Exam 2-203

A client with Crohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance

4. Fluid and electrolyte imbalance

infant has been diagnosed with GERD what can you do to the milk

thicken the formula by adding rice cereal to the formula

A charge nurse is providing information about fat emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by the charge nurse are appropriate? (Select all that apply.) A. "Concentration of lipid emulsion can be up to 30%." B. "Adding lipid emulsion gives the solution a milky appearance." C. "Check for allergies to soybean oil." D. "Lipid emulsion prevents essential fatty acid deficiency." E. "Lipids provide calories by increasing the osmolarity of the PN solution."

A. "Concentration of lipid emulsion can be up to 30%." B. "Adding lipid emulsion gives the solution a milky appearance." C. "Check for allergies to soybean oil." D. "Lipid emulsion prevents essential fatty acid deficiency."

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? A. "I need to increase the fiber in my diet." B. "I will need to avoid caffeinated beverages." C. "I'm going to learn some stress-reduction techniques." D. "I can have exacerbations and remissions with Crohn's disease."

A. "I need to increase the fiber in my diet."

The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? A. "I need to limit my intake of dietary fiber." B. "I need to drink plenty, at least 8 to 10 cups daily." C. "I need to eat regular meals and chew my food well." D. "I will take the prescribed medications because they will regulate my bowel patterns."

A. "I need to limit my intake of dietary fiber."

A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates an understanding of the teaching? A. "I will plan to limit fiber in my diet." B. "I will restrict fluid intake during meals." C. "I will switch to black tea instead of drinking coffee." D. "I will try to eat cold foods rather than warm when my stomach feels upset."

A. "I will plan to limit fiber in my diet."

The nurse determines that the client needs further instruction on cimetidine if which statements were made? Select all that apply. A. "I will take the cimetidine with my meals." B. "I'll know the medication is working if my diarrhea stops." C."My episodes of heartburn will decrease if the medication is effective." D. "Taking the cimetidine with an antacid will increase its effectiveness." E. "I will notify my doctor if I become depressed or anxious." F."Some of my blood levels will need to be monitored closely since I also take warfarin for atrial fibrillation"

A. "I will take the cimetidine with my meals." B. "I'll know the medication is working if my diarrhea stops." D. "Taking the cimetidine with an antacid will increase its effectiveness."

A nurse is discussing the use of a low‑profile gastrostomy device with the guardian of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse? A. "The device is usually comfortable for children." B. "Checking residual is easier with this device." C. "This access requires less maintenance than a traditional nasal tube." D. "Mobility of the child is limited with this device."

A. "The device is usually comfortable for children."

A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? (Select all that apply.) A. A client who has a wired jaw due to a motor vehicle crash B. A client who is 24 hours postoperative temporomandibular joint repair C. A client who has difficulty chewing due to oral surgery D. A client who has hypercholesterolemia due to coronary artery disease E. A client who is scheduled for a colonoscopy the next morning.

A. A client who has a wired jaw due to a motor vehicle crash B. A client who is 24 hours postoperative temporomandibular joint repair C. A client who has difficulty chewing due to oral surgery

A nurse is caring for a client who is receiving TPN through a central venous access device, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? A. Administer 20% dextrose in water IV until the next bag is available. B. Slow the infusion rate of the current bag until the solution is available. C. Monitor for hyperglycemia. D. Monitor for hyperosmolar diuresis.

A. Administer 20% dextrose in water IV until the next bag is available.

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. A. Administer stool softeners as prescribed. B. Instruct the client to limit fluid intake to avoid urinary retention. C. Encourage a high-fiber diet to promote bowel movements without straining. D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. E. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

A. Administer stool softeners as prescribed. C. Encourage a high-fiber diet to promote bowel movements without straining. D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.

A nurse is caring for a client who has a diagnosis of gastroesophageal reflux disease (GERD). The nurse should expect prescriptions for which of the following medications? (Select all that apply.) A. Antacids B. Histamine2 receptor antagonists C. Opioid analgesics D. Fiber Laxatives E. Proton Pump Inhibitors

A. Antacids B. Histamine2 receptor antagonists E. Proton Pump Inhibitors

A nurse is reviewing the effect of culture on nutrition during a staff in‑service. Which of the following groups prescribes eating specific foods to balance forces in the body during illness? (Select all that apply.) A. Asian Culture B. African Culture C. Roman Catholicism D. Hispanic/Latinx Culture E. Buddhism

A. Asian Culture D. Hispanic/Latinx Culture

A nurse is having difficulty arousing a client following an esophagogastroduodenoscopy (EGD). Which of the following is the priority action by the nurse? A. Assess the client's airway. B. Allow the client to sleep. C. Prepare to administer an antidote to the sedative. Evaluate preprocedural laboratory findings

A. Assess the client's airway.

A postoperative client has been placed on a clear liquid diet. The nurse would provide the client with which items that are allowed to be consumed on this diet. Select all that apply. A. Broth B. Coffee C. Gelatin D. Pudding E. Vegetable juice F. Pureed vegetables

A. Broth B. Coffee C. Gelatin

A nurse is reviewing bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following instructions should the nurse include? A. Check with the provider about taking current medications when consuming bowel prep. B. Consume a normal diet until starting the bowel prep. C. Expect the bowel prep not to begin acting until the day after all the prep is consumed. Discontinue the bowel prep once feces start to be expelled

A. Check with the provider about taking current medications when consuming bowel prep.

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances o avoid. Which items would the nurse include on this list? Select all that apply. A. Coffee B. Chocolate C. Peppermint D. Nonfat milk E. Fried chicken F. Scrambled eggs

A. Coffee B. Chocolate C. Peppermint E. Fried chicken

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? A. Cream of wheat, blueberries, coffee B. Sausage and eggs, banana, orange juice C. Bacon, cantaloupe melon, tomato juice D. Cured pork, grits, strawberries, orange juice

A. Cream of wheat, blueberries, coffee

A nurse is planning care for a client who has a small bowel obstruction and nasogastric (NG) tube in place. Which of the following interventions should the nurse include? (Select all that apply.) A. Document the NG drainage with the client's output. B. Irrigate the NG tube every 8 hours. C. Assess bowel sounds. D. Provide oral hygiene every 2 hours. E. Monitor NG tube for placement.

A. Document the NG drainage with the client's output. C. Assess bowel sounds. D. Provide oral hygiene every 2 hours. E. Monitor NG tube for placement.

A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with the diagnosis? (Select all that apply.) A. Emesis greater than 500mL with a fecal odor. B. Report of spasmodic abdominal pain. C. High-pitched bowel sounds. D. Abdomen flat with rebound tenderness to palpation. E. Laboratory findings indicating metabolic acidosis.

A. Emesis greater than 500mL with a fecal odor. B. Report of spasmodic abdominal pain. C. High-pitched bowel sounds.

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should the nurse include in the plan of care? (Select all that apply.) A. Evaluate intake and output. B. Monitor laboratory reports of electrolytes. C. Provide three large meals a day. D. Administer ibuprofen for pain. E. Observe stool characteristics.

A. Evaluate intake and output. B. Monitor laboratory reports of electrolytes.

A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Examine trends in weight loss. B. Review prealbumin finding. C. Administer and IV solution of 20% Dextrose. D. Add a micron filter to IV tubing. E. Use an IV Infusion Pump.

A. Examine trends in weight loss. B. Review prealbumin finding. D. Add a micron filter to IV tubing.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations supports this diagnosis? Select all that apply. A. Fever B. Positive Cullen's sign C. Complaints of indigestion D. Palpable mass in the left upper quadrant E. Pain in the upper right quadrant after a fatty meal F. Vague lower right quadrant abdominal discomfort

A. Fever C. Complaints of indigestion E. Pain in the upper right quadrant after a fatty meal

A school nurse is teaching a high school health class about the possible causes of a negative nitrogen balance. Which of the following causes should the nurse include in the teaching? (Select all that apply.) A. Illness B. Malnutrition C. Adolescence D. Trauma E. Pregnancy

A. Illness B. Malnutrition D. Trauma

A nurse is teaching a client who will undergo a sigmoidoscopy. Which of the following information about the procedure should the nurse include? (Select all that apply.) A. Increased flatulence can occur following the procedure. B. NPO status should be maintained pre-procedure. C. Conscious sedation is used. D. Repositioning will occur throughout the procedure. E. Fluid intake is limited the day after the procedure.

A. Increased flatulence can occur following the procedure. B. NPO status should be maintained pre procedure.

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure. A. Instilling 500 to 1000 mL of lukewarm tap water through the stoma B. Advising the client to hold the breath if cramping occurs during instillation of the solution C. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso D. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to flow into the stoma

A. Instilling 500 to 1000 mL of lukewarm tap water through the stoma

A nurse is completing discharge teaching with a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include? A. Keep a food diary to identify triggers to exacerbation. B. Consume 15 to 20 g of fiber daily. C. Plan three moderate to large meals per day. D. Limit fluid intake to 1 L each day.

A. Keep a food diary to identify triggers to exacerbation.

A charge nurse is conducting a nutritional class for a group of newly licensed nurses regarding basic metabolic rate (BMR). The charge nurse should inform the class that which of the following factors increases BMR? (Select all that apply.) A. Lactation B. Prolonged Stress C. Malnutrition D. Puberty E. Age older than 60 years

A. Lactation B. Prolonged Stress D. Puberty

A client with hiatal hernia chronically experiences heartburn following meals. The nurse would plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? A. Lying recumbent following meals B. Consuming small, frequent bland meals C. Taking H2-receptor antagonist medication D. Raising the head of the bed on 6-inch (15 cm) blocks

A. Lying recumbent following meals

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. A. Maintain NPO (nothing by mouth) status. B. Encourage coughing and deep breathing. C. Give small, frequent high-calorie feedings. D. Maintain the client in a supine and flat position. E. Give hydromorphone intravenously as prescribed for pain. F. Maintain intravenous fluids at 10 mL/hr to keep the vein open.

A. Maintain NPO (nothing by mouth) status. B. Encourage coughing and deep breathing. E. Give hydromorphone intravenously as prescribed for pain.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? A. Malaise B. Dark stools C. Weight gain D. Left upper quadrant discomfort

A. Malaise

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? A. Notify the surgeon. B. Administer the prescribed pain medication. C. Call and ask the operating room team to perform surgery as soon as possible. D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.

A. Notify the surgeon

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Obtain capillary blood glucose four times daily. B. Administer prescribed medications through a secondary port on the TPN IV tubing. C. Monitor vital signs three times during the 12-hr shift. D. Change the TPN IV tubing every 24hr. E. Ensure a daily aPTT is obtained.

A. Obtain capillary blood glucose four times daily. C. Monitor vital signs three times during the 12-hr shift. D. Change the TPN IV tubing every 24hr

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEg/L (150 mmolL). The nurse reports the serum sodium level to the primary health care provider (PHCP, and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. A. Peas B. Nuts C. Cheese D. Cauliflower E. Processed oat cereals

A. Peas B. Nuts D. Cauliflower

A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hours ago, and 400 remain to infuse. Which of the following is the appropriate action for the nurse to take? A. Remove the current bag and hang a new bag. B. Infuse the remaining solution and the current rate and then hang a new bag. C. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag. D. Remove the current bag and hang a bag of Lactated Ringer's.

A. Remove the current bag and hang a new bag.

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (Select all that apply.) A. Rigid Abdomen B. Tachycardia C. Elevated blood pressure D. Circumoral Cyanosis E. Rebound Tenderness

A. Rigid Abdomen B. Tachycardia E. Rebound Tenderness

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain

A. Sweating and pallor

A nurse is teaching a client who has duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Take the medication 1 hour before a meal. B. Limit NSAIDs when taking this medication. C. Expect skin flushing when taking this medication. D. Increase fiber intake when taking this medication. E. Chew the medication thoroughly before swallowing.

A. Take the medication 1 hour before a meal. B. Limit NSAIDs when taking this medication.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event. B. The client is experiencing early signs of ischemic bowel. C. The client should not have the nasogastric tube removed. D. This indicates inadequate preoperative bowel preparation.

A. This is a normal, expected event.

A client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event. B. The client is experiencing early signs of ischemic bowel. C. The client should not have the nasogastric tube removed. D. This indicates inadequate preoperative bowel preparation.

A. This is a normal, expected event.

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods is a major source of magnesium? A. Tuna B. Tomatoes C. Eggs D. Oranges

A. Tuna

A nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? (Select all that apply.) A. Verify the presence of bowel sounds. B. Flush the feeding tube with warm water. C. Elevate the head of the bed 20 degrees. D. Administer the feeding at room temperature. E. Instill the formula over 60 minutes.

A. Verify the presence of bowel sounds. B. Flush the feeding tube with warm water. D. Administer the feeding at room temperature

The primary healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis? A. "I have had unprotected sex with multiple partners." B. "I ate shellfish about 2 weeks ago at a local restaurant." C. "I was an intravenous drug abuser in the past and shared needles. D. "I had a blood transfusion 30 years ago after major abdominal surgery."

B. "I ate shellfish about 2 weeks ago at a local restaurant."

A nurse is reviewing dietary recommendations for a group of clients at a health fair. Which of the following information should the nurse include? A. Fats should be 5% to 15% of daily caloric intake." B. "Make protein 10% to 35% of total calories each day." C. "Consume 1,500 mL of water from liquids and solids each day." D. "The body needs 40mg of iron each day."

B. "Make protein 10% to 35% of total calories each day."

A nurse educator is teaching a class on culture and food to a group of newly hired nurses. Which of the following statements by a nurse indicates an understanding of the teaching? A. "Most clients who practice roman Catholicism do not drink caffeinated beverages." B. "Most clients who practice orthodox Judaism do not eat meat with dairy products." C. "Most clients who are Mormon eat only the protein of animals that are slaughtered under strict guidelines." D. "Most clients who practice Hinduism do not eat dairy products."

B. "Most clients who practice orthodox Judaism do not eat meat with dairy products.

A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching? A. "I can take my medication with soda." B. "Peppermint will increase my indigestion." C. "Wearing an abdominal binder will limit my manifestations." D. "I will drink hot chocolate at bedtime to help me sleep." E. "I can lift weights as a way to exercise."

B. "Peppermint will increase my indigestion."

A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements should the charge nurse make? A. "Use the Y‑port on the TPN IV tubing to administer antibiotics." B. "Regular insulin can be added to the TPN solution." C. "Administer heparin through a port on the TPN tubing." D. "Administer vitamin K IV bolus via a Y‑port on the TPN tubing."

B. "Regular insulin can be added to the TPN solution."

A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following information should the nurse include? A. "Give a feeding every 6 hours." B. "Set the feeding up before you go to bed." C. "Weigh yourself daily." D. "Flush the tube with a carbonated beverage to dislodge clots." E. "Ensure your head is elevated to 15 degrees during administration."

B. "Set the feeding up before you go to bed." C. "Weigh yourself daily."

A charge nurse is teaching a group of nurses about a client who has chronic gastritis and is scheduled for a selective vagotomy. Which of the following statements by a unit nurse indicates an understanding of the procedure? A. "The client will have increased duodenal gastric emptying." B. "The client will have a reduction of gastric acid secretions." C. The client will have an increase of gastric mucus secretion." D. "The client will have an increased secretion of hydrogen/potassium ATPase enzymes."

B. "The client will have a reduction of gastric acid secretions."

A nurse is collecting data from a client who has peptic ulcer disease (PUD). Which of the following findings should the nurse expect? (Select all that apply.) A. Steatorrhea B. Anemia C. Tarry Stools D. Epigastric Pain E. Swollen Lymph Nodes

B. Anemia C. Tarry Stools D. Epigastric Pain

A nurse is providing care to a client who is one day postoperative following a paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site. B. Apply a dry, sterile dressing. C. Apply direct pressure to the site. D. Place the client in supine position.

B. Apply a dry, sterile dressing.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? A. Monitoring the leukocyte count for 2 days after the infusion B. Checking the frequency and consistency of bowel movements C. Checking serum liver enzyme levels before and after the infusion D. Carrying out a Hematest on gastric fluids after the infusion is completed

B. Checking the frequency and consistency of bowel movements

A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads "discontinue NPO status; advance diet as tolerated." Which of the following are appropriate for the nurse to offer the client initially? (Select all that apply.) A. Applesauce B. Chicken Broth C. Sherbet D. Wheat Toast E. Cranberry Juice

B. Chicken Broth E. Cranberry Juice

A nurse is preparing to administer intermittent enteral feeding to a client. Which of the following are appropriate nursing interventions? (Select all that apply.) A. Fill the feeding bag with 24 hours worth of formula. B. Discard feeding equipment after 24 hours. C. Place any unused formula in open cans in the refrigerator. D. Flush the feeding tube every 4 hours. E. Elevate the head of the client's bed for 15 minutes after administration.

B. Discard feeding equipment after 24 hours. C. Place any unused formula in open cans in the refrigerator. D. Flush the feeding tube every 4 hours

A nurse is assessing a client who is postoperative from a gastric bypass and who just finished eating a meal. Which of the following findings are manifestations of dumping syndrome? (Select all that apply.) A. Bradycardia B. Dizziness C. Dry Skin D. Hypotension E. Diarrhea

B. Dizziness D. Hypotension E. Diarrhea

A nurse is educating a client who has anemia about dietary intake. Which of the following is a non-heme source of Iron? A. Ground Beef B. Dried Beans C. Salmon D. Turkey

B. Dried Beans

A nurse is completing discharge with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie-dense foods. B. Drink canned protein supplements. C. Increase intake of high-fiber foods. D. Eat high-residue foods.

B. Drink canned protein supplements.

A nurse is reviewing the laboratory value of a client who has an acute exacerbation of Crohn's disease. Which of the following blood laboratory results should the nurse expect to be elevated? (Select all that apply.) A. Hematocrit B. Erythrocyte sedimentation rate C. WBC D. Folic Acid E. Albumin

B. Erythrocyte sedimentation rate C. WBC

A nurse is teaching about pernicious anemia with a client who has chronic gastritis. Which of the following information should the nurse include in the teaching? A. Pernicious anemia is caused when the cells producing gastric acid are damaged. B. Expect a monthly injection of vitamin B12. C. Plan to take vitamin K supplements. D. Pernicious anemia is caused by an increased production of intrinsic factor.

B. Expect a monthly injection of vitamin B12.

A nurse is instructing a client who has celiac disease about foods to avoid. Which of the following foods should the nurse include in the teaching? A. Potatoes B. Graham Crackers C. Wild Rice D. Canned Pears

B. Graham Crackers

A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? (Select all that apply.) A. Dried Prunes B. Ground Turkey C. Mashed Carrots D. Fresh Strawberries E. Cottage Cheese

B. Ground Turkey C. Mashed Carrots E. Cottage Cheese

A client with peptic ulcer disease has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? A. Diarrhea B. Heartburn C. Flatulence D. Constipation

B. Heartburn

A client diagnosed with viral hepatitis is complaining of "no appetite" and "losing my taste for food " What instruction would the nurse give the client to provide adequate nutrition? A. Select foods high in fat. B. Increase intake of fluids, including juices. C. Eat a good supper, when anorexia is less severe. D. Eat less often, preferably only three large meals daily.

B. Increase intake of fluids, including juices.

A nurse is reviewing prescribed medications with a newly admitted client. Which of the following medications increases the body's rate of metabolism. A. Morphine B. Levothyroxine C. Phenobarbital D. Dilaudid

B. Levothyroxine

The nurse is providing discharge instructions to a client following gastrectomy and would instruct the client to take which measure to assist in preventing dumping syndrome? A. Ambulate following a meal. B. Limit the fluids taken with meals. C. Eat cakes and pastries only if they are homemade. D. Eat three meals a day rather than small frequent meals.

B. Limit the fluids taken with meals.

A nurse is teaching a client who is recovering from pancreatitis about following a low‑fat diet. Which of the following foods should the nurse recommend? (Select all that apply.) A. Ribeye Steak B. Oatmeal C. Ice Cream D. Canned Peaches E. Pretzels

B. Oatmeal D. Canned Peaches E. Pretzels

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing. A. Milk B. Oranges C. Bananas D. Chicken

B. Oranges

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? A. Absence of saliva B. Painful swallowing C. Sweet taste in mouth D. Absence of eructation

B. Painful swallowing

A nurse is caring for a client who is to receive a Level 2 dysphagia diet due to a recent stroke. Which of the following dietary selections is most appropriate? A. Turkey Sandwich B. Poached Eggs C. Peanut Butter Granola Crackers D. Granola

B. Poached Eggs

The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider? A. Stoma is beefy red and shiny B. Purple discoloration of the stoma C. Skin excoriation around the stoma D. Semiformed stool noted in the ostomy pouch

B. Purple discoloration of the stoma

The nurse prepares to provide instructions to a client with a low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? Select all that apply. A. Peas B. Raisins C. Potatoes D. Cantaloupe E. Cauliflower F. Strawberries

B. Raisins C. Potatoes D. Cantaloupe F. Strawberries

A client with gastritis who uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted? A. Resolved diarrhea B. Relief of epigastric pain C. Decreased platelet count D. Decreased white blood cell count

B. Relief of epigastric pain

A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. Which of the following conditions is associated with a deficiency of vitamin C? (Select all that apply.) A. Dysrhythmias B. Scurvy C. Pernicious Anemia D. Megaloblastic Anemia E. Bleeding Gums

B. Scurvy E. Bleeding Gums

A nurse is teaching a client who is starting continuous feedings about the various types of enteral nutrition (EN) formulas. Which of the following should the nurse include in the teaching? A. Formula rich in fiber is recommended when starting EN. B. Standard formula contains whole protein. C. Hydrolyzed formula is recommended for a full-functioning GI tract. D. D. The high-calorie formulas has increased water content.

B. Standard formula contains whole protein.

The nurse is providing care for a client with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon? A Stoma is beefy red and shiny. B. Stoma has a purple discoloration. C. Skin excoriation is noted around the stoma. D. Semiformed stool is noted in the ostomy pouch.

B. Stoma has a purple discoloration.

A nurse is assessing a client in an extended care facility. The nurse should recognize which of the following findings is a manifestation of an obstruction of the large intestine due to fecal impaction? A. The client reports one bowel movement yesterday. B. The client is having small, frequent liquid stools. C. The client is flatulent. D. The client indicates vomiting once this morning.

B. The client is having small, frequent liquid stools.

A nurse is discussing how the body processes food with a client during a routine providers visit. Which of the following statements should the nurse include? A. Glycerol can be broken down into glucose for use by the body. B. The liver converts unused glucose into glycogen. C. Excess fatty acids are stored in the muscle tissue. D. The body uses glycogen for fat before the body using available ATP.

B. The liver converts unused glucose into glycogen.

A nurse is completing an admission assessment for a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Emesis prior to insertion of the nasogastric tube. B. Urine specific gravity 1.040 C. Hematocrit 60% D. Blood potassium 3.0mEq/L E. WBC 10,000/uL

B. Urine specific gravity 1.040 C. Hematocrit 60% D. Blood potassium 3.0mEq/L

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching and would focus on foods high in which vitamin that may be lacking in a vegan diet. A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B. Vitamin B12

A nurse is caring for a client who has multiple sclerosis and requires liquids with honey‑like thickness. Which of the following foods can the client consume without adding a thickening agent? A. Ice Cream B. Yogurt C. Buttermilk D. Cream of Chicken Soup

B. Yogurt

the nurse is caring for a child with intussusception what signs should be noted

Bright red blood and mucus in stools

A nurse is completing discharge teaching with a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching? A. "When sitting in my lounge chair after a meal, I will lower the back of it." B. "I will try to eat three large meals a day." C. "I will elevate the head of my bed on blocks." D. "I will avoid eating within one hour of bedtime."

C. "I will elevate the head of my bed on blocks."

A nurse is completing discharge teaching for a client who has an infection of Helicobacter pylori (H. pylori). Which of the following statements by the clients indicates an understanding of the teaching? A. "I will continue my prescription for corticosteroids." B. "I will schedule a CT scan to monitor improvement." C. "I will take a combination of medicines for treatment." D. "I will have my throat swabbed to recheck for this bacteria."

C. "I will take a combination of medicines for treatment."

A nurse teaching a client who has a new prescription for famotidine. Which of the following statements by the client indicates an understanding of the teaching? A. "The medicine coats the lining of my stomach." B. "The medicine should stop the pain right away." C. "I will take my pill at bedtime." D. "I will monitor for bleeding from my nose."

C. "I will take my pill at bedtime."

The nurse has taught the client with suspected gallbladder disease about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? A. "I know I must sign the consent form." B. "hope the throat spray keeps me from gagging." C. "I'm glad I don't have to lie still for this procedure. D. "I'm glad some intravenous medication will be given to relax me."

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

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching? A. "Take the medication 2 hours after eating." B. "Discontinue the medication if your skin turns yellow-orange." C. "Notify the provider if you experience a sore throat." D. "Expect your stools to turn black."

C. "Notify the provider if you experience a sore throat."

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including Clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? A. "My ulcer will heal because these medications will kill the bacteria. B. "These medications are taken only when I have pain from my ulcer. C. "The medications will kill the bacteria and stop the acid production." D. "These medications will coat the ulcer and decrease the acid production in my stomach.

C. "The medications will kill the bacteria and stop the acid production."

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicates an understanding of the procedure? A. The stoma needs to be cleaned with only water." B. "The best time to change the appliance is at night." C. "The pouch needs to be changed every 5 to 7 days." D. "I'll cut the skin barrier 10 millimeters larger than the stoma.

C. "The pouch needs to be changed every 5 to 7 days."

The nurse has given instructions to a client with biliary disease who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction? A. 'I will continue to take vitamin supplements. B. "This medication will help lower my cholesterol." C. "This medication would only be taken with water." D. "A high-fiber diet is important while taking this medication."

C. "This medication would only be taken with water."

The nurse is assessing a client with bladder cancer who had a cystectomy and the creation of a urethrostomy. Which statement by the client indicates the need for more education about urinary stoma care? A. 'I change my pouch every week." B. "I change the appliance in the morning." C. 'I empty the urinary collection bag when it is two-thirds full. D. "When I'm in the shower, I direct the flow of water away from my stoma.

C. 'I empty the urinary collection bag when it is two-thirds full.

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain? A. A straight catheter B. A Coudé tip catheter C. A triple-lumen catheter D. A double-lumen catheter

C. A triple-lumen catheter

A client with gastroenteritis has an as-needed prescription for loperamide hydrochloride. For which condition would the nurse administer this medication? A. Constipation B. Abdominal pain C. An episode of diarrhea D. Hematest-positive nasogastric tube drainage

C. An episode of diarrhea

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How would the nurse assess for its presence? A. Dorsiflex the client's foot. B. Measure the abdominal girth. C. Ask the client to extend the arms. D. Instruct the client to lean forward.

C. Ask the client to extend the arms.

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply.) A. Client reports pain relieved by eating. B. Client reports that pain often occurs at night. C. Client reports a sensation of bloating. D. Client states that pain occurs 30 minutes to 1 hour after meal. E. Client experiences pain upon palpation of the epigastric region.

C. Client reports a sensation of bloating. D. Client states that pain occurs 30 minutes to 1 hour after meal. E. Client experiences pain upon palpation of the epigastric region.

A nurse is assessing a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should recognize which of the following findings as the priority? A. Client reports difficulty sleeping. B. The client's urine is positive for glucose. C. Client reports having an elevated temperature. D. Client reports gaining 4 pounds in the last 6 months.

C. Client reports having an elevated temperature.

An older client with peptic ulcer disease recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication? A. Tremors B. Dizziness C. Confusion D. Hallucinations

C. Confusion

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because they have been "bored" with the clear liquid diet. The nurse would prepare to offer which full liquid item to the client. A. Tea B. Gelatin C. Custard D. Ice pop

C. Custard

A nurse is reviewing the health record of a client who has a suspected tumor of the jejunum. The nurse should expect a prescription for which of the following tests? (Select all that apply.) A. Blood alpha-fetoprotein B. Endoscopic retrograde cholangiopancreatography (ERCP) C. Gastrointestinal x-ray with contrast. D. Small Bowel capsule endoscopy (M2A) E. Colonoscopy

C. Gastrointestinal x-ray with contrast. D. Small Bowel capsule endoscopy (M2A)

A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify? A. Leg exercises B. Early ambulation C. Irrigating the nasogastric tube D. Coughing and deep-breathing exercises

C. Irrigating the nasogastric tube

A primary healthcare provider has ordered the digital removal of stool for a constipated client. How would the nurse position the client for this procedure? A. Prone position B. Lithotomy position C. Left lateral side-lying position D. Right lateral side-lying position

C. Left lateral side-lying position

The nurse is planning to teach a patient with malabsorption syndrome about the necessity of following a low-fat diet. the nurse develops a list of high-fat foods to avoid and would include which food items are on the list. (select all that apply) A. Oranges B. Broccoli C. Margarine D. Cream Cheese E. Luncheon Meats F. Broiled Haddock

C. Margarine D. Cream Cheese E. Luncheon Meats

The nurse is doing an admission assessment on a client with a history of duodenal ulcers. To determine whether the problem is currently active, the nurse would assess the client for which manifestation of duodenal ulcer? A. Weight loss B. Nausea and vomiting C. Pain relieved by food intake D. Pain radiating down the right arm

C. Pain relieved by food intake

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? A. Roast pork B. Cheese omelet C. Pasta with sauce D. Tuna fish sandwich

C. Pasta with sauce

A nurse is caring for a client who has hypertension. Which of the dietary patterns is sometimes followed by Asian clients and places clients at risk for this condition? A. Incorporation of plant-based foods in diet B. Consumption of raw fruits C. Preparation of food using sodium D. Focus on shellfish in the diet

C. Preparation of food using sodium

A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentrism? A. Asking the client about some favorite food choices. B. Notifying the dietitian to complete the menu. C. Recommending one's own favorite foods. D. Asking the client's family to fill out the menu.

C. Recommending one's own favorite foods.

A client with chronic pancreatitis has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? A. Weight loss B. Relief of heartburn C. Reduction of steatorrhea D. Absence of abdominal pain

C. Reduction of steatorrhea

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching? A. Cleans the catheter proximally to distally with soap and water B. Maintains the urinary collection bag below the level of the bladder C. Removes a loose catheter anchor and places a new anchor on the lower leg D. Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position

C. Removes a loose catheter anchor and places a new anchor on the lower leg

A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following actions should the nurse take? A. Shake the bag to mix the fat. B. Turn the bag upside down one time. C. Return the bag to the pharmacy. D. Administer the bag of solution as it is.

C. Return the bag to the pharmacy.

The nurse is preparing to instruct a client with hypertension on the importance of choosing foods low in sodium. The nurse would plan to teach the client to limit intake of which food? A. Apples B. Bananas C. Smoked salami D. Steamed vegetables

C. Smoked salami

A nurse is completing discharge teaching with a client who is 3 days postoperative following a transverse colostomy. Which of the following should the nurse include in the teaching? A. Mucus will be present in stool for 5-7 days after surgery. B. Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks. C. Stoma should be moist and pink. D. Change the ostomy bag when it is ¾ full.

C. Stoma should be moist and pink.

A nurse is providing discharge teaching to a client who has a new prescription for aluminum hydroxide. Which of the following should the nurse include in the teaching? A. Take the medication with food. B. Monitor for diarrhea. C. Wait 1 hour before taking oral medications. D. Maintain a low-fiber diet.

C. Wait 1 hour before taking oral medications.

A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing in three specimens. Which of the following statements by the client indicates understanding? A. "I will continue taking my warfarin while I complete these tests." B. "I'm glad I don't have to follow any special diet at this time." C. "This test determines if I have parasites in my bowel." D. "This is an easy way to screen for colon cancer."

D. "This is an easy way to screen for colon cancer."

A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? A. 1 cup steamed long-grain brown rice B. 6 medium raw strawberries C. ½ cup boiled Brussel sprouts D. 2 large, poached eggs

D. 2 large, poached eggs

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A. Bradycardia B. Numbness in the legs C. Nausea and vomiting D. A rigid, boardlike abdomen

D. A rigid, boardlike abdomen

A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place the highest priority on which item as part of the client's care plan. A. Monitoring the temperature B. Monitoring complaints of heartburn C. Giving warm gargles for a sore throat D. Assessing for the return of the gag reflex

D. Assessing for the return of the gag reflex

A nurse is teaching a client who has constipation about a high‑fiber, low‑fat diet. Which of the following food choices by the client indicates understanding of the teaching? A. Peanut Butter B. Peeled Apples C. Hardboiled Eggs D. Brown Rice

D. Brown Rice

The nurse is assessing a client 24 hours after a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? A. Clamp the T-tube. B. Irrigate the T-tube. C. Notify the surgeon. D. Document the findings.

D. Document the findings.

A nurse is caring for a client following a paracentesis. Which of the following findings indicates the bowel was perforated during the procedure. A. Client reports upper chest pain. B. Decreased urine output. C. Pallor D. Elevated Temperature.

D. Elevated Temperature.

A client with severe Cohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which the most frequent complications of this type of surgery A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance

D. Fluid and electrolyte imbalance

2. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. A. Diarrhea B. Black, tarry stools C. Hyperactive bowel sounds D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back

D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back

A nurse is teaching a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following information should the nurse include in the teaching? A. Eat three moderately sized meals a day. B. Drink at least one glass of water with each meal. C. Eat a bedtime snack that contains a milk product. D. Increase protein in diet.

D. Increase protein in diet.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? A. Milk B. Chicken C. Broccoli D. Legumes

D. Legumes

A client with gastroenteritis has an as-needed prescription for ondansetron. For which condition(s) would the nurse administer this medication? A. Paralytic ileus B. Incisional pain C. Urinary retention D. Nausea and vomiting

D. Nausea and vomiting

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse would schedule the medication for which times? A. With meals and at bedtime B. Every 6 hours around the clock C. One hour after meals and at bedtime D. One hour before meals and at bedtime

D. One hour before meals and at bedtime

A nurse is teaching a patient who has iron-deficiency anemia about foods the patient needs to include in the diet. The nurse determines that the patient understands the dietary modifications if which items are selected from the menu. A. Nuts and milk B. Coffee and tea C. Cooked rolled oats and fish D. Oranges and dark green leafy vegetables

D. Oranges and dark green leafy vegetables

The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to inflate the balloon, the client starts to complain of pain. Which action would the nurse take? A. Continue to inflate the balloon. B. Deflate the balloon, slightly withdraw the catheter, and attempt to reinflate the balloon. C. Deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider. D. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.

D. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.

A nurse is admitting a client who has bleeding esophageal varices. The nurse should expect a prescription for which of the following medications? A. Propranolol B. Metoclopramide C. Ranitidine D. Vasopressin

D. Vasopressin

A client with gastroesophageal reflux disease has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition? A. Intestinal obstruction B. Peptic ulcer with melena C. Diverticulitis with perforation D. Vomiting following cancer chemotherapy

D. Vomiting following cancer chemotherapy

Clef Lip and palate in patients

-Child is at extreme risk for poor vision and hearing -They have to have special feeder with large nipple chambers -The mothers should begin feeding their children ASAP -They will need multi-specialility team -Pre Op manage their feedings and nutritional status -Post Op manage the patency of incisional site -Elbow immobilizers are used to prevent the infant from affecting the suture site

Appendicitis Nursing Interventions

-If a child is expected of it, make them NPO immediately -Get informed consent for surgery -Teach the patient the turn, cough, deep breathe technique *If patient states there is no more pain but they present grey in color, their appendix has ruptured*

Hypertrophic Pyloric Stenonsis

-It is the banding of the stomach -Patients present very dehydrated -Patients are always hungry and lose a lot of weight -Projectile vomitting -Immediately made NPO and an NG tube is inserted -Patient will always be fussy -Surgeon performs Pylormyotomy laprascopicly and snips the bands in the stomach

Biliary Artresia

-Jaundice not apparent until 2 or 3 weeks -Kasai Method: creates a new drainage system and is "the fix"

Intusseption

-Patients have red jelly like stools -Diagnosis with this via a radiologist guided pneumoenema (air enema)

Appendicitis S/S

-Rebound Tenderness -Vomiting -Fever -Elevated WBC -Radiation of pain into the legs

Hershsprung Disease (Distended Colon)

-Surgery is the only intervention -At high risk for shock -Patients will have ribbon like stools and abdominal distention -visible peristasis

suspected hirsprungs disease what signs most likely led parents to seek help

foul smelling ribbon like stool

a child just returned after surgical repair of a cleft lip on the right side, what position is best for the pt

left lateral position

the nurse admits a child to the hospital with pyloric stenosis what is the key symptom to see with this

projectile vomiting