exam 1: (modules 1-3)

A nurse is caring for a client with recurrent aphthous stomatitis (RAS) who asks about food choices while healing. Which food will the nurse suggest? A. Half of an orange B. Chocolate pudding C. Chips with hummus D. Glass of tomato juice

B. Chocolate pudding

A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply. A. "Avoid places with crowds and individuals who have infection." B. "Report increased bruising to your doctor because the drug can cause bleeding." C. "Get your lab work done regularly because the drug can affect your kidneys." D. "Be careful and avoid falls because the drug can cause fractures." E. "Follow up with the dietitian to ensure that you adhere to your special diet."

A. "Avoid places with crowds and individuals who have infection." C. "Get your lab work done regularly because the drug can affect your kidneys."

A client who had the Stretta procedure to treat severe GERD is being discharged. Which client statement requires further nursing teaching? Select all that apply. A. "Dysphagia after this procedure is normal". B. "It's important to stop my proton pump inhibitor." C. "I will not take NSAIDs and aspirin for at least 10 days." D. "I might cough up some blood following this procedure."

A. "Dysphagia after this procedure is normal". B. "It's important to stop my proton pump inhibitor." D. "I might cough up some blood following this procedure."

Which client statement regarding diet and nutrition after a total gastrectomy requires further teaching by the nurse? A. "I should stay sitting up for an hour after I eat." B. "I will avoid liquids with my meals." C. "I need to eat small frequent meals." D. "I need to stay away from concentrated sweets."

A. "I should stay sitting up for an hour after I eat."

What health teaching will the nurse include to promote gastric health for an adult client? Select all that apply. A. "Stop smoking or using tobacco of any form." B. "Do not drink excessive amounts of alcohol." C. "Consume high-fat protein foods and decrease carbohydrates." D. "Avoid excessive amounts of pickled or smoked food." E. "Avoid taking large amounts of NSAIDs."

A. "Stop smoking or using tobacco of any form." B. "Do not drink excessive amounts of alcohol." D. "Avoid excessive amounts of pickled or smoked food." E. "Avoid taking large amounts of NSAIDs."

While applying compression stockings and pneumatic compression devices, a client questions the purpose of these devices. What is the appropriate nursing response? A. "These will help to prevent blood clots." B. "They make your legs feel more comfortable." C. "These prevent skin breakdown from immobility." D. "The use of these right after surgery makes is easier to start to ambulate".

A. "These will help to prevent blood clots."

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she did not like the way she felt."

A. "When I eat shrimp, my tongue swells and I have trouble breathing."

The nurse is caring for a client in end-stage liver failure. Which interventions should implemented when observing for hepatic encephalopathy? Select all that apply. A. Assess the client's neurologic status as prescribed. B. Monitor the client's hemoglobin and hematocrit levels. C. Monitor the client's serum ammonia level. D. Monitor the client's electrolyte values daily. E. Prepare to insert an esophageal balloon tamponade tube. F. Make sure the client's fingernails are short.

A. Assess the client's neurologic status as prescribed. C. Monitor the client's serum ammonia level.

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? Select all that apply. A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess

A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess

The nurse is teaching a client about nutrition and diverticulosis. Which food will the nurse teach the client to avoid? A. Cucumber B. Beans C. Carrot D. Radish

A. Cucumber

A 63-year-old client with cirrhosis underwent paracentesis today. Which assessment finding alerts the nurse that the procedure was successful? A. Decrease in post-procedure weight B. No residual obtained during procedure C. Substantial decrease in blood pressure D. Immediate sensation of a need to urinate

A. Decrease in post-procedure weight

An older adult client diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse will monitor the client for what condition? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

A. Dehydration

The nurse reviews medications the client has been taking recently. Which medication will the nurse question? A. Ibuprofen (Motrin) B. Mesalamine (Asacol) C. Loperamide (Imodium) D. Prednisone (Deltasone)

A. Ibuprofen (Motrin)

The nurse is caring for an older adult client who experiences an exacerbation of ulcerative colitis with severe diarrhea and rectal bleeding that have lasted a week. For which complication(s) will the nurse assess? Select all that apply. A. Increased BUN B. Hypokalemia C. Leukocytosis D. Anemia E. Hyponatremia

A. Increased BUN B. Hypokalemia C. Leukocytosis D. Anemia E. Hyponatremia

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A. Left arm prosthesis C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity

A nurse is caring for a 34-year-old client newly diagnosed with GERD. Which lifestyle change will the nurse suggest? Select all that apply A. Lose weight if needed B. Do not eat before bed C. Elevate the foot of your bed by 6-12 inches D. Avoid pants with a tight waistband or belt E. Eat fatty foods to minimize ongoing hunger

A. Lose weight if needed B. Do not eat before bed D. Avoid pants with a tight waistband or belt

While reviewing laboratory results, which value does the nurse identify that support the diagnosis of peptic ulcer disease (PUD)? (Select all that apply.) A. Low hematocrit (Hct) B. Low hemoglobin (Hgb) C. Positive for H. pylori bacteria D. Low potassium of 3.1 mEq/L E. Low white blood cells (WBC)

A. Low hematocrit (Hct) B. Low hemoglobin (Hgb) C. Positive for H. pylori bacteria

When providing discharge teaching about mouth care, which substance will the nurse teach the client with oral cancer to avoid? Select all that apply. A. Mouthwash B. Lip lubricant C. Warm saline rinses D. Ultra-soft toothbrush E. Disposable foam brushes F. Bicarbonate mouth rinse

A. Mouthwash E. Disposable foam brushes

An EGD (Esophagogastroduodenoscopy) confirms the client has PUD and a prescription for triple therapy is initiated. Which combination of drugs does the nurse prepare to administer? A. PPI and two antibiotics B. Antibiotic and two PPIs C. Histamine antagonist, antacid, and PPI D. Antacid, PPI, and prostaglandin analogue

A. PPI and two antibiotics

The nurse is caring for a client who is diagnosed with cirrhosis? Which serum laboratory values will the nurse expect to be abnormal? Select all that apply. A. Prothrombin time B. Serum bilirubin C. Albumin D. Aspartate aminotransferase (AST) E. Lactate dehydrogenase (LDH) F. Acid phosphatase

A. Prothrombin time B. Serum bilirubin C. Albumin D. Aspartate aminotransferase (AST) E. Lactate dehydrogenase (LDH)

Later in the afternoon, the client states that the abdominal pain is worsening. Which nursing intervention is appropriate to address the client's discomfort? (Select all that apply.) A. Provide sitz baths as needed B. Administer analgesics as ordered C. Teach music therapy or guided imagery D. Give antidiarrheal medications if ordered E. Evaluate tomorrow's diet for foods that cause pain

A. Provide sitz baths as needed B. Administer analgesics as ordered C. Teach music therapy or guided imagery

To advocate for safe transition in care, for which process will the nurse advocate? Select all that apply. A. Providing patient history and current assessment information B. Communicating updates and changes in condition C. Verbally verifying that the receiving nurse understands the report D. Using a standardized hand-off communication tool E. Encouraging the receiving nurse to interrupt to askquestions during report.

A. Providing patient history and current assessment information B. Communicating updates and changes in condition C. Verbally verifying that the receiving nurse understands the report D. Using a standardized hand-off communication tool

A client is admitted to the hospital yesterday with a diagnosis of acute pancreatitis. What assessment findings will the nurse expect for this client? Select all that apply. A. Severe boring abdominal pain B. Jaundice C. Nausea and/or vomiting D. Decreased serum amylase level E. Leukocytosis F. Dyspnea

A. Severe boring abdominal pain B. Jaundice C. Nausea and/or vomiting E. Leukocytosis F. Dyspnea

As the client prepares for discharge, the nurse provides discharge teaching. Which education does the nurse provide? (Select all that apply.) A. Sit upright 30 to 60 minutes after meals. B. Spices should be added to food to enhance flavor. C. Extreme vomiting should be reported to the health care provider. D. Continue taking triple therapy as prescribed until the medication is finished. E. The goal of initial intervention is to control symptoms and prevent further complications.

A. Sit upright 30 to 60 minutes after meals. C. Extreme vomiting should be reported to the health care provider. D. Continue taking triple therapy as prescribed until the medication is finished. E. The goal of initial intervention is to control symptoms and prevent further complications.

The client was initially NPO, but is now tolerating food. What education will the nurse provide regarding nutrition? A. Small and frequent meals are best. B. Alcohol and caffeine should be consumed in moderation. C. Expect to experience nausea and vomiting when consuming foods. D. Low-carbohydrate, high-protein, and high-fat foods should be consumed.

A. Small and frequent meals are best.

A nurse is caring for four clients. Which individual does the nurse identify at the highest risk for development of oral cancer? A.28-year-old with human papilloma virus (HPV) infection B. 30-year-old with recurrent aphthous stomatitis (RAS) C. 55-year-old who quit chewing tobacco 5 years ago D. 76-year-old who is sometimes negligent in denture care

A.28-year-old with human papilloma virus (HPV) infection

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?"

The nurse is caring for a client with peptic ulcer disease (PUD). Which client statement requires further nursing teaching? A. "I eat out but I avoid spicy foods." B. "I have to take ibuprofen for back pain." C. "I sit up for an hour after I eat my meals." D. "I am changing jobs to decrease my stress."

B. "I have to take ibuprofen for back pain."

Which client statement about GERD triggers requires further nursing teaching? Select all that apply. A. "I will decrease my alcohol intake." B. "Smoking 1-2 cigarettes a day won't hurt." C. "My plan is to eat six small meals daily." D. "Tomato-based foods should be avoided."' E. "I love soda but I am going to stop drinking it." F. "Our family eats Mexican dishes several times weekly."

B. "Smoking 1-2 cigarettes a day won't hurt." F. "Our family eats Mexican dishes several times weekly."

The primary health care provider prescribes bismuth subsalicylate for a client as part of treating H.pylori infection. What health teaching will the nurse include for the client about this drug? A. "Do not crush this drug before taking." B. "The drug may cause your tongue and stool to turn black." C. "Take the drug at night only." D. "The drug may cause you to have diarrhea."

B. "The drug may cause your tongue and stool to turn black."

A public health nurse is assessing community clients for oral health disorders. Which client is identified at highest risk? A. 23-year old with 3 dental fillings B. 34-year-old with schizophrenia C. 55-year-old with stable angina D. 62-year-old with irritable bowel syndrome

B. 34-year-old with schizophrenia

A community health nurse is screening clients for esophageal cancer. Which client is identified at highest risk? A. 22-year-old who drinks a glass of beer weekly. B. 44-year-old who smokes a pack of cigarettes daily. C. 50-year-old who takes over-the-counter omeprazole. D. 63-year old who uses protein supplements regularly.

B. 44-year-old who smokes a pack of cigarettes daily.

The nurse is caring for a client with peritonitis from a perforated appendix. Which abdominal assessment finding will the nurse most likely expect? A. Soft abdomen B. Board-like abdomen C. Slightly distended abdomen D. Absent bowel sounds

B. Board-like abdomen

When a complete assessment of the client is performed, what other signs and symptoms does the nurse expect? (Select all that apply.) A. Muscle twitching B. Dry skin with rash C. Personality changes D. Peripheral dependent edema E. Ecchymosis, spider angiomas

B. Dry skin with rash D. Peripheral dependent edema E. Ecchymosis, spider angiomas

What priority laboratory analysis will the nurse review when caring for a client with Crohn's disease? A. Potassium B. Hemoglobin C. Serum albumin D. C-reactive protein

B. Hemoglobin

An older adult client with poor oral hygiene andundernourishment is admitted with a hip fracture after a fall. What is the priority nursingintervention? A. Initiate oral care every 4 hours. B. Implement aspiration precautions. C. Use swabs to moisten the mouth as needed. D. Request a consult with a registered dietitian nutritionist.

B. Implement aspiration precautions.

A client had an exploratory laparotomy to treat the cause of peritonitis, and has a large incision that is closed with staples and two abdominal drains. Which finding(s) would the nurse report immediately to the surgeon? Select all that apply. A. Serosanguineous drainage B. Increased abdominal distention C. Fever and chills D. Pain level 2 on a scale of 0 to 10 E. Passing flatus

B. Increased abdominal distention C. Fever and chills

The client's assessment reveals yellowish coloration of skin and sclerae. Which laboratory values does the nurse anticipate? A. Increased urine bilirubin, decreased direct bilirubin B. Increased direct bilirubin, increased indirect bilirubin C. Decreased direct bilirubin, increased indirect bilirubin D. Increased direct bilirubin, decreased indirect bilirubin

B. Increased direct bilirubin, increased indirect bilirubin

What is the priority nursing intervention in the management of a client with decompensated cirrhosis? A. Limiting protein intake B. Managing nausea and vomiting C. Monitoring fluid intake and output D. Elevating the head of bed >30 degrees

B. Managing nausea and vomiting

A 23-year old client admitted and just diagnosed with ulcerative colitis (UC) reports approximately 5 bloody stools daily. Vital signs show a pulse of 80 bpm, respiration rate of 18 breaths per minute, blood pressure of 124/88, and temperature of 97.6ºF. Mild abdominal tenderness on palpation is noted. The ESR is mildly elevated. How is the severity of the client's ulcerative colitis documented? A. Mild B. Moderate C. Severe D. Fulminant

B. Moderate

The nurse is caring for a client diagnosed with peptic ulcer disease (PUD). For which potential complications will the nurse monitor? Select all that apply. A. Pneumonia B. Peritonitis C. Anemia D. Stroke E. Hypotension F. Cirrhosis

B. Peritonitis C. Anemia E. Hypotension

In preparing to care for the client, which condition does the nurse recognize as potential complications of acute pancreatitis? (Select all that apply.) A. Strep throat B. Pleural effusion C. Diabetes mellitus D. Pancreatic infection E. Acute kidney failure

B. Pleural effusion C. Diabetes mellitus D. Pancreatic infection E. Acute kidney failure

The surgery for a client scheduled for an 8:00 AM procedure is delayed until 11:00 AM. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 AM as originally prescribed. B. Request an order for the administration time to be changed to 10:00 AM. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

B. Request an order for the administration time to be changed to 10:00 AM.

A 66-year-old client presents to the ED the day after Thanksgiving, stating that he has "eaten and drunk quite a bit." He reports experiencing a sudden onset of pain in the left upper quadrant that radiates to the left flank about an hour ago that still persists. He rates the pain as an 8 on a 0-to-10 scale. The client is admitted with acute pancreatitis. Which laboratory finding corroborates the diagnosis of acute pancreatitis? A. Serum lipase, 150 U/L B. Serum amylase, 200 U/L C. Serum glucose, 80 mg/dL D. White blood cells (WBCs), 6000 mcL

B. Serum amylase, 200 U/L

As the nurse evaluates a laboratory report for aclient scheduled for surgery, which finding requires nursing intervention? A. Hemoglobin 10.4 g/dL B. Serum potassium 2.5 mEq/L C. Serum sodium level 145 mEq/L D. Fasting blood glucose 110 mg/d

B. Serum potassium 2.5 mEq/L

A client with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark,frothy urine. Which priority laboratory finding will the nurse assess? A. Lipase level B. Total bilirubin C. Liver function tests D. White blood cell count

B. Total bilirubin

The client tells the nurse that once he is discharged to home, he has no intention to stop drinking alcohol. What is the appropriate nursing response? A. "Why do you continue to drink?" B. "It's your choice to drink or not to drink." C. "Does it frighten you to consider quitting?" D. "If you continue to drink, you are going to die."

C. "Does it frighten you to consider quitting?"

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

The client is preparing for discharge. She asks what is the best way to take care of her skin. Which teaching will the nurse provide? A. "Add high-fiber or high-cellulose foods to your diet." B. "Apply a pectin-based skin barrier after each bowel movement." C. "Wash with mild soap and warm water after each bowel movement." D. "Take a laxative bedtime to facilitate morning bowel movements."

C. "Wash with mild soap and warm water after each bowel movement."

A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time? A. Anxiety B. Risk for dehydration C. Acute pain D. Malnutrition

C. Acute pain

A client has been diagnosed with an active upper GI bleed. What is the nurse's priority action? A. Obtain vital signs. B. Initiate IV fluids as prescribed. C. Apply oxygen by nasal cannula. D. Type and cross match for blood products.

C. Apply oxygen by nasal cannula.

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pin-prick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

C. Determine level of consciousness and response to environmental stimuli

The nurse is caring for a client who is to undergo surgery at 6:00 AM today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food nor water since 9:00 PM last night

C. Diffuse rash on upper torso* D. Took 650 mg of aspirin yesterday*

A client had a colectomy with creation of an ileo-anal pouch and temporary ileostomy yesterday morning. The nurse assesses the ostomy and its functioning. Which assessment finding will the nurse report to the primary health care provider? A. Client's report of abdominal pain of 3 on a 0-10 pain intensity scale B. Slight abdominal distention C. No drainage from the ileostomy D. Serosanguinous effluent from the drain

C. No drainage from the ileostomy

The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation

C. Seizure

The nurse is interviewing a client who reports abdominal pain after meals for the past several months. The pain occurs often after eating or lying down to sleep. OTC antacids provide some relief. Which assessment finding does the nurse anticipate that increases the client's risk for development of a peptic ulcer? A. Weight loss of 20 pounds B. History of GERD 4 years ago C. Use of NSAIDs to control arthritis pain D. Recent discontinuation of prednisone taper

C. Use of NSAIDs to control arthritis pain

The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? Select all that apply. A. Place client in a private room. B. Wear a mask when handling patient bedpan. C. Wear gloves when touching the client. D. Wear a gown when providing personal care to this patient. E. Wear eye goggles when providing care.

D. Wear a gown when providing personal care to this patient.

A 24-year old client reports one week of red,raised lesions at the base of tongue and on the inside of the mouth. What priority assessment question will the nurse ask? A. "Do you smoke cigarettes?" B. "Have you seen a dentist recently?" C. "What types of foods have you eaten lately?" D. "Do you have a history of human papillomavirus?"

D. "Do you have a history of human papillomavirus?"

Which statement by the client who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse? A. "I need to take the enzymes at every meal and with snacks." B. "After taking the enzymes, I should drink a glass of water." C. "I should wipe my mouth in case any of the enzyme got on my lips." D. "I should chew each capsule carefully so that it works in my stomach."

D. "I should chew each capsule carefully so that it works in my stomach."

The client states, "I am afraid I'll never get to go out with my friends again because I can't be away from the toilet." Which nursing response is appropriate? A. "What makes you say that?" B. "Your friends will understand." C. "I wouldn't worry about it if I were you." D. "It sounds like you are concerned about managing this disorder."

D. "It sounds like you are concerned about managing this disorder."

The nurse is caring for a client with esophageal cancer who is scheduled for surgery. When the client asks, "Is this treatment going to cure me?", which is the appropriate nursing response? Select all that apply. A. "The surgery has been useful for many patients so it should work for you." B. "You can beat this disease if you just put your mind to it and do not give up." C. "Yes, and you have the best surgeon around who specializes in cancer treatment." D. "Your surgeon can give more information about the effectiveness of this treatment." E. "It sounds like you are concerned about surgical outcomes; let's talk about your feelings."

D. "Your surgeon can give more information about the effectiveness of this treatment." E. "It sounds like you are concerned about surgical outcomes; let's talk about your feelings."

Which client is more likely to develop gallstones? A. 42-year-old Caucasian female with colon cancer B. 51-year-old African-American male with a history of hypertension C. 63-year-old Hispanic/Latino female with a history of irritable bowel syndrome D. 70-year-old American-Indian female with obesity

D. 70-year-old American-Indian female with obesity

The nurse is caring for a client with a long history of osteoarthritis. Which risk factor will the nurse teach that may contribute to development of gastroesophageal refluxdisease (GERD)? A. Weight of 150 pounds B. Walks 15 minutes once daily C. Chooses foods high in calcium D. Frequently takes NSAIDs for pain.

D. Frequently takes NSAIDs for pain.

A client has recently been placed on corticosteroids to treat ulcerative colitis. The nurse will monitor the client's laboratory results for evidence of which condition? A. Hyperkalemia B. Hypernatremia C. Hypercalcemia D. Hyperglycemia

D. Hyperglycemia

In the early postoperative period, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

D. Increase in back pain when coughing

Which food item will the nurse remove from the dietary tray of a client with hepatic encephalopathy? A. Salad B. Apple C. Bread D. Legumes

D. Legumes

A 66-year-old client with a history of arthritis and hypertension is admitted with epigastric cramping, dyspepsia, nausea, and dark, sticky stools for 3 days. Which order will the nurse discuss with the health care provider? A. Guaiac stool sample X2 B. Stool sample for bacterial testing C. IV fluids, normal saline at 125 ml/hr D. Naproxen (Naprosyn) 500 mg twice daily

D. Naproxen (Naprosyn) 500 mg twice daily

The client describes the pain as intense and continuous. He states that sometimes, when he curls up in a fetal position, the pain decreases. Which medication does the nurse anticipate will be ordered to provide the most comprehensive pain relief? A. IM fentanyl B. PCA meperidine C. Oral hydromorphone D. PCA morphine sulfate

D. PCA morphine sulfate

When caring for a client with acute pancreatitis,which assessment finding requires immediate nursing intervention? A. Heart rate of 105 beats/min B. Serum glucose of 136 mg/dL C. Blood pressure of 102/76 mm Hg D. Respiratory rate of 28 breaths/min

D. Respiratory rate of 28 breaths/min

Which assessment finding requires immediate nursing intervention in a client with severe ascites? A. Confusion B. Temperature 38.2º C C. Tachycardia, rate 110 beats/min D. Shallow respirations, rate 32 breaths/min

D. Shallow respirations, rate 32 breaths/min

The client is being discharged to home. What teaching will the nurse provide regarding when the client should notify the health care provider?

The client should be instructed to notify the health care provider if acute abdominal pain occurs. Also, jaundice, clay-colored stools, or dark urine should be reported, because these are signs of biliary tract disease that may indicate complications as the disease progresses.