Adult health exam 3

The client with an acute exacerbation of chronic pancreatitis has a nasogastric tube and is NPO. Which interventions should the nurse implement? Select all that apply. 1. Monitor the bowel sounds. 2. Weigh the client daily. 3. Assess the intravenous site. 4. Provide oral and nasal care. 5. Monitor the blood glucose.

***1. The return of bowel sounds indicates the return of peristalsis, and the nasogastric suction is usually discontinued within 24 to 48 hours after ***3. The nurse should assess for signs of infection or infiltration. ***4. Fasting and the N/G tube increase the client's risk for mucous membrane irritation and breakdown. ***5. Blood glucose levels are monitored because clients with chronic pancreatitis can develop diabetes mellitus.

The client is diagnosed with cancer of the head of the pancreas. Which signs and symptoms should the nurse expect to assess? 1. Clay-colored stools and dark urine. 2. Night sweats and fever 3. Left lower abdominal cramps and tenesmus 4. Nausea and coffee ground emesis

1

The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement? 1. Document the findings as normal 2. Assess the client's bowel sounds 3. Determine the client's last bowel movement 4. Insert the N/G tube at least 2 more inches

1

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP? 1. Assist the client with abdominal pain to turn to the side and flex the knees. 2. Monitor the Jackson Pratt drainage tube to ensure it is draining properly. 3. Check to see if the client is sleeping after pain medication is administered. 4. Empty the bedside commode of the client who has been having melena.

1

The nurse is administering a pancreatic enzyme to the client diagnosed with chronic pancreatitis. Which statement best explains the rationale for administering this medication? 1. It is an exogenous source of protease, amylase, and lipase. 2. This enzyme increases the number of bowel movements. 3. This medication breaks down in the stomach to help with digestion. 4. Pancreatic enzymes help break down fat in the small intestine.

1

The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD? 1. Adult onset asthma 2, pancreatitis 3. peptic ulcer disease 4. increased gastric emptying

1

Which physical exam should the nurse implement first when assessing the client diagnosed with peptic ulcer disease? 1. Auscultate the clients bowel sounds in all 4 quadrants 2. Palpate the abdominal area for tenderness 3. percuss the abdominal borders to identify organs 4. Assess the tender area progressing to nontender

1

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

1 - Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing 2. Use sterile gloves to replace protruding parts 3. Place the client in reverse Trendelenburg position 4. Administer intravenous antibiotic STAT

1 - Evisceration is a life-threatening condi- tion in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile nor- mal saline gauze on it, which prevents the intestines from drying out and necrosing.

The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5′10′′ tall and weighs 45 kg. Which assessment data should the nurse obtain first? 1. Ask the client to recall what she ate for the last 24 hours. 2. Determine what type of birth control the client has been using. 3. Reweigh the client to confirm the data. 4. Take the client's pulse and blood pressure.

1 - Menses will cease if the client is severely emaciated. A 24-hour dietary recall is a step toward assessing the client's eating patterns.

The nurse is performing an admission assessment on a client diagnosed with GERD. Which sign and symptoms would indicate GERD? 1. Pyrosis, water brash, and flatulence 2. Weight loss, dysarthria, and diarrhea 3. Decreased abdominal fat, proteinuria, and constipation 4. Midepigastric pain, positive H pylori test, and melena

1 - Pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas—all symptoms of GERD.

The client diagnosed with IBD is prescribed total parental nutrition. Which intervention should the nurse implement? 1. Check the clients glucose level 2. Administer an oral hypoglycemic 3. Assess the peripheral IV site 4. Monitor the clients oral food intake

1 - TPN is high in dextrose which is also glucose

The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard rigid abdomen and T 102 degrees Fahrenheit. Which intervention should the nurse implement? 1. Notify the HCP 2. Prepare to administer a Fleet's enema 3. Administer an antipyretic suppository 4. Continue to monitor the client closely

1 - These are signs of peritonitis, which is life threatening. The health-care provider should be notified immediately.

The nurse caring for a client diagnosed with GERD writes the client problem of "behavior modification." Which intervention should be included for this problem? 1. Teach the client to sleep with a foam wedge under the head 2. Encourage the client to decrease the amount of smoking 3. Instruct the client to take OTC medication for the relief of pain 4. Discuss the need to attend AA meetings to stop drinking

1 - client should elevate their head to keep the gastric acid in the stomach and precent reflux

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day 2. Oral temp of 102 f 3. Hard, rigid abdomen 4. Urinary stress incontinence

1 - most common symptom for ulcerative colitis

The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately? 1. A serum sodium of 139 mEq/L in a client diagnosed with obstipation. 2. The client diagnosed with fecal impaction who had two (2) hard formed stools. 3. A serum potassium level of 3.0 mEq/L in a client diagnosed with diarrhea. 4. The client with diarrhea who had two (2) semi-liquid stools totaling 300 mL.

1 - normal sodium levels are 135-152

The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrants immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid 2. The drainage tube is taped to the dressing 3. The JP insertion site is pink and has no drainage 4. The JP bulb has suction and is sunken in

1 - round bulb means its full

The nurse is admitting a client diagnosed with protein calorie malnutrition. Which interventions should the nurse implement? Select all that apply. 1. Place the client on a 72-hour calorie count. 2. Ask the client to describe the stools. 3. Have the UAP weigh the client. 4. Obtain a list of current medications. 5. Make a referral to the dietitian.

1,2,3,4,5 1. The nurse should assess the client's intake; a 72-hour calorie count will allow the nurse to do this. 2. Protein calorie malnutrition can result from several different diseases. Diarrhea can impart the ability to absorb calories and nutrition from food. 3. Daily weights will monitor the client's weight loss or gain. 4. The nurse should assess medications for drug and food interactions. 5. The dietitian can be invaluable in assist- ing this client to gain or at least maintain weight.

146. The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply. 1. Tell the client not to eat or drink. 2. Start an intravenous line. 3. Assess the client for abdominal tenderness. 4. Have the dietitian consult for a low-residue diet. 5. Place the client on bedrest with bathroom privileges.

1,2,3,5 1. The client should remain NPO until the inflammation in the colon resolves. 2. The client should have an IV to maintain hydration while being NPO. 3. The nurse should assess the client for complications of a ruptured diverticulum. 4. The client will be NPO to rest the bowel. 5. The client is kept on bedrest with bath- room privileges to decrease colon activ- ity. Ambulation increases peristalsis.

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? SATA 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours.

1,2,4

Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy? Select all that apply. 1. Clay-colored stools. 2. Yellow-tinted sclera. 3. Amber-colored urine. 4. Wound approximated. 5. Abdominal pain.

1,2,5 1. Clay-colored stools are caused by recurring stricture of the common bile duct, which is a sign of post-cholecystectomy syndrome. 2. Yellow-tinted sclera and skin indicate residual effects of stricture of the common bile duct, which is a sign of post- cholecystectomy syndrome. 5. Abdominal pain indicates a residual effect of a stricture of the common bile duct, inflammation, or calculi, which is a sign of post-cholecystectomy syndrome.

The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement? Select all that apply. 1. Provide meticulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semirecumbent.

1,3,5 1. Colostomy stomas are openings through the abdominal wall into the colon, through which feces exit the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed. 3. Because of the perineal wound, the client will have an indwelling catheter to keep urine out of the incision. 5. The client should not sit upright because this causes pressure on the perineum.

The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply. 1. Monitor diarrhea, charting amount, character, and consistency. 2. Assess the client's tissue turgor every day. 3. Encourage the client to drink carbonated soft drinks. 4. Weigh the client daily in the same clothes and at the same time. 5. Assist the client with a warm sitz bath PRN.

1,4,5.

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "my pain goes away when I have a bowel movement" 2. "I have bright red blood in my stool all the time" 3. "I have episodes of diarrhea and constipation" 4. "My abdomen is hard and rigid and I have a fever"

1- terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.

Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series? 1. Chalky white stools. 2. Increased heart rate. 3. A firm hard abdomen. 4. Hyperactive bowel sounds.

1. A UGI series requires the client to swallow barium, which passes through the intestines, making the stools a chalky white color.

The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement? 1. Apply a heating pad to the abdomen for 15 to 20 minutes. 2. Administer morphine sulfate intravenously after diluting with saline. 3. Contact the surgeon for an order to x-ray the right shoulder. 4. Apply a sling to the right arm, which was injured during surgery.

1. A heating pad should be applied for 15 to 20 minutes to assist the migration of the CO2 used to insufflate the abdomen. Shoulder pain is an expected occurrence.

The 85-year-old male client diagnosed with cancer of the colon asks the nurse, "Why did I get this cancer?" Which statement is the nurse's best response? 1. "Research shows a lack of fiber in the diet can cause colon cancer." 2. "It is not common to get colon cancer at your age; it is usually in young people." 3. "No one knows why anyone gets cancer, it just happens to certain people." 4. "Women usually get colon cancer more often than men but not always."

1. A long history of low-fiber, high-fat, and high-protein diets results in a prolonged transit time. This allows the carcinogenic agents in the waste products to have a greater exposure to the lumen of the colon.

Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.

1. Fluid volume deficit secondary to diarrhea is the priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly.

The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group? Select all that apply. 1. Do not share needles or equipment. 2. Use barrier protection during sex. 3. Get the hepatitis B vaccine. 4. Obtain immune globulin injections. 5. Avoid any type of hepatotoxic medications.

1. Hepatitis B can be transmitted by sharing any type of needles, especially those used by drug abusers. 2. Hepatitis B can be transmitted through sexual activity; therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. 3. Three doses of hepatitis B vaccine provide immunity in 90% of healthy adults.

22. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client? 1. Deep tendon reflexes. 2. Arterial blood gases. 3. Skin turgor. 4. Capillary refill time.

1. If deep tendon reflexes are hypoactive or absent, the nurse should hold the magnesium and notify the health-care provider.

The weight loss clinic nurse identifies the concept of nutrition for a client diagnosed with obesity. Which interventions should the nurse implement? Select all that apply. 1. Ask the client about previous diet attempts. 2. Refer the client to the dietitian. 3. Discuss maintaining a sedentary lifestyle. 4. Weigh the client. 5. Assist the client to set a realistic weight loss goal.

1. Knowledge of previous weight loss attempts will assist in planning a weight loss program. 2. The dietitian will monitor the nutritional intake and help in planning a nutrition- ally balanced diet. 4. The client's weight will be useful in determining the client's progress. 5.Clients who desire weight loss frequently want a quick fix. The nurse should as- sist the client to determine a consistent weight loss goal in order to achieve behavior modification to maintain the weight loss.

The nurse is preparing to administer A.M. medications to the following clients. Which medication should the nurse question before administering? 1. Pancreatic enzymes to the client who has finished breakfast. 2. The pain medication, morphine, to the client who has a respiratory rate of 20. 3. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L. 4. The beta blocker to the client who has an apical pulse of 68 bpm.

1. Pancreatic enzymes must be administered with meals to enhance the digestion of starches and fats in the gastrointestinal tract.

The nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care? 1. Provide a high-calorie intake diet. 2. Discuss total parenteral nutrition (TPN). 3. Instruct the client to decrease salt intake. 4. Encourage the client to increase water intake.

1. Sufficient energy is required for healing. Adequate carbohydrate intake can spare protein. The client should eat approximately 16 carbohydrate kilocalories for each kilogram of ideal body weight daily.

The client is diagnosed with salmonellosis secondary to eating some slightly cooked hamburger meat. Which clinical manifestations should the nurse expect the client to report? 1. Abdominal cramping, nausea, and vomiting. 2. Neuromuscular paralysis and dysphagia. 3. Gross amounts of explosive bloody diarrhea. 4. Frequent "rice water stool" with no fecal odor.

1. Symptoms develop 8 to 48 hours after ingesting the Salmonella bacteria and include diarrhea, abdominal cramping, nausea, and vomiting, along with low-grade fever, chills, and weakness.

The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority? 1. Monitor respiratory status. 2. Weigh the client daily. 3. Teach a healthy diet. 4. Assist the client in behavior modification.

1. The client that is morbidly obese will have a large abdomen that prevents the lungs from expanding

The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? 1. Hepatitis A. 2. Hepatitis B. 3. Hepatitis C. 4. Hepatitis D.

1. The hepatitis A virus is in the stool of infected people and takes up to two (2) weeks before symptoms develop.

The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health-care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

1. The nurse should mark the drainage on the dressing to determine if active bleeding is occurring, because dark reddish-brown drainage indicates old blood.

The charge nurse is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? 1. An elevated white blood cell count. 2. A decreased lactate dehydrogenase. 3. An elevated alkaline phosphatase. 4. A decreased direct bilirubin level.

1. The white blood cell count should be elevated in clients with chronic inflammation.

Which laboratory data indicate the client's pancreatitis is improving? 1. The amylase and lipase serum levels are decreased. 2. The white blood cell count (WBC) is decreased. 3. The conjugated and unconjugated bilirubin levels are decreased. 4. The blood urea nitrogen (BUN) serum level is decreased.

1. These laboratory data are used to diagnose and monitor pancreatitis because amylase and lipase are the enzymes produced by the pancreas.

The client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority? 1. Altered nutrition. 2. Low self-esteem. 3. Disturbed body image. 4. Altered sexuality

1. This client is severely underweight and nutrition is the priority.

The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast food restaurant. Which intervention should be implemented first? 1. Provide the client with a specimen collection to collect a stool sample. 2. Initiate antibiotic therapy intravenously. 3. Have the laboratory draw a complete blood count. 4. Administer the antidiarrheal medication Lomotil.

1. This client may have developed an infection from the undercooked meat. The nurse should try to get a specimen for the laboratory to analyze and for the nurse to be able to assess.

The client has had a stool that is dark, watery, and shiny in appearance. Which intervention should be the nurse's first action? 1. Check for a fecal impaction. 2. Encourage the client to drink fluids. 3. Check the chart for sodium and potassium levels. 4. Apply a protective barrier cream to the perianal area.

1. This is a symptom of diarrhea moving around an impaction higher up in the colon.

The client at the eating disorder clinic weighs 35 kg and is 5 ft 7 inches tall. Which would the nurse document as the Body Mass Index (BMI)? ________________

12.06

The client has a nasogastric tube. The health-care provider orders IV fluid replacement based on the previous hour's output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900 the client's N/G tube drained 45 mL. At 0900, what rate should the nurse set the IV pump?_______

170 mL/hr

The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach? 1. Jog for two (2) to three (3) hours every day. 2. Lifestyle behaviors must be modified. 3. Eat one large meal every day in the evening. 4. Eat 1000 calories a day and don't take vitamins

2

The client diagnosed with cancer of the pancreas is being discharged to start chemotherapy inthe HCP's office. Which statement made bythe client indicates the client understands the discharge instructions? 1. "I will have to see the HCP every day for six (6) weeks for my treatments." 2. "I should write down all my questions so I can ask them when I see the HCP." 3. "I am sure this is not going to be a serious problem for me to deal with." 4. "The nurse will give me an injection in my leg and I will get to go home."

2

The client diagnosed with cancer of thehead of the pancreas is two (2) days post- pancreatoduodenectomy (Whipple's procedure). Which nursing problem has the highest priority? 1. Anticipatory grieving. 2. Fluid volume imbalance. 3. Alteration in comfort. 4. Altered nutrition.

2

The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client? 1. Determine the client's food preferences. 2. Ask the client if there is an advance directive. 3. Find out about insurance/Medicare reimbursement. 4. Explain the client should eat as much as possible.

2

The post-anesthesia care nurse is caring for a client who has had abdominal surgery. The client is complaining of nausea. Which intervention should the nurse implement first? 1. Medicate the client with a narcotic analgesic IVP. 2. Assess the nasogastric tube for patency. 3. Check the temperature for elevation. 4. Hyperextend the neck to prevent stridor.

2

The nurse is caring for the following clients on a surgical unit. Which client would the nurse assess first? 1. The client who had an inguinal hernia repair and has not voided in four (4) hours. 2. The client who was admitted with abdominal pain who suddenly has no pain. 3. The client four (4) hours postoperative abdominal surgery with no bowel sounds. 4. The client who is one (1) day postoperative appendectomy who is being discharged.

2 - A sudden cessation of pain may indicate a ruptured appendix, which could lead to peritonitis, a life-threatening complica- tion; therefore, the nurse should assess this client first.

The client is one (1) day postoperative major abdominal surgery. Which client problem is priority? 1. Impaired skin integrity. 2. Fluid and electrolyte imbalance. 3. Altered bowel elimination. 4. Altered body image.

2 - After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular com- partment to the interstitial space, which causes potential fluid and electrolyte imbalance.

The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first? 1. Ask the parent about the child's diet. 2. Assess the child's tissue turgor. 3. Give the child a sucker if she is "good." 4. Notify the HCP the child is waiting to be seen.

2 - Assessing the skin turgor will give the nurse information about the hydration status of the toddler. The nurse should perform an assessment based on the presenting symptoms

The client with hepatitis asks the nurse, "I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?" Which statement is the nurse's best response? 1. "You are concerned about taking an herb." 2. "The herb has been used to treat liver disease." 3. "I would not take anything that is not prescribed." 4. "Why would you want to take any herbs?"

2 - Milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2,000 years. It is a powerful oxidant and promotes liver cell growth.

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? 1. History of side effects experienced from medication 2. Used of NSAIDS 3. Any known allergies 4. Medical histories of 3 generations

2 - Use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid.

The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment? 1. Assess the gag reflex every shift. 2. Stay with the client at all times. 3. Administer the laxative lactulose (Chronulac). 4. Monitor the client's ammonia level.

2 - While the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. This is a safety issue.

The nurse is preparing to administer the initial does of an aminoglycoside antibiotic to the client just admitted with a diagnosis of acute diverticulitis. Which intervention should the nurse implement? 1. Obtain a serum trough level. 2. Ask about drug allergies. 3. Monitor the peak level. 4. Assess the vital signs.

2 - always ask about drug allergies before administering antibiotics

Which statement made by the client indicates to the nurse the client may be experiencing GERD? 1. "My chest hurts when I walk up the stairs in my home" 2. "I take antacid tablets with me wherever I go" 3. "My spouse tells me I snore very loudly at night" 4. "I drink 6 to 7 soft drinks a day"

2 - frequent use of antacids indicates an acid reflux problem

client tells nurse he's experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? 1. "how much weight have you gained recently?" 2. "what have you done to alleviate the heartburn" 3. "Do you consume many milk and dairy products" 4. "Have you been around anyone with a stomach virus"

2 - most clients use OTC meds to treat the heartburn before seeking medical advice, its important to know what the client was using

The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention would the nurse anticipate the health-care provider ordering? 1. Administer total parenteral nutrition. 2. Maintain NPO and nasogastric tube. 3. Maintain on a high-fiber diet and increase fluids. 4. Obtain consent for abdominal surgery.

2 - the bowel needs to be put to rest

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4. Which action should the nurse implement first? 1. Notify the HCP 2. Assess the client for muscle weakness 3. Request telemetry for the client 4. Prepare to administer IV potassium

2 - this is a sign of hypokalemia which can lead to dysrhythmias

The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet 2. Rest the clients bowel 3. Assess vital signs daily 4. Administer antacids orally

2 - this is the first thing to do and client should be NPO with IVF to prevent dehydration also

The client who is obese presents to the clinic before beginning a weight loss program. Which interventions should the nurse teach? SATA 1. Walk for 30 minutes three (3) times a day. 2. Determine situations that initiate eating behavior. 3. Weigh at the same time every day. 4. Limit sodium in the diet. 5. Refer to a weight support group.

2, 5.

The client had a total pancreatectomy and splenectomy for cancer of the body of the pancreas. Which discharge instructions should the nurse teach? Select all that apply. 1. Keep a careful record of intake and output. 2. Use a stool softener or bulk laxative regularly. 3. Use correct insulin injection technique. 4. Take the pain medication before the pain gets too bad. 5. Sleep with the head of the bed on blocks.

2,3,4

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist" 2. "I will irrigate my ileostomy every am" 3. "If i get a red, bumpy, itchy rash I will call my HCP" 4. "I will change my pouch if it starts leaking"

2- the ileostomy will drain liquid and should. not be routinely irrigated, sigmoid may need irrigation daily to evacuate feces

Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C? 1. Decrease alcohol intake. 2. Encourage rest periods. 3. Eat a large evening meal. 4. Drink diet drinks and juices.

2. Adequate rest is needed for maintaining optimal immune function.

The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective? 1. "I will take my lipid-lowering medicine at the same time each night." 2. "I may experience some discomfort when I eat a high-fat meal." 3. "I need someone to stay with me for about a week after surgery." 4. "I should not splint my incision when I deep breathe and cough."

2. After removal of the gallbladder, some clients experience abdominal discomfort when eating fatty foods.

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? 1. The client's pulse is 65 beats per minute. 2. The client has shallow respirations. 3. The client's bowel sounds are 20 per minute. 4. The client uses a pillow to splint when coughing.

2. An open cholecystectomy requires a large incision under the diaphragm. Deep breathing places pressure on the diaphragm and the incision, causing pain. Shallow respirations indicate inadequate pain control, and the nurse should intervene.

Which client problem has priority for the client diagnosed with acute pancreatitis? 1. Risk for fluid volume deficit. 2. Alteration in comfort. 3. Imbalanced nutrition: less than body requirements. 4. Knowledge deficit.

2. Autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness, and muscle guarding.

The client diagnosed with liver problems asks the nurse, "Why are my stools claycolored?" On which scientific rationale should the nurse base the response? 1. There is an increase in serum ammonia level. 2. The liver is unable to excrete bilirubin. 3. The liver is unable to metabolize fatty foods. 4. A damaged liver cannot detoxify vitamins.

2. Bilirubin, the by-product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color. If the liver is damaged, the bilirubin is excreted via the urine and skin.

The dietician and nurse in a long-term care facility are planning the menu for the day. Which foods would be recommended for the immobile clients for whom swallowing is not an issue? 1. Cheeseburger and milk shake. 2. Canned peaches and a sandwich on whole-wheat bread. 3. Mashed potatoes and mechanically ground red meat. 4. Biscuits and gravy with bacon.

2. Canned peaches are soft and can be chewed and swallowed easily while providing some fiber, and whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility.

The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. While assessing the client, which question should the nurse ask to identify behaviors that suggest bulimia? 1. "When was the last time you exercised?" 2. "What over-the-counter medications do you take?" 3. "How long have you had a positive self-image?" 4. "Do you eat a lot of high-fiber foods for bowel movements?"

2. Clients diagnosed with bulimia frequently take cathartic laxatives to prevent absorption of calories from the food consumed.

The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? 1. Wear a high-filtration mask when around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multiple vitamin every day. 4. Do not engage in high-risk sexual behaviors.

2. Cruciferous vegetables, such as broccoli, cauliflower, and cabbage, are high in fiber. One of the risks for cancer of the colon is a high-fat, low-fiber, and high-protein diet. The longer the transit time (the time from ingestion of the food to the elimination of the waste products), the greater the chance of developing cancer of the colon.

The nurse identifies the client problem "excess fluid volume" for the client in liver failure. Which short-term goal would be most appropriate for this problem? 1. The client will not gain more than two (2) kg a day. 2. The client will have no increase in abdominal girth. 3. The client's vital signs will remain within normal limits. 4. The client will receive a low-sodium diet.

2. Excess fluid volume could be secondary to portal hypertension. Therefore, no increase in abdominal girth would be an appropriate short-term goal, indicating no excess of fluid volume.

The client diagnosed with acute pancreatitis is being discharged home. Which statement by the client indicates the teaching has been effective? 1. "I should decrease my intake of coffee, tea, and cola." 2. "I will eat a low-fat diet and avoid spicy foods." 3. "I will check my amylase and lipase levels daily." 4. "I will return to work tomorrow but take it easy."

2. High-fat and spicy foods stimulate gastric and pancreatic secretions and may precipitate an acute pancreatic attack.

Which statement made by the client admitted with electrolyte imbalance from frequent cathartic use demonstrates an understanding of the discharge teaching? 1. "In the future I will eat a banana every time I take the medication." 2. "I don't have to have a bowel movement every day." 3. "I should limit the fluids I drink with my meals." 4. "If I feel sluggish, I will eat a lot of cheese and dairy products."

2. It is not necessary to have a bowel movement every day to have normal bowel functioning.

Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis? Select all that apply. 1. Assess the skin turgor on the back of the client's hands. 2. Monitor the client for orthostatic hypotension. 3. Record the frequency and characteristics of sputum. 4. Use Standard Precautions when caring for the client. 5. Institute safety precautions when ambulating the client.

2. Orthostatic hypotension indicates fluid volume deficit, which can occur in an elderly client who is having many episodes of diarrhea. 4. Standard Precautions, including wearing gloves and hand washing, help prevent the spread of the infection to others. 5. The elderly client is at risk for orthostatic hypotension; therefore, safety precautions should be instituted to ensure the client doesn't fall as a result of a decrease in blood pressure.

Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne Precautions. 2. Standard Precautions. 3. Droplet Precautions. 4. Exposure Precautions.

2. Standard Precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood.

The 79-year-old client diagnosed with acute gastroenteritis is admitted to the medical unit. Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the client's intake and output. 2. Take the client's vital signs. 3. Change the client's intravenous solution. 4. Assess the client's perianal area.

2. The UAP can take the vital signs for a client who is stable; the nurse must interpret and evaluate the vital signs.

The nurse is assessing a client with complaints of vague upper abdominal pain that is worse at night but is relieved by sitting up and leaning forward. Which assessment question should the nurse ask next? 1. "Have you noticed a yellow haze when you look at things?" 2. "Does the pain get worse when you eat a meal or snack?" 3. "Have you had your amylase and lipase checked recently?" 4. "How much weight have you gained since you saw the HCP?"

2. The abdominal pain is often made worse by eating and lying supine in clients diagnosed with cancer of the pancreas.

The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement? 1. Instruct the client to take a cathartic laxative daily. 2. Encourage the client to drink lots of Gatorade. 3. Discuss the need to increase protein in the diet. 4. Explain the client should weigh herself daily.

2. The client probably has traveler's diarrhea, and oral rehydration is the preferred choice for replacing fluids lost as a result of diarrhea. An oral glucose electrolyte solution, such as Gatorade, All-Sport, or Pedialyte, is recommended.

The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching? 1. "If I notice any skin breakdown, I will call the HCP." 2. "I should drink only liquids until the colostomy starts to work." 3. "I should not take a tub bath until the HCP okays it." 4. "I should not drive or lift more than five (5) pounds."

2. The client should be on a regular diet, and the colostomy will have been working for several days prior to discharge.

The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next? 1. Call the HCP and suggest he or she talk with the client. 2. Determine what about the HCP is bothering the client. 3. Notify the nursing supervisor to arrange a new HCP to take over. 4. Explain the client cannot request another HCP until after discharge.

2. The nurse should determine what is concerning the client. It could be a misunderstanding or a real situation where the client's care is unsafe or inadequate.

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first? 1. Notify the infection control nurse. 2. Cleanse the area with soap and water. 3. Request postexposure prophylaxis. 4. Check the hepatitis status of the client.

2. The nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin.

The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication? 1. "I should have two to three soft stools a day." 2. "I must check my ammonia level daily." 3. "If I have diarrhea, I will call my doctor." 4. "I should check my stool for any blood."

2. There is no instrument used at home to test daily ammonia levels. The ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment.

The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with Crohn's disease who had two (2) semi-formed stools on the previous shift. 2. The elderly client admitted from another facility who is complaining of constipation. 3. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor. 4. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.

2. This client has just arrived so the nurse does not know if the complaint is valid and needs intervention unless this client is seen and assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility.

The client diagnosed with gastroenteritis is being discharged from the emergency department. Which intervention should the nurse include in the discharge teaching? 1. If diarrhea persists for more than 96 hours, contact the health-care provider. 2. Instruct the client to wash hands thoroughly before handling any type of food. 3. Explain the importance of decreasing steroids gradually as instructed. 4. Discuss how to collect all stool samples for the next 24 hours.

2. Washing hands should be done by the client at all times, but especially when the client has gastroenteritis. The bacteria in feces may be transferred to other people via food if hands are not washed properly.

The nurse is caring for a client diagnosed with bulimia nervosa. Which nursing intervention should the nurse implement after the client's evening meal? 1. Praise the client for eating all the food on the tray. 2. Stay with the client for 45 minutes to an hour. 3. Allow the client to work out on the treadmill. 4. Place the client on bed rest until morning

2. the client will be prevented from inducing vomiting and ridding the body of the meal before it can be metabolized.

The client diagnosed with crohns disease is crying and tells the nurse "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurses best response? 1. I understand how frustrating this must be for you 2. You must keep thinking about the good things in your life 3. I can see you are very upset. Ill sit down and we can talk 4. Are you thinking about doing anything like committing suicide?

3

The client has had abdominal surgery and tells the nurse, "I felt as something just give way in my stomach." Which action should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess for serosanguineous wound drainage. 4. Administer pain medication intravenously

3

The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weight the client daily and document in the clients chart 2. Teach coping strategies such as dietary modifications 3. record the frequency, amount, and color of stools 4. Monitor the clients oral fluid intake every shift

3

The client is diagnosed with peritonitis. Which assessment data indicate the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two (2) soft, formed bowel movements

3

The nurse is completing discharge teachingto the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client? 1. Instruct the client to decrease alcohol intake. 2. Explain the need to avoid all stress. 3. Discuss the importance of stopping smoking. 4. Teach the correct way to take pancreatic enzymes.

3

The nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. Which complication should the nurse discuss with the client? 1. Diabetes insipidus (DI). 2. Crohn's disease. 3. Narcotic addiction. 4. Peritonitis.

3

The nurse is planning a program for clients at a health fair regarding the prevention and early detection of cancer of the pancreas. Which self-care activity should the nurse discuss as an example of a primary nursing intervention? 1. Monitor for elevated blood glucose at random intervals. 2. Inspect the skin and sclera of the eyes for a yellow tint. 3. Limit meat in the diet and eat a diet low in fat. 4. Instruct the client with hyperglycemia about insulin injections.

3

The nurse is teaching the American Diabetes Association diet to a client diagnosed with diabetes mellitus type 2. Which should the nurse teach the client? 1. Instruct the client to weigh all food before cooking it. 2. Teach the client to eat only carbohydrates if the blood glucose is low. 3. Demonstrate how to determine the amount of carbohydrates being eaten. 4. Explain that proteins should be 75% of the recommended diet.

3

Which disease is the client diagnosed with GERD at greater risk for developing? 1. Hiatal hernia 2. Gastroenteritis 3. Esophageal cancer 4. Gastric cancer

3

The clinic nurse is returning client calls. Which client should the nurse call first? 1. The 39-year-old client complaining of headache pain with a 3 on the pain scale. 2. The 45-year-old client who needs a prescription refill for warfarin. 3. The 54-year-old client diagnosed with diabetes type 1 who has been vomiting. 4. The 60-year-old client who cannot afford to buy food and needs assistance.

3 - A client who has diabetes type 1 and is vomiting is at risk for diabetes ketoaci- dosis. The nurse should have the client come in immediately.

The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes 2. A chicken salad sandwich and lettuce and tomato salad 3. Roast pork, white rice, and plain custard 4. Fried fish, whole grain pasta and fruit salad

3 - A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended.

The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question would be most appropriate for the nurse to ask the client? 1. "When was your last bowel movement?" 2. "Did you have a high-fat meal last night?" 3. "How long have you had this pain?" 4. "Have you been experiencing any gas?"

3 - An elderly client may experience a ruptured appendix with minimal pain; therefore, the nurse should assess the characteristics of the pain.

The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis? 1. A 60-year-old male with a sedentary lifestyle 2. A 72-year-old female with multiple childbirths 3. A 63-year-old female with hemorrhoids 4. A 40-year-old male with a family history of diverticulosis

3 - Hemorrhoids would indicate the client has chronic constipation, which is a strong risk factor for diverticulosis. Constipation increases the intraluminal pressure in the sigmoid colon, leading to weakness in the intestinal lining, which, in turn, causes outpouchings, or diverticula.

The nurse is assessing the client recovering from abdominal surgery who has a PCA pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement? 1. Insist the client take deep breaths 2. Notify the surgeon to request a chest x-ray 3. Determine the last time the client used the PCA pump 4. Administer oxygen at 2 L/min via nasal cannula

3 - Shallow respirations and refusal to deep breathe could be the result of abdominal pain. The nurse should assess the client for pain and determine the last time the PCA pump was used.

The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client? 1. Tell the client to measure the amount of stool. 2. Recommend the client come to the clinic immediately. 3. Explain the client should follow the BRAT diet. 4. Discuss taking an over-the-counter histamine-2 blocker.

3 - The BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is low residue and produces nutrition while not irritating the GI system.

The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which health-care provider's order should the nurse question? 1. Insert a nasogastric tube. 2. Start IV D5W at 125 mL/hr. 3. Put client on a clear liquid diet. 4. Place client on bed rest with bathroom privileges.

3 - because bowel needs to be on total rest, which means NPO

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notify the HCP? 1. The clients bernstein esophageal test was positive 2. The abdominal xray shows a hiatal hernia 3. The clients WBC count is 14,000 4. The clients hgb is 13.8

3 - indicates possible infection

The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor? 1. The sodium level. 2. The albumin level. 3. The potassium level. 4. The glucose level.

3 - potassium is excreted through diarrhea

The nurse, a licensed practical nurse, and an unlicensed nursing assistant are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the licensed practical nurse? 1. Assist the unlicensed nursing assistant to learn to perform blood glucose checks. 2. Monitor the potassium levels of a client with diarrhea. 3. Administer a bulk laxative to a client diagnosed with constipation. 4. Assess the abdomen of a client who has had complaints of pain.

3 - they can administer laxatives

The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take the medication on an empty stomach 2. Notify the HCP if experiencing a moon face 3. Take the steroid medication as prescribed 4. Notify the HCP if the blood glucose is over 160

3 - this med needs to be tapered off to prevent adrenal suppression

The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the clients favorite foods as long as the amount is limited 2. Have the client perform eructation exercises several times a day 3. Eat 4 to 6 small meals a day and limit fluids during meal times 4. Encourage the client to consume a glass of red wine with one meal a day

3 - this prevents reflux

The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? SATA 1. Perform a complete pain assessment 2. Assess the clients vitals frequently 3. Administer a proton pump inhibitor 4. Obtain permission and administer blood products 5. Monitor the intake of a soft bland diet

3,4 - these are collab intervention it requires an order from the HCP

The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching? 1. Fried fish, mashed potatoes, and iced tea. 2. Ham sandwich, applesauce, and whole milk. 3. Chicken salad on whole-wheat bread and water. 4. Lettuce, tomato, and cucumber salad and coffee.

3- Chicken salad, which has vegetables such as celery, grapes, and apples, and whole-wheat bread are high in fiber, which is the therapeutic diet prescribed for clients with diverticulosis. An adequate intake of water helps prevent constipation.

The charge nurse is making assignments. Staffing includes a RN with 5 years of med- surg experience, a new grad RN , and 2 UAPs. Which client should be assigned to the most experienced nurse? 1. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis. 2. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning. 3. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes. 4. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.

3- the client has symptoms of asthma, a complication of GERD

Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the abdominal dressings for bleeding. 2. Increase the IV fluid if the blood pressure is low. 3. Ambulate the client to the bathroom. 4. Auscultate the breath sounds in all lobes

3. A day surgery client can be ambulated to the bathroom, so this task can be delegated to the UAP.

The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia? 1. The client jogs two (2) miles a day. 2. The client has not gained weight. 3. The client's teeth are a green color. 4. The client has smooth knuckles.

3. Bulimia is characterized by bingeing and purging by inducing vomiting after a meal. Stomach contents are acidic and the acid wears away the enamel on the teeth, leaving the teeth a green color

Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure? 1. Hypoalbuminemia and muscle wasting. 2. Oligomenorrhea and decreased body hair. 3. Clay-colored stools and hemorrhoids. 4. Dyspnea and caput medusae.

3. Clay-colored stools and hemorrhoids are gastrointestinal effects of liver failure.

The client has had a liver biopsy. Which postprocedure intervention should the nurse implement? 1. Instruct the client to void immediately. 2. Keep the client NPO for eight (8) hours. 3. Place the client on the right side. 4. Monitor BUN and creatinine level.

3. Direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure.

The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse? 1. A serum sodium level of 137 mEq/L. 2. Arterial blood gases of pH 7.37, Pao2 95, Paco2 43, HCO3 24. 3. A serum potassium level of 3.3 mEq/L. 4. A stool sample positive for fecal leukocytes.

3. In gastroenteritis, diarrhea often results in metabolic acidosis and loss of potassium. The normal serum potassium level is 3.5 to 5.5 mEq/L; therefore, a level of 3.3 mEq/L would require immediate intervention. Hypokalemia can lead to life-threatening cardiac dysrhythmias.

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication, every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer oil retention enemas. 4. Prepare for an upper gastrointestinal (UGI) series x-ray.

3. Oil retention enemas will help to soften the feces and evacuate the stool.

Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching? 1. "I will probably have some leg cramps while I have gastroenteritis." 2. "I should decrease my fluid intake until the diarrhea subsides." 3. "I should reintroduce solid foods very slowly back into my diet." 4. "I should only drink bottled water until the abdominal cramping stops."

3. Reintroducing solid foods slowly, in small amounts, will allow the bowel to rest and the mucosa to return to normal functioning after acute gastroenteritis.

The client is admitted to the medical department with a diagnosis of R/O acute pancreatitis. Which laboratory value should the nurse monitor to confirm this diagnosis? 1. Creatinine and BUN. 2. Troponin and CPK-MB. 3. Serum amylase and lipase. 4. Serum bilirubin and calcium.

3. Serum amylase increases within 2 to 12 hours of the onset of acute pancreatitis to 2 to 3 times normal and returns to normal in 3 to 4 days; lipase elevates and remains elevated for 7 to 14 days.

The male client diagnosed with chronic pancreatitis calls and reports to the clinic nurse that he has been having a lot of "gas," along with frothy and very foul-smelling stools. Which action should the nurse take? 1. Explain that this is common for chronic pancreatitis. 2. Ask the client to bring in a stool specimen to the clinic. 3. Arrange an appointment with the HCP for today. 4. Discuss the need to decrease fat in the diet so that this won't happen.

3. Steatorrhea (fatty, frothy, foul-smelling stool) is caused by a decrease in pancreatic enzyme secretion and indicates impaired digestion and possibly an increase in the severity of the pancreatitis. The client should see the HCP.

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain. 2. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night. 3. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes. 4. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.

3. Tented skin turgor and dry mucous membranes indicate dehydration, which warrants the nurse assessing this client first.

The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer? 1. Beginning at age 60, a digital rectal examination should be done yearly. 2. After reaching middle age, a yearly fecal occult blood test should be done. 3. Have a colonoscopy at age 50 and then once every five (5) to 10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

3. The American Cancer Society recommends a colonoscopy at age 50 and every five (5) to 10 years thereafter, and a flexible sigmoidoscopy and a barium enema every five (5) years.

The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care? 1. Instruct the client to cough forcefully. 2. Encourage early ambulation. 3. Assess for return of a gag reflex. 4. Administer held medications.

3. The ERCP requires an anesthetic spray be used prior to insertion of the endoscope. If medications, food, or fluid are given orally prior to the return of the gag reflex, the client may aspirate.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Draw the serum liver function test. 2. Evaluate the client's intake and output. 3. Perform the bedside glucometer check. 4. Help the ward clerk transcribe orders.

3. The UAP can perform a bedside glucometer check, but the nurse must evaluate the result and determine any action needed.

The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client? 1. Explain the procedure will be done in the operating room. 2. Instruct the client a Foley catheter will have to be inserted. 3. Tell the client vital signs will be taken frequently after the procedure. 4. Provide instructions on holding the breath when the HCP inserts the catheter.

3. The client is at risk for hypovolemia; therefore, vital signs will be assessed frequently to monitor for signs of hemorrhaging.

The client is being admitted to the outpatient department prior to an endoscopic retrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Which pre-procedure instruction should the nurse teach? 1. Prepare to be admitted to the hospital after the procedure for observation. 2. If something happens during the procedure, then emergency surgery will be done. 3. Do not eat or drink anything after midnight the night before the test. 4. If done correctly, this procedure will correct the blockage of the stomach.

3. The client should be NPO after midnight to make sure the stomach is empty to reduce the risk of aspiration during the procedure.

The client has just had an endoscopic retrograde cholangiopancreatogram (ERCP). Which post-procedure intervention should the nurse implement? 1. Assess for rectal bleeding. 2. Increase fluid intake. 3. Assess gag reflex. 4. Keep in supine position.

3. The gag reflex will be suppressed as a result of the local anesthesia applied to the throat to insert the endoscope into the esophagus; therefore, the gag reflex must be assessed prior to allowing the client to resume eating or drinking.

The nurse is admitting a client to a medical floor with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. The client reports up to 20 bloody stools per day. 2. The client has a feeling of fullness after a heavy meal. 3. The client has diarrhea alternating with constipation. 4. The client complains of right lower quadrant pain.

3. The most common symptom of colon cancer is a change in bowel habits, specifically diarrhea alternating with constipation.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which should be the first intervention implemented by the nurse? 1. Start an IV with D5W. 2. Notify the health-care provider. 3. Perform a bedside glucose check. 4. Give the client some orange juice.

3. These are symptoms of an insulin reaction (hypoglycemia). A bedside glucose check should be done. Pancreatic islet tumors can produce hyperinsulinemia or hypoglycemia.

The client presents with a complete blockage of the large intestine from a tumor. Which health-care provider's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of GoLYTELY. 4. Give tap water enemas until it is clear.

3. This client has an intestinal blockage from a solid tumor blocking the colon. Although the client needs to be cleaned out for the colonoscopy, GoLYTELY could cause severe cramping without a reasonable benefit to the client and could cause a medical emergency.

The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? 1. Recommend lying in the prone position with legs extended. 2. Maintain a tripod position over the bedside table. 3. Place in side-lying position with knees flexed. 4. Encourage a supine position with a pillow under the knees.

3. This fetal position decreases pain caused by stretching of the peritoneum as a result of edema

The client is diagnosed with end-stage liver failure. The client asks the nurse, "Why is my doctor decreasing the doses of my medications?" Which statement is the nurse's best response? 1. "You are worried because your doctor has decreased the dosage." 2. "You really should ask your doctor. I am sure there is a good reason." 3. "You may have an overdose of the medications because your liver is damaged." 4. "The half-life of the medications is altered because the liver is damaged."

3. This is the main reason the HCP decreases the client's medication dose and is an explanation appropriate for the client.

The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement? 1. Measure the abdominal girth. 2. Palpate the lower abdomen for a mass. 3. Turn client onto side to assess for further drainage. 4. Remove the dressing to determine the source.

3. Turning the client to the side to assess the amount of drainage and possible bleeding is important prior to contacting the surgeon.

Which diagnostic tests should be monitored for the client diagnosed with severe anorexia nervosa? 1. Liver function tests. 2. Kidney function tests. 3. Cardiac function tests. 4. Bone density scan.

3. in severe anorexia muscle tissue is catabolized to provide energy to the body. The client is at risk for death from cardiac complications.

The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation 2. This medication slows GI motility and reduced diarrhea 3. This medication kills the bacteria causing the exacerbation 4. It acts topically on the colon mucosa to decrease inflammation

4

The client has been experiencing difficulty and straining when expelling feces. Which intervention should be taught to the client? 1. Explain that some blood in the stool will be normal for the client. 2. Instruct the client in manual removal of feces. 3. Encourage the client to use a cathartic laxative on a daily basis. 4. Place the client on a high-residue diet.

4

The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of "risk for altered skin integrity related to pruritus." Which intervention should the nurse implement? 1. Assess tissue turgor. 2. Apply antifungal creams. 3. Monitor bony prominences for breakdown. 4. Have the client keep the fingernails short.

4

The occupational health nurse has had five (5) clients come to the clinic complaining of abdominal cramping, nausea, and vomiting. Which information should the nurse teach the employees to decrease the spread of this condition? 1. Teach the employees to cough into the sleeve. 2. Teach the housekeepers to use an antibacterial soap. 3. Teach the coworkers to get a hepatitis vaccine. 4. Teach the employees to wash their hands frequently.

4

The client is 2 hours post-colonoscopy. Which assessment data would warrant intermediate intervention by the nurse? 1. The client has a soft, nontender abdomen. 2. The client has a loose, watery stool. 3. The client has hyperactive bowel sounds. 4. The client's pulse is 104 and BP is 98/60.

4 - Bowel perforation is a potential complica- tion of a colonoscopy. Therefore, signs of hypotension—decreased BP and increased pulse—warrant immediate intervention from the nurse.

Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications? 1. Alteration in bowel elimination patterns 2. Knowledge deficit in the causes of ulcers 3. Inability to cope with changing family roles 4. Potential for alteration in gastric emptying

4 - Potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness," vomiting of undigested food, or abdominal distention

Which assessment data supports the clients diagnosis of gastric ulcer? 1. Presence of blood in the clients stool for the past month 2. Reports of a burning sensation moving like a wave 3. Sharp pain in the upper abdomen after eating a heavy meal 4. C/O epigastric pain 30-60 minutes after ingesting food.

4 - client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 minutes after eating but not at night. In contrast, a cli- ent with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs one (1) to three (3) hours after meals.

The client developed a paralytic ileum after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice 2. Encourage client to increase oral fluids 3. Encourage client to take deep breaths 4. Maintain a patent nasogastric tube

4 - client is NPO so this will help with intake until bowel sounds return

The nurse is preparing a client diagnosed with GERD for discharge following an EGD. Which statement indicated the client understands the discharge instructions? 1. "I should not eat for at least 1 day following this procedure" 2. "I can lie down whenever I want after a meal. It won't make a difference" 3. "The stomach contents won't bother my esophagus but will make me nauseous" 4. "I should avoid orange juice and eating tomatoes until my esophagus heals"

4 - clients with GERD should avoid foods that are acidic

The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session? 1. Discuss the importance of drinking 1,000mL of water daily 2. Instruct the client to exercise at least three (3) times a week 3. Teach the client about eating a low-residue diet 4. Explain the need to have daily bowel movements

4 - constipation can cause diverticulitis

The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6 degrees Fahrenheit. Which intervention should the nurse implement first? 1. Notify the HCP 2. Document the findings in the chart 3. Administer an oral antipyretic 4. Assess the client's abdomen

4 - needs to determine id abdomen is soft or rigid, rigid indicates peritonitis

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented? 1. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications 2. Have the client remain upright at all times and walk for 30 minutes 3 times a week 3. Instruct the client to maintain a right lateral side-lying position and take antacids before meals 4. elevate the head of the bed 30 degrees and discuss lifestyle modifications with the client

4 - prevents reflux

The male client has had abdominal surgery and is now diagnosed with peritonitis. Which assessment data support the client's diagnosis of peritonitis? 1. Absent bowel sounds and potassium level of 3.9 mEq/L. 2. Abdominal cramping and hemoglobin of 14 gm/dL. 3. Profuse diarrhea and stool specimen shows Campylobacter. 4. Hard, rigid abdomen and white blood cell count 22,000 mm.

4 - this indicates inflamed peritoneum resulting from infection which is why WBC are elevated

The nurse is administering morning medications at 0730. Which medication should have priority? 1. A proton pump inhibitor 2. A nonnarcotic analgesic 3. A histamine receptor antagonist 4. A mucosal barrier agent

4- must be given on an empty stomach in order to coat the stomach

The 36-year-old female client diagnosed with anorexia tells the nurse "I am so fat. I won't be able to eat today." Which response by the nurse is most appropriate? 1. "Can you tell me why you think you are fat?" 2. "You are skinny. Many women wish they had your problem." 3. "If you don't eat, we will have to restrain you and feed you." 4. "Not eating might cause physical problems."

4.

The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first? 1. Ask the client why she is eating too much. 2. Refer the client to a gymnasium for exercise. 3. Have the client set a realistic weight loss goal. 4. Determine the client's eating patterns.

4.

The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? 1. Clay-colored stools and jaundice. 2. Normal appetite and pruritus. 3. Being afebrile and left upper quadrant pain. 4. Complaints of fatigue and diarrhea

4. "Flu-like" symptoms are the first com-plaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously.

The nurse caring for a client diagnosed with cancer of the pancreas writes the collaborative problem of "altered nutrition." Which intervention should the nurse include in the plan of care? 1. Continuous feedings via PEG tube. 2. Have the family bring in foods from home. 3. Assess for food preferences. 4. Refer to the dietitian.

4. A collaborative intervention would be to refer to the nutrition expert, the dietitian.

The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy." Which intervention should the nurse implement? 1. Tell the client there should be no intimacy for at least three (3) months. 2. Ensure the client and significant other are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the client to assume. 4. Teach the client to protect the pouch from becoming dislodged during sex.

4. A pouch that becomes dislodged during the sexual act would cause embarrassment for the client, whose body image has already been dealt a blow.

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? 1. Alteration in nutrition. 2. Alteration in skin integrity. 3. Alteration in urinary pattern. 4. Alteration in comfort.

4. Acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem.

The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication? 1. Restrict sodium intake to 2 g/day. 2. Limit oral fluids to 1,500 mL/day. 3. Decrease the daily fat intake. 4. Reduce protein intake to 60 to 80 g/day.

4. Ammonia is a by-product of protein metabolism and contributes to hepatic encephalopathy. Reducing protein intake should decrease ammonia levels.

Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism? 1. Make sure all hamburger meat is well cooked. 2. Ensure all dairy products are refrigerated. 3. Discuss why campers should drink only bottled water. 4. Discard damaged canned goods.

4. Any discolored food, food from a damaged can or jar, or food from a can or jar not having a tight seal should be destroyed without tasting or touching it.

Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis? 1. Decreased gurgling sounds on auscultation of the abdominal wall. 2. A hard, firm, edematous abdomen on palpation. 3. Frequent, small melena-type liquid bowel movements. 4. Bowel assessment reveals loud, rushing bowel sounds.

4. Borborygmi, or loud, rushing bowel sounds, indicates increased peristalsis, which occurs in clients with diarrhea and is the primary clinical manifestation in a client diagnosed with acute gastroenteritis.

The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers? 1. Do not allow students to eat or drink after each other. 2. Drink bottled water as much as possible. 3. Encourage protected sexual activity. 4. Sing the happy birthday song while washing hands.

4. Hepatitis A is transmitted via the fecal-oral route. Good hand washing helps to prevent its spread. Singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands.

The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? 1. Absent bowel sounds in all four (4) quadrants. 2. The T-tube has 60 mL of green drainage. 3. Urine output of 100 mL in the past three (3) hours. 4. Refusal to turn, deep breathe, and cough.

4. Refusing to turn, deep breathe, and cough places the client at risk for pneumonia. This client needs immediate intervention to prevent complications.

Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse? 1. "I will not drink any type of beer or mixed drink." 2. "I will get adequate rest so I don't get exhausted." 3. "I had a big hearty breakfast this morning." 4. "I took some cough syrup for this nasty head cold."

4. The client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver; therefore, this statement requires intervention.

The client is diagnosed with acute pancreatitis. Which health-care provider's admitting order should the nurse question? 1. Bed rest with bathroom privileges. 2. Initiate IV therapy at D5W 125 mL/hr. 3. Weigh client daily. 4. Low-fat, low-carbohydrate diet.

4. The client will be NPO, which will decrease stimulation of the pancreatic enzymes, which will result in decreased autodigestion of the pancreas, therefore decreasing pain.

14. Which client problem is the nurse's priority concern for the client diagnosed with acute pancreatitis? 1. Impaired nutrition. 2. Skin integrity. 3. Anxiety. 4. Pain relief.

4. The client with pancreatitis is in excruciating pain because the enzymes are autodigesting the pancreas; severe abdominal pain is the hallmark symptom of pancreatitis.

The nurse writes a nursing diagnosis of "altered nutrition: less than body requirements related to low self-esteem" for a client diagnosed with anorexia. Which client goal should be included in the plan of care? 1. The nurse will prevent the client from doing excessive exercise. 2. The client eats 50% of the meals provided. 3. Dietary will provide high-protein milk shakes t.i.d. 4. The client will verbalize one positive attribute.

4. The etiology of the diagnosis of anorexia is "low self-esteem." Therefore the goal must address the client's low self-esteem.

The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain medication when the pain level is at an "8." 4. Empty the pouch when it is one-third to one-half full.

4. The pouch should be emptied when it is one-third to one-half full to prevent the contents from becoming too heavy for the seal to hold and to prevent leakage from occurring.

The client is placed on percutaneous gastrostomy (PEG) tube feedings. Which occurrence would warrant immediate intervention by the nurse? 1. The client tolerates the feedings being infused at 50 mL/hour. 2. The client pulls the nasogastric feeding tube out. 3. The client complains of being thirsty. 4. The client has green, watery stool.

4. This client needs to be cleaned immediately

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? 1. Decreased pain management. 2. Ambulate first day postoperative. 3. No break in skin integrity. 4. Knowledge of postoperative care.

4. This would be an expected outcome for the client scheduled for surgery. This indicates preoperative teaching has been effective.

The nurse is preparing to administer a 250-mL intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing 10 gtts/min. At what rate should the nurse infuse the medication?_______

42 gtts/min.

The nurse is preparing to hang a new bag of total parental nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?

85 mL/hr. First determine the total amount to be infused over 24 hours: 1500 + 500 + 20 + 20 = 2,040 mL over 24 hours. Then, determine the rate per hour:2,040 ÷ 24 = 85 mL/hr.

A client has Chronic Obstructive Pulmonary Disease (COPD). Which intervention for airway management can the RN delegate to the UAP? A. Assisting the patient to sit up on the side of the bed B. Instructing the client to cough effectively C. Teach the client to use the incentive spirometer D.Auscultating breath sounds every 4 hours

A

Acute pancreatitis presents with fever, jaundice, confusion, agitation, and abdominal guarding A. True B. False

A

The client with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action for the RN to delegate to the LPN/LVN? A. Observing how well the patient performs pursed-lip breathing B. Develop a plan of care for this client that includes gradually increasing activity tolerance C. Assisting the client with basic ADLs D. Consulting with the physical therapy department about reconditioning excercises

A

The plan of care for a client with diabetes include all of these interventions. Which intervention can the RN delegate to the UAP? A. Checking to make sure the client's bath water is not too hot B. Discussing community resoures for diabetic outpatient care C. Teaching the client to preform daily foot inspection D. Assessing the client's technique for drawing insulin into a syringe

A

A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following as a risk factor for cholecystitis? A. Obesity B. Rapid weight gain C. Decreased blood triglyceride level D. Male sex

A - Obesity, rapid weight loss, increased blood cholesterol levels, and female sex are risk factors for the development of cholecystitis.

One of the complications of obesity is: A. Hypertension B. Type 1 diabetes C. Hypothyroidism D. Cancer

A - obese patients are most likely to have type 2 diabetes

A patient with liver disease is scheduled for an invasive procedure. The nurse will monitor which test result to ensure the safety of the patient? A. Coagulation Studies B. Liver enzyme levels C. Serum chemistries D. White blood cell count

A - peritonitis caused by blood or bile after liver biopsy is the most common complication

The nurse is caring for a newly admitted client with acute pancreatitis. Which interventions should the nurse implement? A. NS 1000ml IV over 1 hour, then IV fluids at 250ml/hr B. Initiate enteral tube feedings with a low-fat formula C. Up to chair for meals and ambulate four times daily D. Insert a urinary catheter and monitor output every 2 hours E. Vital signs every shiftF. Administer antibiotics every 6 hours

A,,B,C,D

The nurse is caring for a patient in the cardiac acute care floor who was admitted yesterday for chest palpitations. The patient calls to the desk stating they are having 10/10 pain in their chest and neck. Upon assessment the nurse determines normal si and S2, no adventitious breath sounds, and no Gl abnormalities. They check the vitals which are HR 105, RR 22, BP 140/95, 02 91%, temp 97.8 F. Which intervention should the nurse do next? A. Call the patient's emergency contact B. Assist the patient to safe positioning if needed and provide MONA interventions per hospital protocol C. Page the MD D. Complete a full head-to-toe assessment of the patient

A. Call the patient's emergency contact - this is not needed since the patient is alert B. Assist the patient to safe positioning if needed and provide MONA interventions per hospital protocol - there is enough assessment to determine an action, the patient C. Page the MD - there is already a protocol in place that provides orders, since the assessment indicates it is safe to proceed, the doctor can be notified after the patient begins to stabilize D. Complete a full head-to-toe assessment of the patient - this is an urgent situation and the complete head-to-toe is not needed. The focused assessmenf is completed already and the nurse has enough information to proceed with an action.

Which oral medication should the nurse question before administering to the client with peptic ulcer disease? A. E-mycin, an antibiotic B. Prilosec, a proton pump inhibitor C. Flagyl, an anti microbial agent D. Tylenol, a nonnarcotic analgesic

A. E-mycinis irritating to stomach, and it's use in a client with peptic ulcer disease should be questioned

The nurse is completing a PQRST pain assessment on a patient complaining of substernal chest pain. Which patient statement would indicate this pain is most likely stable angina? A. The pain began while I was watching television B. The pain resolved after taking my NTG tablets C. The pain is radiating to my left arm D. The pain started this morning and has lasted all day

A. The pain began while I was watching television - this is unstable, there should be no pain at rest B. The pain resolved after taking my NTG tablets - this is predictable and when chest pain resolves with rest it is considered stable C. The pain is radiating to my left arm - radiating pain is unstable D. The pain started this morning and has lasted all day - pain greater than 30 minutes is unstable

The nurse on the telemetry unit has just finished report and is reviewing their assignment. Which patient should they see first? A. The patient who was admitted last night at 2100 with chest pain that was unrelieved by their home NTG and showed a troponin of 0.05 (@2100) and then 0.3 (@0700) B. The patient that had a myocardial infarct 2 days ago and has questions about going home today C. The patient who was admitted this morning at 0500 with chest pain that decreased with NTG ointment and has a troponin of 0.04 (0500) D. The patient who had a left heart catheterization with stents yesterday at 0800 and has a resolving hematoma in their left groin hint

A. This is the priority patient. This patient is showing clinical changes that indicate worsening cardiac damage (unrelieved chest pain and increasing Trop level) *remember that unstable angina can progress into a myocardial infarct B. This patient is stable and is the least priority since their cardiac event has resolved and they are going home formisperiese suppol inerardy ness ours dbe sheil goin isrelieved., and her fioplevels D. This patient is not the priority because their procedural complication is resolving and the cardiac blockages have already been fixed. This patient should be assessed second so that the nurse can assess any changes to the hematoma and ensure it is stillimproving.

The nurse is caring for a patient being admitted to the cardiac telemetry floor following a left heart catheterization with PCI via femoral approach. Upon initial assessment the nurse notes there is a large amount of blood under the patient's buttocks. What is the nurse's priority action? A. Call Rapid Response for help B. Assess your patient's vital signs and call the doctor C. Ask the client to raise their hips so you can assess underneath D. Assess the client's groin site

A. This may be needed if you have an active bleed and need help to hold pressure, you would not do this until after you have assessed the groin. B. This could be appropriate if the patient has lost a lot of blood. This would be the second action following an assessment of the groin for active bleeding. C. This is incorrect. The nurse needs to keep the patient's hips flat and straight. This type of movement from the patient can increase bleeding and the risk for a hematoma. D. this is the correct answer. The blood could just be from the procedure, but it could also be from an active bleed. The only way to know if this is an active bleed is to assess the groin site for bleeding. The priorify action in an active bleed is to hold pressure, but the nurse cannot do this until they assess (ABC's).

The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP is assisting the client to take a hot soapy shower. 2. The UAP applies an emollient to the client's legs and back. 3. The UAP puts mittens on both hands of the client. 4. The UAP pats the client's skin dry with a clean towel.

Ans 1 1. Hot water increases pruritus, and soap will cause dry skin, which increases pruritus; therefore, the nurse should discuss this with the UAP. 2. Applying emollient lotion will help prevent dry skin, which will help decrease pruritus 3. Mittens will help prevent the client from scratching the skin and causing skin break-down. 4. The skin should be patted dry, not rubbed, because rubbing the skin will cause increased irritation.

The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. 1. Avoid rectal temperatures. 2. Use only a soft toothbrush. 3. Monitor the platelet count. 4. Use small-gauge needles. 5. Assess for asterixis.

Ans 1,2,3,4 1. Vitamin K deficiency causes impaired coagulation; therefore, rectal thermometers should be avoided to prevent bleeding. 2. Soft-bristle toothbrushes will help prevent bleeding of the gums. 3. Platelet count, partial thromboplastin time/prothrombin time (PTT/PT), and international normalized ratio (INR) should be monitored to assess coagulation status. 4. Injections should be avoided, if at all possible, because the client is unable to clot, but if they are absolutely necessary, the nurse should use small-gauge needles. 5. Asterixis is a flapping tremor of the hands when the arms are extended and indicates an elevated ammonia level not associated with vitamin K deficiency.

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A.Ineffective coping related to fear of diagnosis of chronic illness B. Deficient knowledge related to unfamiliarity with significant signs and symptoms C. Constipation related to decreased gastric motility D. Imbalanced nutrition: Less than body requirements related to gastric bleeding

B

Immediately after a liver biopsy, which complication should a patient be closely monitored for? A. Abdominal Cramping B. Hemorrhage C. Nausea and vomiting D. Elevated BP

B - bleeding is a post op complication of a liver biopsy

A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy.Which of the following instructions should the nurse include in the teaching? SATA A. Take baths rather than showers B. Resume a diet of choice C. Cleanse the puncture site using mild soap and water D. Remove adhesive strips from the puncture site in 24hrs E. Report nausea and vomiting to the surgeon

B,C,E

A nurse receives report on four assigned clients. Prioritize the order that the nurse should assess the clients. A. 82 yo who is cant void with a bladder scan showing 300ml of urine. B. 57 yo with possible acute pancreatitis, severe abdominal pain, low BP & O2 sats C. 47 yo client two days post cholecystectomy who has pain rated 2/10 D. 64 yo with cirrhosis, jaundice, itching, and elevated ammonia level

B,D,A,C The client with possible acute pancreatitis should beseen first because they are the most unstable and could bedeveloping hypovolemic shock. The client with itching andelevated ammonia level needs attention, however their conditionis not life threatening at the moment. The client unable to voidmay need orders for intermittent catheterization. The client 2days post cholecystectomy is the most stable of the fourpatients.

Which assessment data indicate to the nurse the clients gastric ulcer has perforated? A. Complaints of sudden, sharp, substernal pain B. Rigid, boardlike abdomen with rebound tenderness C. Frequent, clay-colored, liquid stool D. Complaints of vague abdominal pain in the right upper quadrant

B. A rigid, boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis, which is a complication of a perforated gastric ulcer

The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? A. Maintain a strict record of intake and output B. Insert a nasogastric tube and begin saline lavage C. Assist the client with keeping a detailed calorie count D. Provide a quiet environment to promote rest

B. Inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding

Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? A. The clients pain is controlled with the use of NSAIDs B. The client maintains lifestyle modifications C. The client has no signs and symptoms of hemoptysis D. The client take s antacids with each meal

B. Maintaining lifestyle changes such as following an appropriate diet and reducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications.

A female patient is admitted to the ED complaining of indigestion and nausea, in addition to pressure in her chest and shoulder. The patient also appears to be anxious, dyspneic, and diaphoretic. Which doctor's orders should the nurse anticipate? A. Keep NPO; draw labs - CMP, liver enzymes; abdominal CT B. Кеер NPO; draw labs - troponin, CK-MB, myoglobin; EKG and echo C. Chest and shoulder MRI D. Head CT

B. This is the correct answer because the symptoms of the female patient could indicate a possible cardiac event. After ruling out a cardiac event, the provider may direct the focus to the Gl system. (Address systems of ABC's first) A. This could be appropriate but would not be complete since the patient also has chest pressure; since the patient is female, the Gl symptoms can be of cardiac nature C. This could be appropriate but would not be complete since the patient also has chest pressure; this would only focus on the possibility of musculoskeletal causes of the chest and shoulder pain. This combination of symptoms could be of cardiac nature D. This would not be appropriate for this patient

A client is being admitted with acute gastritis. The nurse knows the immediate collaborative treatment plan will include which of the following? A. Reducing work stress B. Completing a gastric resection C. Treating the underlying cause D. Administering enteral tube feedings

C

A client with sleep apnea has a nursing diagnosis of sleep deprivation. Which action should the RN delegate to the UAP? A. Discussing weight loss strategies such as diet and exercise with the client B. Teaching the patient how to set up the (BiPap) machine before sleeping C. Reminding the patient to sleep on his side instead of back D. Administering Provigil to promote daytime wakefulness

C

The RN is initiating a nursing careplan for a client with pneumonia . Which intervention for cough enhancement should the RN delegate to the UAP? A. Teaching the client about the importance of adequate fluid intake and hydration B. Assisting the client to a sitting position with neck flexed, shoulders relaxed, and knees flexed C. Reminding the client to use an incentive spirometer every 1 to 2 hours while awake D. Instructing the client to take a deep breath, hold it for 2 seconds, then cough two or three times in succession

C

The nurse is caring for a client who has been admitted with a leg ulcer. Which nursing action can the RN delegate to the LPN/LVN? A. planning ways to improve the client's oral protein intake B. Teaching the client about homecare of the leg C. Obtaining the ordered wound cultures during a dressing change D. Assessing the risk of further skin breakdown

C

The nurse is caring for a 50-year-old male patient with a family history of CAD who was prescribed Atorvastatin for the management of his cholesterol levels. The patient is concerned about side effects of this medication, so the nurse tells him which of the following statements: A. 'This medication has no side effects; you should not worry about that" B. "Because this medication directly impacts your normal cardiac function, the doctor will monitor your labs routinely" C. "Because this medication directly impacts your normal liver function, the doctor will monitor your labs routinely" D. "A heart attack is worse than any side effect you may have, and because it is so important you should just take what the doctor ordered"

C is the answer. The nurse should present factual information that addresses the patient's concern and reassure the patient that care will be ongoing A is not correct because the nurse should not discount the patient's concerns and the medication does have side effects B is not correct because the medication does not directly work on the heart D is not correct because it does not acknowledge the patient's concerns and also does not promote patient involvement in the care plan by stating they should just do what they are told

A nurse teaches a client experiencing heartburn to take 1.5 oz of Maalox when symptoms appear. How many milliliters should the client take? A. 15 mL B. 30 mL C. 45 mL D. 60 mL

C- 1 oz. = 30 mL + 0.5oz. = 45 mL

The nurse is reviewing medication lists for clients who are being treated for peptic ulcer disease. The nurse is most likely to question the use of which medication? A. Omeprazole B. Amoxicillin C. Ibuprofen D. Clarithromycin

C- its an NSAID which aggravates PUD

The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention? A. Bowel sour s auscultated 15 times in 1 minute B. Belching after eating a heavy and fatty meal late at night C. A decrease in systolic BP of 20 mm Hg from lying to sitting D. A decreased frequency of distress located in the epigastric region

C. A decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate client is bleeding.

The nurse is evaluating a 12 lead ECG of their patient who is experiencing an inferior wall MI. While discussing with the healthcare team, which of the following ECG changes has the nurse correctly identified: A. Notched T wave and prolonged QTc B. Inverted P wave and prolonged PR interval C. ST segment elevation and inverted T wave D. Irregular QRS complexes and no P wave

C. This is the correct answer because ST elevation and T wave inversion both indicate damage to the myocardium, ST elevation indicates that it is acute (new) and this is the most life-threatening type of myocardial event A. These signs are more related to chronic (long-term) cardiac damage or medication use; although a prolonged QTC can be dangerous, this is not as imminently threatening as ST elevation B. These signs relate more to chronic atrial disease and are not as imminently threatening as ST elevation D. These are the characteristics of Atrial fibrillation: while this can have dangerous complications, this is not as imminently threatening as ST elevation

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? A. Pain in the upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain is relieved with defecation D. Epigastric pain radiating to the left shoulder

D

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. Initiate contact precautions B. Weigh the client weekly C. Measure abdominal girth at the base of the ribcage D. Provide a high-calorie, high carbohydrate diet

D

Which intervention for a client with a pulmonary embolus would an RN assign to an LPN/LVN on a patient care team? A. Evaluate the patient's report of chest pain B. Monitor lab values for changes in oxygenation C. Assess for symptoms of respiratory failure D. Auscultating the lungs for crackles

D

When assessing a patient in the early stages of cirrhosis of the liver, what sign would be anticipated? A. Jaundice B. Peripheral edema C. Ascites D. Anorexia

D - Early manifestations of cirrhosis are vague andusually include GI symptoms such as anorexia, indigestion,nausea, vomiting , or bowel pattern problems.

You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious? A. projectile vomiting B. Burning sensation 2 hours after eating C. Coffee-ground emesis D. Rigid - board like abdomen

D - this is an emergent manifestation of perforation

The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto- Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective? A. A decrease in alcohol intake B. Maintaining a bland diet C. A return to previous activities D. A decrease in gastric distress

D. Antibiotics, proton pump inhibitors, and Pepto-Bismol are administered to decrease the irritation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medication is effective

The nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test confirms this diagnosis?

EGD

patient with a BMI of 37.9 falls into which BMI class?

Obese

The patient with chronic pancreatitis often has frequent, frothy, foul-smelling stools, a condition known as_______.

steatorrhea

The nurse is assigned to a new patient being admitted to the cardiac telemetry floor for chest pain. The nurse assesses the patient's medical history and current physical status. Which statement from the patient indicates a misunderstanding in the way to use nitroglycerin tablets? A. "I can take up to 3 tablets before calling 911" B. "I let it sit under my tongue instead of swallowing them whole" C. "I only use them when I have chest pain" D. "I keep a couple of the tablets in my general pill organizer for quick access"

• A. - this is a correct understanding • B. - this is a correct understanding • C. - this is a correct understanding • D. - this is the correct answer because this is an incorrect understanding because the pills should be kept in their original pharmacy bottle (labeled for safety and dark to protect from light)

The nurse is taking care of a patient diagnosed with angina. Which of the following is the primary treatment goal? A. Reversal of ischemia B. Reversal of infarction C. Reduction of stress and anxiety D. Reduction of risk factors

• A. Reversal of ischemia - this is the correct answer. Angina is the pain associated with ischemic (impaired) cardiac tissue. All nursing care is aimed at reversing this damage before it becomes necrotic and is done by increasing 02 supply/decreasing 02 demand • B. Reversal of infarction - this is not correct, infarction is permanent and can not be reversed • C. Reduction of stress and anxiety - this is an appropriate action to take for the patient but is not the priority of all actions for angina D. Reduction of risk factors - this is an appropriate action to take for the patient but is not the priority of all actions for angina