120 ati questions remediation

the nurse is caring for a client who has acute pancreatitis. which of the following serum lab values should the nurse anticipate returning to the expected reference range within 72 hours after tx begins?

amylase serum amylase begins to increase about 3-6 hours following the onset of acute pancreatitis. it will peak in 20-30 hours and return to the expected reference range within 2-3 days.

a nurse is caring for a client who has hearing loss. the nurse should plan which of the following interventions when communicating with the client?

attract the clients attention before speaking. attracting the clients attention ensues the client knows that the nurse is about to speak.

a nurse is collecting data from a client who is experiencing perforation of a peptic ulcer. which of the following manifestations should the nurse expect?

board like abdomen. the nurse should expect this client to exhibit a board like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. vomiting of blood and shock can occur if the perforation also causes hemorrhaging.

a nurse is caring for a client who has diverticulitis and a new prescription for a low fiber diet. which of the following food items should the nurse remove from the clients meal tray?

coleslaw coleslaw contains raw cabbage, which is high in fiber. clients who are following a low fiber diet should avoid most raw veggies.

a nurse is caring for a client who has gi bleeding. the provider suspects a bleeding lesion in the colon. the nurse should anticipate that the most likely initial approach to tx will involve which of the following procedures?

colonoscopy a colonoscopy involves the insertion of a flexible scope into the rectum. the provider advances the scope carefully until it enters the colon. this procedure can provide direct visualization of the inside of the colon and helps the provider identify the exact cause and location of the bleeding.

a nurse is planning discharge teaching for a client who is post op following a traditional open cholecystectomy. which of the following learning needs of the client is the nurses priority?

coughing and deep breathing exercises.

a nurse is reinforcing teaching about hypoglycemia with a client who has DM. which of the following manifestations should the nurse include?

diaphoresis, palpitations, shakiness.

a nurse is reinforcing teaching with a group of clients about the functions of the liver and gall bladder. which of the following should the nurse include in the teaching as the purpose of bile?

digests fats. bile is a product of the liver and aids in the digestion of fats.

a nurse is contributing to the plan of care for a client who has dumping syndrome. which of the following instructions should the nurse include?

eat a source of protein with each meal. the nurse should recommend eating a source of protein with each meal because protein delays gastric emptying.

a nurse is demonstrating colostomy care to a client who has a new colostomy. which of the following actions should the nurse instruct the client to perform?

empty the bag when it is 1/3 to 1/2 full. cut the skin barrier opening a little larger than the ostomy. wash the peristomal skin with mild soap and water.

a nurse is caring for a client who has an acute exacerbation of crohns disease. which of the following actions should the nurse take?

ensure bowel rest. clients who have an exacerbation of crohns disease usually require npo status to ensure bowel rest and promote healing and recovery.

a nurse is assisting with the care of a client who has a hx of cirrhosis and was recently admitted with manifestations of hepatic encephalopathy. the nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent alcohol use?

gamma-glutamyl transferase (ggt) ggt lab test is specific to hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. therefore, is it useful for monitoring for drug toxicity and excessive alcohol use.

a nurse is reinforcing teaching with a group of community residents about hep b. which of the following statements should the nurse include in the teaching?

hep b immunization is given to infants and children. this is part of standard childhood immunizations.

a nurse is caring for a client who has schizophrenia. the client tells the nurse that he hears voices in his head right now, telling him that he has to purchase a knife today. he states that he knows purchasing the knife will make him do something bad. which of the following responses should the nurse offer?

i dont hear any voices, just yours and mine. but, i understand that you are fearful.

a nurse is assisting with data collection from a client who is 12 hr. post op following an open cholecystectomy. which of the following findings should the nurse report to the charge nurse?

indwelling urinary catheter output of 25 ml/hr. the nurse should report a urinary output of less than 30 ml/hr to the charge nurse, as this can indicate hypovolemia or renal complication.

a nurse is caring for a client who is npo and has an ng tube to suction. the client reports nausea. which of the following actions should the nurse take?

irrigate the tube with a normal saline solution. nurse should attempt to irrigate the tube to determine patency. if tube is not patent, gastric pressure cannot decrease, and the pressure can cause nausea.

a nurse is beginning a counseling session with a client who states, "we are really wasting time with these meetings. i cannot trust anyone with what is really bothering me about things ive done." which of the following responses should the nurse offer?

is it because you feel like no one would understand what you are experiencing?

a nurse is caring for a client who is scheduled for a biopsy of a mass in a testicle. the client asks, "do you think the doctor will find cancer?" which of the following responses should the nurse make?

it must be difficult for you not to know what the doctor will find. the nurse is expressing empathy in order to acknowledge the clients feelings and encourage further communication.

A nurse is caring for a client who has type 1 DM and is scheduled to receive hemodialysis. the client says "i dont even know why im doing this. there is no cue." which of the following statements should the nurse make?

it sounds as though you have given up. the nurse is using the therapeutic communication technique of resentment to encourage the clients expression of feelings.

a nurse is caring for a client who has ulcerative colitis. the provider prescribes bed rest with bathroom privileges. when the client asks why he has to say in bed, how should the nurse respond to explain the most important reason for this prescription?

lying quietly in bed helps slow down the activity in your intestines.

a nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon resection with colostomy. which of the following statements by the client indicates a need for further teaching?

my diet will have to change to a soft diet after surgery. the nurse should identify that this statement requires further reinforcement of teaching. after surgery, the clients diet quickly returns to a regular diet, and and there are no food restrictions unless the client chooses to decrease intake of foods that increase gas or odor.

a nurse is assisting with the admission of a client who has cirrhosis. which of the following prescriptions should the nurse anticipate?

obtain the clients pt and inr measurements. administer lactulose 30 ml po 4x daily. obtain daily weight and abdominal girth meansurements. administer a daily multivitamins.

a nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. the nurse finds the clients wound has eviscerated. which of the following actions should the nurse take?

place the client in a supine position with hips and knees flexed. leave the room to call the surgeon. cover the cound and intestine with a sterile moistened dressing. monitor the client for manifestations of shock.

a nurse is preparing to reinforce teaching about self care with a client who is 4 days post op following the creation of a colostomy. the client refuses to look at the stoma. which of the following actions should the nurse take?

postpone any teaching with the client at this time. refusal to look at the stoma indicates the cliet is in the denial stage of grief and might not be able to learn anything further at this time.

a nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. the client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. the nurse should explain that the ng tube serves which of the following purposes?

preventing excessive pressure on the suture lines. the ng tube remains in place after surgery to prevent excessive pressure on suture lines post op. it drains the air and fluid that can cause pressure from inside the gi tract. in doing so, it also prevents vomiting and gi distention.

a nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. which of the following lab findings should the nurse monitor prior to the procedure?

prothrombin time liver dysfunction reduces the production of blood clotting factors, which leads to an increased incidence of bruising, nosebleeds, wound bleeding, and gi bleeding.

a nurse on a med surg unit is talking with a client who pauses while discussing his feelings about being in the facility. the nurse says please go on. which of the following communication techniques is the nurse using?

providing a general lead. providing a general lead encourages the client to continue the conversation.

a nurse is caring for a client who is post op following a laparotomy. the client has an indwelling urinary catheter and a jackson-pratt drain in place. which of the following findings indicates that the client is developing a post op complication?

pulse ox of 85% clients who have had abdominal surgery should have an o2sat above 95%. a client whose o2 is 85% has hypoxemia and requires immediate intervention.

a nurse is caring for a client who is 4 hours post op following a laparoscopic cholecystectomy. which of the following findings should the nurse expect?

right shoulder pain the client can experience pain in the right upper shoulder due to gas injected into the abdominal cavity during the procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. the pain disappears in 1-2 days. mild analgesics and a recumbent position can help review the clients pain.

a nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. the client says she does not understand how she will be alright without her gallbladder. the nurse should explain that which of the following is the main function of the gallbladder?

storing bile the primary function of the gallbaldder is to store bile. because this organ is only for storage, the clients liver will still produce the bile needed for digestion. small amounts of bile will continuously enter the duodenum and perform various functions.

a nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 ml/hr. when the nurse checks the client at 0800, which of the following findings requires intervention by the nurse?

the head of the bed is elevated to 20 degrees. hob should be elevated to at least 30 degrees (semi fowlers position) while the tube feeding is administered.

a nurse is caring for a client who has a new diagnosis of breast cancer. after becoming quiet and withdrawn, the client asks the nurse, "what do you think people will say about me when im gone?" which of the following responses should the nurse provide?

the thought of having breast cancer must seem hopeless.

a nurse is assisting with the admission of a client who has bleeding esophageal varices. the nurse should anticipate a prescription for which of the following medications?

vasopressin vasopressin constricts the splanchnic bed and decreases portal pressure. vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system.

a nurse is caring for a client who states there is no one in the world who cares about me. which of the following responses should the nurse offer?

you are feeling totally alone and without support? the nurse is checking perception or seeking consensual validation of the clients statement. the nurse encourages further discussion by using an open ended statement that acknowledges the clients feelings.

a nurse is caring for a client who has a reputation for being demanding of the nursing staff. the nurse says to the charge nurse, "i cant believe i have to care for this client again today!" which of the following responses should the charge nurse provide?

you are upset about having this client assigned to you today. the charge nurse is using restatement. by making this open ended comment, the charge nurse acknowledges the nurses feelings about the assignment while encouraging further professional discussion.

a nurse is assisting with the care of a client who is in premature labor and is not responding to therapy. the client says to the nurse, i am so worried about my baby. which of the following responses should the nurse make?

you are very frightened for your baby.

a nurse is reinforcing teaching with a client who is preparing to perform a return demonstration of a subcutaneous injection of medication for the second time. the client hesitates and says im not sure i can do this. which of the following responses should the nurse offer?

you did great last time. give it a try. the response by the nurse encourages the client to complete the procedure and acknowledges the clients effort in learning the new skill.

a nurse is caring for an adolescent client who was recently diagnosed with testicular cancer. when the nurse asks the client a question, he angrily spits in the nurse's face. which of the following responses should the nurse make?

you seem to be very upset. this is a therapeutic response that allows the client to explore his feelings and can de-escalate the situation.

a nurse is caring for a client who has a new diagnosis of terminal cancer. when the nurse enters the room to set up bath equipment, the client says, "im not an invalid, you know. i can take care of myself. get out and leave me alone." which of the following is an appropriate response by the nurse?

you seem upset. lets talk about your concerns. the nurse is seeking consensual validation for mutual understanding and clarification. this response lets the client know that her concerns about self care are important and encourages the client to provide additional information.