474 exam 4
A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowl disease and is to start a low lactose diet. Which of the following foods is the best choice for the client? A) soy milk B) cheddar cheese C) low fat yogurt D) cottage cheese
A
A patient in the outpatient clinic is diagnosed with acutre hepatitis C (HCV) infection. Which action by the nurse is appropriate? A) schedule for HCV genotyping B) administer the HCV vaccine and immune globulin
A
A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client? A) remove the parenteral nutrition solution from the refrigerator 2 hours before infusion B) remove unused parental nutrition after 12 hours of use C) monitor daily laboratory values and report as needed D) monitor the flow rate of the parenteral nutrition carefully and increase the rate as needed if it fall behind
C
Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade? A) monitor the patient for shortness of breath B) encourage the patient to cough every 4 hours C) deflate the gastric balloon every 8 to 12 hours D) verify the position of the balloon every 6 hours
A
A diabetic patient is admitted with ketoacidosis and the health care provider writes these orders. Which order should the nurse implement first? A) administer regular IV insulin 30 U B) infuse 1 liter of normal saline per hour C) give sodium bicarbonate 50 mEq IV push D) start an infusion of regular insulin at 50 U/hr
B
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? A) initiate a low residue diet B) pantoprazole 80mg IV bolus twice daily C) ambulate twice daily D) pancrelipase 500 units/kg PO three times daily with meals
B
The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (viokase). A) at bedtime B) with meals C) in the morning D) for abdominal pain
B
A nurse is caring for a child who has addisons disease. Which of the following actions should the nurse take? A) teach the parents about cortisol replacement therapy B) place the child on a low Na+ diet C) monitor the child for fluid volume excess D) discuss the manifestations of hypoglycemia with the parents
A
A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer? A) vitamin K B) heparin C) warfarin D) ferrous sulfate
A
A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal HTN. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is disgesting and absorbing blood? A) elevated BUN B) elevated HbA1C C) decreased chloride D) decreased bilirubin
A
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history. A) gallstones B) hypolipidemia C) COPD D) diabetes melitus
A
A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A) decrease the clients fluid intake B) increase the clients saturated fat intake C) increase the clients sodium intake D) decrease the clients carbohydrate intake
A
A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? A) provide a high carbohydrate diet B) administer acetaminophen for pain C) encourage eating three large meals daily D) include high protein snacks
A
After a hypophysectomy for acromegaly immediate postoperative nursing care should focus on A) monitoring serum and urine osmolality B) adminstrating of GH receptor angonists meds C) keeping the patient recumbent D) pt teaching regarding hormone replacement
A
The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? A) the patient is alert and oriented B) patients lung sounds are clear C) patients urinary output decreases D) patients potassium level is 5.7 mEq/L
A
The nurse is planning care for a patient with acute severe pancreatitis. The highest priority patient outcome is A) maintaining normal respiratory function B) expressing satisfaction with pain control C) developing no ongoing pancreatic disease D) developing no ongoing pancreatic disease
A
A nurse is caring for a client who has cushings syndrome. Which of the following interventions should the nurse expect to perform. select all that apply A) assess blood glucose level B) assess for neck vein distention C) monitor for an irregular heart rate D) monitor for postural hypotension E) weigh the client daily
A, B, E
A nurse is planning are for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? select all that apply A) administer furosemine B) administer warfarin C) implement a low-sodium diet D) measure the clients abdominal girth E) encourage weight lifting during physical therapy
A, C, D
A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? select all that apply A) administer furosemide B) administer warfarin C) implement a low sodium diet D) measure the clients abdominal firth E) encourage weight lifting during physical therapy
A, C, D
Nursing management of the patient with acute pancreatitis include (select all the apply) A) checking for hypocalcemia B) providing a diet low in carbohydrates C) giving insulin based on a sliding scale D) observing stool for signs of diarrhea E) monitoring for infection especially respiratory tract infections
A, E
A nurse is caring for a client who has addisons disease and is at risk for addisonian crisis. Which of the following actions should the nurse take? A) provide a low carbohydrate diet B) weigh the client daily C) administer oral corticosteroids D) restruct fluids
B
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate? A) maintain an IV of 0.45% sodium chloride B) restrict fluid intake to 1,000 mL per day C) provide a diet containing 2g of sodium per day D) adminster desmopressin acetate 0.2 mg orally
B
A nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? A) patient complains of right upper quadrant pain with palpation B) patients hands flap back and forth when the arms are extended C) patient has ascities and a 2kg weight gain from the previous day D) patient has ascites and a 2kg weight gain from the previous day
B
A patient with cirrhosis who has scheduled doses of spironolactone (aldactone) and furosemind (lasix) has a serum potassium level of 3.2 mEG/L (3.2mmol/L). Which action should the nurse take? A) give both drugs as acheduled B) administer the spironolactone C) administer the furosemide and withhold the spironolactone D) withhold both drugs until taking with the health care provider
B
A young woman who has Crohn's disease develops a fever and symptoms of UTI with tan, fecal smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for the patient? A) bacteria in the perianal area can ent the urethra B) fistulas can form between the bowel and the bladder C) drink adequate fluids to maintain normal hydration D) empty the bladder before and after sexual intercourse
B
The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that A) there is a lack of clotting factors, causing collection of blood in the peritoneum B) portal HTN and low albumin cause fluid shifts C) decreased peristalsis contributes to massive gas D) bile salts irritate peritoneum, causing edema of the stomach
B
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? A) restrict fluid intake to prevent constant liquid drainage from the stoma B) use care when eating high-fiber foods to avoid obstruction of the ileum C) irrigate the ileostomy daily to avoid having to wear a drainage application D) change the pouch everyday to prevent leakage of contents onto the skin
B
which patient statement indicates that the nurse's teaching about sulfasalazine (azulfidine) for ulcerative colitis has been effective? A) the medication will be tapered if i need surgery B) i will need to use a sunscreen when i am outdoors C) I will need to avoid contact with people who are sick D) the medication prevents the infections that cause diarrhea
B
A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? A) droplet B) contact C) airborne D) standard
D
A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the clients lunch tray, which of the following items should the nurse identify as contraindicated for the client? A) baked potato B) stewed tomatoes C) ham sandwich D) milkshake
C
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric ballon tamponade with a sengstaken blankemore tube to control the bleeding. Which of the following actions should the nurse take? A) ambulate the client four times per day B) encourage the client to consume clean liquids C) provide frequent oral and nares care D) keep the client in a supine position
C
A nurse is planning care for a client who had end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the clients amonia level? A) administer diuretics B) restrict the clients intake of fluids C) reduce the clients intake of protein D) administer vitamin K
C
A nurse is teaching a class about preventative care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? A) avoid covering sores with bandage B) avoid hand washing after eating C) avoid foods prepared with tap water D) avoid eating meat
C
A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? A) avoid eating at fast food restaurants B) avoid serving raw foods C) practice effective hand hygiene D) wear barrier protective during vaginal intercourse
C
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? A) feel free to donate blood in about 6 months B) eat a great deal of protein C) take planned rest periods throughout the day D) take tylenol every 4 hours
C
A patient with a head injury develops SIADH. manifestations the nurse would expect to find include A) hypernatremia and edema B) muscle spasticity and HTN C) low urine output and hyponatremia D) weight gain and decreased GFR
C
During a change of shift report, the nurse learns about the following four patients. Which patient requires assessment first? A) 40 year old with chronic pancreatitis who has gnawing abdominal pain B) 58 year old who has compensated cirrhosis and is complaining of anorexia C) 55 year old with cirrhosis and ascites who has an oral temperature of 102 F D) 36 year old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
C
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? A) nausea and vomiting B) hypotonic bowel sounds C) muscle twitching and finger numbness D) upper abdominal tenderness and guarding
C
A nurse is caring for a client who has cushing's syndrome. The nurse should recognize that which of the following are manifestations of cushings syndrome? select all that apply A) alopecia B) tremors C) moon face D) purple striations E) buffalo hump
C, D, E
A nurse is caring for a client who has acute pancreatitis. After treating the clients pain, which of the following should the nurse address as the priority intervention? A) auscultate the clients lungs B) assist the client to a side lying position C) provide oral hygiene D) withhold oral fluids as good
D
A client is about to undergo an abdominal paracentesis. In which of the following positions should the nurse place the client? A) prone B) supine C) lateral D) upright
D
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) soak 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 perianal area with warm water and apply a barrier cream
D
A nurse is providing teaching to a client who has a history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid? A) noodles B) vegetable soup C) baked fish D) cheddar cheese
D
A nurse is reviewing the laboratory results for four clients. the nurse should recognize which of the following client has a manifestation of hypoparathyroidism? A) client who has a vitamin D of 25 ng/mL B) client who has a magnesium of 1.8 mEq/L C) client who has a calcium of 9.8 mg/dL D) a client who has a phosphate of 5.7 mg/dL
D
A patient is treated with demeclocycline (declomycin) to control the symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse determines that the demeclocycline is effective upon finding that the A) peripheral edema is decreased B) patients weight has increased C) urine specific gravity is increased D) patients urinary output is increased
D
A patient with acute pancreatitis is NPO and has a nasgogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective? A) bowel sounds are present B) grey turners sign resolves C) electrolyte levels are normal D) abdominal pain is decreased
D
A patient with advance cirrhosis with ascites is short of breath and has an increased respiratory rate. The nurse should A) initiate oxygen therapy at 2 L/min to increase gas exchange B) notify the health care provider so a paracentesis can be performed C) ask patient to cough and deep breathe to clear respiratory secretions D) place the patient in fowlers position to relieve pressure on the diaphragm
D
A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patients A) hemoglobin B) temperature C) activity level D) albumin level
D
After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops A) muscle weakness and weight loss B) hyperthermia and severe tachycardia C) hypertension and difficulty swallowing D) laryngospasms and tingling in the hands and feel
D
During preoperative teaching for a patient scheduled for transsphenoidial hypophysectomy for treatment of a pituitary adenoma, the nurse instructions the patient about the need to A) cough and deep breathe every 2 hours postoperatively B) remain on red rest for the first 48 hours after the surgery C) be positioned flat with sandbags at the head postoperatively D) avoid brushing the teeth for at least 10 days after the surgery
D
Which patient should the nurse assess first after receiving change of shift report? A) 60 year old patient whose new ileostomy has drained 800 ML of the previous 8 hours B) 50 year of patient with familial adenomatous polyposis who has occult blood in stool C) 40 year old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours D) 30 year old patient who has abdominal distention and an apical heart rate of 136 BPM
D
A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? A) droplet B) contact C) airborne D) standard
DA