EAQ- GI/Hepatic

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider? 1 Weight of 6 lb 4 oz (2835 g) 2 Hemoglobin of 16.2 g/dL (162 mmol/L) 3 Three wet diapers over the last 12 hours 4 Total serum bilirubin of 10 mg/dL (171 µmol/L)

1 A loss of 12 oz (340 g) since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL (162 mmol/L), total serum bilirubin of 10 mg/dL (171 µmol/L), and three wet diapers over the last 12 hours are all normal and expected findings.

During the assessment, the nurse discovers the client takes megadoses of vitamin A. How should the nurse interpret this finding? 1 Vitamin A is highly toxic, even in small amounts. 2 The body stores excess vitamin A, even to toxic amounts. 3 Vitamin A cannot be stored; therefore excess amounts will saturate the general body tissues. 4 Although the body's requirement for vitamin A is great, the cells can synthesize more as needed.

2 Vitamin A is a fat-soluble vitamin that accumulates in the body and is not significantly excreted, even if extremely large amounts are ingested. After prolonged ingestion of extremely large doses, toxic effects can occur. Vitamin A is toxic only after prolonged large dosages. Vitamin A is stored in the body. Vitamin A cannot be synthesized by the body.

A school-aged child with sickle cell anemia is admitted to the pediatric unit in a vaso-occlusive crisis. The nurse's priority is to relieve the excruciating pain. What interventions should be implemented after the pain is under control? Select all that apply. 1 Antibiotics 2 Rehydration 3 Oxygen therapy 4 Nutritional supplements 5 Psychological counseling

2, 3 During a sickle cell crisis the RBCs are sickled and interfere with the peripheral vascular circulation; fluids are needed to increase the circulating volume. Supplemental oxygen is beneficial to limit sickling. There is no indication of an infection that requires antibiotic therapy. There is no indication that the child is malnourished. Although counseling may be needed in the future, there is no indication that it is needed at this time.

A nursing student is listing the steps that need to be followed when obtaining informed consent from research subjects. Which point mentioned by the nursing student needs correction? 1 "I should give full and complete information to clients about the research study." 2 "I should ensure that clients are able to understand the implications of participation in the study." 3 "I should inform the clients that may provide voluntary consent or decline participation." 4 "I should make sure clients understand that any information provided by them will be available outside the research team."

4 When obtaining informed consent from research subjects, the research team should explain that confidentiality and anonymity will be maintained and that any information provided will not be available to persons beyond said team. When obtaining consent, the subjects should be given complete information regarding the purpose of the study, procedures, data collection, potential harm and benefits, and available alternative treatment plans. This enables the client to make proper decisions. Clients should also be able to understand the research process and the implications of participating in the study. Clients should also know that they may give voluntary consent or refrain from participating in the study.

A client develops a gallstone that becomes lodged in the common bile duct and is scheduled for an endoscopic sphincterotomy. The client asks about what type of anesthesia will be used for the procedure. What type of anesthesia does the nurse describe? 1 Spinal anesthetic 2 Epidural block 3 General anesthesia 4 Intravenous sedative

4 During the procedure, a sedative is administered intravenously as needed to help the client stay calm. A spinal anesthetic is not used during this procedure. An epidural block is not used during this procedure. A general anesthetic is not used during this procedure.

A nurse is preparing to administer a nasogastric tube feeding. List the steps of the procedure in the order in which they should be performed. 1. Verify the solution to be administered 2. Wash the hands 3. Aspirate the contents of the stomach 4. Instill the prescribed solution 5. Document the client's response to the procedure

2, 1, 3, 4, 5 The hands should be washed to prevent contamination of the formula and the delivery system. Because numerous formulas may be used to correct specific nutritional problems, the nurse should verify that the formula to be administered is the one prescribed. The stomach contents should be aspirated to observe the fluid removed and to ascertain the feeding tube's location in the stomach. If the tube is correctly positioned, the solution is administered. The amount of formula given, the length of time involved, and the client's response to the procedure are recorded.

A nurse is teaching menu planning to a client who has a high triglyceride level. Which item avoided by the client indicates that teaching about foods that are high in saturated fat is understood? 1 Fruits 2 Grains 3 Red meat 4 Vegetable oils

3 Red meat is high in dense saturated fats and should be avoided. Fruits do not contain saturated fats. Grains do not contain saturated fats. Vegetable oils contain unsaturated fats.

A nurse is caring for a 3-month-old infant whose abdomen is distended and whose vomitus is bile stained. The nurse suspects an intestinal obstruction. What clinical manifestations support this suspicion? Select all that apply. 1 Weak pulse 2 Hypotonicity 3 High-pitched cry 4 Paroxysmal pain 5 Grunting respirations

4, 5 Paroxysmal pain is related to the peristaltic action associated with intestinal obstruction. Abdominal distention pushes the diaphragm upward, causing respiratory distress characterized by grunting respirations. Weak pulse, hypotonicity, and high-pitched cry are unrelated to intestinal obstruction; a high-pitched cry is related to neurologic problems.

The nurse is caring for a client who recently was diagnosed with urinary phosphate calculi. What should the nurse plan to teach this client to include in the diet? 1 Pears 2 Hamburgers 3 Baked salmon 4 Cheddar cheese

1 All fresh fruits are low in phosphate, which should be limited in a client with urinary phosphate calculi. Beef and fish contain phosphate; all protein foods are high in phosphate. Cheddar cheese is made with milk, which contains phosphate; dairy products are high in phosphorus.

Which statement by a client with type 2 diabetes indicates to the nurse that additional dietary teaching is needed? 1 "I can eat as much dietetic fruit as I want." 2 "I can have a lettuce salad whenever I want it." 3 "I know that half of my diet should be carbohydrates." 4 "I need to reduce the amounts of saturated fats in my diet."

1 The client needs further teaching; dietetic fruit is not sugar-free and must be calculated in a diabetic individual's diet. Lettuce is considered a free food in the diet of a diabetic person. It is suggested that the caloric intake of a diabetic person's diet should be 50% carbohydrate, 20% protein, and 30% fat. Saturated fats should be limited to 10% of the fat intake; 90% of fat should be unsaturated fats.

A client is started on a clear liquid diet after surgery. Which items should the nurse offer the client? Select all that apply. 1 Gelatin 2 Broth 3 Yogurt 4 Ice milk 5 Ginger ale

1, 2, 5 Gelatin, broth, and ginger ale would be included in a clear liquid diet. Yogurt and ice milk would be part of a full liquid diet rather than a clear liquid diet.

A nurse is caring for a client with chronic kidney failure. What should the nurse teach the client to limit the intake of to help control uremia associated with end-stage renal disease (ESRD)? 1 Fluid 2 Protein 3 Sodium 4 Potassium

2 The waste products of protein metabolism are the main cause of uremia. The degree of protein restriction is determined by the severity of the disease. Fluid restriction may be necessary to prevent edema, heart failure, or hypertension; fluid intake does not directly influence uremia. Sodium is restricted to control fluid retention, not uremia. Potassium is restricted to prevent hyperkalemia, not uremia.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder? 1 Ham sandwich with cheese, whole milk, and potato chips 2 Penne pasta, spinach, banana, and decaffeinated iced tea 3 Baked lasagna with sausage, salad, and milkshake 4 Hamburger, french fries, and cola

2 A client with cirrhosis and ascites will require moderate to low fat and low sodium (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume.

A client with varicose veins is scheduled for surgery. Which clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1 Pallor 2 Ankle edema 3 Yellowed toenails 4 Diminished pedal pulses

2 Ankle edema results from increased venous pressure. Pigmentation, not pallor, may occur with varicosities. Yellowed toenails occur with arterial, not venous, insufficiency. Diminished pedal pulses occur with arterial, not venous, insufficiency.

Which should the nurse identify as a risk factor for hyponatremia? 1 Inadequate fluid intake 2 Drainage from a T-tube 3 Total parenteral nutrition 4 Hypertonic tube feedings

2 Bile is rich in sodium; therefore, continuous bile loss caused by drainage, fistulas, and excessive vomiting can result in hyponatremia. Inadequate fluid intake results in hypernatremia, not hyponatremia. Total parenteral nutrition results in hypernatremia, not hyponatremia. Hypertonic tube feedings result in hypernatremia, not hyponatremia.

A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg, and the height is 1.7 meters. What is the client's BMI? Record your answer using one decimal place. ________ BMI

22.5 The formula for BMI is: weight in kg ÷ (height in meters)2. The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9

A nurse is caring for a client with end-stage renal disease. For which clinical indicator should the nurse monitor the client? 1 Polyuria 2 Jaundice 3 Azotemia 4 Hypotension

3 Azotemia is an increase in nitrogenous waste (particularly urea) in the blood, which is common with end-stage renal disease. Excessive nephron damage in end-stage renal disease causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency because of the inability to concentrate urine. Jaundice is common to biliary obstruction, not to end-stage renal disease. The blood pressure may be elevated as a result of hypervolemia associated with increased total body fluid.

A 10-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage? 1 Baked potato, meatloaf, banana, and pretzels 2 Baked ham, bread and butter, peaches, and milk 3 Corn on the cob, baked chicken, rice, apple, and milk 4 Hot dog on a bun, potato chips, dill pickle slices, and brownie

3 Corn, chicken, rice, apples, and milk are permitted on the low-sodium, low-potassium diet that the child should be following. Bananas and potatoes are high in potassium, and pretzels are high in sodium. Only the peaches are low in sodium, and all but the butter are fairly high in potassium. Processed foods are high in sodium and fairly high in potassium.

What characteristic of an adolescent girl suggests to the nurse that she has bulimia? 1 History of gastritis 2 Positive self-concept 3 Excessively stained teeth 4 Frequent re-swallowing of food

3 Dental enamel erosion occurs with repeated self-induced vomiting. History of gastritis is not associated with bulimia. Often body image is disturbed and there is low self-esteem. Habitual regurgitation of small amounts of undigested food (rumination) and re-swallowing of food are not associated with bulimia; emptying of the stomach contents through the mouth (vomiting) is associated with bulimia.

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action? 1 Change the client's diet to bland. 2 Obtain a stool specimen for occult blood. 3 Prepare for insertion of a nasogastric tube. 4 Monitor recent laboratory reports for hemoglobin levels.

3 The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should monitor the amount and characteristics of the drainage. Coffee-ground gastric fluid indicates blood that has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory reports for hemoglobin levels is unsafe; the client needs immediate medical attention.

A young woman who is receiving treatment for premenstrual syndrome visits the primary healthcare provider and reports a headache and dry mouth. Which drugs would be responsible for these side effects? Select all that apply. 1 Danazol 2 Ibuprofen 3 Sertraline 4 Fluoxetine 5 Escitalopram

3, 4, 5 Drugs used to treat premenstrual syndrome include sertraline, fluoxetine, and escitalopram. The side effects of these drugs are headaches, dry mouth, dizziness, and sleep disturbances. Danazol is used to treat endometriosis. Side effects are edema and oily skin. Ibuprofen is used to treat primary dysmenorrhea. The side effects include nausea, vomiting, and indigestion.

A nurse is assisting a healthcare provider to perform a sigmoidoscopy. In which position should the nurse place the client for this procedure? 1 Sims 2 Prone 3 Lithotomy 4 Knee-chest

4 Knee-chest position maximally exposes the rectal area and facilitates entry of the sigmoidoscope. The Sims position does not expose the rectal area to the same extent as does the knee-chest position; it can be used for a sigmoidoscopy if a client is unable to maintain the knee-chest position. Although prone refers to a facedown position, the rectal area is not exposed. The lithotomy position is appropriate for gynecologic examinations.

A nurse administers several vitamins as part of a client's medical regimen. Which prescribed vitamin is essential for the synthesis of prothrombin by the liver? 1 B12 2 C 3 D 4 K

4 Prothrombin, which is present in the plasma, is synthesized in the liver in the presence of vitamin K from the amino acid glutamine; vitamin K initiates the vital process of coagulation. Vitamin B12 is needed for hemoglobin synthesis. Vitamin C plays a role in collagen formation. Vitamin D is involved in calcium absorption and metabolism.

A client attending a prenatal class about nutrition tells the nurse that she is a strict vegetarian (vegan). What should the nurse encourage the client to eat that includes all of the essential amino acids? 1 Macaroni and cheese 2 Whole-grain cereals and nuts 3 Scrambled eggs and buttermilk 4 Brown rice and whole-wheat bread

2 This combination provides a complete protein for vegans because they do not eat foods from animal sources, which contain all of the essential amino acids. Macaroni and cheese provides a complete protein and is acceptable to ovo-lacto-vegetarians, who eat milk, eggs, and cheese, but is not acceptable to vegans. Eggs are a complete protein, but are not acceptable to vegans, only to ovo-lacto-vegetarians, who eat milk, eggs, and cheese. Brown rice and whole-wheat bread are both unrefined grains, but together they do not provide a complete protein.

A client eats a meal that contains 13 g of fat, 31 g of carbohydrates, and 5 g of protein. What is this client's total caloric intake for this meal? Record your answer using a whole number. ___ calories

261 Fat contains 9 kilocalories per gram; carbohydrates and proteins contain 4 kilocalories per gram; therefore, 117 + 124 + 20 = 261 kilocalories.

The parents of a young man suspected of having Cushing syndrome express anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness? 1 He will need to take exogenous steroids for several months. 2 His condition will indicate improvement when he gains weight. 3 He may have mood swings or depression as a result of his illness. 4 His physical changes are permanent but may improve with therapy.

3 High levels of steroids result in emotional changes; the actual cause is unknown, but knowing the response may help the parents to better cope with their son's behavior. The need to receive exogenous steroids for several months is unnecessary. Cushing syndrome is related to an excessive production of steroids. Weight loss, not weight gain, indicates an improving condition. The changes are not permanent with adequate therapy.

Which explanation should the nurse consider when formulating a response to a client's inquiry about intussusception of the bowel? 1 Kinking of the bowel onto itself 2 A band of connective tissue compressing the bowel 3 Telescoping of a proximal loop of bowel into a distal loop 4 A protrusion of an organ or part of an organ through the wall that contains it

3 Intussusception is the telescoping or prolapse of a segment of the bowel into the lumen of an immediately connecting segment of the bowel. Volvulus is a twisting of the bowel onto itself. Adhesions are bands of scar tissue that can compress the bowel. Herniation describes protrusion of an organ through the wall that contains it.

When a Schilling test is prescribed for a client suspected of having cobalamin deficiency because of pernicious anemia, what should the nurse plan to do? 1 Give medications on time 2 Prescribe foods low in vitamin B12 3 Keep an accurate intake and output 4 Collect a 24-hour to 48-hour urine specimen

4 A 24-hour to 48-hour urine specimen assesses parietal cell function. After radioactive cobalamin is administered, its excretion is measured; if cobalamin cannot be absorbed, as in pernicious anemia, very little is excreted in the urine. This test is not affected by medications. The results of this test are not affected by food; with pernicious anemia there is a deficiency of intrinsic factor, which is necessary for vitamin B12 use. Intake and output records are not necessary with a Schilling test.

According to Erikson's theory, what might the nurse suggest to the parent of a preschooler who has conflicts with the child due to strict behavior standards? 1 "Your behavior may induce a feeling of isolation in your child." 2 "You need to establish a sense of trust or the child may lose trust in you." 3 "Your child needs support and love or may develop feelings of shame and doubt." 4 "You need to cooperate with the child's desires within reason, or the child may suffer guilt and frustration."

4 According to Erikson, a child between 3 to 5 years of age is in the initiative versus guilt stage. The nurse might tell the parent to cooperate with the child's desires within reason in order to reduce conflicts. Otherwise, the child may have developed a sense of guilt and frustration. If a young adult is not able to develop companionship with others, then this can lead to a feeling of isolation. A feeling of mistrust can be seen in infants less than 1 year of age. Giving harsh punishments to a child may lead to a feeling of shame and doubt in the child and may hamper his or her healthy growth.

After a subtotal gastrectomy a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. What does the nurse determine is the cause of the latter effect? 1 A second, more extensive rise in glucose 2 An overwhelmed insulin-adjusting mechanism 3 A distention of the duodenum from an excessive amount of chyme 4 An overproduction of insulin that occurs in response to the rise in blood glucose

4 The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome. The physiological adaptations related to late dumping syndrome are caused by an increase in insulin, not glucose. The insulin-adjusting mechanism is not overwhelmed but responds vigorously, causing rebound hypoglycemia. Dumping syndrome is related to the high glucose content of food, not the amount of food, entering the duodenum.

A pregnant woman tells the nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse which foods contain a significant amount of folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply. 1 Lean ground beef 2 Milk and cheese 3 Chicken breast meat 4 Black and pinto beans 5 Enriched bread and pasta

4, 5 Legumes contain large amounts of folate, as do enriched grain products. Lean ground beef is not a source of significant dietary folate. Milk and cheese do not contain significant amounts of folate; nor does chicken breast meat.

The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the client makes which statement about tube feedings? 1 "I will need tube feedings until healing of the incision is complete." 2 "I will need tube feedings until the gag reflex returns." 3 "I will need tube feedings until the ability to belch is restored." 4 "I will need tube feedings until my oral feedings can be digested."

1 Food should be avoided until the area is healed completely; this will keep the area from becoming irritated and contaminated. Because of the alterations in structure, the gag reflex is no longer present. The ability to belch has no bearing on the decision to resume oral feedings. The ability to tolerate oral feedings is not lost; such feedings are withheld to prevent irritation to the surgical site until healing has taken place.

A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect? 1 Retinol (vitamin A) 2 Thiamine (vitamin B1) 3 Pyridoxine (vitamin B6) 4 Ascorbic acid (vitamin C)

1 Joint pain, hair loss, jaundice, anemia, irritability, pruritus, and enlarged liver and spleen are signs of vitamin A toxicity. Unlike retinol, which is lipid soluble and eliminated by the liver, thiamine, pyridoxine, and ascorbic acid are water soluble, so they are typically excreted in the urine before toxic blood levels can be achieved. However, excess thiamine may elicit an allergic reaction in some individuals, excess vitamin C (ascorbic acid) may cause diarrhea or renal calculi, and ultrahigh doses (about 800 times the normal dose) of pyridoxine (vitamin B6) can promote neuropathy. Remember that lipid-soluble vitamins normally take longer to eliminate and accumulate faster than water-soluble vitamins.

The nurse is counseling a client with type 1 diabetes about the client's favorite foods that are lowest in carbohydrates (CHO). Which food choice picked by the client determines that teaching was effective? 1 Skim milk 2 Apple juice 3 Nonfat yogurt 4 Fresh orange juice

1 Skim milk contains about 12 grams of CHO per cup. There are about 30 grams CHO in 1 cup of apple juice. There are about 16 grams CHO in 1 cup of nonfat yogurt. There are about 25 grams CHO in 1 cup of orange juice.

A client with severe diabetes insipidus is receiving desmopressin acetate, which is administered intranasally in a metered spray. During the follow-up visits, the client reports chest tightness to the primary healthcare provider. Which intervention would effectively reduce complications in the client? Select all that apply. 1 Administration of desmopressin acetate orally 2 Administration of lithium carbonate intranasally 3 Administration of antidiuretic hormone intravenously 4 Administration of antidiuretic hormone intramuscularly 5 Administration of desmopressin acetate subcutaneously

1, 5 During the treatment of severe diabetes insipidus with nasal administration of desmopressin acetate, if the client reports any side effects, such as chest pain, then the mode of administration of the drug should be changed to oral or subcutaneous. It will help to reduce the complications in the client. Lithium carbonate should not be prescribed to a client with diabetic insipidus because it causes drug-related diabetes insipidus as it decreases the levels of antidiuretic hormone by interfering with the response of the kidneys. Administration of antidiuretic hormone does not relieve such symptoms as chest pain. It should be given to the clients during severe dehydration either intravenously or intramuscularly.

A client has a low hemoglobin level that is attributed to a nutritional deficiency. Which foods should the nurse teach the client to increase in the diet? Select all that apply. 1 Liver 2 Apples 3 Carrots 4 Cheese 5 Spinach

1, 5 Liver and spinach are high in iron. The client needs iron for red blood cell production and hemoglobin; a low hemoglobin indicates the client is anemic. Apples are high in fiber. Carrots are high in Vitamin A. Cheese is high in calcium. Apples, carrots, and cheese are low in iron.

A nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information should the nurse include in the teaching session? Select all that apply. 1 Adhering to a low-carbohydrate diet 2 Avoiding aspirin and aspirin-containing products 3 Limiting alcohol consumption to two drinks weekly 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement

2, 4, 5 Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high-carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.

Which information in a postpartum client's health history should alert the nurse to monitor the client for signs of infection? 1 Three spontaneous abortions 2 B-negative maternal blood type 3 Blood loss of 850 mL after a vaginal birth 4 Temperature of 99.9° F (37.7° C) during the first postpartum day

3 Excessive blood loss predisposes the client to infection because of decreased maternal resistance; the expected blood loss is 350 to 500 mL. Neither a history of spontaneous abortions nor B-negative blood predisposes the client to postpartum infection. A 99.9° F (37.7° C) temperature is acceptable, because a maternal temperature of up to 100.4° F (38.0° C) may occur in response to the exertion and dehydration associated with labor.

Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate? 1 Plastic spoon 2 Cross-cut nipple 3 Parenteral infusion 4 Rubber-tipped syringe

4 Because the infant with a cleft lip and palate is unable to form the vacuum needed for sucking, a rubber-tipped syringe or dropper is used. This allows formula to flow along the sides to the back of the mouth, minimizing the danger of aspiration. A spoon is ineffective because the infant's extrusion reflex will prevent fluid from entering the mouth. A cross-cut nipple may be used with some infants, but rapid flow is dangerous because it can cause aspiration. Feeding can be accomplished with the use of special equipment; intravenous fluids are not necessary

The nurse is providing care to an infant diagnosed with Down syndrome. Which parental statement related to the infant's growth indicates the need for further education? 1 "My baby will have growth deficiencies during infancy." 2 "My child will have accelerated growth during adolescence." 3 "My child will most likely be overweight by 3 years of age." 4 "My baby will have reduced growth in both height and weight."

2 Children diagnosed with Down syndrome will often have growth deficiencies. These deficiencies are most pronounced during adolescence and infancy. Because weight gain is more rapid than growth in stature, many children with Down syndrome are overweight by 3 years of age. Overall reduced growth is noted for both height and weight.

A nurse is planning care for a client who gave birth to a preterm male infant. Which response does the nurse anticipate that this mother may experience? 1 Feelings of failure and loss of control 2 Thoughts related to guilt and withdrawal 3 Fear of forming a healthy relationship with her son until he is out of danger 4 Need for increased attachment behaviors because of her son's life-threatening condition

1 Attachment theory states that the experience of the birth of a preterm infant carries with it feelings of loss of control for the mother. Withdrawal from the situation is maladaptive and requires special help. A healthy relationship may develop regardless of the infant's health. There is no basis to believe that increased attachment behaviors are necessary.

A client describes abdominal discomfort following ingestion of milk. Which enzyme, as a result of a genetic deficiency, should the nurse consider to be the cause of the client's discomfort? 1 Lactase 2 Sucrase 3 Maltase 4 Amylase

1 Milk and milk products are not tolerated well because they contain lactose, a sugar that is converted to galactose by lactase. Sucrase assists in the digestion of sucrose, which is not a milk sugar. Maltase assists in the digestion of maltose, which is not a milk sugar. Amylase assists in the digestion of starch, which is not a milk sugar.

A client with a parotid tumor expresses anxiety about the surgery to remove the tumor. The client states that perhaps surgery should be performed soon, even if the preoperative radiotherapy is not completed. What response by the nurse is the best? 1 "You are concerned about the delay of surgery?" 2 "You are anxious about the effects of radiotherapy?" 3 "I think you do not have confidence in your healthcare provider's decisions." 4 "I can understand your anxiety concerning the delay of your surgery."

1 Reflection of the client's statement will enhance further communication. The client did not indicate anxiety concerning the effects of radiotherapy; the response "You are anxious about the effects of radiotherapy?" is an assumption. The response "I think you do not have confidence in your healthcare provider's decisions" is a conclusion that does not reflect the client's stated concern. The response "I can understand your anxiety concerning the delay of your surgery" may close the opportunity for further exploration and may reinforce the client's concern.

A client with ascites has been scheduled for a paracentesis. What intervention should the nurse implement immediately before the procedure? 1 Instruct the client to void 2 Position the client onto the side 3 Measure the client's abdominal girth 4 Have the client drink a glass of water

1 The bladder should be empty to avoid injury during insertion of the abdominal trocar. The upright position is preferred to allow accumulation of fluid in the lower abdomen by gravity. Although regular monitoring of girth is important, it is not necessary immediately before paracentesis. Having the client drink a glass of water is unrelated to the procedure; however, it is preferable to offer fluids after the procedure if permitted by the healthcare provider.

After gastrointestinal surgery, a client's condition improves, and a regular diet is prescribed. Which food, included on a regular diet, should the nurse encourage the client to consume to decrease discomfort? 1 Fresh fruit 2 Baked fish 3 Bran cereal 4 Whole milk

2 Baked fish is a low-residue, low-fat, high-protein, and non-gas-producing food that usually is tolerated well. Fresh fruit has fiber that irritates the gastrointestinal tract. Bran cereal has fiber that irritates the gastrointestinal tract. Whole milk irritates the gastrointestinal tract and stimulates mucus production.

A nurse provides nutrition instruction to the parents of a school-aged child with celiac disease, including foods that their child may safely eat. What foods selected by the parents indicate that the teaching has been successful? 1 Apple crisp and milk 2 Hamburger patty and fries 3 Spaghetti and meatballs 4 Chicken tenders and sauce

2 Celiac disease impairs the body's ability to handle gluten. Hamburgers, potatoes, and fat for cooking do not contain gluten. The "crisp" in apple crisp is made with flour. Spaghetti is made of flour, and meatballs may have added bread crumbs. Chicken tenders are dipped in flour or crumbs, both of which contain gluten.

What is the primary focus of nursing care for a client admitted with tetanus caused by a puncture wound? 1 Monitoring urinary output 2 Decreasing external stimuli 3 Maintaining body alignment 4 Encouraging high intake of fluid

2 The slightest stimulation can set off a wave of severe, painful muscle spasms involving the whole body. Nerve impulses cross the myoneural junction and stimulate muscle contractions caused by exotoxins produced by Clostridium tetani. Monitoring urinary output is not a major nursing concern for clients with tetanus. Body alignment is not an important consideration for clients with tetanus. Oral intake of fluids may not be possible because of excessive secretions and laryngospasms.

What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply. 1 Hemorrhoids 2 Increased age 3 High-fiber diet 4 Ulcerative colitis 5 Low hemoglobin level

2, 4 A slower fecal transit time, which occurs with aging, may increase the risk for colon cancer. Chronic irritation of the intestinal mucosa, such as occurs in ulcerative colitis, increases the risk for colon cancer. Hemorrhoids are not a risk factor; they are associated with constipation. A high-fiber diet is linked to a decreased risk for colon cancer. Low hemoglobin level is not a risk factor for colon cancer; this may occur as a result of cancer and its therapies.

A client who had a laparoscopic cholecystectomy reports pain in the shoulder. In what position should the nurse place the client? 1 Prone 2 Supine 3 Left Sims 4 Trendelenburg

3 Retained carbon dioxide can irritate the phrenic nerve. Placing the client in the left Sims position helps to move the gas pocket away from the diaphragm. Deep breathing and ambulation should be encouraged. Prone, supine, and Trendelenburg positions will not help to alleviate the problem but could aggravate the problem.

A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which physical parameters should the nurse consider to determine the safe resumption of sexual activity? 1 When the client and partner are not fearful of sexual intimacy 2 When the client feels emotionally ready to resume sexual activity 3 The point at which two flights of stairs can be climbed without dyspnea 4 Laboratory data showing that enzyme results have returned to preinfarction levels

3 The point at which two flights of stairs can be climbed approximates the energy expended during sexual activity. Emotionally, the client or partner may never be ready; studies have shown that individuals fear resumption of sexual activity. The client may be emotionally ready to resume sexual activity before being physically ready. Enzyme studies, such as creatine kinase (CK), creatine kinase myoglobin (CK-MB), lactate dehydrogenase (LDH), and aspartate transaminase (AST), return to expected levels after 3 to 14 days, which may be too soon to resume sexual activity.

A toddler undergoes the implantation of a low-profile (skin-level) device (button) for a gastrostomy. The gastrostomy is now healed, and the parents are being taught to care for the stoma. What parental behavior indicates to the nurse that additional teaching is needed? 1 A parent is cleaning the stoma with soapy water. 2 Gastric contents are aspirated before the start of a feeding. 3 A parent inserts an adapter into the button to initiate a feeding. 4 The button is being maintained in the same position within the stoma.

4 Further teaching is necessary because the button should be rotated to prevent adherence to the skin. The stoma and the skin around the button should be kept clean and free of drainage. As with other gastrostomy tube feedings, use of a gastrostomy button requires patency to be determined; residual gastric fluid should be present. Extension tubing should be inserted into the device for feedings.

Optimal discharge teaching with regard to dumping syndrome following gastroduodenostomy should include what information? 1 Encouraging the client to plan for a light walk immediately after meals 2 Encouraging the client to drink adequate fluids with and between meals 3 Instructing the client to follow a high carbohydrate, low fat, low protein diet 4 Assuring the client that symptoms generally resolve within a year of surgery

4 The symptoms of dumping syndrome generally resolve within several months to a year after surgery. Including this information in the client's instructions offers reassurance and may increase cooperation with the therapeutic treatment plan. The client should rest for 30 minutes after each meal to decrease the sweating, palpitations, and dizziness that result from the stimulation of the sympathetic nervous system that accompanies dumping syndrome. To decrease the volume of chyme entering the small intestine after eating, meals should be small and dry. Fluids should be consumed between rather than with meals. To decrease the hyperosmolar composition of chyme, the client should follow a low carbohydrate, low refined sugar, moderate protein, and moderate fat diet.

A nurse is assessing a client 8 hours after the creation of a colostomy. Which assessment finding should the nurse expect? 1 Presence of hyperactive bowel sounds 2 Absence of drainage from the colostomy 3 Dusky-colored, edematous-appearing stoma 4 Bright bloody drainage from the nasogastric tube

2 A colostomy does not function for several days postoperatively because of the lack of peristalsis. Bowel sounds will be absent until peristaltic activity returns. A dusky-colored, edematous-appearing stoma indicates a problem with circulation to the stoma; it should be cherry red. Bright bloody drainage from the nasogastric tube indicates gastric bleeding, which is abnormal.

A client with phosphate-based urinary calculi asks why aluminum hydroxide gel has been prescribed. The nurse explains that the medication decreases serum phosphorus by which action? 1 Binding with phosphorus in the intestine 2 Preventing absorption of phosphorus in the stomach 3 Promoting excretion of excessive urinary phosphorus 4 Dissolving stones as they pass through the urinary tract

1 Aluminum hydroxide binds phosphorus in the intestine, preventing its absorption; this decreases serum phosphorus. Preventing absorption of phosphorus in the stomach, promoting excretion of excessive urinary phosphorus, and dissolving stones as they pass through the urinary tract are not actions of this drug.

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. What is the best response by the nurse? 1 "The client will gain excessive weight if sodium is not limited." 2 "An inadequate intake of potassium contributed to the disease." 3 "This type of diet increases emotional stability." 4 "Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium.

4 Clients with Cushing syndrome or those receiving cortical hormones must limit their intake of sodium and increase their intake of potassium, because the kidneys are retaining sodium and excreting potassium. Although sodium retention causes fluid retention and weight gain, the need for increased potassium must be considered as well. An excessive secretion of adrenocortical hormones in Cushing syndrome, not inadequate potassium intake, is the problem. This type of diet has no direct effect on the client's emotional status.

The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. What does the nurse conclude? 1 Fluid is leaking into the intestine. 2 The pancreas has been lacerated. 3 This is a typical, expected response. 4 A biliary vessel has been penetrated.

4 The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy. Fluid will leak through the puncture site or into the peritoneum, not the intestine. The pancreas does not contain bile; it is in the upper left, not upper right, quadrant. This is a complication, not an expected outcome.

The nurse teaches the client about foods to avoid while on phenelzine therapy. Which response given by the client indicates the need for further education? 1 "I should avoid raisins in my diet." 2 "I should avoid corned beef in my diet." 3 "I should avoid burgundy and sherry in my diet." 4 "I should avoid the foods that are made of pepperoni."

1 Most adverse effects of monoamine oxidase inhibitors (MOAIs) are caused by their interactions with food and other medications. Therefore the client should avoid foods that contain high amounts of tyramine. Raisins contain low permissible amounts of tyramine. Therefore the client can eat raisins. Corned beef contains high amounts of tyramine. Red wines such as burgundy and sherry contain high amounts of tyramine. Foods made of pepperoni also contain high contents of tyramine.

A 28-year-old woman who has phenylketonuria (PKU) visits the fertility clinic for genetic counseling. After deciding that she wants to become pregnant, she tells the nurse that she ate a low-phenylalanine diet until she was 18 years old. What is the nurse's best response? 1 "Eat a regular pregnancy diet after becoming pregnant." 2 "Start the low-phenylalanine diet during the third trimester." 3 "Maintain a low-protein diet starting in the second trimester." 4 "Return to the low-phenylalanine diet before becoming pregnant."

4 It is essential that a woman with PKU return to a low-phenylalanine diet before becoming pregnant; phenylalanine crosses the placenta, and a high blood level can damage the fetus, especially during organogenesis. Eating a regular pregnancy diet can endanger the fetus. Starting the low-phenylalanine diet in the third trimester is too late to protect the fetus. Advising a client to eat a low-protein diet is too vague, and starting the diet in the second trimester is too late to protect the fetus.

The nurse is educating the mother of an 8-year-old girl about the sequences of maturational changes. Which response by the mother indicates effective learning? 1 "Appearance of pubic hair is not a maturational change." 2 "Appearance of axillary hair is the first stage of maturation." 3 "Appearance of breast buds is an initial indication of puberty." 4 "Abrupt deceleration of height is followed by the breast changes."

3 Appearance of breast buds is the initial indication of puberty in girls. Appearance of pubic hair is a maturation change followed by the appearance of axillary hair, and it is the second stage of maturation. Abrupt deceleration of height is the last stage of maturation, and it is not followed by any other maturational changes.

The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. How should the nurse interpret this rhythm? 1 Complete heart block 2 Normal sinus rhythm (NSR) 3 Sinus rhythm with first degree AV block 4 Sinus rhythm with second degree atrioventricular (AV) block

3 In first degree block, P and QRS waves are consistent in shape. A P wave precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20 seconds. NSR reflects normal conduction of the sinus impulse through the atria and ventricles; PR interval is 0.12 to 0.20 seconds. In second degree AV block, QRS may be normal or widened and have at least one or more nonconducted QRS complexes. In third degree AV block, QRS has no relationship with P waves.

A nurse in the fertility clinic works with couples who have been trying to become pregnant for more than 1 year. How can the nurse help ease the feeling of isolation that infertile couples often experience? Teach them about infertility and its treatment. 2 Identify activities that are interesting and satisfying. 3 Explore ways to promote communication with family and friends. 4 Explain to them that men and women cope differently with stressful situations.

3 Couples who are experiencing infertility often distance themselves from family and friends because they find communication painful; improved communication techniques may help them interact with family and friends and reduce the sense of isolation they may feel. Knowledge is power; however, it may not ease the couple's feeling of isolation. Identifying activities that are interesting and satisfying may promote a positive self-image but may not relieve the sense of isolation from others. Explaining to the couple that men and women cope differently with stressful situations may improve communication between the man and the woman but will probably not relieve their sense of isolation from others. Often these couples would benefit from joining a support group where they can communicate with others in a similar situation.

A client had an abdominal cholecystectomy. The nurse is caring for the client 24 hours after the surgery and notes 150 mL of bile drainage from a client's T-tube. What is the next action the nurse should take? 1 Notify the healthcare provider immediately of the excessive bile drainage. 2 Clamp the tube and drain small amounts of bile every four hours. 3 Check the tube for kinks because the drainage is less than expected. 4 Empty the drainage bag and record the amount on the intake and output record.

4 Bile drainage for the first 24 hours usually is 300 to 400 mL; kinks in the tubing hinder the flow of bile. Drainage of 150 mL is less than expected in the first 24 hours. Clamping the tube is contraindicated during the first 24 hours. Further intervention is necessary because this amount of bile is less than expected.

A client who had a myocardial infarction requests assistance to have a bowel movement. What should the nurse do? 1 Place the client on a bedpan. 2 Help the client into the bathroom. 3 Roll the client onto a fracture pan. 4 Assist the client to a bedside commode.

4 Defecation in the sitting position on a bedside commode uses less energy than walking to the bathroom or getting on and off a bedpan. Defecation is difficult on a bedpan and may cause straining and an increase in oxygen demands. Walking to the bathroom uses more energy than using a bedside commode. Although the use of a fracture pan takes less energy than using a regular bedpan, it takes more energy than using a commode.

A nurse is caring for a client who recently is diagnosed with a gastric ulcer. The nurse expects that the plan of care will include a prescription for which type of diet? 1 Soft diet 2 Low-fat, high-protein liquid diet 3 Hourly feedings of dairy products 4 Regular diet with foods that are tolerated

4 No specific diet is recommended; the client is encouraged to avoid meals that overdistend the stomach and foods that cause gastrointestinal (GI) distress. There is no need for a soft diet; a soft diet is appropriate for those who have difficulty with chewing and swallowing. The client does not require a liquid diet. High-fat dairy products increase GI secretions and may not be tolerated by some clients.

Which description would most likely fit the wound healing process shown in the figure? 1 Shortened phase of tissue repair 2 Lined-up skin layers in correct position 3 Elimination of dead space by the closed wound 4 Gradual filling of the cavity with connective tissue

4 The figure signifies gaping and irregular healing of a chronic wound or a wound with tissue damage. It is associated with the gradual filling of the cavity with connective tissue. The first intention involves shortening of the phase of tissue repair. In the first intention of wound healing, the wound edges are brought together with the skin layers lining up in the correct anatomic position. The first intention includes elimination of dead space by the closed wound.

A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results? 1 Conduct a complete nutritional assessment of the client 2 Nothing, because these are expected values for this client's age 3 Advise the client to come back to the clinic to have the test repeated in three months 4 Investigate the cause of the anemia while understanding that mild anemia is an expected response to the aging process

1 A nutritional assessment starts the investigation for a cause of the client's anemia and is an independent function of the nurse. These are not expected values; an intervention is indicated. Medical treatment should be initiated first, and then the test should be repeated to determine the client's response to therapy; it is not within the legal function of the nurse to give medical advice. Anemia is not an expected response to the aging process.

A client who is 60 pounds (27.2 kilograms) more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight? 1 Obesity leads to insulin resistance. 2 Surplus fat causes excretion of insulin. 3 Fat cells absorb insulin and prevent its circulation to other cells. 4 Lipids accumulate in the pancreas and interfere with insulin production.

1 Excess fat alters glucose metabolism, causing cells to become insulin resistant. Fat cells have no relationship to the function of the kidneys. Fat cells do not absorb insulin and therefore do not prevent the circulation of insulin to other cells. Clients with type 1 diabetes do not produce insulin. If lipids should accumulate in the pancreas of a healthy adult, they do not interfere with insulin production.

An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting? 1 Start with small, frequent feedings. 2 Rock for 20 minutes after a feeding. 3 Keep the infant awake for 30 minutes after feeding. 4 Position the infant flat on the right side during feedings.

1 Starting with small feedings will decrease the risk of vomiting. Rocking, keeping the infant awake, and positioning the infant horizontally all increase the chance of vomiting.

Before major abdominal surgery for cancer, a client says to a nurse, "I really don't think this is cancer at all. I'll bet they won't find anything." Which is the most appropriate initial response by the nurse? 1 "I can understand why you'd like to believe that." 2 "I hope you're right, although tests indicate cancer." 3 "It must be difficult to be facing such serious surgery." 4 "You think the healthcare provider may have made a wrong diagnosis?"

1 The response, "I can understand why you'd like to believe that," indicates recognition of the client's need to use denial and opens the way for a discussion of feelings. Some texts, like Comprehensive Review for the NCLEX-RN Examination 4th edition, labels this response "Acknowledgment" which means recognizing the client's opinions and statements without imposing your own values and judgment. The response, "I hope you're right, although tests indicate cancer," forces reality on the client and blocks a discussion of feelings. The reply, "It must be difficult to be facing such serious surgery," focuses on the surgery, which is not the concern expressed by the client. The reply, "You think the healthcare provider may have made a wrong diagnosis?" focuses on the healthcare provider rather than on the client's feelings.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action? 1 Prepare the client for surgery. 2 Administer oxygen per nasal catheter. 3 Place in the supine position, with legs elevated. 4 Ask the client if there have been any black stools.

1 These symptoms are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may be helpful, it is not the priority. The symptoms are more indicative of perforation than of shock, so placing the client in the supine position with legs elevated is not appropriate at this time. Black, tarry stools indicate bleeding, not perforation.

Which food selections by a client with celiac disease indicate that the nurse's dietary teaching is successful? Select all that apply. 1 Green beans 2 Baked potato 3 Noodle pudding 4 Turkey sandwich 5 Whole wheat cereal

1, 2 Clients with celiac disease need to follow a gluten-free diet. Green beans are a vegetable; fresh fruits and vegetables are permitted on a gluten-free diet. A baked potato is permitted on a gluten-free diet. Noodles are made of flour high in gluten and should be avoided. Bread in the turkey sandwich is made with flour high in gluten and should be avoided. Whole wheat cereal is high in gluten and should be avoided.

A nursing student is listing points that make nursing a profession and not just a job. Which points have been correctly stated? Select all that apply. 1 "Nursing provides a specific service." 2 "Nursing requires a basic liberal foundation and an advanced education." 3 "Nursing has a theoretical body of knowledge leading to defined skills, abilities, and norms." 4 "Members of a profession do not have any autonomy in decision-making and practice." 5 "The profession as a whole lacks a code of ethics for practice and simply follows the state rules and regulations."

1, 2, 3 Nursing is considered a profession because it provides a specific service. Nursing has a basic liberal foundation and requires advanced education. Nursing has a theoretical body of knowledge used to define skills, abilities, and norms of practice. Members of the nursing profession have autonomy in decision-making and practice. The profession of nursing follows a code of ethics for practice and abides by the rules and regulations of the state.

A client is admitted with renal calculi. Which clinical manifestations does a nurse expect the client to report? Select all that apply. 1 Blood in the urine 2 Irritability and twitching 3 Dry, itchy skin and pyuria 4 Frequency and urgency of urination 5 Pain radiating from the kidney to a shoulder

1, 4 Hematuria is a common clinical manifestation of renal calculi. Frequency and a sense of urgency may occur because of irritation caused by the calculi; the most common expectation is sharp, severe pain. Irritability may occur because of discomfort; twitching does not occur. Pyuria may occur when infection is present; skin problems do not occur. Pain radiates from the flank to the groin area.

After abdominal surgery, a client is transferred to the post-anesthesia care unit (PACU) with a nasogastric tube in place and attached to low-intermittent wall suction. Which action should the nurse take initially when the client vomits 90 mL of bile-colored fluid? 1 Elevate the head of the bed. 2 Check the patency of the tube. 3 Administer the prescribed antiemetic. 4 Encourage the client to take several deep breaths.

2 A nasogastric tube attached to suction removes gastric secretions and prevents vomiting. However, if it becomes obstructed, secretions accumulate, leading to distention, nausea, and vomiting. The client initially should be turned on the side to prevent aspiration. An antiemetic may be administered after tube patency is verified. Deep breathing will not prevent vomiting if a nasogastric tube is not patent.

A client is scheduled for a computed tomography (CT) scan of the chest with intravenous (IV) contrast. Which assessment is the priority before the test is performed? 1 Breath sounds 2 Serum creatinine level 3 Any allergies to betadine 4 History of claustrophobia

2 Adequate kidney function must be present before IV contrast can be given. Normally, the creatinine level is checked before IV contrast is given. If the creatinine is elevated, a primary healthcare provider's prescription must be obtained before performing the test. Assessment of breath sounds and allergy to betadine are important assessments for all clients but are not the highest priority for the client undergoing a CT scan with IV contrast. The client's head will be outside the CT scanner during the procedure. Therefore claustrophobia is generally not a factor as it is with a magnetic resonance imaging test.

An infant is receiving the first diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) at 2 months of age. What instructions should the nurse give the parents? 1 Give the baby aspirin if there is pain. 2 Call the clinic if marked drowsiness occurs. 3 Apply ice to the injection site if there is swelling. 4 Provide heat at the injection site if redness occurs.

2 Altered level of consciousness and seizures are rare but serious complications of the pertussis vaccine. Aspirin should not be given to infants and children because it is associated with Reye syndrome, and the nurse is not legally allowed to prescribe medications anyway. Infants are sensitive to the application of ice. Heat will cause an extension of the inflammatory response and should be avoided.

The nurse is counseling the parents of a young child with a recently confirmed diagnosis of celiac disease. The parents ask how the diagnosis was confirmed. Before responding, the nurse recalls that the child's jejunal biopsy result indicated what? 1 Small areas of fatty plaques 2 Atrophic changes in the mucosal wall 3 Irregular areas of superficial ulcerations 4 Diffuse degenerative fibrosis of the acini

2 The biopsy of the small intestine of a child with celiac disease reveals mucosal irritation, crypt hyperplasia, and villous atrophy. Fatty plaques do not occur in celiac disease. Superficial ulcerations do not occur in celiac disease. The pancreatic acini degenerate in cystic fibrosis, not celiac disease.

A client with a history of alcoholism and cirrhosis is admitted with severe dyspnea as a result of ascites. Which process that most likely caused the ascites should the nurse consider when planning care? 1 Increased secretion of bile salts 2 Increased pressure in the portal vein 3 Increased interstitial osmotic pressure 4 Increased production of serum albumin

2 The enlarged cirrhotic liver impinges on the portal system, causing increased hydrostatic pressure from increased pressure in the portal vein, resulting in ascites. Bile salts are not responsible for fluid shifts; increased serum bile results from biliary obstruction, not increased secretion of bile. Interstitial osmotic pressure is unchanged; decreased intravascular osmotic pressure accounts for fluid movement into interstitial spaces. The liver's production of serum albumin is decreased with cirrhosis of the liver.

What is the recommended protein intake for preschoolers? 1 1 g/day 2 13 g/day 3 300 mg/day 4 700 mg/day

2 The recommended protein intake for preschoolers is 13 to 19 g/day. The recommended protein intake for preschoolers is not 1 g/day. The recommended cholesterol consumption for children over the age of 2 years should be less than 300 mg/day, while the recommended daily allowance for calcium for children 1 to 3 years old is 700 mg.

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Because long-term use of antibiotics interferes with the absorption of fat, what prescription does the nurse anticipate? 1 High-fat diet 2 Supplemental cod liver oil 3 Total parenteral nutrition (TPN) 4 Water-soluble forms of vitamins A and E

4 Vitamins A, D, E, and K are known as fat-soluble vitamins because bile salts and other fat-related compounds aid their absorption. A high-fat diet will not achieve the uptake of fat-soluble vitamins in this client. Supplemental cod liver oil will not achieve the uptake of fat-soluble vitamins in this client. TPN is unnecessary; a well-balanced diet is preferred. Water-miscible forms of vitamins A and E can be absorbed with water-soluble nutrients.

A client is admitted to the hospital in the oliguric phase of acute kidney injury. The nurse estimates that the urine output for the last 12 hours is about 200 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. What does the nurse conclude about the amount of fluid prescribed? 1 It equals the expected urinary output for the next 24 hours. 2 It will prevent the development of pneumonia and a high fever. 3 It will compensate for both insensible and expected output over the next 24 hours. 4 It will reduce hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

3 Insensible losses are 500 to 1000 mL in 24 hours, with an average of about 600 mL; the measured output is about 400 mL in 24 hours based on the available history (about 200 mL in 12 hours). Based on the history, the expected urinary output should be about 400 mL in the next 24 hours, far less than 900 mL. More than 900 mL daily is necessary to help prevent pneumonia and its associated fever. Hyperkalemia in acute kidney injury is caused by inadequate glomerular filtration and is not related to fluid intake.

After taking spironolactone, the client inquires about foods and fluids that contain potassium. Which juice should the nurse recommend? 1 Prune juice 2 Orange juice 3 Tomato juice 4 Cranberry juice

4 Spironolactone is a potassium-sparing diuretic, and foods high in potassium should be avoided. Cranberry juice should be recommended because it contains the least amount of potassium. Prune, orange, and tomato juice are all high in potassium. Cranberry juice contains approximately 46 mg of potassium per 8 ounces. Apple juice contains approximately 295 mg of potassium per 8 ounces. Orange juice contains approximately 496 mg of potassium per 8 ounces. Tomato juice contains approximately 535 mg of potassium per 8 ounces.

An adolescent at 10 weeks' gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate? 1 The caloric content will result in too great a weight gain. 2 The ingredients in soft drinks and candy can be teratogenic in early pregnancy. 3 The salt in this diet will contribute to the development of gestational hypertension. 4 The nutritional composition of the diet places her at risk for a low-birth-weight infant.

4 The diet does not reflect a healthy balance of foods and nutrients, especially protein; adequate nutrition is necessary for the birth of a healthy full-term infant whose weight is appropriate for gestational age. The caloric content of these foods is not high if small amounts are consumed; in addition, this client's weight gain may not be reflective of an adequate weight gain in the developing fetus. No data are available to support the assertion that the ingredients of candy and soft drinks are teratogenic. Unrestricted salt intake does not contribute to the development of gestational hypertension.

Four nurse leaders are performing different tasks. Which nurse leader's action indicates the role of the community nurse leader? Nurse Leader A Scheduling a client for surgery Nurse Leader B Assisting the client to positioning on bed Nurse Leader C Teaching the student nurse to administer an intramuscular medication Nurse Leader D Vaccinating children in a school

Nurse Leader D The nurse as a community leader has the unique opportunity to work with schools, city or county governments, and other community entities. The nurse as a community leader formulates a vision for improving the health of the community through disease prevention and health promotion. Therefore administering vaccines by Nurse leader D to the children in school to prevent disease indicates that the nurse is performing the role of the community nurse leader. Scheduling the client for a surgery may not be done in a community; therefore this action of Nurse leader A does not indicate the role of the community nurse leader. Assisting the client in positioning him or her on a bed can be done wherever possible, such as in client's home or healthcare facility. Therefore this action by Nurse leader B does not indicate the role of the community nurse leader. Teaching the student nurse to administer an intramuscular medication can be done in a healthcare facility also, therefore this action by Nurse leader C does not indicate the role of the community nurse leader.

Which information would the nurse include regarding appliance care and maintenance, when teaching a client with a new colostomy? Select all that apply. 1 Change the ostomy pouch on a routine basis. 2 Replace the ostomy wafer weekly or sooner as needed. 3 Remove the ostomy pouch when showering. 4 Empty the ostomy pouch when three-quarters full of stool or gas. 5 Empty the ostomy pouch before exercise and at bedtime.

1, 2, 5 Tips for limiting stool leakage are important for the client with an ostomy, in regards to comfort and dignity. Changing the ostomy pouch on a routine basis will decrease the risk of leakage. Twice weekly changes are considered typical. It is also recommended that the skin barrier (wafer) be changed at least once weekly and as needed if sooner, in order to protect the integrity of the skin beneath and around it. Emptying the pouch before activities and before bedtime will also help prevent leakage and overfill. It is recommended to shower or bathe with the pouch on, not off. This helps to maintain the integrity of the wafer and to prevent any stool from leaking onto the skin or into the shower while bathing. Clients should be instructed to have a new pouch at the ready, to be exchanged with the old pouch, after showering. Waiting to empty the pouch until it is more than one-half full increases the likelihood of leakage. Emptying the pouch sooner will prevent overfill and leakage.

An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply. 1 Insulin therapy 2 Prophylactic antibiotics 3 Blood glucose monitoring 4 Oral hypoglycemic agents 5 Adherence to the treatment regimen

1, 3, 5 Because clients with type 1 diabetes have little or no endogenous insulin, they must take insulin. Blood glucose monitoring is an important aspect of therapy because it aids evaluation of the effectiveness of diabetic control. Dietary control and exercise reduce the amount of exogenous insulin needed. Although adhering to the diabetic regimen is difficult, especially for adolescents who need to identify with their peers, its importance in promoting euglycemia should be discussed. Although infection increases insulin requirements, prophylactic antibiotics are not needed. Oral hypoglycemics are ineffective in stimulating insulin secretion in clients with type 1 diabetes.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? Checking for the last bowel movement 2 Checking for residual stomach contents 3 Checking to determine time of last medication for nausea 4 Checking to make sure the head of bed is elevated at least 15 degrees

2 Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? 1 Offering clear fluids whenever the child is awake 2 Checking the child's level of consciousness hourly 3 Assessing the child's blood pressure every four hours 4 Administering the prescribed oral antibiotic medication

2 Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation. The child is too ill to ingest anything by mouth; also, vomiting is likely. Hydration is maintained intravenously. Taking the blood pressure and other vital signs every four hours is insufficient monitoring; many changes can occur in this time span. Intravenous antibiotics have a rapid systemic effect and are preferable to those administered by way of the oral route.

A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct? 1 Urinary frequency due to bladder spasticity 2 Urinary retention due to bladder atony 3 Pain due to urinary tract calculi 4 Urinary urgency due to urinary tract infections

2 Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention. Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder. Cholinergics will not prevent renal calculi. Urinary tract infections are a secondary gain because cholinergics help prevent urinary retention that can lead to urinary tract infection, but this is not the primary purpose for administering a cholinergic.

A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize? 1 Medical treatment is curative; surgery is not required. 2 For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. 3 For most clients, surgery is recommended early in the course of treatment. 4 Medical treatment is all that will be needed if the client can maintain emotional stability.

2 Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. That medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.

A nurse is planning to assess the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained? 1 The bile duct is obstructed by the pyloric sphincter. 2 There is an obstruction above the opening of the common bile duct. 3 The bile duct sphincter is connected to the hypertrophied pyloric muscle. 4 There is a constriction of the cardiac sphincter that obstructs the flow of bile.

2 The common bile duct enters the duodenum. The pyloric sphincter is located between the end of the stomach and the beginning of the duodenum; therefore when it is hypertrophied the tight sphincter prevents any mixing of vomited formula with bile. Pyloric stenosis involves hypertrophy and hyperplasia of the muscle of the pyloric sphincter; the bile duct is intact. The bile duct enters the duodenum at a site different from the pyloric sphincter and is uninvolved in pyloric stenosis. The area affected in pyloric stenosis is the pyloric sphincter (which is between the stomach and duodenum), not the cardiac sphincter (which is between the stomach and esophagus).

A Total Parenteral Nutrition (TPN) solution is prescribed to infuse one liter every 12 hours for a malnourished client. What is most important for the nurse to monitor? 1 Daily weight 2 Urinary output 3 Administration rate 4 Serum glucose levels

4 The solution is hyperosmolar and is a concentrated source of glucose. Serum glucose should be monitored every six hours until client and glucose levels become stable. Glucose abnormalities (hyperglycemia or hypoglycemia) or liver dysfunction occurs in greater than 90% of clients. Weight, complete blood count (CBC), electrolytes, and blood urea nitrogen (BUN) should be monitored daily. Fluid intake and output should be monitored continuously. When the client's blood tests have stabilized, monitoring can be done less often. The infusion should always be administered with an infusion pump keeping the rate of infusion at a constant rate. Abruptly stopping an infusion should be avoided.

When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. What should the nurse teach the client? 1 Substitute a variety of cheeses for the milk. 2 Replace fat-free or low-fat milk for whole milk. 3 Increase intake of prenatal supplements and omit the milk. 4 Treat constipation when it occurs and continue drinking milk.

4 Unless lactose intolerance is present, the client should drink milk; eating dried fruits and high-fiber foods and increasing fluids and activity will help ease constipation. Substituting cheeses for milk and replacing fat-free or low-fat milk with whole milk can both cause constipation. Megadoses of vitamins can be harmful, and prenatal vitamins are not a substitute for milk.

A client who recently immigrated to the United States (Canada) has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1 Vitamin A is an integral part of the retina's pigment called melanin. 2 It is a component of the rods and cones, which control color visualization. 3 Vitamin A is the material in the cornea that prevents the formation of cataracts. 4 It is a necessary element of rhodopsin, which controls responses to light and dark environments.

4 Vitamin A is used in the formation of retinol, a component of the light-sensitive rhodopsin (visual purple) molecule. Melanin is a pigment of the skin. Vitamin A does not influence color vision, which is centered in the cones. The cornea is a transparent part of the anterior portion of the sclera; a cataract is opacity of the usually transparent crystalline lens. Vitamin A does not prevent cataracts.

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? Select all that apply. 1 Yogurt 2 Oily fish 3 Apricots 4 Raw shellfish 5 Herbal supplements 6 Soft-scrambled eggs

4, 5, 6 The March of Dimes has included raw shellfish, which may be contaminated with hepatitis or typhoid, on its list of foods to avoid during pregnancy. Herbal supplements and teas often contain ingredients that are medicinal and should not be taken during pregnancy unless a primary healthcare provider has been consulted regarding their safety. The March of Dimes has included soft-scrambled eggs on its list of foods to avoid during pregnancy because they may be contaminated with Salmonella. Yogurt is an excellent source of calcium and is safe to eat during pregnancy. Oily fish has a high level of omega-3 oils and is safe to eat in limited amounts during pregnancy. Apricots are a source of potassium and are safe to eat during pregnancy.

A nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching? 1 "I will increase my meat consumption." 2 "I will perform a self-breast examination every week." 3 "I will schedule routine mammograms." 4 "I will reduce my caffeine and theophylline intake."

1 Meat consumption should be reduced to prevent breast cancer; a high meat consumption may lead to obesity, which is a risk factor for breast cancer. Performing self-breast examinations is an effective way to feel changes or any abnormal growth in the breast. The client should undergo mammograms regularly to check for early signs and abnormalities of the breast. Although the approach of reduced intake of caffeine and theophylline is controversial, these actions may reduce the symptoms of benign breast disease.

The nurse provides a list of appropriate food choices to a client with newly diagnosed diabetes. The client reviews the list and says, "I do not like and refuse to eat asparagus, broccoli, and mushrooms." In response, the nurse teaches the client about the food exchange list. The nurse evaluates that teaching was effective when the client states, "Instead of asparagus, broccoli, and mushrooms, I will eat which foods?" 1 String beans, beets, or carrots." 2 Corn, lima beans, or dried peas." 3 Baked beans, potatoes, or parsnips." 4 Corn muffins, corn chips, or pretzels."

1 String beans, beets, and carrots are in the vegetable exchange, as are asparagus, broccoli, and mushrooms. Corn, lima beans, dried peas, baked beans, potatoes, or parsnips are starchy vegetables and are listed as bread exchanges. Corn muffins, corn chips, or pretzels are from the bread exchange list.

A client with biliary cirrhosis receives serum albumin therapy. What is the most effective method for the nurse to evaluate the client's response to therapy? 1 Weight daily 2 Vital signs frequently 3 Urine output every half hour 4 Urine albumin level every shift

1 The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss. The vital signs will not change drastically; "frequently" is a nonspecific timeframe. The urinary output is measured hourly; half-hour outputs are insignificant in this instance. A serum, not urine, albumin level is significant; albumin in the urine indicates kidney dysfunction, not liver dysfunction.

Which pharmacokinetic condition of a drug may result in a high intensity and long duration of response? 1 When both absorption and elimination are rapid 2 When both absorption and elimination are delayed 3 When absorption is rapid but elimination is delayed 4 When absorption is delayed but elimination is rapid

3 Pharmacokinetic factors determine the concentration of a drug at its sites of action. When the drug's absorption is rapid and elimination is delayed, the concentration of the drug at the site of action is high. This action increases the intensity and duration of the drug response. When both the absorption and elimination rates are rapid, the concentration of drug at the site of action is lesser. This in turn decreases the duration of the drug response. In contrast, when both the absorption and elimination of the drug are delayed, the intensity of the drug's effect is also decreased. When absorption is delayed but elimination is rapid, the duration and intensity of the drug are decreased because the concentration of the drug at the site of action is low.

The nurse is working in a care area employing the "Transforming Care at the Bedside" program. The nurse wants to use the rapid cycle change process for a unit design issue. In which order should the nurse perform the steps of this process? 1. Move the item in the client's room. 2. Determine if moving the item was successful as planned. 3. Identify the steps to implement the change in the remaining client rooms. 4. Define how changing a client room item would contribute to cost-effective care.

4, 1, 2, 3 When implementing the rapid cycle change process, the first step is defining the objectives and predicting how the identified change would contribute to something, or in this case, contribute to cost-effective care. In the next step, the do phase, the change occurs, or in this case the item was moved. Then the study phase occurs, which in this case involves determining if the item that was moved was successful as planned. The final phase is the act phase in which the next steps are planned, or for this situation, the steps are identified to implement the change in the remaining client rooms.