Exam 6 Study Questions 3

A client is admitted to the hospital with severe jaundice and is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. Which of the following problems most likely is the reason for the client's reluctance to walk in the hall? a.Unfamiliarity with the hospital b.Fear of catching another disease c.Feeling self-conscious about appearance d.Not wanting to overexert and get overtired

c.Feeling self-conscious about appearance

A licensed practical nurse (LPN) is assisting in insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by measuring: a.A 30 inch length on the tube b.An 18 inch length on the tube c.From the tip of the client's nose to the earlobe and then down to the xiphoid process d.From the tip of the client's nose to the earlobe and then down to the top of the sternum

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

A nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement, if made by the client would support the diagnosis of gastric ulcer? a."The pain doesn't usually come right after I eat" b."The pain gets so bad that it wakes me up at night" c."The pain that I get is located on the right side of my chest" d."My pain comes shortly after I eat, maybe a half hour or so later"

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

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? a.Offer small sips of water frequently b.Encourage the client to suck on sour, hard candy c.Use lemon glycerin swabs to provide oral hygiene d.Brush the client's teeth frequently. Use diluted mouthwash and water to rinse the mouth

d.Brush the client's teeth frequently. Use diluted mouthwash and water to rinse the mouth

A client with hepatic encephalopathy is receiving lactulose (Cephulac). The nurse determines that the medication is effective if which of the following is observed? a.Absence of blood in emesis and stool b.Urine output increases from 250 to 400 mL per 8 hour shift c.Episodes of frequent liquid bowel movements diminish to one time/day d.Client previously oriented to person only; can now state name, year and present location

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

A nurse is caring for a client with a Sengstaken-Blakemore tube. To prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to: a.Provide tracheal suction as needed b.Keep scissors at the bedside for emergency deflation c.Provide frequent oral and nasal care on a regular basis d.Have a family member remain with the client as much as possible

c.Provide frequent oral and nasal care on a regular basis

A nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information, the nurse would do which of the following? a.Instruct the client to lean forward b.Measure the abdominal girth c.Ask the client to extend the arms d.Ask the client to dorsiflex the calf

c.Ask the client to extend the arms

A nurse is collecting admission data on the client with hepatitis. Which of the following findings would be a direct result of this client's condition? a.Blurred vision b.Urinary frequency c.Drowsiness d.Diarrhea

c.Drowsiness

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. The nurse understands that the rationale for checking gastric residual volume before administering the tube feeding is to: a.Observe the digestion of formula b.Check fluid and electrolyte status c.Evaluate absorption of the last feeding d.Confirm proper nasogastric tube placement

c.Evaluate absorption of the last feeding

A nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client most closely for which of the following? a.Swelling of the abdomen b.Bloody diarrhea c.Hematemesis d.An elevated temperature and a rise in blood pressure

c.Hematemesis

A nurse is assisting with the insertion of a nasogastric tube into the client. The nurse places the client in which position for insertion? a.Right side b.Low fowler's position c.High fowler's position d.Supine with the head flat

c.High fowler's position

A nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse plans to set the suction to which of the following pressures? a.Low and continuous b.High and intermittent c.Low and intermittent d.High and continuous

c.Low and intermittent

A nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks their pH level. Which of the following pH values indicates the correct placement of the tube? a.4.0 b.7.0 c.7.5 d.7.35

a.4.0

A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care providers prescriptions (orders). Which of the following would the nurse question if written on the health care provider's prescription form? a.Administration of an analgesic b.Insertion of a nasogastric (NG) tube c.Insertion of an intravenous (IV) line d.Maintaining a nothing-by-mouth (NPO) status

a.Administration of an analgesic

A nurse is preparing to administer an enema to an adult client. Choose the interventions that the nurse would perform for this procedure. Select all that apply. a.Apply disposable gloves b.Place the client in the right Sim's position c.Lubricate the enema tube and insert it approximately 4 inches d.Clamp the tubing if the client expresses discomfort during the procedure e.Hand the container containing the enema solution 24 inches above the client' s anus f.Ensure that the temperature of the solution is between 100 and 105 degrees F

a.Apply disposable gloves c.Lubricate the enema tube and insert it approximately 4 inches d.Clamp the tubing if the client expresses discomfort during the procedure f.Ensure that the temperature of the solution is between 100 and 105 degrees F

A nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to see documented in the record? a.Diarrhea b.Constipation c.Bloody stools d.Stool constantly oozing from the rectum

a.Diarrhea

A client has asymptomatic diverticular disease. What type of diet should the nurse anticipate to be prescribed? a.High- iron diet b.High- fiber diet c.Low-purine diet d.Low- sodium diet

b.High- fiber diet

A nurse has a prescription to give 30 mL of an antacid to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse would do which of the following to perform this procedure correctly? a.Adjust the suction to low-intermittent setting for an hour after medication administration b.Aspirate the NG tube following medication administration to maintain patency c.Position the client supine to assist in medication absorption d.Clamp the NG tube for 30 minutes following administration of the medication

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

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by: a.Monitoring red blood cell and white blood cell counts daily b.Bathing the client with tepid water and mild soap only c.Assessing and recording the client's weight twice daily d.Monitoring prothrombin and partial thromboplastin values

d.Monitoring prothrombin and partial thromboplastin values

It has been determined that a client with hepatitis has contracted the infection from contaminated food. What type of hepatitis is this client most likely experiencing? a.Hepatitis A b.Hepatitis B c.Hepatitis C d.Hepatitis D

a.Hepatitis A

Of the following infection control methods, which would be the priority to include in the plan of care to specifically prevent hepatitis B in a client considered to be at high risk for exposure? a.Hepatitis B vaccine b.Proper personal hygiene c.Use of immune globulin d.Correct handwashing technique

a.Hepatitis B vaccine

A nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200 mL. the nurse would: a.Hold the feeding b.Administer the feeding c.Flush the tubing with 30 mL of water d.Elevate the head of the bed to 90 degrees and administer the feeding

a.Hold the feeding

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicates poor absorption of dietary fats? a.Steatorrhea b.Bloody diarrhea c.Electrolyte disturbances d.Gastrointestinal reflux disease

a.Steatorrhea

A nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. Which of the following is the appropriate nursing action? a.Stop the irrigation temporarily b.Increase the height of the irrigation c.Medicate for pain and resume irrigation d.Notify the registered nurse immediately

a.Stop the irrigation temporarily

A nurse is assigned to care for a client with a Sengstaken-Blakemore tube. The nurse should suspect that the client has which diagnosis? a.Gastritis b.Esophageal varices c.Bowel obstruction d.Small bowel tumor

b.Esophageal varices

A nurse is reviewing the medication record of a client with acute gastritis. Which of the following medications, if noted on the client's record, would the nurse question? a.Digoxin (Lanoxin) b.Ibuprofen (Motrin) c.Furosemide (Lasix) d.Propanolol hydrochloride (Inderal LA)

b.Ibuprofen (Motrin)

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain? a.Sitting up b.Lying flat c.Leaning forward d.Flexing the left leg

b.Lying flat

A nurse is reviewing the health care providers prescriptions (orders) written for a client admitted with acute pancreatitis. Which health care provider prescription would the nurse verify if noted on the client's chart? a.NPO status b.An anticholinergic medication c.Position the client supine and flat d.Prepare to insert a nasogastric tube

c.Position the client supine and flat

A nurse is caring for a client suspected to having appendicitis. Which of the following would the nurse anticipate will be prescribed for this client? a.Full liquid diet b.Clear liquid diet c.Mechanical soft diet d.No oral intake of liquids or food

d.No oral intake of liquids or food

A nurse is caring for a client with a nasogastric tube. Which observation is reliable in determining that the tube is correctly placed? a.The aspirate is dark green b.The aspirate is negative for guaiac c.The tube is inserted the length measured from the client's ear to nose and nose to xiphoid process d.The pH of the aspirate is 5

d.The pH of the aspirate is 5