3500 Unit 5 questions
The nurse is educating a client who is scheduled for a permanent ileostomy. What should the nurse include regarding bowel function and care? A. A collection device over the stoma will always be required. B. Stool will gradually become semi-solid and formed C. Bowel control will progressively return. D. Oral fluid intake should be limited
A A collection device is required because an ileostomy drains frequently with loose stool. Over time, the stool may become thicker (pastelike) but will not be semi-solid or formed because it does not pass through the colon and absorb water. The patient will not regain bowel control because the colon and rectum have been removed. Oral fluid intake should be increased to prevent dehydration due to the frequency of output from the ileostomy.
When caring for a patient who has just had an upper GI endoscopy, the nurse assesses that the client has developed a temperature of 101.8 F (38.8C). What is the appropriate nursing intervention? a. promptly assess the client for potential perforation b. ask the nursing assistant to bathe the client with tepid water c. administer acetaminophen (tylenol) to lower the temperature d. delegate to an unlicensed assistive personnel (UAP) to retake the temperature
A A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a physician's order; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? a. graham crackers b. 1 tsp sugar c. 4 oz diet soda d. 4 oz skin milk
A After establishing that the client has hypoglycemia, the nurse should give the client about 15 g of a rapid-acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk, 3 tsp of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. The nurse should recheck the client's blood glucose level in 15 minutes.
What will the nurse teach the client with type 2 diabetes regarding exercise in his or her treatment program? A. During exercise, the body will use carbohydrates for energy production, which in turn, will decrease the need for insulin. B. With an increase in activity, the body will use more carbohydrates; therefore more insulin will be required. C. The increase in activity results in an increase in the use of insulin; therefore the client should decrease his or her carbohydrate intake. D. Exercise will improve pancreatic circulation and stimulate the Islets of Langerhans increase the production of intrinsic insulin.
A During exercise, the body will use carbohydrates for energy production, which in turn will decrease the need for insulin. Therefore during exercise, carbohydrate intake should be increased to cover the increased energy requirements. The beneficial effects of regular exercise may result in a decreased need for diabetic medications in order to reach the target blood glucose levels. Furthermore, it may help to reduce triglycerides, LDL cholesterol levels, increase HDLs, reduce blood pressure, and improve circulation.
A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels? a. 6.3% b. 7.8% c. 8.5% d. 10%
A The client who has diabetes mellitus needs to manage activity and diet while monitoring blood glucose levels. High levels of blood glucose cause damage to the macro and microcirculation, affecting such things as eyesight and kidney function. The goal for a client who has diabetes mellitus is to keep the HbA1c values at 6.5% or less.
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching? a. drink 3 L of fluid every day b. take 3,000 mg of vitamin C daily c. restrict calcium intake to one serving per day d. eat 12 oz of animal protein daily
A The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.
A patient arrives to the clinic for evaluation of epigastric pain. The patient describes the pain to be relieved by food intake. In addition, the patient reports awaking in the middle of the night with a gnawing pain in the stomach. Based on the patient's description this appears to be what type of peptic ulcer? A. Duodenal B. Gastric C. Esophageal D. Stress
A The patient signs and symptoms describe a duodenal ulcer. Gastric ulcer tend to not cause pain in the middle of the night and epigastric pain is worst with food.
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? a. I will need to wipe my perineal area from back to front after urination b. I will need to empty my bladder regularly and completely c. I will need to drink apple cider vinegar each day d. I need to drink 8 cups of liquid each day
A Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.
A nurse is completing preprocedure teaching for a client who will undergo a sigmoidoscopy. Which of the following information should the nurse include in the teaching? (select all that apply) A. Increase flatulence can occur following the procedure B. NPO status should be maintained preprocedure C. Conscious sedation is used D. Repositioning will occur throughout the procedure E. Fluid intake is limited the day after the procedure
A B
A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (select all that apply) A. "You will need a monthly injection of Vit B12 for the rest of your life" B. "Using the nasal spray form of Vit B12 on a daily basis can be an option" C. "An oral supplement of Vit B12 taken on a daily basis can be an option" D. "You should increase your intake of animal protein, legumes and dairy products to increase Vit B12 in your diet" E. "Add soy milk fortified with Vit B12 to your diet to decrease the risk of pernicious anemia"
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 caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnoses? (select all that apply) A. Emesis greater than 500 mL with a fecal odor B. Report of spasmodic abdominal pain C. High-pitched bowel sounds D. Abdomen flat with rebound tenderness to palpation E. Laboratory findings indicating metabolic acidosis
A B C
A nurse is reviewing the health record of a client who has hyperglycemic-hyperosmolar state (HHS). The nurse should identify that which of the following data confirms this diagnosis? (select all that apply) A. Evidence of recent myocardial infarction B. BUN 35 mg/dL C. Takes a calcium channel blocker D. Age 77 years E. No insulin production
A B C D
A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (select all that apply) A. Eat less meat and processed foods B. Decreased intake of saturated fats C. Increase daily fiber intake D. Limit saturated fat intake 15% of daily caloric intake E. Include omega-3 fatty acids in the diet
A B C E
A nurse is providing discharge teaching to a client who has experienced diabetic ketoacidosis. Which of the following information should the nurse include in the teaching. (select all that apply). A. Drink 2 L fluids daily B. Monitor blood glucose every 4 hr. when ill C. Administer insulin as prescribed when ill D. Notify the provider when blood glucose is 200 mg/dL E. Report ketones in the urine after 24 hr of illness
A B C E
A nurse is providing teaching to a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select all that apply) A.Cottage cheese B.Milkshakes C.Tuna fish D.Strawberries and bananas E.Egg and ham omelet
A B C E
A nurse is teaching a parent of an infant about gastrointestinal reflux disease. 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 feeding E. Use a wide-based nipple for feeding
A B D
A nurse is caring for a client who has hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (select all that apply) A. Provide assistance with ambulation B. Monitor oxygen saturation C. Weigh the client weekly D. Obtain stool specimen for occult blood E. Schedule daily rest period
A B D E
A nurse is reviewing discharge instructions with a client who had spontaneous passage of 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 hrs 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 is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (select all that apply) A. Projectile vomiting B. Dry mucous membranes C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger
A B E
A nurse is caring for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The nurse should anticipate prescriptions for which of the following medications? (select all that apply) A. Antacids B. Histamine 2 receptor agonists C. Opioid analgesics D. Fiber laxatives E. Proton pump inhibitors
A B E
A nurse is planning care for a client who has a small bowel obstruction and nasogastric (NG) tube in place. Which of the following interventions should the nurse include in the plan of care? (select all that apply) A. Document the NG drainage with the client's output B. Irrigate the NG tube every 8 hours C. Assess bowel sounds D. Provide oral hygiene every 2 hrs E. Monitor NG tube placement
A C D E
A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following 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 nurse is teaching patients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods would the nurse include in the teaching? (Select all that apply) A. Chocolate B. Chicken C. Citrus fruits D. Herbal tea E. Tomato Sauce
A C E Chocolate, citrus fruits such as oranges and grapefruit, and tomato-based products all contribute to the reflux associated with GERD. Oatmeal, whole grains, ginger, lean meats, vegetables, noncitrus fruits, and herbal tea can help relieve symptoms of GERD.
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (select all that apply.) a. poor skin turgor b. bradycardia c. hypotension d. pale yellow urine e. flat neck veins
A C E Poor skin turgor is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as skin that lacks elasticity. Bradycardia is incorrect. Frequent vomiting and diarrhea cause dehydration, which manifests as tachycardia. Hypotension is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as postural hypotension. Pale yellow urine is incorrect. Frequent vomiting and diarrhea cause dehydration, which manifests as dark yellow, concentrated urine. Flat neck veins is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as flat neck veins when the client is lying supine.
Which physiologic actions result from normal insulin secretion? Select all that apply a. increased liver storage of glucose as glycogen b. increased gluconeogenesis c. increased cellular uptake of blood glucose d. increased breakdown of lipids (fats) for fuel e. increased production and release of epinephrine f. decreased storage of free fatty acids in fat cells g. decreased blood glucose levels h. decreased blood cholesterol levels
A C G H
A nurse is completing discharge teaching with a client who has irritable bowel syndrome (IBS). Which of the following findings should the nurse include in the teaching? (select all that apply) A. Avoid foods that trigger exacerbation B. Consume 15 to 20 g of fiber daily C. Plan 3 moderate to large meals a day D. Drink at least 2 L of water a day
A D
A client is admitted to the hospital with signs and symptoms of type 1 diabetes mellitus. Which findings is the nurse most likely to observe in this client? (Select all that apply) A. Excessive thirst B. Weight gain C. Constipation D. Excessive hunger E. Frequent, high-volume urination
A D E Classic signs of diabetes mellitus include polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination). Because the body is starving from the lack of glucose the cells are using for energy, the client has weight loss, not weight gain. Clients with diabetes mellitus usually don't present with constipation. Urine retention is only a problem if the patient has another renal-related condition.
A nurse is teaching a client who has a new prescription for ranitidine to treat peptic ulcer disease. Which of the following statements by the client indicate an understanding of the teaching? (Select all that apply.) a. i can take this medication with or without food b. i will take this medication in the morning c. i should expect my stools to turn black d. i will take this medication with an antacid e. i will take this medication when i need it for pain f. i will eat five small meals each day
A, F "I can take this medication with or without food." is correct. Food does not affect the absorption of ranitidine."I will take this medication in the morning." is incorrect. The client should take ranitidine in the evening to reduce nocturnal acid production."I should expect my stools to turn black" is incorrect. The client should report black stools because this is a manifestation of gastro-intestinal bleeding."I will take this medication with an antacid" is incorrect. The client should take an antacid 1 hr before or after the ranitidine to increase absorption."I will take this medication when I need it for pain" is incorrect. Ranitidine is taken on a regular basis to relieve pain, promote healing, and prevent recurrence."I will eat five small meals each day" is correct. The client should eat 5 to 6 small meals each day to enhance the therapeutic effects of ranitidine.
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 three moderate to large meals a day"
A.
A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hr. ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? A. Remove the current bag and hang a new bag B. Infuse the remaining solution at the current rate and then hang a new bag C. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag D. Remove the current bag and hang a bag of lactated ringers
A.
A nurse is having difficulty arousing a client following an EGD. Which of the following is the priority action by the nurse? A. Assess the client's airway B. Allow the client to sleep C. Prepare to administer an antidote to the sedative D. Evaluate preprocedure laboratory findings
A.
A nurse is reviewing a bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following instructions should the nurse include in the teaching? A. Check with the provider about taking current medications when consuming bowel prep. B. Consume a normal diet until starting the bowel prep C. Expect the bowel prep to not begin acting until the day after all the prep is consumed D. Discontinue the bowel prep once feces started to expell
A.
A nurse is assessing an older adult client in an extended care facility. The nurse should recognize which of the following findings is a manifestation of an obstruction of the large intestine due to fecal impaction? A. The client reports he had a bowel movement yesterday B. The client is having small frequent liquid stools C. The client is flatulent D. The client indicates he vomited once this morning
B
A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation? A.Hyperactive bowel sounds B.Sudden abdominal pain C.Increased blood pressure D.Bradycardia
B
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid? A.Nonfat milk B.Chocolate C.Apples D.Oatmeal
B
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition? A.History of bulimia B.History of NSAID use C.Drinks green tea D.Has a glass of wine with dinner each day
B
A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan? A.Yogurt and mozzarella B.Spinach and beef C.Milk and turkey slices D.Fish and cottage cheese
B
On assessment of a client with GERD, which statement requires nursing intervention? a. I quit smoking several years ago b. sometimes I wake up gasping for air in the middle of the night c. my family likes to eat small frequent meals every 3 to 4 hours throughout the day d. when I buy meat, I ask for the leanest cut that is available
B
Which client does the nurse caution to avoid self-monitoring of blood glucose at alternate sites? a. 75 yr old client whose blood glucose levels show little variation b. 55 yr old client who has hypoglycemic unawareness c. 80 yr old client with type 2 DM d. 45 yr old client with type 1 DM
B
A client who has type 2 diabetes mellitus asks the nurse, "why did I develop diabetes?" Which of the following responses should the nurse make? a. your body is destroying the cells that secrete insulin b. your body has insulin resistance and decreased insulin secretion c. an infection in your pancreas destroyed the cells that make insulin d. your kidneys are not able to reabsorb water which leads to type 2 diabetes mellitus
B A client genetically susceptible can develop Type 2 diabetes mellitus when obesity and physical inactivity lead to insulin resistance at cells as well as decreased secretion of insulin by pancreatic beta-cells.
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Assess elimination patterns B. Elevate the head of the client's bed 30 - 45 degrees. C. Monitor intake and output every 8 hours. D. Check residual volume every 4 to 6 hours.
B A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration. A, C, and D are appropriate actions, but not the priority action by the nurse.
A patient has vague symptoms that indicate an acute inflammatory bowel disorder. Which signs & symptoms are most indicative of Crohn's disease (CD)? A. Lower abdominal colicky pain relieved with defecation B. Chronic diarrhea, constant abdominal pain in the right lower quadrant, and low-grade fever. C. Multiple episodes of bloody diarrhea D. Constipation, weight loss, fatigue, and constant need to have a bowel movement that is not relieved by having a bowel movement.
B Chronic diarrhea, constant abdominal pain in the right lower quadrant, and low-grade fever are common symptoms of Crohn's Disease. Colicky abdominal pain and bloody diarrhea are characteristic of Ulcerative Colitis. Constipation, weight loss, fatigue, and constant need to have a bowel movement that is not relieved by having a bowel movement is characteristic of colorectal cancer which is a complication of ulcerative colitis lasting longer than 10 years.
A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation? a. hyperactive BS b. sudden abdominal pain c. increased BP d. bradycardia
B Classic indications of gastrointestinal perforation include sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock.
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? A. COPD B. diabetes mellitus C. anemia D. osteoporosis
B Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.
A nurse is reviewing the care plan for a client after a urinary diversion with an ileal conduit that includes all of the nursing diagnoses listed below. Which nursing diagnosis should the nurse place as the lowest priority? A. Altered skin integrity B. Disturbed body image C. Deficient fluid volume D. Acute pain
B Disturbed body image is a wellness nursing diagnosis and would not be the priority. The remaining nursing diagnoses require immediate intervention while in the hospital.
A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide. Which of the following statements by the nurse best describes the action of glipizide? a. glipizide absorbs the excess carbohydrates in your system b. glipizide stimulates your pancreas to release insulin c. glipizide replaces insulin that is not being produced by your pancreas d. glipizide prevents your liver from destroying your insulin
B Glipizide is an oral antidiabetic medication in the pharmacological classification of sulfonylurea agents. These medications help to lower blood glucose levels in clients who have type 2 diabetes mellitus using several methods, including reducing glucose output by the liver, increasing peripheral sensitivity to insulin, and stimulating the release of insulin from the functioning beta cells of the pancreas.
When caring for a patient having a hypoglycemic episode, the nurse knows which symptom requires immediate intervention? A. Hunger B. Confusion C. Headache D. Tachycardia
B Glucose is necessary for brain function. Confusion is a marker of severe hypoglycemia requiring immediate intervention. Irritability/anxiety, hunger, tachycardia, headache, sweating, and seizures are additional signs of hypoglycemia.
A client with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the client that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes: A. The client is totally dependent on an outside source of insulin. B. There are a decreased insulin secretion and cellular resistance to insulin that is produced. C. The immune system destroys the pancreatic insulin-producing cells. D. The insulin precursor that is secreted by the pancreas is not activated by the liver.
B In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes
The nurse is preparing to discharge a patient with urinary diversion. The nurse anticipates the patient will require some teaching prior to going home. Which of the following points will the nurse incorporate into the plan? A. The need to change the appliance every day. B. The importance of increasing fluid intake. C. Instructing the patient to notify the physician if the stoma is deep pink and moist. D. Instructing the patient that strands of blood may appear in the urine.
B Increasing fluid intake helps to flush out any mucus that may be present. The appliance only needs to be changed every 5-7 days. A deep pink and moist stoma is normal. Blood in the urine is not a normal finding and would require PCP follow-up.
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? A. BP 126/80 B. A1C 9% C. Fingerstick Blood Glucose 130mg/dL D. LDL cholesterol 100mg/dL
B Lowering hemoglobin A1C (to an average of 7%) reduces microvascular and neuropathic complications. Tighter glycemic control (normal A1C < 6%) may further reduce complications but increases hypoglycemia risk. The remaining values are not a cause for concern.
The nurse is caring for a client with a bleeding duodenal ulcer who was admitted to the hospital after vomiting bright, red blood. Which condition does the nurse anticipate when the client develops a sudden, sharp pain in the mid-epigastric region and a rigid, board-like abdomen? a. pancreatitis b. ulcer perforation c. small bowel obstruction d. development of additional ulcers
B The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like muscle rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause mid-epigastric pain. Esophageal inflammation or the development of additional ulcers would not cause a rigid, board-like abdomen.
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid a. nonfat milk b. chocolate c. apples d. oatmeal
B The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty and fried foods, chocolate, caffeine, alcohol, and carbonated drinks.
A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take? a. reconstitute formula with tap water b. discard unused formula after 8 hr. c. administer 200 mL of formula during the initial infusion d. give the initial feeding over 15 min
B The nurse should discard unused formula 8 to 12 hr after reconstitution to reduce the risk for bacterial growth.
A diabetic patient has recently been diagnosed with peripheral neuropathy. What statement made by the patient indicates to the nurse that a knowledge deficit is present? A. "I will monitor my feet for injury on a daily basis." B. "My shoes are a half size to small, but I will continue to wear them because they do not cause pain." C. I will follow up with my physician if I notice wounds on my feet." D. "I will alternate what shoes I wear each day."
B Tight shoes can damage the tissue on the foot, so shoes should be 1/2 to 5/8 inches longer than the longest toe. Wearing shoes that are a 1/2 to small can cause tissue damage and the patient likely does not feel pain due to poor sensory perception from peripheral neuropathy. The remaining answers are appropriate actions for the patient to take.
A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of crohn's disease. Which of the following laboratory tests 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 C
A nurse is completing an admission assessment for a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider? (select all that apply) A. Emesis prior to insertion of nasogastric tube B. Urine specific gravity 1.040 C. Hematocrit 60% D. Serum potassium 3.0 mEq/L E. WBC 10,000/uL
B C D
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply) A. Sitting upright after meals B. Eating large meals C. Hiatal hernia D. Obesity E. Viral infections
B C D Many factors predispose a person to GERD, including eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori bacteria is. Sitting upright after meals is encouraged to reduce the symptoms of GERD.
A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (select all that apply) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis
B C D E
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following manifestations of hypoglycemia? (Select all that apply.) a. polyuria b. blurred vision c. polydipsia d. tachycardia e. moist, clammy skin
B D E Polyuria is incorrect. Manifestations of hyperglycemia include polyuria (excessive urination). Blurred vision is correct. Manifestations of hypoglycemia include blurred vision. Polydipsia is incorrect. Manifestations of hyperglycemia include polydipsia (excessive thirst). Tachycardia is correct. Manifestations of hypoglycemia include tachycardia. Moist, clammy skin is correct. Manifestations of hypoglycemia include moist, clammy skin.
A nurse is completing discharge instruction with a client who has spontaneously passed a calcium oxalate calculus. To decrease the chance of recurrence, the nurse should instruct the client to 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 in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly B. The client should have his hemoglobin checked twice a week C. Oxygen saturation levels should be monitored D. Folic acid production will increase
B.
A nurse is caring for an infant who has just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take? A. Remove the packing in the mouth B. Place the infant in an upright position C. Offer a pacifier with sucrose D. Assess the mouth with a tongue blade
B.
A nurse is completing a 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 food B. Drink canned protein supplements C. Increase intake of high fiber foods D. Take a bulk-forming laxative daily
B.
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. Loss of tooth enamel C. Sweet taste in mouth D. Absence of eructation
B.
A nurse is completing an integumentary assessment on a client who has anemia. Which of the following findings should the nurse expect? A. Absent turgor B. Spoon-shaped nails D. Shiny, hairless legs E. Yellow mucous membranes
B.
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.
A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse implement? A. Check blood glucose immediately after breakfast B. Administer insulin when breakfast arrives C. Hold breakfast for 1 hr after insulin administration D. Clarify the prescription because insulin should not be administered at this time
B.
A nurse is providing care to a client who is 1 day post-op following a paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? A. place a clean towel near the drainage site B. Apply a dry, sterile dressing C. Apply direct pressure to the site D. Place the client in supine position
B.
A nurse is reviewing laboratory reports of a client who has hyperglycemic-hyperosmolar state (HHS). The nurse should expect which of the following findings? A. Serum pH 7.2 B. Serum osmolarity 350 mOsm/L C. Serum potassium 3.8 mg/dL D. Serum creatinine 0.8 mg/dL
B.
A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection? A. Positive hyaline casts B. Positive leukocyte esterase C. Positive ketones D. Positive for crystals
B.
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 medication with soda" B. "Peppermint tea will increase my indigestion" C. "Wearing an abdominal binder will limit my symptoms" D. "I will drink hot chocolate at bedtime to help me sleep" E. "I can lift weights as a way to exercise"
B.
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia? A.Folic acid deficiency anemia B.Pernicious anemia C.Iron-deficiency anemia D.Sickle cell anemia
C
A nurse is preparing to administer IV fluids to a client who has diabetic ketoacidosis. Which of the following actions should the nurse take? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr B. Administer an IV infusion of 0.45% sodium chloride C. Rapidly administer IV infusion of 0.9% sodium chloride D. Add glucose to the IV infusion when serum glucose is 350 mg/dL
C
Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes? a. avoid drinking ice cold beverages b. be sure to check your blood pressure twice daily c. change positions slowly when moving from sitting to standing d. check your hands and feet weekly for areas of numbness or sensation change
C
A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance A. twice a day B. daily at bedtime C. when the bag is 2/3 full D. when the bag is full
C An ileal conduit is used to divert urine outside of the body when the urinary bladder has been removed. The conduit cannot store urine the way the bladder did; therefore, urine will be flowing continuously, and an appliance must be worn as a collecting device. The bag should be emptied when it becomes 2/3 full to prevent leakage, skin irritation, and infection.
A nurse is providing dietary teaching to a client who has nephropathy secondary to diabetes mellitus and plans to make dietary adjustments. Which of the following instructions should the nurse include? a. consume less than 45% of total calories from carbohydrates per day b. eat no more than 300 mg of cholesterol per day c. consume less than 0.8 g/kg of body weight of protein per day d. eat at least 45 g of fiber per day
C Clients who have diabetes should adjust protein intake to less than 0.8 g/kg of body weight per day to delay renal injury.
A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia. The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals. Which of the following responses should the nurse make? a. taking the medication between meals will help you avoid becoming constipated b. taking the medication with food increases the risk of esophagitis c. taking the medication between meals will help you absorb the medication more efficiently d. the medication can cause nausea if taken with food
C Ferrous sulfate provides the iron needed by the body to produce red blood cells. Taking iron supplements between meals helps to increase the bioavailability of the iron.
A nurse is teaching a client who is at risk for iron-deficiency anemia about optimizing her dietary intake of iron. The nurse should explain that which of the following sources of iron is easiest for the body to absorb? A. Spinach B. Cantaloupe C. Chicken D. Lentils
C Food sources of iron fall into two categories - heme iron (from lean red meat, poultry, and fish) and nonheme iron (from fruit, vegetables, grains, and dried peas and beans). The body more easily absorbs heme iron. Chicken is a source of heme iron. Spinach, cantaloupe, and lentils are sources of nonheme iron.
A patient with Type 1 diabetes presents to the emergency department complaining of abdominal pain, vomiting, dehydration from excessive urination, and lethargy. The nurse discovers his finger stick blood sugar is "high" and that he is having Kussmaul's respirations. She is concerned the patient may be in diabetic ketoacidosis (DKA). Which of the following lab values would confirm the nurses' suspicion? A. Negative ketones on the urine dipstick B. Serum glucose of 1018 C. Positive ketones on the urine dipstick D. Serum bicarbonate level of 24
C In DKA, patients lose ketones in their blood and urine due. Ketones are formed when the body burns fat for energy, and without efficient glucose use, extra fats are broken down which increases ketone production. The increase causes ketones to be excreted in the urine and therefore shows up as present on a urine dipstick. Patients with DKA rarely have a glucose over 600 - that is typically characteristic of HHNS. In DKA, the body is in an acidotic state so the serum bicarbonate level would be less than 15.
A patient has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the patient about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."
C Lactose-containing foods should be reduced or eliminated because they are poorly tolerated. Smoking and carbonated beverages are GI stimulants that can cause abdominal discomfort. Raw vegetables and high-fiber foods can also cause GI symptoms and should be eaten sparingly or avoided.
The nurse is working with an overweight client who has a high-stress job and smokes. This client has just received a diagnosis of type 2 diabetes and has just been started on an oral hypoglycemic agent. Which of the following goals for the client, which if met, would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require oral hypoglycemic agents? A. Comply with medication regimen 100% for 6 months. B. Quit the use of any tobacco products by the end of three months. C. Lose a pound a week until weight is in the normal range for height and exercise 30 minutes daily. D. Practice relaxation techniques for at least five minutes five times a day for at least five months."
C Lose a pound a week until weight is in the normal range for height and exercise 30 minutes daily. When type II diabetics lose weight through diet and exercise they sometimes have an improvement in insulin efficiency sufficient to the degree they no longer require oral hypoglycemic agents. The remaining answers would certainly be beneficial to his health but are not associated with improvement in insulin efficiency to the point of no longer requiring oral hypoglycemic pills.
A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include? a. discard the NPH solution if it appears cloudy b. shake the insulin vigorously before loading the syringe c. expect the NPH insulin to peak in 6 to 14 hr d. freeze unopened insulin vials
C NPH insulin is an intermediate-acting insulin. Its onset of action is 1 to 2 hr, peaking at 6 to 14 hr. Its duration of action is 16 to 24 hr. The client is at risk for hypoglycemia during the peak time.
Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Patients with Crohn's Disease experience about 20 loose, bloody stools daily. B. Nutritional issues are common with Ulcerative Colitis. C. Patients with Ulcerative Colitis may experience hemorrhage. D. Very few complications are associated with Crohn's Disease.
C Patients with ulcerative colitis may experience hemorrhage due to erosion of the bowel wall. In Crohn's Disease, it may be 5-6 stools per day. 10-20 stools is characteristic of Ulcerative Colitis. Nutritional deficiencies are common in both disorders. Crohn's Disease is often associated with a lot of complications - such as fistulas and frequent surgeries.
A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect? a. red currant jelly stools b. distended neck veins c. projectile vomiting d. ridged abdomen
C Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine. The narrowing does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.
A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? a. oranges b. cashews c. red meat d. yogurt
C Red meat is a good source of iron. If the client is vegetarian, kidney beans with a high iron content are a good substitute.
A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? a. 0720 b. 0730 c. 0745 d. 0815
C Regular insulin should be given 20 to 30 minutes before eating because the onset of action is 30 minutes. There are circumstances when this lag time guide can be adjusted.
A client with a chronic urinary tract infection (UTI) is scheduled for a number of laboratory tests. The nurse would note that which test result best evaluates whether the kidneys are being adversely affected? A. Serum potassium 3.8 mEq/L B. Urinalysis specific gravity 1.015 C. Serum creatinine 2.0 mg/dL D. Urine culture negative
C Serum creatinine should be between 0.5 and 1.2 mg/dL. An elevated level indicates an issue with the kidneys. The remaining lab values are all within normal ranges.
A nurse is teaching a client who has iron deficiency anemia about ferrous sulfate. Which of the following instructions should the nurse include in the teaching? A. Take the ferrous sulfate at bedtime. B. Take the ferrous sulfate with an antacid. C. Take the ferrous sulfate between meals. D. Take the ferrous sulfate with yogurt.
C The client should take the medication between meals for optimal absorption. The client should take the medication at least 1 hr before bedtime to reduce the risk of stomach irritation. Antacids interfere with the absorption of ferrous sulfate. Dairy products interfere with the absorption of carbonyl iron; therefore, the client should not take the medication with yogurt.
The patient with diabetes mellitus reports having difficulty cutting his toenails. The patient states the toenails are thick and ingrown. Which of the following recommendations should be provided to this patient from the nurse? A. Cut the nails straight across with a clipper after the bath. B. Make an appointment with a nail shop for a pedicure. C. Make an appointment with a podiatrist. D. Offer to file the tops of the nails to reduce thickness after cutting.
C The toenails of the patient with diabetes require close care. If the nails are thick or ingrown, they require the attention of a podiatrist. Cutting the nails across after the bath is correct for toenails that do not demonstrate the complications listed. The patient with diabetes is at an increased risk for infection and should avoid situations in which this risk is increased, such as the nail shop pedicure. The nurse should not cut the patient's toenails.
A nurse is caring for a client who has uncontrolled type 1 diabetes mellitus. Which of the following findings should the nurse expect? a. hypertension b. hematuria c. weight loss d. bradycardia
C Weight loss is an expected finding for a client who has uncontrolled diabetes.
A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in plan of care? (select all that apply) A. Obtain capillary blood glucose four times daily B. Administer prescribed medications through a secondary port on the TPN IV tubing C. Monitor vital signs three times during the 12-hr shift D. Change the TPN IV tubing every 24 hr. E. Ensure a daily aPTT is obtained
C D
The nurse is reviewing the health record of a client who has a suspected tumor of the jejunum. The nurse should anticipate a prescription for which of the following tests? (select all that apply) A. Serum alpha-fetoprotein B. Endoscopic retrograde cholangiopancreatography (ERCP) C. Gastrointestinal x-ray with contrast D. Small bowel capsule endoscopy (M2A) E. Colonoscopy
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 meal E. Client experiences pain upon palpation of the epigastric region
C D E
A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (select all that apply) A. Remove calluses using over-the-counter remedies B. Apply lotion between toes C. Perform nail care after bathing D. Trim toenails straight across E. Wear close-toed shoes
C D E
A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply.) a. notify the provider immediately if mucus is present in the urine b. maintain the client on a fluid restriction c. apply skin barrier around the stoma site d. educate the client that hematuria is expected following the procedure e. monitor hourly urine output
C D E Notify the provider immediately if mucus is present in the urine is incorrect. Mucus in the urine is an expected finding following an ileal conduit procedure. Maintain the client on a fluid restriction is incorrect. Fluids should be encouraged following an ileal conduit procedure to flush the ileal conduit. Apply skin barrier around the stoma site is correct. Applying skin barrier around the stoma site is appropriate following an ileal conduit procedure to help prevent skin breakdown. Educate the client that hematuria is expected following the procedure is correct. Hematuria is an expected finding during the first 48 hr following an ileal conduit procedure. Monitor hourly urine output is correct. Monitoring hourly urine output is appropriate following an ileal conduit procedure ensure adequate urine output and provide for early detection of a blockage.
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 clients urine is positive for glucose C. The client reports having an elevated body temperature D. Client reports gaining 4 lbs in the last 6 months
C.
A nurse is caring for a client who has a blood glucose 52 mg/dL. The client is lethargic but arousable. which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min B. Provide carbohydrate and protein diet C. provide 4 oz of grape juice D. Report findings to the provider
C.
A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment 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. Serum WBC 15,000/mm3
C.
A nurse is completing discharge for 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 eat three large meals a day" C. "I will elevate the head if my bed on blocks" D. "When sleeping, I will lay on my left side"
C.
A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori (H. pylori). Which of the following statements made 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.
A nurse is completing discharge teaching with a client who is 3 days post-op following a transverse colostomy. Which of the following should the nurse include in the teaching? A. Mucus will be present in stool for 5 to 7 days after surgery. B. Expect 500 to 1,000 mL of semi liquid stool after 2 weeks C. Stoma should be moist and pink D. Change the ostomy bag when it is 3/4 full
C.
A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A. Draw up regular insulin and then glargine insulin in the same syringe B. Draw up glargine insulin then the regular insulin in the same syringe C. Draw up and administer regular and glargine insulin in separate syringes D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin
C.
A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. Stools will be dark red B. Take with a glass of milk if gastrointestinal distress occurs C. Foods high in Vit C will promote absorption D. Take for 14 days
C.
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 hr 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.
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A.The nurse initiates the feeding after aspirating 50 mL of gastric residual. B. The nurse irrigates the NG tube with tap water after feeding. C.The nurse administers the feeding through a syringe barrel by gravity. D.The nurse allows the client to rest in a supine position during feeding.
D
A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? A."Sleep upright in a chair to prevent nighttime reflux." B."Avoid snacking between meals." C."Limits foods that are high in fiber." D."Avoid eating 2 to 3 hours before bedtime."
D
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status? A. Enroll the client in a nutritional class on the unit. B. Weigh the client at the same time every morning. C. Ask provider to arrange a consultation with the facility chaplain. D. Sit with the client during meals and snacks
D
The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 82 mg/dL and hemoglobin A1C of 5.9%. What is the nurse's interpretation of these findings? a. the client's glucose control for the past 24 hours has been good, but the overall control is poor. b. the client's glucose control for the past 24 hours has been poor, but the overall control is good. c. the values indicate that the client has poorly managed his or her disease d. the values indicate that the client has managed his or her disease well
D
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. Creatine kinase B. Troponin C. Total bilirubin D. Albumin
D A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. Total bilirubin is altered in clients who are experiencing hepatobiliary disease. These are not laboratory tests that supports a diagnosis of malnutrition.
A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicated an understanding of the treatment for this disorder? A. "I take oral insulin instead of shots." B. "By taking these medications I am able to eat more." C. "When I become ill, I need to increase the number of pills I take." D. "The medications I'm taking help me use the insulin I already make."
D Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Answers B and C are incorrect.
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? a. urinary retention b. low back pain c. incontinence d. confusion
D Confusion is a clinical finding of UTIs specifically associated with older adult clients.
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A. Increased vital capacity B. Moist skin C. Heat intolerance D. Decreased mental status
D Lethargy and depression are manifestation of malnutrition. The brain requires glucose to function. When the body lacks adequate glucose, the body will metabolize tissue such as muscle and fat. The resulting metabolic acidosis can further decrease the client's mental status. Decreased, not increased, vital capacity due to respiratory muscle atrophy is a manifestation of malnutrition. Dry, flaking skin, rather than moist skin, is a manifestation of malnutrition. Cold, not heat, intolerance is a manifestation of malnutrition.
A school nurse is speaking with a teenage girl. The girl asks the school nurse why she is getting frequent urinary tract infections. The nurse concludes that the nursing diagnosis for this patient is knowledge deficit based on the patient's incorrect response to which of the following questions? A. "How often do you shower?" B. "Do you have a family history of urinary problems?" C. "When was your last UTI?" D. "In what direction do you wipe after a bowel movement?"
D People should wipe front to back after a bowel movement. If the patient answered incorrectly (she wipes back to front) then she has a knowledge deficit related to why she has frequent UTIs. A family history of UTIs, the date of her last UTI, and how frequently she showers are not the most relevant to her issue of frequent UTIs.
A nurse is providing teaching to the parents of a child who has iron deficiency anemia and is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching? a. the medication should be administered in one large dose every day b. restricting fiber from our child's diet will help with absorption of iron c. the medication will be more effective if it is administered with meals d. our child's blood count will need to be monitored routinely for several weeks
D The child's response to treatment will be determined by monitoring hemoglobin and hematocrit levels through routine blood tests. Treatment can take up to 3 months to be effective.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? a. mix the three medications together prior to administering b. dilute each medication with 10mL of tap water c. maintain the HOB in a flat position for 30 min following medication administration d. flush the NG feeding tube with 30 mL of water immediately following medication administration
D The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications. Administer each one separately, only dilute with sterile water, and HOB at least 30*
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Maintain the head of bed in a flat position for 30 minutes following medication administration. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration.
D The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications. The nurse should administer each medication separately and flush the tube with 15 to 30 mL of sterile water to ensure the client receives the entire dose. If the nurse needs to further dilute the medication because it is viscous, the nurse should only use sterile water because tap water can contain contaminants that can adversely interact with the medication. The nurse should ensure the head of the bed is elevated to at least 30° when a client is receiving enteral feedings and also following medication administration through an enteral tube.
A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include? a. elevate the HOB by 18 inches b. avoid snacking btw meals c. limit foods that are high in fiber d. lie on your right side when sleeping
D The nurse should instruct the client to lie on the right side when sleeping to prevent nighttime reflux.
A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan? a. soaking in a sitz bath for 20 min after each stool b. administer a soap-suds enema to cleanse the colon c. cleanse with antimicrobial scrub and vigorously dry d. wipe perineal area with warm water and apply a barrier cream
D The nurse should instruct the client to wipe the perianal area and apply a barrier cream to decrease skin breakdown when in contact with fecal material.
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? a. to confirm the placement of the NG tube b. to remove gastric acid that might cause dyspepsia c. to determine the client's electrolyte balance d. to identify delayed gastric emptying
D The nurse should measure the amount of unabsorbed formula from the previous enteral feeding to identify delayed gastric emptying. If it is delayed, the nurse should avoid overfeeding the client and causing gastric distention.
A nurse is assessing a client's colostomy during a pouching change and finds that the stoma is reddish pink and moist with slight bleeding when the mucosa is rubbed. What should the nurse do? A. Leave the pouch off because due to redness of the stoma. B. Reapply the pouch, and then call the healthcare provider about the bleeding at the stoma site. C. Immediately call the healthcare provider to report bleeding at the stoma site. D. Complete the pouching change because this is a normal assessment of the stoma.
D The stoma site should be reddish pink and moist. Mucosa is highly vascular and may bleed slightly when rubbed. These are normal findings and there is no need to call the provider or leave the pouch off.
A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for client's who have Crohn's disease? a. vanilla milkshake b. buttered popcorn c. tossed green salad d. toast with jelly
D Toast with jelly is an appropriate food choice by the client. It does not contain large amounts of lactose, fat, or fiber.
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? a. epigastric discomfort b. dyspepsia c. epigastric discomfort d. hematemesis
D When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding.
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort B. Dyspepsia C. Constipation D. Hematemesis
D When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding. Epigastric discomfort, dyspepsia, and constipation are non-urgent because these are expected findings for a client who has peptic ulcer disease; therefore, there is another finding that is the priority.
A nurse in a clinic is instructing a client about a fecal occult blood test, Which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching? A. "I will continue taking my warfarin while I complete these tests" B. "I'm glad I don't have to following any special diet at this time" C. "This test determines if I have any parasites in my bowel" D. "This is an easy way to screen for colon cancer"
D.
A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A. Client report of upper chest pain B. Decreased urine output C. Pallor D. Temperature elevation
D.
A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention for the nurse? A. Offer a warm sitz bath B. Recommend drinking cranberry juice C. Encourage increased fluids D. Administer an antibiotic
D.
A nurse is teaching a client who has a new diagnoses 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 products D. Increase protein in diet
D.
A nurse is teaching a client who is scheduled for extracorporeal shockwave lithotripsy (ESWL). 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.
