Common board questions

Pain in the left lower quadrant

A 56-year-old patient with diverticulitis has been admitted to the medical unit. The nurse will most likely document which assessment in the charting?

A left side-lying position with a small pillow or folded towel under the puncture site

After a liver biopsy, the nurse places the client in which of the following positions?

Hemorrhage

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication?

to administer the feeding in six small daily meals high in protein and fat.

Dumping syndrome after a Billroth II procedure occurs when high-carbohydrate foods are ingested over a period of less than 20 minutes. A nursing measure that will prevent or minimize dumping syndrome is

vitamin B12 deficiency.

Following a gastrectomy, the nurse would anticipate that the patient would need to be assessed for

Disturbed body image.

The patient, age 32, has ulcerative colitis, and his condition is deteriorating. An ileostomy is scheduled. After the procedure, this patient may be at risk for

Nasogastric

Treatment measures have been implemented for a client with bleeding esophageal varices and have been unsuccessful. The health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse prepares for insertion via which of the following routes?

"This opioid will cause very deep sleep, which is what my husband needs."

Which statement by the spouse of a client with end-stage liver failure indicates the need for additional teaching by the multidisciplinary team regarding the management of pain?

encourage a diet high in fiber content.

A 63-year-old patient is admitted with acute diverticulitis. The most appropriate nursing intervention to lessen this patient's signs and symptoms of increased flatus and chronic constipation alternating with diarrhea, anorexia, and nausea would be to

Disturbed body image.

A NANDA-accepted nursing diagnosis that could be written for a patient with an abdominoperineal resection and a permanent colostomy would include

Prevent weight loss. Correct and prevent malnutrition. Provide adequate nutrition. Replace fluid and electrolyte losses.

A NANDA-accepted nursing diagnosis that could be written for the patient who is hemorrhaging and in hypovolemic shock from a bleeding peptic ulcer would include Ineffective tissue perfusion (gastrointestinal). The goals of diet management in a patient with inflammatory bowel disease are: (Select all that apply.)

Administration of an analgesic

A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which of the following prescriptions would the nurse question if written on the health care provider's prescription form?

"Remove jewelry before the test."

A client being seen in a health care provider's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?

History of alcohol use, smoking, and weight loss

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which of the following additional supportive data for this diagnosis from the client?

History of alcohol use, smoking, and weight loss

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. Which of the following data would further support this diagnosis?

Hemigastrectomy

A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is likely a result of which of the following conditions that is part of the client's health history?

D. Unresponsive

A client has a Glasgow coma scale score of 4. This is interpreted to mean that the client is: A. Awake B. Lethargic C. Oriented D. Unresponsive

Vitamin B12 injections

A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which of the following will be prescribed to treat the problem?

Vitamin B12 injections

A client has been diagnosed with chronic gastritis and has been told that there is too little intrinsic factor being produced. The nurse tells the client that which of the following will be prescribed to treat the problem?

"That is because the empty stomach sends signals to the brain to stimulate hunger."

A client has had extensive surgery on the gastrointestinal tract and has been started on parenteral nutrition (PN). The client tells the nurse, "I think I'm going crazy...I feel like I'm starving and yet that bag is supposed to be feeding me." The best response of the nurse would be:

A laxative

A client has just returned from the radiology` department following an upper gastrointestinal (GI) series. The nurse reviews the health care provider's prescriptions, expecting to note which of the following needed for routine post- procedure care?

Monitoring for the gag reflex

A client has just undergone a gastroscopy.Which action should be taken by the nurse as the essential post-procedure nursing intervention?

Checking for return of a gag reflex

A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which of the following items as part of the client's care plan?

Smaller, more frequent meals should be eaten.

A client has undergone subtotal gastrectomy and the nurse is preparing the client for discharge. Which item should be included when teaching the client about ongoing self- management?

"What is your understanding of celiac disease?"

A client is admitted to an acute care facility with complications of celiac disease. Which question would be helpful initially in obtaining information for the nursing care plan?

Remain with the client and be silent.

A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, the nurse determines that the best action is to:

Fatigue

A client is admitted to the hospital with acute viral hepatitis. Which signs or symptoms would the nurse expect to note, based upon this diagnosis?

Increase intake of fluids.

A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, the nurse encourages the client to:

After the procedure, keep client nothing by mouth (NPO) until the gag reflex returns.

A client is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?

Fat-free

A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test?

D. Army navy <~ is retracting instrument used to hold the tissue of the perioperative sie

A client is to undergo an exploratory laparotomy for vague abdominal discomforts that has led to abdominal rigidity and severe pain.As the surgeon opens the client's abdomen, which of the following instruments should the nurse anticipate the surgeon to use? A. Kocher B. Mixtner C. Kelly D. Army navy

Takes the client's vital signs

A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse takes which immediate action?

Clamp the tubing for 30 seconds and restart the flow at a slower rate.

A client receiving a high cleansing enema complains of pain and cramping. The nurse would take which corrective action?

Blood loss

A client who has a history of chronic ulcerative colitis is anemic. The nurse interprets that which factor is likely responsible for this laboratory finding?

Occult blood

A client who has been prescribed indomethacin (Indocin) for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to determine:

"I should take a laxative and my stool should return to normal color."

A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. The nurse determines that the client has understood the discharge instructions if the client states:

Smaller and more frequent meals should be eaten

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which item concerning ongoing self- management should the nurse reinforce to the client? .

"I should take a laxative, and my stool will then return to a normal color."

A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client states:

Avoid eating or drinking after midnight before the test.

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, the nurse instructs the client to:

30 minutes before meals

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should time the medication so that each dose is taken:

Cut the tube and pull it out.

A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless. The client's heart rate and blood pressure increase and the client has difficulty breathing. The important initial nursing action is to:

A low-fiber diet

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse suggests foods that are on which of the following diets?

Nasogastric (NG) tube

A client with a tentative diagnosis of gastroesophageal reflux is going to undergo ambulatory pH monitoring. The nurse brings which of the following items to the bedside?

Upright

A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

Client previously oriented to person only; can now state name, year, and present location

A client with hepatic encephalopathy is receiving lactulose (Cephulac). The nurse determines that the medication is effective if which of the following is observed?

A. Atropine Sulfate

A client with myasthenia gravis was admitted due to muscle weakness and bradycardia. Which drug of choice will the nurse anticipate the doctor to order? A. Atropine Sulfate B. Neostigmine C. Pyridostigmine D. Diazepam (Valium)

Protect the gastric mucosa.

A client with peptic ulcer disease has been prescribed to take misoprostol (Cytotec) and sucralfate (Carafate). The nurse teaches the client that these two medications will work primarily to:

A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.

A client with peptic ulcer disease is scheduled for a pyloroplasty and the client asks the nurse about the procedure. The nurse bases the response on which of the following?

Tube with a lumen and an air vent

A health care provider asks a nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which of the following tubes from the unit storage area?

Upright Position

A health care provider is about to perform a paracentesis on a client with abdominal ascites. The nurse would assist the client to assume which of the following positions?

Document the finding in the client's record

A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?

Take and hold a deep breath.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN would instruct the client to do which of the following?

Semi-Fowler's

A nurse assigned to care for a client with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care, knowing that which client position will best assist in facilitating breathing?

Supine with the head raised slightly and the knees slightly flexed

A nurse assistant is helping a registered nurse (RN) conduct an abdominal assessment. The LPN assists the client into which of the following positions?

Consuming low-fat or nonfat foods

A nurse documents that a client with a hiatal hernia is complying with the prescribed treatment if the client reports doing which of the following?

Eating low-fat or nonfat foods

A nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which of the following?

Aspiration

A nurse gathers data from a client admitted tothe hospital with gastroesophageal reflux disease (GERD) who is scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse determines that the client may be at risk for which complication?

Clamp the NG tube for 30 minutes following administration of the medication.

A nurse has a prescription to give 30 mL of an antacid to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse would do which of the following to perform this procedure correctly?

Low and intermittent

A nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which of the following pressures?

Low and intermittent

A nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse expects that the health care provider will prescribe the suction setting at:

A decrease in sour eructation

A nurse has been reinforcing dietary teaching for a client with peptic ulcer disease who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client?

It is all right to drive an hour after the test is finished.

A nurse has given postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that the client did not fully understand the directions if the client states that:

"I'm glad I don't have to lie still for this procedure."

A nurse has taught a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs additional information if the client makes which statement?

Left Sims' position

A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse assists the client to which of the following positions?

Esophageal varices

A nurse is assigned to care for a client with a Sengstaken-Blakemore tube. The nurse should suspect that the client has which diagnosis?

Give frequent oral and nasal care.

A nurse is assisting in caring for a client with aSengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse plans to:

From the tip of the client's nose to the earlobe and then down to the xiphoid process

A nurse is assisting in insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by measuring:

Irrigating the nasogastric (NG) tube

A nurse is caring for a client after a Billroth II procedure. On review of the postoperative prescriptions, which of the following, if prescribed, would the nurse question and verify?

Provide frequent oral and nasal care on a regular basis.

A nurse is caring for a client with a Sengstaken- Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to:

Placement of the NG tube is accurate.

A nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The nurse notes that the pH is 5 and determines that the:

A pair of scissors

A nurse is caring for a client with esophageal varices who is going to have a Sengstaken- Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?

Constipation

A nurse is caring for a client with pneumonia who has a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that it is important to prevent:

Drowsiness

A nurse is collecting admission data on the client with hepatitis. Which of the following findings would be a direct result of this client's condition?

A mechanical and chemical process involving the breakdown of foods

A nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. The nurse recalls that digestion is best defined as:

The transfer of digested food molecules from the GI tract into the bloodstream

A nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to absorb food. While carrying out this function, the nurse recalls that absorption is best defined as:

A mechanical and chemical process involving the breakdown of food

A nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. The nurse recalls that digestion is best defined as:

"My pain comes shortly after I eat, maybe a half hour or so later."

A nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer?

"My pain comes shortly after I eat, maybe a half hour or so later."

A nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer?

Pruritus

A nurse is collecting data on a client admitted to the hospital with hepatitis. Which data would indicate that the client may have liver damage?

Turkey and lettuce sandwich

A nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet?

Avoid coughing.

A nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse tells the client that it is important to continue to do which of the following after discharge?

Sweating and pallor

A nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following symptoms indicate this occurrence?

Personal history of ulcerative colitis or gastrointestinal (GI) polyps

A nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. The nurse would plan to include which risk factor for colorectal cancer in the material?

Pulsation between the umbilicus and pubis

A nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be reported t the registered nurse (RN) or health care provider?

Stop the irrigation temporarily.

A nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. Which of the following is the appropriate nursing action?

Left Sim's

A nurse is preparing to administer a soapsuds enema to a client. Into which position does the nurse place the client to administer the enema?

Fowler's

A nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse would place the client in which position during and after the feedings?

Vitamin B12 and folic acid studies

A nurse is providing discharge instructions to a client who has had a total gastrectomy. The nurse tells the client about the importance of returning to the health care clinic as scheduled for which priority assessment?

Cimetidine (Tagamet) results in decreased secretion of stomach acid.

A nurse is providing medication instructions to a client with peptic ulcer disease. Which of the following represents correct information given by the nurse?

1 to 2 days

A nurse is providing post-procedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately:

Eat anything as long as it does not aggravate or cause pain.

A nurse is reinforcing dietary instructions to a client with peptic ulcer disease. The nurse encourages the client to:

Position the client supine and flat.

A nurse is reviewing the health care provider's prescriptions written for a client admitted with prescription would the nurse verify if noted on the client's chart?

Administer antacids, as prescribed. Encourage coughing and deep breathing. Administer anticholinergics, as prescribed.

A nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Choose the interventions that the nurse would expect to be prescribed for the client. Select all that apply.

Diarrhea

A nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to see documented in the record?

"Be sure to sleep with your head elevated in bed."

A nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement would be included in the teaching?

Impaired nutritional status

A nurse is working with a client diagnosed with anorexia nervosa. The nurse plans care, focusing on which of the following as the primary problem?

Ask the client to extend the arms.

A nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information, the nurse would do which of the following?

Regular monthly injections of vitamin B12 will prevent this complication.

A nurse reinforces instructions to a client following a gastrectomy about the signs and symptoms of pernicious anemia, knowing that:

Take action to prevent dumping syndrome.

A nurse who is providing instructions to a client following gastric resection would include which of the following suggestions?

Monitor for return of the gag reflex

A nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). The nurse would plan to do which of the following first once the client arrives?

a temporary colostomy to allow healing of the bowel by diverting feces.

A patient had a ruptured diverticulum in his descending colon. He has undergone a transverse loop colostomy. He asks the nurse the purpose of this procedure, and the nurse tells him that it is

Daily weight Monitor I & O every shift Accessibility to bedside commode

A patient is admitted with a diagnosis of Crohn's disease. What nursing interventions would be appropriate when caring for this patient? (Select all that apply.)

keep the duct open and allow drainage of the bile until edema resolves.

A patient was scheduled for a laparoscopic cholecystectomy, but complications developed and he underwent an open cholecystectomy with a T-tube inserted into the common bile duct. The purpose of the T-tube is to

strangulated hernia.

A patient, age 84, has a history of a large left inguinal hernia. He is complaining of nausea, vomiting, abdominal distention, and inguinal pain. A serious complication of a hernia in which the blood supply to the tissue becomes occluded is called a(n)

B. I & II

A positive Dx(diagnosis) for HIV infection is made based on the result of which of the ff test? I. Elisa II. Western blot III. WBC count IV CD4 cell count A. I & III B. I & II C. I, II, III D. I, II, IV

Postprandial blood glucose readings

A post-gastrectomy client is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse plans to monitor the:

Reducing stressors in life

A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss:

peristalsis

A progressive wavelike movement that occurs involuntarily in hollow tubes of the body, especially in the alimentary canal, to propel fluids, gas, and digestive substances forward is called

Patient expels all barium rectally.

After barium swallow contrast studies are performed, the nurse should ensure that the

usually include keeping the patient on the right side for minimum of 2 hours.

After the physician has performed a liver biopsy, the nursing interventions would

B, Observe the dressing at the back of the neck for the presence of blood.

After thyroidectomy, which of the following interventions is the highest priority of the nurse? A Monitor the client's vital signs every 4 hrs B, Observe the dressing at the back of the neck for the presence of blood. C.Press gently around the incision to assess for subcutaneous emphysema D. Position the client laterally to promote drainage of secretions from the stomach

70 mcg/dL

An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL and receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best and most optimal response if the level changes to which of the following after medication administration?

B. Right lower quadrant

An appendectomy is usually performed on a client for kidney transplant to provide adequate space for the transplated kidney, which is usually placed in the client's: A. left lower quadrant B. Right lower quadrant C. Right upper quadrant D. Left lower quadrant

providing oral or intravenous fluids.

An essential nursing measure to prevent peritonitis after a paracentesis is

Requires the client to lie still for short intervals

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. The nurse explains to the client that this test:

Prothrombin time

Because vitamin K is malabsorbed in the presence of cirrhosis, which laboratory value would be elevated?

return of peristalsis.

Bowel sound assessment is especially important for a postoperative patient who has had abdominal surgery as it can determine the:

Nutritional diet high in fiber Increasing fluid intake Increasing daily activity

Constipation is a problem for many older adults. The medical management to prevent constipation includes (Select all that apply):

C. Safety

Followiing cataract surgery , which aspect of nursing care is the highest priority of the nurse? A. Nutrition B. Airway C. Safety D. Fluids

B. Decreased urine output

Hourly monitoring of the client's urine is essential following nephrectomy to assess a common sign of kidney transplant rejection which is: A. Abdominal pain B. Decreased urine output C. Decreased blood pressure D.Anemia

B. Use a needle to assess for facial sensation

How should the nurse asses the trigeminal nerve? A. Ask the client to say "ah" and asses the swallowing ability B. Use a needle to assess for facial sensation C. Assess the client's sense of taste in the posterior tongue D. Use a tongue blade to check for the gag reflex

A. Deduct the amount of the irrigant solution instilled from the total amount of outpu

How should the nurse determine the urine output of a client on continuous bladder irrigation? A. Deduct the amount of the irrigant solution instilled from the total amount of output B. deduct the amount of IV Fluid infusion from the total fluid intake of the client C. Add the amount of all fluid intake then deduct all the amount of output D. Measure the amount of output from the bladder irrigation

would be to position and secure the drainage bag at the abdominal level.

If the patient has a T-tube in place after a cholecystectomy, the best nursing intervention

A. HEart & Liver

In a client with COPD, cor pulmonale can possibly result in the enlargement of which of the ff. organs? A. HEart & Liver B. Heart & stomach C. Liver & Gall bladder D. Lungs and Stomach

Gavage

Instillation of liquid nutritional supplements into stomach

Compression

Internal application of pressure by means of inflated balloon to prevent GI Bleeding

Lavage

Irrigation of stomach to remove secretions

Hepatitis A

It has been determined that a client with hepatitis has contracted the infection from contaminated food. What type of hepatitis is this client most likely experiencing?

C. Risk for Aspiration

Mask-like faces occur in clients with myasthenia gravis and Parkinson's D. Which of the following nursing diagnosis is the highest priority for a client with Parkinson's Disease? A. Altered Nutrition: Less than body requirement B. Risk for injury C. Risk for Aspiration D. Altered Bowel elimination

D. Visual problems

Muscle weakness also occurs in clients with multiple sclerosis. Following treatment with steroid, an assessment finding in a client with multiple sclerosis that indicates a positive response to therapy is decreased: A. Mood swings B. Muscle rigidity C.Pain in the lower extremity D. Visual problems

NSAIDs

Peptic ulcers are often common in the aging population. Which medications should be taken with caution to help prevent this problem?

B. Neomycin sulfate <~ R: an antibiotic will kill pathogens present in urinary tract

Physical preparation for a client sheduled for cystectomy and ileal conduit includes the administration of : A, Intravenous vitamin C B. Neomycin sulfate C. Bladder analgesic D. Urinary antibiotic

A. Swan Ganz

Pulmonary capillary wedge pressure (PCWP) is an indirect measure of left ventricle end diastole pressure. This provides data on ventricular contractility. Which catheter is appropriate to measure PCWP? A. Swan Ganz B. CVP C. Tenckhoff D. Groshong

Decompression

Relieve abdominal distention

ensuring adequate hydration to prevent crystallization in kidneys.

Sulfasalazine is the recommended medication for treatment of Crohn's disease. Patient teaching should include:

A. Straight needle

Surgical closure of the skin surfaces usually invovles the use of which type of needle? A. Straight needle B. curved needle/ C. round needle

Remain upright for 1 to 2 hours post meals

Symptoms of GERD (gastroesophageal reflux disease) can be modified or eliminated by which nursing interventions?

Apply heat to the abdomen

The emergency room staff is caring for a patient with an acute inflammatory intestinal disorder who is being observed to rule out appendicitis. Which intervention is contraindicated?

Monitor NG for patency and irrigate with sterile normal saline PRN as ordered.

The most important nursing intervention to assure the patency of a nasogastric tube (NG) is to:

perforation

The most lethal complication of a peptic ulcer is

"Right after the test, I want breakfast with black coffee."

The nurse realizes that the patient requires additional teaching about an esophagoscopy after the patient states

encourage him to express his concern.

The patient complains that he will never adjust to his colostomy. In this situation, it would be best for the nurse to

Edema

The patient has cirrhosis of the liver and an albumin/globulin ratio of 0.9 g/dL. The normal ratio is 1.2 to 2.2 g/dL. In collecting objective data for her, the nurse would probably note which outstanding clinical sign?

fluid and electrolyte replacement

The patient, age 32, is admitted with possible appendicitis after being evaluated by the physician. It is appropriate for the nurse to administer

abdominal paracentesis.

The patient, age 56, has cirrhosis of the liver with severe ascites. The nurse is assisting the physician in the procedure to remove this fluid from his abdominal cavity. This procedure is called an

Eradicates H. pylori.

The purpose of antibiotic therapy in treating stomach disorders is that it

D. 2

The use of the Snellen chart helps to evaluate cranial nerve: A. 6 B. 4 C. 3 D. 2

B. Turn the client to the operative side every 2-3 hours

To facilitate drainage of secretions from the operative site, the nurse should: A. Turn the client to the unoperative side every 2-3hours B. Turn the client to the operative side every 2-3 hours C. keep the client supine until wound healing D. Place the client on semi fowlers postion at least once every shift

B. Given six small meals a day

To limit the client's oxygen needs, a client with COPD should be: A. Served three large meals a day B. Given six small meals a day C. Forced to drink large amount of fluids D. Instructed to immediately sleep after meals.

D. Ensuring patency of the continuous bladder irrigation

To promote bladder decompression and to prevent clot formation after transurethral resection of the prostate(TURP), which intervention should be the nurse's priority? A. Monitoring the client for signs of hemorrhage B. Maintaining patency of the cystostomy tube C. Assessing the client for signs of infection D. Ensuring patency of the continuous bladder irrigation

B. To the leg

To promote hemostasis in a client with TURP, the client's retention catheter is secured: A. To the lower abdomen B. To the leg C. to the bed D. to the intravenous pole

Alkaline phosphatase

Which abnormal lab value would be found in a patient with a pathological condition of the liver?

C. A 28 yr. old who weighs 310 lbs.

Which client does not have any risk from undergoing Magnetic Resonance Imaging (MRI) A. A 35 yr. old with insulin pump B. A 55 yr. old with cardiac pacemaker C. A 28 yr. old who weighs 310 lbs. D. A 19 yr. old with pierced ear

Assessment of severity, location, and duration of pain

Which nursing intervention would be the highest priority in evaluating a patient with peritonitis from a ruptured appendix?

C. Nasal Cannula

Which of the following equipment does not interfere with eating or talking and can best deliver oxygen in a hypoxic client? A. Oxygen tent B. Oxygen mask C. Nasal Cannula D. Endotracheal tube

C. Maintaining an airway

Which of the following intervention is the highest priority of the nurse when a caring for a client with myasthenia gravis? A. Controlling the blood pressure B. Preventing injury C. Maintaining an airway D. Promoting bowel elimination

C. Bleeding

Which of the following is the most common complication of TURP in the early post-operative period? A. Impotence B.Infection C. Bleeding D. Urinary retention

B.WBC count: 3,800/mmᵌ

Which of the following laboratory data indicates the adverse effects of the anti-kidney rejection administered to a client: A.Platelet count: 200,000/mmᵌ B.WBC count: 3,800/mmᵌ C. RBC count: 5.1million/mmᵌ D. Hemoglobin: 14 mg/mmᵌ

D. Urinary drainage from the surgical wound a week after surgery.

Which of the following observations is expected in a post-nephrectomy client? A. Urine output of 20ml/h B. Dark red urine on the third post-op day C. Urine specific gravity: 1.003 D. Urinary drainage from the surgical wound a week after surgery.

C. Donating 200ml of blood

Which of the following practices limits a client;s exposure to the human immunodeficiency virus (HIV)? A. Using condom during sexual intercourse B. Limiting sexual contact only to the spouse C. Donating 200ml of blood D. Having sexual intercourse only to those without HIV antibodies.

Available bedside commode for possible weakness

You administered the medication GoLYTELY to a 78-year-old woman in preparation for diagnostic tests. In planning for her care, which would be most appropriate?

B. Muscle, deep fascia,subcutaneous tissue, skin

the surgeon closes the client's abdominal tissue layer. the nurse knows that closure of the abdominal tissue layers begins with the peritonuem, extra peritoneal fat, transversalis fascia followed by: A. Deep fascia, muscle subcutaneous tissue, skin B. Muscle, deep fascia,subcutaneous tissue, skin C. Subcutaneous tissue, deep fascia, muscle ski

B. to prevent bleeding

what is the highest priority in terms of goal of care, by the nurse after a client's prostatectomy? A. to prevent infaction B. to prevent bleeding C. to prevent impotence D, to prevent Respi Distress