AH2 Prep U's 43-47, 51, 52
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: "It indicates if a cancer is present." "It detects a protein normally found in the blood." "It tells the physician what type of cancer is present." "It determines functionality of the liver."
"It indicates if a cancer is present."
A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition? Infection Possible necrosis Venous congestion Arterial thrombosis
Arterial thrombosis
A nurse educates a group of clients with diabetes mellitus on the prevention of diabetic nephropathy. Which of the following suggestions would be most important? Drink plenty of fluids. Eat a high-fiber diet. Take the antidiabetic drugs regularly. Control blood glucose levels.
Control blood glucose levels.
Which of the following is a function of the stomach? Select all that apply. Secretion of digestive fluids Secretion of digestive enzymes Propels partially digested food into small intestine Secretion of bile Food storage
Food storage Secretion of digestive fluids Propels partially digested food into small intestine
Postoperatively, a client with a radical neck dissection should be placed in which position? Fowler Prone Side-lying Supine
Fowler
A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply. Ketosis-prone Older than 65 years of age Little endogenous insulin Younger than 30 years of age Obesity at diagnoses
Ketosis-prone Little endogenous insulin Younger than 30 years of age
Which type of insulin acts most quickly? NPH Regular Glargine Lispro
Lispro
After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings? Call the health care provider to report absent bowel sounds. Return in 1 hour and listen again to confirm findings. Document that the client is constipated. Listen longer for the sounds.
Listen longer for the sounds.
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? Spleen Liver appendix sigmoid colon
Liver
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Famotidine (Pepcid) Nizatidine (Axid) Metoclopramide (Reglan) Esomeprazole (Nexium)
Esomeprazole (Nexium)
A client with diabetes is receiving an oral anti diabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer? Repaglinide Metformin Glipizide Glyburide
Metformin
A patient who is diagnosed with type 1 diabetes would be expected to: Have no damage to the islet cells of the pancreas. Need exogenous insulin. Receive daily doses of a hypoglycemic agent. Be restricted to an American Diabetic Association diet.
Need exogenous insulin.
Rebound hypoglycemia is a complication of parenteral nutrition caused by feedings stopped too abruptly. fluid infusing rapidly. a cap missing from the port. glucose intolerance.
feedings stopped too abruptly.
The nurse cares for a client who receives continuous parenteral nutrition (PN) through a Hickman catheter and notices that the client's solution has run out. No PN solution is currently available from the pharmacy. What should the nurse do? hang 10% dextrose and water stop the infusion and flush the line hang normal saline with potassium hang 5% dextrose and water
hang 10% dextrose and water
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are Normal hypoactive hyperactive absent
Normal
Peptic ulcer disease occurs more frequently in people with which blood type? O B A AB
O
The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply. Oral hygiene Follow-up medical appointment Use of humidification Follow-up dental appointment
Oral hygiene Follow-up medical appointment Use of humidification Follow-up dental appointment
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? Right lower quadrant Left lower quadrant Right upper quadrant Left upper quadrant
Right lower quadrant
The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet? Nephropathy Retinopathy Sensory neuropathy Autonomic neuropathy
Sensory neuropathy
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? A complete blood count including differential Gastric analysis Serum antibodies for H. pylori A sigmoidoscopy
Serum antibodies for H. pylori
A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? Serum glucose level of 450 mg/dl Serum calcium level of 8.9 mg/dl Serum glucose level of 52 mg/dl Serum calcium level of 10.2 mg/dl
Serum glucose level of 52 mg/dl
A nurse is providing education to a client who is newly diagnosed with diabetes mellitus. What are classic symptoms associated with diabetes? increased thirst, hunger, and urination Increased weight gain, appetite, and thirst Loss of appetite, increased urination, and dehydration Increased weight loss, dehydration, and fatigue
increased thirst, hunger, and urination
A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition? hyperosmolar hyperglycemic nonketotic syndrome All options are correct. hepatic disorder ketoacidosis
ketoacidosis
A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition? ketoacidosis hyperosmolar hyperglycemic nonketotic syndrome All options are correct. hepatic disorder
ketoacidosis
The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is increased urination. elevated blood pressure. loose, watery stools. decreased pulse rate.
loose, watery stools.
The nurse provides health teaching to inform the client with oral cancer that most oral cancers are painful at the outset. a typical lesion is soft and craterlike. many oral cancers produce no symptoms in the early stages. blood testing is used to diagnose oral cancer.
many oral cancers produce no symptoms in the early stages.
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? Three meals and 120 ml fluid daily Six small meals and 120 mL fluid daily Six small meals daily with 120 mL fluid between meals Three meals and three snacks and 120 mL fluid daily
Six small meals daily with 120 mL fluid between meals
The nurse is caring for a geriatric client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location? The stomach The small bowel The large bowel The cecum
Small bowel
The nurse cares for a client who receives parenteral nutrition (PN). The nurse notes on the care plan that the catheter will need to be removed 6 weeks after insertion and that the client's venous access device is a peripherally inserted central catheter . nontunneled central catheter. tunneled central catheter. implanted port.
nontunneled central catheter.
Which condition is caused by improper catheter placement and inadvertent puncture of the pleura? pneumothorax air embolism fluid overload sepsis
penumothorax
A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease: symptoms include oral numbness. symptoms include mouth pain. there are usually no symptoms. symptoms include oral bleeding.
there are usually no symptoms.
The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented? magnetic resonance imaging abdominal ultrasound positron emission tomography upper GI enteroclysis
upper GI enteroclysis
The nurse is teaching an older client how to self-administer insulin. Which of the following would be most helpful to the client who is having difficulty drawing up the correct dosage of insulin in the syringe? Insulin pen Jet injector Syringe magnifier Insulin pump
Syringe magnifier
A client with diabetes comes to the clinic for a follow-up visit. The nurse reviews the client's glycosylated hemoglobin test results. Which result would indicate to the nurse that the client's blood glucose level has been well-controlled? 6.5% 8.0% 8.5% 7.5 %
6.5%
The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care? Mouthwash and water Dextrose and water Full-strength peroxide Baking soda and water
Baking soda and water
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? Serum alkalosis Elevated serum acetone level Below-normal serum potassium level Serum ketone bodies
Below-normal serum potassium level
Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high? Increased energy Blurred vision Hyperactivity Oliguria
Blurred vision
A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem? Bowel perforation Rectal fissures Appendicitis Diverticulitis
Bowel perforation
Which clinical manifestation is not associated with hemorrhage? Tachycardia Hypotension Tachypnea Bradycardia
Bradycardia BRADYCARDIA IS NOT ASSOCIATED WITH HEMORRHAGE
The primary source of microorganisms for catheter-related infections are the skin and the IV fluid bag. catheter hub. catheter tubing. IV tubing.
Catheter Hub
The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n) leukoplakia. lichen planus. chancre. actinic cheilitis.
Chancre
When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important? Checking if the mucous membranes are dry Observing for distended abdominal veins Examining the sclera if it is yellow Checking if the skin is discolored
Checking if the mucous membranes are dry
A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? Upper GI series Computer tomography Colonoscopy Small bowel series
Colonoscopy
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? Pain Malnutrition Dysphagia Regurgitation of food
Dysphagia (difficulty swallowing)
A client reports diarrhea after having bariatric surgery. What nonpharmacologic treatment can the nurse suggest to decrease the incidence of diarrhea? Increase the fiber content in the diet. Increase the protein content in the diet. Decrease the amount of fluid the patient is drinking. Decrease the fat content in the diet.
Decrease the fat content in the diet.
A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? Slowed heart beat Hyperglycemia Dry skin Diarrhea
Diarrhea
Symptoms associated with pyloric obstruction include all of the following except: Diarrhea Anorexia Epigastric fullness Nausea and vomiting
Diarrhea NO DIARRHEA WITH PYLORIC OBSTRUCTION
Which of the following appears to be a significant factor in the development of gastric cancer? Age Diet Gender Ethnicity
Diet
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as Impaired tissue integrity related to surgical intervention Imbalanced nutrition: less than body requirements, related to treatment Risk for infection related to surgical intervention Ineffective airway clearance related to obstruction by mucus
Ineffective airway clearance related to obstruction by mucus
A nurse understands that a major concern with type 2 diabetes is: Older age (> 60 years). Obesity (>20% of IBW). Insulin resistance. Overactive insulin secretion.
Insulin resistance.
The pancreas continues to release a small amount of basal insulin overnight, while a person is sleeping. The nurse knows that if the body needs more sugar: The process of gluconeogenesis will be inhibited. The pancreatic hormone glucagon will stimulate the liver to release stored glucose. Insulin will be released to facilitate the transport of sugar. Glycogenesis will be decreased by the liver.
The pancreatic hormone glucagon will stimulate the liver to release stored glucose.
A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? The client may eat a light meal before either test. Both tests need to be done before breakfast. The upper GI should be scheduled before the ultrasonography. The ultrasonography should be scheduled before the GI procedure.
The ultrasonography should be scheduled before the GI procedure.
A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately? Serum sodium 135 mEq/L Serum potassium 4.2 mEq/L Hematocrit 42% White blood cell (WBC) count 22.8/mm3
White blood cell (WBC) count 22.8/mm3
To ensure patency of central venous line ports, diluted heparin flushes are used with continuous infusions. daily when not in use. when the line is discontinued. before drawing blood.
daily when not in use.
A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia? Polydipsia, pallor, and irritability Nervousness, diaphoresis, and confusion Polyphagia and flushed, dry skin Polyuria, headache, and fatigue
Nervousness, diaphoresis, and confusion
The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? Gallbladder Pancreas Stomach Liver
Pancreas
The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously? Lantus Lispro Regular NPH
Regular
Which of the following is the most successful treatment for gastric cancer? Palliation Chemotherapy Radiation Removal of the tumor
Removal of the tumor
Which instruction about insulin administration should a nurse give to a client? "Discard the intermediate-acting insulin if it appears cloudy." "Store unopened vials of insulin in the freezer at temperatures well below freezing." "Always follow the same order when drawing the different insulins into the syringe." "Shake the vials before withdrawing the insulin."
"Always follow the same order when drawing the different insulins into the syringe."
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Avoid coffee and alcoholic beverages." "Lie down after meals to promote digestion." "Take antacids with meals." "Limit fluid intake with meals."
"Avoid coffee and alcoholic beverages."
A client is prescribed tetracycline to treat peptic ulcer disease. Which instruction would the nurse give the client? "Be sure to wear sunscreen while taking this medicine." "Take the medication with milk." "Do not drive when taking this medication." "Expect a metallic taste when taking this medicine, which is normal."
"Be sure to wear sunscreen while taking this medicine."
A client has just been diagnosed with type 1 diabetes. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline? "You'll need more insulin when you exercise or decrease your food intake." "You'll need less insulin when you increase your food intake." "You'll need less insulin when you exercise or reduce your food intake." "You'll need more insulin when you exercise or increase your food intake."
"You'll need less insulin when you exercise or reduce your food intake."
During postoperative neck dissection assessment, the nurse notices excessive bleeding from the dressing site. She suspects possible carotid artery rupture and takes the immediate first step to: Notify the surgeon to repair the vessel. Elevate the head of the patient's bed. Apply pressure to the bleeding site or major associated vessel. Summon assistance.
Apply pressure to the bleeding site or major associated vessel.
Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis? Hypokalemia and hypoglycemia Hypocalcemia and hyperkalemia Hyperkalemia and hyperglycemia Hypernatremia and hypercalcemia
Hypokalemia and hypoglycemia LOW POTASSIUM LOW BLOOD GLUCOSE
Review the following four examples of ideal body weight (IBW), actual weight, and body mass index (BMI). Using three criteria for each example, select the body weight that indicates morbid obesity. IBW = 175 lbs; weight = 265 lbs; BMI = 29 kg/m2 IBW = 145 lbs; weight = 290 lbs; BMI = 31 kg/m2 IBW = 132 lbs; weight = 184 lbs; BMI = 28 kg/m2 IBW = 150 lbs; weight = 190 lbs; BMI = 26 kg/m2
IBW = 145 lbs; weight = 290 lbs; BMI = 31 kg/m2 OBESITY!!
A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow? Monitoring the stool passage and its color. Observing the color of urine. Monitoring the volume of urine. Placing any stool passed in a specific preservative.
Monitoring the stool passage and its color.
The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate? Notify the physician Administer a breathing treatment Document the presence of stridor Lower the head of the bed
Notify the physician
Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the: Storage of glucose as glycogen in the liver. Synthesis of glucose from noncarbohydrate sources. Transport of potassium. Release of glucose.
Synthesis of glucose from noncarbohydrate sources.
Specific disease processes and ingestion of certain foods and medications may change the appearance of the stool. If blood is shed in sufficient quantities into the upper gastrointestinal (GI) tract, it produces which change in the stool appearance? Blood-streaked Tarry-black Dark brown Bright red
Tarry-black
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes? The client has eaten and has not taken or received insulin. The client continues medication therapy despite adequate food intake. The client has been exercising more than usual. The client has not consumed sufficient calories.
The client has eaten and has not taken or received insulin.
A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client? History of radiographic contrast studies that used iodine The client's mental and emotional status The client's exercise routine The client's consumption of carbohydrates
The client's consumption of carbohydrates
A client realizes that regular use of laxatives has greatly improved bowel patterns. However, the nurse cautions this client against the prolonged use of laxatives for which reason? The client's natural bowel function may become sluggish. The client may develop inflammatory bowel disease. The client may lose his or her appetite. The client may develop arthritis or arthralgia.
The client's natural bowel function may become sluggish.
A client tells the nurse, "I am not having normal bowel movements." When differentiating between what are normal and abnormal bowel habits, what indicators are the most important? That the stool is formed and soft That the client has a bowel movement daily The client is able to fully evacuate with each bowel movement The consistency of stool and comfort when passing stool
The consistency of stool and comfort when passing stool
Which of the following interventions are appropriate for clients with gastritis? Select all that apply. Discourage cigarette smoking. Notify the physician of inidicators of hemorrhagic gastritis. Use a calm approach to reduce anxiety. Give the client food and fluids every 4 hours. Provide general education about how to prevent recurrences.
Use a calm approach to reduce anxiety. Discourage cigarette smoking. Notify the physician of inidicators of hemorrhagic gastritis.
A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. What will the nurse suspect? Dehiscence of the surgical wound A normal reaction to surgery Peritonitis Vasomotor symptoms associated with dumping syndrome
Vasomotor symptoms associated with dumping syndrome
A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check: serum fructosamine level. urine glucose level. glycosylated hemoglobin level. fasting blood glucose level.
glycosylated hemoglobin level.
A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called: polyuria. polyphagia. polydipsia. anorexia.
polyphagia.
Which client requires immediate nursing intervention? The client who: complains of anorexia and periumbilical pain. complains of epigastric pain after eating. presents with a rigid, boardlike abdomen. presents with ribbonlike stools.
presents with a rigid, boardlike abdomen. PERFORATED
During postoperative neck dissection assessment, the nurse notices excessive bleeding from the dressing site. She suspects possible carotid artery rupture and takes the immediate first step to: Elevate the head of the patient's bed. Apply pressure to the bleeding site or major associated vessel. Summon assistance. Notify the surgeon to repair the vessel.
Apply pressure to the bleeding site or major associated vessel.
Which of the following is considered the gold standard for the diagnosis of liver disease? Cholecystography Ultrasonography Paracentesis Biopsy
Biopsy
The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? Green Red Dark brown Black
Black
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? Foley catheter bag containing 500 ml of amber urine A piggyback infusion of levofloxacin The client lying in a lateral position, with the head of bed flat Serosanguineous drainage on the dressing
The client lying in a lateral position, with the head of bed flat
The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours). The client must fast for 8 hours before the examination. The client must have bowel cleansing prior to the procedure. The health care provider will be able to determine if there is a presence of bowel disease. The throat will be sprayed with a local anesthetic.
The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours).
The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.) Until flatus is passed Until bowel sound is present Until peristalsis is resumed Until the tube comes out on its own Until the patient stops vomiting
Until flatus is passed Until bowel sound is present Until peristalsis is resumed
The nurse is talking with a group of clients who are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider? Abdominal cramping when having a bowel movement Daily bowel movements Excess gas Change in bowel habits
Change in bowel habits
Which is the most common presenting symptom of colon cancer? Fatigue Weight loss Anorexia Change in bowel habits
Change in bowel habits
Which of the following medications is classified as a proton pump inhibitor (PPI)? Omeprazole Ranitidine Cimetidine Famotidine
Omeprazole
Which is the primary symptom of achalasia? Heartburn Chest pain Difficulty swallowing Pulmonary symptoms
difficulty swallowing
When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report? Pain Rectal bleeding Soreness Itching
Rectal bleeding
Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. The patient cannot experience the deprivational stress of not swallowing. Feedings can be administered with the patient in the recumbent position.
Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.
A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand? Epinephrine Hydrocortisone 50% dextrose Glucagon
Glucagon
The major carbohydrate that tissue cells use as fuel is fats. chyme. proteins. glucose.
Glucose
A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan? Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns Determining whether the patient is on insulin or taking oral antidiabetic medication Ensuring that the patient understands that some favorite foods may not be allowed on the meal plan and substitutes will need to be found Making sure that the patient is aware that quantity of foods will be limited
Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns
A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times? Supine with a small pillow under the patient's head Side-lying with the head slightly lower than the chest High Fowler's with the patient sitting erect Semi-Fowler's with the head of the bed elevated 30 to 45 degrees
Semi-Fowler's with the head of the bed elevated 30 to 45 degrees
The nurse is assessing a client for constipation. Which review should the nurse conduct first to identify the cause of constipation? Alcohol consumption Activity levels Usual pattern of elimination Current medications
Usual pattern of elimination
A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? "I'll take a laxative to clear my bowels before the test." "There is no need for special preparation before the test." "I'll drink full liquids the day before the test." "I'll avoid eating or drinking anything 6 to 8 hours before the test."
"I'll avoid eating or drinking anything 6 to 8 hours before the test."
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? 6 10 8 4
4
What is the duration of regular insulin? 3 to 5 hours 12 to 16 hours 24 hours 4 to 6 hours
4 to 6 hours
Once digested, what percentage of carbohydrates is converted to glucose?
100%
A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R taken at 6:30 AM will reach peak effectiveness by: 12:30 PM. 2:30 PM. 10:30 AM. 8:30 AM.
8:30 AM.
A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems? Gastric cancer Acute gastritis Duodenal ulcer Gastric ulcer
Acute gastritis
Which of the following digestive enzymes aids in the digesting of starch? Bile Trypsin Amylase Lipase
Amylase
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to Assess the graft for color and temperature. Administer prescribed intravenous vancomycin at the correct time. Reinforce the neck dressing when blood is present on the dressing. Cleanse around the drain using aseptic technique.
Assess the graft for color and temperature.
A patient comes to the clinic with the complaint, "I think I have an ulcer." What is a characteristic associated with peptic ulcer pain that the nurse should inquire about? Select all that apply. Severe gnawing pain that increases in severity as the day progresses Vomiting without associated nausea Pain that radiates to the shoulder or jaw Feeling of emptiness that precedes meals from 1 to 3 hours Burning sensation localized in the back or mid-epigastrium
Burning sensation localized in the back or mid-epigastrium Feeling of emptiness that precedes meals from 1 to 3 hours Severe gnawing pain that increases in severity as the day progresses
Which term refers to the first portion of the small intestine? Pylorus Peritoneum Duodenum Omentum
Duodenum
A 60-year-old client comes to the ED reporting weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the client has diabetes. Which classic symptom should the nurse watch for to confirm the diagnosis of diabetes? Numbness Increased hunger Fatigue Dizziness
Increased hunger
The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes? Onset most common during adolescence Little relation to prediabetes Less common than type 1 diabetes Insufficient insulin production
Insufficient insulin production
NPH is an example of which type of insulin? Intermediate-acting Long-acting Rapid-acting Short-acting
Intermediate-acting
Which of the following is an enzyme secreted by the gastric mucosa? Bile Pepsin Ptyalin Trypsin
Pepsin
A nurse is interviewing a client about past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? Polyps Duodenal ulcers Weight gain Hemorrhoids
Polys
The nurse is teaching a client about self-administration of insulin and about mixing regular and neutral protamine Hagedorn (NPH) insulin. Which information is important to include in the teaching plan? When mixing insulin, the NPH insulin is drawn up into the syringe first. When mixing insulin, the regular insulin is drawn up into the syringe first. If two different types of insulin are ordered, they need to be given in separate injections. There is no need to inject air into the bottle of insulin before withdrawing the insulin.
When mixing insulin, the regular insulin is drawn up into the syringe first. REGULAR then NPH
Which term refers to a protrusion of the intestine through a weakened area in the abdominal wall? Hernia Volvulus Tumor Adhesion
hernia
A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find? severe abdominal pain with direct palpation or rebound tenderness rectal bleeding and a change in bowel habits tenderness and pain in the right upper abdominal quadrant jaundice and vomiting
severe abdominal pain with direct palpation or rebound tenderness
The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every shift. 24 hours. 12 hours. hour.
shift.
The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is neck distension. shoulder drop. venous engorgement. clavical fracture.
shoulder drop.
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? Stomach Ileum Liver Large Intestine
stomach
The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process A length of 50 cm (20 in) A point that equals the distance from the nose to the xiphoid process The distance determined by measuring from the tragus of the ear to the xiphoid process
The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin? They have no effect. They increase the need for insulin. They decrease the need for insulin. They cause wide fluctuations in the need for insulin.
They increase the need for insulin.
A client with severe peptic ulcer disease has undergone surgery and is several hours postoperative. During assessment, the nurse notes that the client has developed cool skin, tachycardia, labored breathing, and appears to be confused. Which complication has the client most likely developed? Penetration Hemorrhage Pyloric obstruction Perforation
Hemorrhage
The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds? Normal Borborygmi Hyperactive Hypoactive
Hyperactive
A patient with diabetic ketoacidosis (DKA) has had a large volume of fluid infused for rehydration. What potential complication from rehydration should the nurse monitor for? Hyperkalemia Hypokalemia Hyperglycemia Hyponatremia
Hypokalemia
An elderly client diagnosed with diarrhea is taking digoxin. Which electrolyte imbalance should the nurse be alert to? Hyponatremia Hyperkalemia Hypernatremia Hypokalemia
Hypokalemia
For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? Decreased serum sodium level Jugular vein distention Increased urine osmolarity Cool, clammy skin
Increased urine osmolarity
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia? Decreased appetite Diaphoresis Increased urine output Cheyne-Stokes respirations
Increased urine output
Which of the following is one of the first clinical manifestations of esophageal cancer? Hiccups Foul breath Increasing difficulty in swallowing Sensation of a mass in throat
Increasing difficulty in swallowing
The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction? Resume regular diet. Increase fluid intake. Continue a clear liquid diet. Avoid driving for 24 hours.
resume regular diet
The most significant complication related to continuous tube feedings is a disturbance of intestinal and hepatic metabolism. the interruption of GI integrity. an interruption in fat metabolism and lipoprotein synthesis. the increased potential for aspiration.
the increased potential for aspiration.
Which is an accurate statement regarding cancer of the esophagus? It is three times more common in women than men in the United States. Chronic irritation of the esophagus is a known risk factor. It usually occurs in the fourth decade of life. It is seen more frequently in Caucasian Americans than in African Americans.
Chronic irritation of the esophagus is a known risk factor.
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? Impaired urinary elimination Deficient fluid volume Excess fluid volume Risk for imbalanced nutrition, more than body requirements
Excess fluid volume
A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which explanation from the nurse would be most accurate? "Caffeine increases the fluid volume in your system, which irritates your digestive organs." "Caffeine intake can cause tears in your esophagus and intestines, which can lead to hemorrhage." "Caffeine can interfere with absorption of vitamin B12, which leads to anemia and further digestive problems." "Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."
A controlled type 2 diabetic client states, "The doctor said if my blood sugars remain stable, I may not need to take any medication." Which response by the nurse is most appropriate? "You will be placed on a strict low-sugar diet for better control." "Diet, exercise, and weight loss can eliminate the need for medication." "You misunderstood the doctor. Let's ask for clarification." "Some doctors do not treat blood sugar elevation until symptoms appear."
"Diet, exercise, and weight loss can eliminate the need for medication."
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it? "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes. Which statement indicates the need for further client teaching about managing this disease? "I always carry hard candy to eat in case my blood sugar level drops." "I always wear my medical identification bracelet." "I skip lunch when I don't feel hungry." "I avoid exposure to the sun as much as possible.
"I skip lunch when I don't feel hungry."
After teaching a client about the procedure for inserting a nontunneled central catheter, the nurse determines that the client has understood the instructions based on which statement? "I'll have to wear a thick, bulky dressing over the site." "I will need to take long, slow, deep breaths when the catheter is inserted." "I need to keep my head turned directly toward you and the health care provider." "I will be lying on my back but my legs will be higher than my head."
"I will be lying on my back but my legs will be higher than my head."
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll lie down immediately after a meal." "I'll eat frequent, small, bland meals that are high in fiber." "I'll eat three large meals every day without any food restrictions." "I'll gradually increase the amount of heavy lifting I do."
"I'll eat frequent, small, bland meals that are high in fiber."
A patient has been diagnosed with acute gastritis and asks the nurse what could have caused it. What is the best response by the nurse? (Select all that apply.) "It is probably your nerves." "It is a hereditary disease." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin." "It can be caused by ingestion of strong acids."
"It can be caused by ingestion of strong acids." "You may have ingested some irritating foods." "Is it possible that you are overusing aspirin."
A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? "It acts as a siphon, pulling secretions into the clear tubing." "It is a vent that prevents backflow of the secretions." "It works as a marker to make sure that the tube stays in place." "It helps regulate the pressure on the suction machine."
"It is a vent that prevents backflow of the secretions."
A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response? "Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood." "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." "When the body does not have enough insulin, hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic by-products to be released." "Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid."
"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."
The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they state "Blood testing is used to diagnose oral cancer." "Many oral cancers produce no symptoms in the early stages." "A typical lesion is soft and craterlike." "Most oral cancers are painful at the outset."
"Many oral cancers produce no symptoms in the early stages."
The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? "If the health care provider massages over the exact painful area, the pain will disappear." "The area may determine the severity of the pain." "Often the area of pain is referred from another area." "This determines the pain medication to be ordered."
"Often the area of pain is referred from another area."
Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"? "Don't take your insulin or oral antidiabetic agent if you don't eat." "Follow your regular meal plan, even if you're nauseous." "It's okay for your blood glucose to go above 300 mg/dl while you're sick." "Test your blood glucose every 4 hours."
"Test your blood glucose every 4 hours."
A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure? "A capsule will be inserted into your rectum." "The health care provider will use a scope called a capsule to view your intestine." "You will need to swallow a capsule." "An x-ray machine will use a capsule ray to follow your intestinal tract."
"You will need to swallow a capsule."
A 16-year-old client newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The client is upset because friends frequently state, "You look anorexic." Which statement by the nurse would be the best response to help this client understand the cause of weight loss due to this condition? "Don't worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism." "Your body is using protein and fat for energy instead of glucose." "You may be having undiagnosed infections, causing you to lose extra weight." "I will refer you to a dietician who can help you with your weight."
"Your body is using protein and fat for energy instead of glucose."
A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube. 1Instruct the client to lower the head and swallow 2Measure the length of the tube that will be inserted 3Apply gloves to the nurse's hands 4Tilt the client's nose upward 6Apply water-soluble lubricant to the tip of the tube 5Sit the client in an upright position
1-Sit the client in an upright position 2-Apply gloves to the nurse's hands 3-Measure the length of the tube that will be inserted 4-Apply water-soluble lubricant to the tip of the tube 5-Tilt the client's nose upward 6-Instruct the client to lower the head and swallow
A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective? 1/2 tbsp honey or syrup three to six LifeSavers candies 1/2 cup fruit juice or regular soft drink 4 oz of skim milk
1/2 cup fruit juice or regular soft drink
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting: 25 to 30 g of a simple carbohydrate. 10 to 15 g of a simple carbohydrate. 18 to 20 g of a simple carbohydrate. 2 to 5 g of a simple carbohydrate.
10 to 15g
A patient who is 6 months' pregnant was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of: 90 mg/dL before meals. 138 mg/dL, 2 hours postprandial. 80 mg/dL, 1 hour postprandial. 120 mg/dL, 1 hour postprandial.
138 mg/dL, 2 hours postprandial.
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every: 25 g of carbohydrates. 10 g of carbohydrates. 15 g of carbohydrates. 20 g of carbohydrates.
15 g of carbohydrates.
A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer: 10 units of fast-acting insulin. 15 to 20 g of a fast-acting carbohydrate such as orange juice. I.M. or subcutaneous glucagon. I.V. bolus of dextrose 50%.
15 to 20 g of a fast-acting carbohydrate such as orange juice.
Glycosylated hemoglobin reflects blood glucose concentrations over which period of time? 1 month 3 months 6 months 9 months
3 months
While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit? Between 120 and 160 mL Between 40 and 80 mL Approximately 80 to 120 mL Greater than 160 mL
Approximately 80 to 120 mL
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse? An acute stomach infection An early sign of peptic ulcer disease Acid indigestion A canker sore of the oral soft tissues
A canker sore of the oral soft tissues
A client with type 1 diabetes is to receive a short-acting insulin and an intermediate-acting insulin subcutaneously before breakfast. The nurse would administer the insulin at which site as the preferred site? Thighs Upper buttock Arms Abdomen
Abdomen
Which of the following is the primary function of the small intestine? Peristalsis Digestion Absorption Secretion
Absorption
When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind? Area for insulin injection Duration of the insulin Technique for injecting Accuracy of the dosage
Accuracy of the dosage
The nurse is performing an assessment for a patient who presents to the clinic with a lip lesion. The lesion is erythemic, is fissuring, and has white hyperkeratosis. What does the nurse suspect that these findings are characteristic of? Sialadenitis Actinic cheilitis Frey syndrome Human papillomavirus lesion
Actinic cheilitis
The nurse is caring for a patient who has dumping syndrome from high carbohydrate foods being administered over a period of less than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. Administer the feeding at a warm temperature to decrease peristalsis. Administer the feeding by bolus to prevent continuous intestinal distention. Administer the feeding with about 100 mL of fluid to dilute the high carbohydrate concentration.
Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity.
A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate? Administering 1 ampule of 50% dextrose solution, per physician's order Inserting a feeding tube and providing tube feedings Observing the client for 1 hour, then rechecking the fingerstick glucose level Administering a 500-ml bolus of normal saline solution
Administering 1 ampule of 50% dextrose solution, per physician's order
A client has a family history of stomach cancer. Which factor would further increase the client's risk for developing gastric cancer? Select all that apply. Caucasian ancestry Female gender Age 55 years High intake of fruits and vegetables Previous infection with H. pylori
Age 55 years Previous infection with H. pylori
A client has been diagnosed with prediabetes and discusses treatment strategies with the nurse. What can be the consequences of untreated prediabetes? CVA cardiac disease type 2 diabetes All options are correct.
All options are correct. CVA cardiac disease type 2 diabetes
The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? Have the patient eat a cracker as the tube is being inserted. Have the patient maintain a backward tilt head position. Spray the oropharynx with an anesthetic spray. Allow the patient to sip water as the tube is being inserted.
Allow the patient to sip water as the tube is being inserted.
When caring for a client with an acute exacerbation of a peptic ulcer, the nurse finds the client doubled up in bed with severe pain in the right shoulder. What is the intial appropriate action by the nurse? Notify the health care provider. Place the client in the high-Fowler's position. Irrigate the client's NG tube. Assess the client's abdomen and vital signs.
Assess the client's abdomen and vital signs.
The nurse is evaluating a client's ulcer symptoms to differentiate ulcer as duodenal or gastric. Which symptom should the nurse at attribute to a duodenal ulcer? Awakening in pain Weight loss Hemorrhage Vomiting
Awakening in pain DUODENAL ULCER HAS PAIN, GASTRIC DOES NOT
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description?
Black and Tarry
Which clinical characteristic is associated with type 2 diabetes (previously referred to as non-insulin-dependent diabetes mellitus)? Client is usually thin at diagnosis Blood glucose can be controlled through diet and exercise Clients demonstrate islet cell antibodies Client is prone to ketosis
Blood glucose can be controlled through diet and exercise
A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client? Plasma bicarbonate 12 mEq/L Arterial pH 7.25 Blood glucose level 1,100 mg/dl Blood urea nitrogen (BUN) 15 mg/dl
Blood glucose level 1,100 mg/dl
During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring? Colonic polyp Infection Rectal fissure Bowel perforation
Bowel perforation
Which statement provides accurate information regarding cancer of the colon and rectum? Rectal cancer affects more than twice as many people as colon cancer. The incidence of colon and rectal cancer decreases with age. Colorectal cancer is the third most common site of cancer in the United States. Colon cancer has no hereditary component.
Colorectal cancer is the third most common site of cancer in the United States.
A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms? Polyuria, polydipsia, hypotension, and hypernatremia Coma, anxiety, confusion, headache, and cool, moist skin Kussmaul's respirations, dry skin, hypotension, and bradycardia Polyuria, polydipsia, polyphagia, and weight loss
Coma, anxiety, confusion, headache, and cool, moist skin
A client has given a confirmed diagnosis of gastric cancer. Two more procedures may be performed to assess tumor depth and lymph node involvement and surgical resectability. Which two are the procedures? Choose the two that apply. Barium x-ray of the upper GI tract Endoscopic ultrasound Esophagogastroduodenoscopy (EGD) Computed tomography (CT)
Computed tomography (CT) Endoscopic ultrasound
A nurse is preparing a client with type 1 diabetes for discharge. The client can care for himself; however, he's had a problem with unstable blood glucose levels in the past. Based on the client's history, he should be referred to which health care worker? Home health nurse Dietitian Psychiatrist Social worker
Dietitian
The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching? Avoid daily exercise. Use laxatives weekly. Drink 8 to 10 glasses of fluid daily. Avoid unprocessed bran.
Drink 8 to 10 glasses of fluid daily.
What information should the nurse include in the teaching plan for a client being treated for diverticulosis? Avoid unprocessed bran in the diet Avoid daily exercise; indulge only in mild activity Use laxatives or enemas at least once a week Drink at least 8 to 10 large glasses of fluid every day
Drink at least 8 to 10 large glasses of fluid every day
The nurse is teaching a client with an ostomy how to change the pouching system. Which information should the nurse include when teaching a client with no peristomal skin irritation? Apply barrier powder Dry skin thoroughly after washing Apply triamcinolone acetonide spray Dust with nystatin powder
Dry skin thoroughly after washing
A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event? Dumping syndrome Bile reflux Celiac disease Gastric outlet obstruction
Dumping syndrome
A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event? Gastric outlet obstruction Celiac disease Bile reflux Dumping syndrome
Dumping syndrome
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? Gastritis Gastroesophageal reflux disease Hiatal hernia Esophageal tumor
Esophageal tumor
A client has been brought into the ED via ambulance, reporting acute generalized abdominal pain, nausea, fever, and constipation. The healthcare provider suspects appendicitis, but testing has not been performed yet to make a definitive diagnosis. What will the nurse most likely do while initially caring for this client? Administer a laxative to relieve the client's constipation. Frequently palpate the abdomen to assess for changes that might indicate the onset of a perforation. Explain to the client why analgesics are being withheld. Perform the test for rebound tenderness.
Explain to the client why analgesics are being withheld.
Which medication is classified as a histamine-2 receptor antagonist? Lansoprazole Metronidazole Famotidine Esomeprazole
Famotidine
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Withdraw the tube gently for 6 to 8 inches. Remove the tape from the nose of the client. Flush with 10 mL of water. Provide oral hygiene.
Flush with 10 mL of water.
A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites? Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Insulin is absorbed more slowly at abdominal injection sites than at other sites. Insulin is absorbed unpredictably at all injection sites.
Insulin is absorbed more rapidly at abdominal injection sites than at other sites.
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? Liver enzyme Intrinsic factor Histamine Hydrochloric acid
Intrinsic Factor
Which statement is correct regarding glargine insulin? It is given twice daily. Its peak action occurs in 2 to 3 hours. It cannot be mixed with any other type of insulin. It is absorbed rapidly.
It cannot be mixed with any other type of insulin.
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following? Calorie restriction Low residue Iron restriction Low protein
Low residue Low fiber diet to let the bowel rest
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? Maintaining a patent airway Helping the client cope with body image changes Ensuring adequate nutrition Preventing injury
Maintaining a patent airway
Which is a true statement regarding gastric cancer? Women have a higher incidence of gastric cancer. The prognosis for gastric cancer is good. Most clients are asymptomatic during the early stage of the disease. Most cases are discovered before metastasis.
Most clients are asymptomatic during the early stage of the disease.
What part of the GI tract begins the digestion of food? Duodenum Mouth Esophagus Stomach
Mouth
The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer? Iletin II Glargine (Lantus) Lispro (Humalog) NPH
NPH
A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse? Reinsert the nasogastric tube to the stomach. Document the discontinuation of the nasogastric tube. Place the nasogastric tube to the level of the esophagus. Notify the surgeon about the tube's removal.
Notify the surgeon about the tube's removal.
A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Acyclovir Cephalexin Fluocinolone acetonide oral base gel Nystatin
Nystatin
The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition? Systemic infection Pernicious anemia Colostomy Peptic ulcers
Peptic ulcers
A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate? Ineffective treatment for the peptic ulcer A reaction to the medication given for the ulcer Gastric penetration Perforation of the peptic ulcer
Perforation of the peptic ulcer
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? Provide saline gargles to the client. Instruct the client to have low-residue meals. Allow the client to ingest fat-free meal. Permit the client to drink only clear liquids.
Permit the client to drink only clear liquids.
A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes? Altered glucose metabolism Rare ketosis Obesity Presence of autoantibodies against islet cells
Presence of autoantibodies against islet cells
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): Protrusion of the upper stomach into the lower portion of the thorax. Extension of the esophagus through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture. Twisting of the duodenum through an opening in the diaphragm.
Protrusion of the upper stomach into the lower portion of the thorax.
The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care? Flush the tube with water before adding the feedings. Keep the feeding formula refrigerated. Provide frequent mouth care. Ensure adequate hydration with additional water.
Provide frequent mouth care.
A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client? Provide the client with an irrigating solution of baking soda and warm water. Urge the client to regularly rinse the mouth with tap water. Regularly wipe the outside of the client's mouth to prevent germs from entering. Recommend that the client drink a small glass of alcohol at the end of the day to kill germs.
Provide the client with an irrigating solution of baking soda and warm water.
Lispro (Humalog) is an example of which type of insulin? Rapid-acting Long-acting Short-acting Intermediate-acting
Rapid-acting
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for....? recent foods ingested. occult blood. pilonidal cyst. ingestion of bismuth.
Recent foods ingested
An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis? Pneumococcus Staphylococcus aureus Methicillin-resistant Streptococcus aureus (MRSA) Streptococcus viridans
Staphylococcus aureus
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? Ileum Large Intestine Liver Stomach
Stomach
Select the assessment finding that the nurse should immediately report, post radical neck dissection. Stridor Pain Localized wound tenderness Temperature of 99°F
Stridor
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction? Sudden, sustained abdominal pain Decreased blood pressure Purulent drainage from the gluteal fold Decreased urine output
Sudden, sustained abdominal pain
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client? Suggest fluid intake of at least 2 L/day Assist the client regarding the correct diet or to minimize food intake Instruct the client to avoid prune or apple juice Instruct the client to keep a record of food intake
Suggest fluid intake of at least 2 L/day
The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? Supine with knees flexed Left Sim's lateral Knee-chest Lithotomy
Supine with knees flexed
A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? Bradycardia, thirst, and anxiety Dry skin, bradycardia, and somnolence Polyuria, polydipsia, and polyphagia Sweating, tremors, and tachycardia
Sweating, tremors, and tachycardia
A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer her a complex carbohydrate snack as soon as possible? To stimulate her appetite To decrease the amount of glycogen in her system To restore liver glycogen and prevent secondary hypoglycemia To decrease the possibility of nausea and vomiting
To restore liver glycogen and prevent secondary hypoglycemia
When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase? Starch Glucose Protein Triglycerides
Triglycerides
A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following? Uncontrolled rhythmic movements of the face or limbs Dry mouth not relieved by sugar-free hard candy Excessive drowsiness Anxiety or irritability
Uncontrolled rhythmic movements of the face or limbs
A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason? Need for lifelong immunosuppressive therapy Underlying problem of insulin resistance Increased risk for urologic complications Need for exocrine enzymatic drainage
Underlying problem of insulin resistance
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? constipation, dehydration, and hypercapnia. manifestations of electrolyte disturbances. manifestations of hypoglycemia. diaphoresis, vomiting, and diarrhea.
diaphoresis, vomiting, and diarrhea.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? Weakness, diaphoresis, diarrhea 90 minutes after eating Abdominal distention, elevated temperature, weakness before eating Persistent loose stools, chills, hiccups after eating Constipation, rectal bleeding following bowel movements
Weakness, diaphoresis, diarrhea 90 minutes after eating
The nurse is assigned to care for a patient 2 days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred? Infection has developed. The surgical wound has begun to bleed. A drain may have become dislodged. Wound dehiscence has occurred.
Wound dehiscence has occurred.
A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate? White blood cells Bacteria Red blood cells Albumin
albumin
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: a history of hemorrhoids and smoking. a sedentary lifestyle and smoking. alcohol abuse and a history of acute renal failure. alcohol abuse and smoking
alcohol abuse and smoking
A longitudinal tear or ulceration in the lining of the anal canal is termed a(n): anal fissure. anorectal abscess. hemorrhoid. anal fistula.
anal fissure.
During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise: every day. at least three times per week. at least once per week. at least five times per week.
at least three times per week.
The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? soft diet 1 day prior nothing by mouth (NPO) 2 days prior high-fiber diet 1 to 2 days prior clear liquids day before
clear liquids day before
A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: increasing saturated fat intake and fasting in the afternoon. eating a candy bar if light-headedness occurs. increasing intake of vitamins B and D and taking iron supplements. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
consuming a low-carbohydrate, high-protein diet and avoiding fasting.
A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. The nurse determines which nursing intervention is advised for this client? measure fluid output for at least 24 hours after the procedure do not give any food and fluids until the gag reflex returns monitor for cramping or abdominal distention monitor for any breathing-related disorder or discomforts
do not give any food and fluids until the gag reflex returns
Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system? jejunum duodenum cecum ileum
duodenum
The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record? soft, gelatin capsules filled with liquid enteric-coated tablets simple compressed tablets buccal or sublingual tablets
enteric-coated tablets
A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are effective only if the client: has type 1 diabetes. prefers to take insulin orally. is pregnant and has type 2 diabetes. has type 2 diabetes.
has type 2 diabetes.
A client with diabetes mellitus is receiving an oral antidiabetic agent. When caring for this client, the nurse should observe for signs of: polyuria polydipsia hypoglycemia blurred vision
hypoglycemia
A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? lack of exercise lack of free water intake increased fiber lack of solid food
lack of free water intake
