients abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation.

A nurse is preparing to administer a patients intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurses action? A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B) The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D) The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. Feedback: Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The patient does not need another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing.

A nurse is preparing to place a patients ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube? A) Place distal tip to nose, then ear tip and end of xiphoid process. B) Instruct the patient to lie prone and measure tip of nose to umbilical area. C) Insert the tube into the patients nose until secretions can be aspirated. D) Obtain an order from the physician for the length of tube to insert.

A) Place distal tip to nose, then ear tip and end of xiphoid process. Feedback: Tube length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 6 inches for NG placement or at least 8 to 10 inches or more for intestinal placement, although studies do not necessarily confirm that this is a reliable technique. The physician would not prescribe a specific length and the umbilicus is not a landmark for this process. Length is not determined by aspirating from the tube.

A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patients health complaint? A) Stomach emptying takes place more slowly. B) The villi and epithelium of the small intestine become thinner. C) The esophageal sphincter becomes incompetent. D) Saliva production decreases.

A) Stomach emptying takes place more slowly. Feedback: Delayed gastric emptying occurs in older adults and may contribute to nausea. Changes to the small intestine and decreased saliva production would be less likely to contribute to nausea. Loss of esophageal sphincter function is pathologic and is not considered an age-related change.

A medical patients CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding? A) The patient may have cancer, but other GI disease must be ruled out. B) The patient most likely has early-stage colorectal cancer. C) The patient has a genetic predisposition to gastric cancer. D) The patient has cancer, but the site is unknown.

A) The patient may have cancer, but other GI disease must be ruled out. Feedback: A 19-9 levels are elevated in most patients with advanced pancreatic cancer, but they may also be elevated in other conditions such as colorectal, lung, and gallbladder cancers; gallstones; pancreatitis; cystic fibrosis; and liver disease. A cancer diagnosis cannot be made solely on CA 19-9 results.

A patients sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patients discharge education? A) The patient should drink at least 2 liters of fluid in the next 12 hours. B) The patient can resume a normal routine immediately. C) The patient should expect fecal urgency for several hours. D) The patient can expect some scant rectal bleeding.

A) The patient should drink at least 2 liters of fluid in the next 12 hours. Feedback: Following sigmoidoscopy, patients can resume their regular activities and diet. There is no need to push fluids and neither fecal urgency nor rectal bleeding is expected.

A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect? A) The patients BUN and creatinine levels are within reference range following the CT. B) The CT yields high-quality images. C) The patients electrolytes are stable in the 48 hours following the CT. D) The patients intake and output are in balance on the day after the CT.

A) The patients BUN and creatinine levels are within reference range following the CT. Feedback: Both sodium bicarbonate and Mucomyst are free radical scavengers that sequester the contrast byproducts that are destructive to renal cells. Kidney damage would be evident by increased BUN and creatinine levels. These medications are unrelated to electrolyte or fluid balance and they play no role in the results of the CT.

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? A) Your appendix doesn't play a major role, so you won't notice any difference after you recover from surgery. B) The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate. C) Your body will absorb slightly fewer nutrients from the food you eat, but you wont be aware of this. D) Your large intestine will adapt over time to the absence of your appendix.

A) Your appendix doesn't play a major role, so you won't notice any difference after you recover from surgery. Feedback: The appendix is an appendage of the cecum (not the large intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption.

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. A) Splenic vein B) Inferior mesenteric vein C) Gastric vein D) Inferior vena cava E) Saphenous vein

A, B, C Feedback: This portal venous system is composed of five large veins: the superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins, which eventually form the vena portae that enters the liver. The inferior vena cava is not part of the portal system. The saphenous vein is located in the leg.

An advanced practice nurse is assessing the size and density of a patients abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented? A) Percussion B) Auscultation C) Inspection D) Rectal examination

A. Percussion Feedback: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings.

A patient has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. The release of this substance would have what effect on the patient's gastrointestinal function? Select all that apply. A) Decreased motility B) Increased sphincter tone C) Increased enzyme release D) Inhibition of secretions E) Increased peristalsis

A,D Feedback: Norepinephrine generally decreases GI motility and secretions, but increases muscle tone of sphincters. Norepinephrine does not increase the release of enzymes.

A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps? A) Colonoscopy B) Barium enema C) ERCP D) Upper gastrointestinal fibroscopy

A. Colonoscopy Feedback: During colonoscopy, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. This is not possible during a barium enema, ERCP, or gastroscopy.

A patient presents at the walk-in clinic complaining of recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the patient may have an ulcer. How would the nurse explain the formation and role of acid in the stomach to the patient? A) Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food. B) As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid. C) The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment. D) The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus.

A. Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food. The stomach, which stores and mixes food with secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. The stomach does not turn food directly into acid and the esophagus is not highly alkaline. Pancreatic enzymes are not synthesized in a highly acidic environment.

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A) Inflammatory bowel disease B) Intestinal polyps C) Diverticulitis D) Colon cancer

A. Inflammatory Bowel Disease Feedback: The use of a lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. It can safely be used with patients who have polyps, colon cancer, or diverticulitis.

A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample? A) NSAIDs B) Acetaminophen C) OTC vitamin D supplements D) Fiber supplements

A. NSAIDS Feedback: NSAIDs can cause a false-positive fecal occult blood test. Acetaminophen, vitamin D supplements, and fiber supplements do not have this effect.

A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? A) Premature removal of the G tube B) Bowel perforation C) Constipation D) Development of peptic ulcer disease (PUD)

A. Premature removal of the G tube. Feedback: A significant postoperative complication of a gastrostomy is premature removal of the G tube. Constipation is a less immediate threat and bowel perforation and PUD are not noted to be likely complications.

A patient has come to the clinic complaining of blood in his stool. A FOBT test is performed but is negative. Based on the patients history, the physician suggests a colonoscopy, but the patient refuses, citing a strong aversion to the invasive nature of the test. What other test might the physician order to check for blood in the stool? A) A laparoscopic intestinal mucosa biopsy. B) A quantitative fecal immunochemical test. C) Computed tomography (CT) D) Magnetic resonance imagery (MRI)

B) A quantitative fecal immunochemical test. Feedback: Quantitative fecal immunochemical tests may be more accurate than guaiac testing and useful for patients who refuse invasive testing. CT or MRI cannot detect blood in stool. Laparoscopic intestinal mucosa biopsy is not performed.

A female patient has presented to the emergency department with right upper quadrant pain; the physician has ordered an abdominal ultrasound to rule out cholecystitis (gallbladder infection). The patient expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A) Abdominal ultrasound is very safe, but it cant be performed if you're pregnant. B) Abdominal ultrasound poses no known safety risks of any kind. C) Current guidelines state that a person can have up to 3 ultrasounds per year. D) Current guidelines state that a person can have up to 6 ultrasounds per year.

B) Abdominal ultrasound poses no known safety risks of any kind. Feedback: An ultrasound produces no ill effects and there are not specific limits on its use, even during pregnancy.

A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions? A) Starting with a rapid infusion rate to meet the patients nutritional needs as quickly as possible B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance C) Changing the rate of administration every 2 hours based on serum electrolyte values D) Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance. Feedback: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the patients fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual patient based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.

A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? A) Prime the tubing with 20 mL of normal saline. B) Keep the vent lumen above the patients waist. C) Maintain the patient in a high Fowlers position. D) Have the patient pin the tube to the thigh.

B) Keep the vent lumen above the patients waist. Feedback: The blue vent lumen should be kept above the patients waist to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way anti-reflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, the nurse does not prime the tubing, maintain the patient in a high Fowlers position, or have the patient pin the tube to the thigh.

A patients physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device? A) Peripheral catheter B) Nontunneled central catheter C) Implantable port D) Tunneled central catheter

B) Nontunneled central catheter Feedback: Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy. A peripheral catheter can be used for the administration of peripheral parenteral nutrition for 5 to 7 days. Implantable ports and tunneled central catheters are for long-term use and may remain in place for many years. Peripherally inserted central catheters (PICCs) are another potential option.

A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action? A) Prevent gastric ulcers B) Prevent aspiration C) Prevent abdominal distention D) Prevent diarrhea

B) Prevent aspiration Feedback: Protecting the client from aspirating is essential because aspiration can cause pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea can both be associated with tube feeding, but prevention of these problems is not the primary rationale for confirming placement.

A patient has been scheduled for a urea breath test in one months time. What nursing diagnosis most likely prompted this diagnostic test? A) Impaired Dentition Related to Gingivitis B) Risk For Impaired Skin Integrity Related to Peptic Ulcers C) Imbalanced Nutrition: Less Than Body Requirements Related to Enzyme Deficiency D) Diarrhea Related to Clostridium Difficile Infection

B) Risk For Impaired Skin Integrity Related to Peptic Ulcers Feedback: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. This test does not address fluid volume, nutritional status, or dentition.

A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize? A) Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter B) Risk for Infection Related to the Presence of a Subclavian Catheter C) Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter D) Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter

B) Risk for Infection Related to the Presence of a Subclavian Catheter. Feedback: The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The patient will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these.

A nurse is caring for a patient admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. A) Pepsin B) Lipase C) Amylase D) Trypsin E) Ptyalin

B,C,D Feedback: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Pepsin is secreted by the stomach and ptyalin is secreted in the saliva.

A nurse is caring for a patient with biliary colic and is aware that the patient may experience referred abdominal pain. Where would the nurse most likely expect this patient to experience referred pain? A) Midline near the umbilicus B) Below the right nipple C) Left groin area D) Right lower abdominal quadrant

B. Below the right nipple. Feedback: Patients with referred abdominal pain associated with biliary colic complain of pain below the right nipple. Referred pain above the left nipple may be associated with the heart. Groin pain may be referred pain from ureteral colic.

A nursing student has auscultated a patients abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patients bowel sounds? A) Normal B) Hypoactive C) Hyperactive D) Paralytic ileus

B. Hypoactive Feedback: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.

A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patients ability to swallow? A) Temporal lobe B) Medulla oblongata C) Cerebellum D) Pons

B. Medulla Oblongata Feedback: Swallowing is a voluntary act that is regulated by a swallowing center in the medulla oblongata of the central nervous system. Swallowing is not regulated by the temporal lobe, cerebellum, or pons.

Results of a patients preliminary assessment prompted an examination of the patient's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding? A) Perform a focused abdominal assessment. B) Prepare to meet the patient's psychosocial needs. C) Liaise with the nurse practitioner to perform an anorectal examination. D) Encourage the patient to adhere to recommended screening protocols.

B. Prepare to meet the patient's psychosocial needs. Feedbacks: CEA is a protein that is normally not detected in the blood of a healthy person; therefore, when detected it indicates that cancer is present, but not what type of cancer is present. The patient would likely be learning that he or she has cancer, so the nurse must prioritize the patients immediate psychosocial needs, not abdominal assessment. Future screening is not a high priority in the short term.

nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patients stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A) Sigmoid colon B) Upper GI tract C) Large intestine D) Anus or rectum

B. Upper GI tract Feedback: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate? A) Stop the tube feed and aspirate stomach contents. B) Increase the hourly feed rate so it finishes earlier. C) Dilute the concentration of the feeding solution. D) Administer fluid replacement by IV.

C) Dilute the concentration of the feeding solution. Feedback: Dumping syndrome can generally be alleviated by starting with a dilute solution and then increasing the concentration of the solution over several days. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.

An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? A) The stool will be yellow for the first 24 hours postprocedure. B) The barium may cause diarrhea for the next 24 hours. C) Fluids must be increased to facilitate the evacuation of the stool. D) Slight anal bleeding may be noted as the barium is passed.

C) Fluids must be increased to facilitate the evacuation of the stool. Feedback: Post-procedural patient education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements, because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected.

A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding? A) Frequent assessment of the patients abdominal girth. B) Assessment for hemorrhage from the nasal insertion site. C) Frequent lung auscultation. D) Vigilant monitoring of the frequency and character of bowel movements.

C) Frequent lung auscultation. Feedback: Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the patients cognitive deficits. Consequently, the nurse should auscultate the patients lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the patients abdominal girth is not a main focus of assessment.

A nurse is assessing the abdomen of a patient just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the patients abdomen. How should the nurse best interpret this assessment finding? A) Abdominal lesions are usually due to age-related skin changes. B) Integumentary diseases often cause GI disorders. C) GI diseases often produce skin changes. D) The patient needs to be assessed for self-harm.

C) GI diseases often produce skin changes. Feedback: Abdominal lesions are of particular importance, because GI diseases often produce skin changes. Skin problems do not normally cause GI disorders. Age-related skin changes do not have a pronounced effect on the skin of the abdomen when compared to other skin surfaces. Self-harm is a less likely explanation for skin lesions on the abdomen.

A clinic patient has described recent dark-colored stools; the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patients current health status would contraindicate FOBT? A) Gastroesophageal reflux disease (GERD) B) Peptic ulcers C) Hemorrhoids D) Recurrent nausea and vomiting

C) Hemorrhoids Feedback: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool.

A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what? A) 5% deficit in body weight compared to preillness weight and increased caloric need B) Calorie deficit and muscle wasting combined with low electrolyte levels C) Inability to take in adequate oral food or fluids within 7 days D) Significant risk of aspiration coupled with decreased level of consciousness

C) Inability to take in adequate oral food or fluids within 7 days. Feedback: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parenteral.

A patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A) Remain NPO for 6 hours postprocedure. B) Administer a Fleet enema to cleanse the bowel of the barium. C) Increase fluid intake to evacuate the barium. D) Avoid dairy products for 24 hours postprocedure.

C) Increase fluid intake to evacuate the barium. Feedback: Adequate fluid intake is necessary to rid the GI tract of barium. The patient must not remain NPO after the test and enemas are not used to cleanse the bowel of barium. There is no need to avoid dairy products.

The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test? A) In a knee-chest position (lithotomy position) B) Lying prone with legs drawn toward the chest C) Lying on the left side with legs drawn toward the chest. D) In a prone position with two pillows elevating the buttocks

C) Lying on the left side with legs drawn toward the chest. Feedback: For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A kneechest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization.

A nurse is participating in a patients care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN? A) TNA can be mixed by a certified registered nurse. B) TNA can be administered over 8 hours, while PN requires 24-hour administration. C) TNA is less costly than PN. D) TNA does not require the use of a micron filter.

C) TNA is less costly than PN. Feedback: TNA is mixed in one container and administered to the patient over a 24-hour period. A 1.5-micron filter is used with the TNA solution. Advantages of the TNA over PN include cost savings. Pharmacy staff must prepare both solutions.

The physiology instructor is discussing the GI system with the pre-nursing class. What should the instructor describe as a major function of the GI tract? A) The breakdown of food particles into cell form for digestion B) The maintenance of fluid and acid-base balance C) The absorption into the bloodstream of nutrient molecules produced by digestion D) The control of absorption and elimination of electrolytes

C) The absorption into the bloodstream of nutrient molecules produced by digestion. Feedback: Primary functions of the GI tract include the breakdown of food particles into molecular form for digestion; the absorption into the bloodstream of small nutrient molecules produced by digestion; and the elimination of undigested unabsorbed food stuffs and other waste products. Nutrients must be broken down into molecular form, not cell form. Fluid, electrolyte, and acid-base balance are primarily under the control of the kidneys.

A nurse is providing pre-procedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation? A) Youll need to fast for at least 18 hours prior to your test. B) Starting today, take over-the-counter stool softeners twice daily. C) Youll need to have enemas the day before the test. D) For 24 hours before the test, insert a glycerin suppository every 4 hours.

C) You'll need to have enemas the day before the test. Feedback: Preparation of the patient includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning.

The nurse is caring for a patient with a duodenal ulcer and is relating the patients symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A) Secretion of hydrochloric acid (HCl) B) Reabsorption of water C) Secretion of mucus D) Absorption of nutrients E) Movement of nutrients into the bloodstream

C, D, E Feedback: The small intestine folds back and forth on itself, providing approximately 7000 cm2 (70 m2) of surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. Water reabsorption primarily takes place in the large bowel. HCl is secreted by the stomach.

A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of? A) Diet high in red meat B) Upper GI bleed C) Hemorrhoids D) Use of iron supplements

C. Hemorrhoids Feedback: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.

A patient with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the patient, what advantage should the nurse describe? A) The test allows visualization of the entire peritoneal cavity. B) The test allows for painless biopsy collection. C) The test does not require fasting. D) The test is noninvasive.

D) The test is noninvasive. Feedback: Capsule endoscopy allows the noninvasive visualization of the mucosa throughout the entire small intestine. Bowel preparation is necessary and biopsies cannot be collected. This procedure allows visualization of the entire GI tract, but not the peritoneal cavity.

A nurse is caring for a patient with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy (UGF). How should the nurse in the radiology department prepare this patient? A) Insert a nasogastric tube. B) Administer a micro Fleet enema at least 3 hours before the procedure. C) Have the patient lie in a supine position for the procedure. D) Apply local anesthetic to the back of the patients throat.

D) Apply local anesthetic to the back of the patients throat. Feedback: Preparation for UGF includes spraying or gargling with a local anesthetic. A nasogastric tube or a micro Fleet enema is not required for this procedure. The patient should be positioned in a side-lying position in case of emesis.

Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient? A) Take all your medications as usual. B) Take all your medications except the antihypertensive medications. C) Dont eat highly acidic foods 72 hours before you start the test. D) Avoid vitamin C for 72 hours before you start the test.

D) Avoid vitamin C for 72 hours before you start the test. Feedback: Red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish should be avoided for 72 hours prior to the study, because they may cause a false-positive result. Also, ingestion of vitamin C from supplements or foods can cause a false-negative result. Acidic foods do not need to be avoided.

The nurse is caring for a patient who has a diagnosis of AIDS. Inspection of the patients mouth reveals the new presence of white lesions on the patients oral mucosa. What is the nurses most appropriate response? A) Encourage the patient to gargle with salt water twice daily. B) Attempt to remove the lesions with a tongue depressor. C) Make a referral to the units dietitian. D) Inform the primary care provider of this finding.

D) Inform the primary care provider of this finding. Feedback: The nurse should inform the primary care provider of this abnormal finding in the patients oral cavity, since it necessitates medical treatment. It would be inappropriate to try to remove skin lesions from a patients mouth and salt water will not resolve this problem, which is likely due to candidiasis. A dietitian referral is unnecessary.

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A) Increased gastric motility B) Decreased gastric pH C) Increased gag reflex D) Decreased mucus secretion

D. Decreased mucus secretion. Feedback: Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.

A patient with cystic fibrosis takes pancreatic enzyme replacements on a regular basis. The patients intake of trypsin facilitates what aspect of GI function? A) Vitamin D synthesis B) Digestion of fats C) Maintenance of peristalsis D) Digestion of proteins

D. Digestion of proteins. Feedback: Trypsin facilitates the digestion of proteins. It does not influence vitamin D synthesis, the digestion of fats, or peristalsis.

A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production? A) Muscle wasting B) Chronic jaundice in the absence of liver disease C) The presence of fat in the patients stool D) Persistently low hemoglobin and hematocrit

D. Persistently low hemoglobin and hematocrit. Feedback: In the absence of intrinsic factor, vitamin B12 cannot be absorbed, and pernicious anemia results. This would result in a marked reduction in hemoglobin and hematocrit.

An inpatient has returned to the medical unit after a barium enema. When assessing the patients subsequent bowel patterns and stools, what finding should the nurse report to the physician? A) Large, wide stools B) Milky white stools C) Three stools during an 8-hour period of time D) Streaks of blood present in the stool

D. Streaks of blood present in the stool. Feedback: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.