Final Exam Study Questions

When caring for a patient who had a hip replacement that morning, a nurse is providing what level of care? Primary Secondary Tertiary Essential

B

Interventions for IBS

-Gradually increase fiber intake (Aim for a minimum of 20 g/day, preferably 30-40g)-Use a stool bulking agent-gradual changes to diet to avoid bloating & discomfort-Eliminate gas-producing foods (Brussels sprouts, cabbage, cauliflower, raw onions, beans)-Eliminate fructose and sorbitol (peaches, apricots, prunes)-Probiotics may be used-avoid alcohol & caffeine-consume 2-3L of fluids/day-tell pt to keep a food diary

Which clinical manifestations of hypokalemia will the nurse expect to note while assessing a client? A) weak peripheral pulses B) Orthostatic hypotension C) Decreased urine output D) An absence of deep tendon reflexes E) Decreased bowel sounds and constipation

A, B, D

With fluid and Electrolyte Imbalances what ECG findings would you expect to see? Select all that apply A) Flat P wave B) Peaked T wave C) Prominent U wave D) Prolonged PR interval E) Depressed ST segment F) Widened QRS complexes

C & E

A client has returned to the hospital with heart failure after being discharged three days prior. The client mentions eating some of the following items. THe nurse determines which foods likely contributed to the re-admission? Select all that apply. A) Ketchup B) Broccoli C) Baked ham D) Cantaloupe E) Watermelon F) American cheese

A, C, F Processed foods are generally high in sodium. Some commonly eaten foods that are high in sodium are bacon, butter, canned foods, cheeses, hot dogs, ham, ketchup, lunchmeats, milk, mustard, snack foods, soy sauce, table salt, white and whole-wheat bread.

A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

ANS: A Shock leads to decreased renal perfusion. An elevated BUN accompanies this condition. The creatinine should be normal because no kidney damage occurred. A low BUN signifies overhydration, malnutrition, or liver damage. A low BUN/creatinine ratio indicates fluid volume excess or acute renal tubular acidosis.

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

ANS: A A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the clients provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease.

A serious condition which is not locally observable and is typically manifested by decreased blood flow to a distal extremity is known as __________ thrombosis. a. arterial b. venous c. partial d. atrial

ANS: A Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ. For example, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of blood to the leg. This is an emergent condition and requires immediate intervention

Immunity which occurs when antibodies are passed from the mother to the fetus through the placenta or through breast milk is called: a. natural passive b. artifical passive c. natural active d. artifical active

ANS: A Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs via vaccination or immunization

A nurse cares for a client with ulcerative colitis. The client states, I feel like I am tied to the toilet. This disease is controlling my life. How should the nurse respond? a. Lets discuss potential factors that increase your symptoms. b. If you take the prescribed medications, you will no longer have diarrhea. c. To decrease distress, do not eat anything before you go out. d. You must retake control of your life. I will consult a therapist to help.

ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response

A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds

ANS: A Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the clients respiratory rate, rhythm, and depth. b. Measure the clients pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care provider.

ANS: A In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

The nurse is caring for four hypertensive clients. Which drug laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

ANS: A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconis anemia c. Hemolytic anemia d. Vitamin B12 anemia

ANS: A Malabsorption syndromes such as Crohns disease leave a client prone to folic acid deficiency. Fanconis anemia, hemolytic anemia, and vitamin B12 anemia are not related to Crohns disease.

The nurse would expect a patient with respiratory acidosis to have an excessive amount of a. Hydrogen ions. b. Bicarbonate. c. Oxygen. d. Phosphate.

ANS: A Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygen and phosphate are not characteristic of respiratory acidosis.

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? A) Use a pill organizer to ensure you take this medication as prescribed. B) Transient muscle aching is a common side effect of this medication. C) Follow up with your provider in 1 week to test your blood for toxicity. D) Take your radial pulse for 1 minute prior to taking this medication.

ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position.

ANS: B Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.

.A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer e. Fistula Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness

ANS: A, B, E Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.) a. Which food types cause an exacerbation of symptoms? b. Where is your pain and what does it feel like? c. Have you lost a significant amount of weight lately? d. Are your stools soft, watery, and black in color? e. Do you experience nausea associated with defecation?

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the clients pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a. Ask all family members and visitors to perform hand hygiene before touching the client. b. Carefully monitor burn wounds when providing each dressing change c. Clean equipment with alcohol between uses with each client on the unit. d. Allow family members to only bring the client plants from the hospitals gift shop. e. Use aseptic technique and wear gloves when performing wound care.

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the clients room.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia Flaccid paralysis with respiratory depression b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness c. Hyponatremia Decreased level of consciousness d. Hypercalcemia Positive Trousseaus and Chvosteks signs e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension

ANS: A, C Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia

. The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

ANS: A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching? a. I must drink a quart of water or other liquid each day. b. I will weigh myself each morning before I eat or drink. c. I will use a salt substitute when making and eating my meals. d. I will not drink liquids after 6 PM so I wont have to get up at night.

ANS: B One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will avoid large crowds and people who are sick. b. I will take this medication with my breakfast each morning. c. Nausea and vomiting are common side effects of this drug. d. I must wash my hands after I play with my dog.

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving

A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional state is known as: a. dementia b. delerium c. amnesia d. depression

ANS: B Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problems.

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help? How should the nurse respond? a. This drug is still in the research phase and is not available for public use yet. b. Unfortunately, lubiprostone is approved only for use in women. c. Lubiprostone works well. I will recommend this prescription to your provider. d. This drug should not be used with bulk-forming laxatives.

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men.

A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this clients teaching prior to beginning rehabilitation activities? a. Use analgesics before and after activity, even if you are not experiencing pain. b. Let me know if you start to experience shortness of breath, chest pain, or fatigue. c. Do not take your prescribed beta blocker until after you exercise with physical therapy. d. If you experience knee pain, ask the physical therapist to reschedule your therapy.

ANS: B Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must determine the clients ability to tolerate different activity levels. Asking the client to notify the nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in developing an appropriate cardiac rehabilitation plan.

A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the clients skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohns disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250 mOsm/L

ANS: B, E Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the clients risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

ANS: C The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body. Decreased calcium levels and increased phosphorus levels are common findings with CKD. Edema would indicate a fluid imbalance

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure

ANS: C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

ANS: C In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, Why am I taking this medication? How should the nurse respond? a. Tagamet stimulates intestinal movement so you can eat more. b. It improves fluid retention, which helps prevent hypovolemic shock. c. It helps prevent stomach ulcers, which are common after burns. d. Tagamet protects the kidney from damage caused by dehydration.

ANS: C Ulcerative gastrointestinal disease (Curlings ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in: a. calcium b. magnesium c. sodium d. potassium

ANS: D Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because it often causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.

ANS: C Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a providers order.

The best indicator of fluid volume changes in the body is: a. skin dryness b. weight changes c. blood pressure d. pulse rate

ANS: C Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure, checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary indicators

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? A) There are a variety of support groups for people who have COPD. B) I will ask your provider to prescribe you with an antianxiety agent. C) Share any thoughts and feelings that cause you to limit social activities. D) Friends can be a good support system for clients with chronic disorders.

ANS: C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation

A 55-year-old male client is admitted to the emergency department with symptoms of a myocardial infarction. Which question by the nurse is the most appropriate before administering nitroglycerin? a. On a scale from 0 to 10, what is the rating of your chest pain? b. Are you allergic to any food or medications? c. Have you taken any drugs like Viagra recently? d. Are you light-headed or dizzy right now?

ANS: C Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin.

. A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphys sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohns disease. A positive Murphys sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohns disease. Nightly worsening of abdominal cramping is not consistent with Crohns disease.

After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

ANS: C, D A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a. Administer furosemide (Lasix). b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the clients urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? A) Sedate the client to prevent tube dislodgement. B) Maintain balloon pressure at 15 and 20 mm Hg. C) Irrigate the gastric lumen with normal saline. D) The client for airway patency

ANS: D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? A) Nausea and vomiting B) Frontal headache C)Vertigo and syncope D) Mid-sternal chest pain

ANS: D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin

. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Decreased skin turgor on the clients posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness and dizziness

ANS: D The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse. d. Slow down the normal saline infusion

ANS: D The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion. The calculation of the MAP also reflects perfusion. The insertion of a pulmonary artery catheter would evaluate the clients hemodynamic status, but this should not be the initial action by the nurse. Vital signs are also important after adjusting the intravenous infusion

During bedside rounds, a surgeon turns to the charge nurse and says, "The poor nursing care has caused this wound to become infected. Can't nurses at this hospital do anything right?" What is the appropriate response by the charge nurse? A) "The nursing care on this unit has received awards and certainly is not the problem." B) "Let's first decide what to do for Mrs. Johnson and then step into the hall and talk further about your concerns."Correct Answer C) "It is inappropriate to talk to me that way. I will report this to my supervisor." D) "Would you like to change the antibiotic Mrs. Johnson is receiving?"

B

The staff nurse discovers that the one of the CNAs refused to help a co-worker ambulate a very obese, high-risk pregnant patient to the bathroom. What is the appropriate response by the nurse? A) Give them a lecture on working together as a team. B) Ask questions about the safety of the patient related to the behavior. C) Describe the anger and upset as inappropriate behavior. D) Assist the CNA to ambulate the patient and ignore the CNS issues.

B

A nurse is reviewing the medical record of the assigned clients. Which client is at the greatest risk for hypercalcemia? A) A client with Crohn disease B) A client with lactose intolerance C) A client with severe dehydration D) A client who has undergone thyroidectomy

C

The nurse is monitoring a patients serum potassium level while administering the IV potassium. Which serum potassium level indicates the the treatment has been effective? A) 3.0 mEq/L (3.0 mmol/L) B) 3.3 mEq/L (3.3 mmol/L) C) 4.0 mEq/L (4.0 mmol/L) D) 5.6 mEq/L (5.6 mmol/L)

C

Two of the CNAs on the unit have a history of problems with each other and typically do not work the same shift. Working together today is a rare occurrence. What is the appropriate response by the nurse? A) Separate the two and send each to a different area on the unit. B) Ask them not to talk to each other for the remainder of the shift. C) Ask questions about what triggered the upset. D) Make certain they are not schedule together again.

C

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? A. Restricted to rectum B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine.

C & D

A nurse is reviewing the medical records of the clients for whom she will be caring. Which of these clients does the nurse identify as being at risk for a fluid-volume deficit? Select all that apply. A) A client with congestive heart failure B) A client with syndrome of inappropriate antidiuretic hormone C) A client with a nasogastric tube attached to suction D) A client undergoing long-term corticosteroid therapy E) A client with a fever who is experiencing severe diaphoresis

C & E

The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? A) Increases bulk in the stool B) Lubricates the intestinal tract to soften feces C) Increases fluid retention in the intestinal tract D) Increases peristalsis by stimulating nerves in the colon wall

C, D Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease

Two employees disagree about who should work on Christmas Day. The bottom line is that one employee will have to work, and the schedule must be posted tomorrow. What is the best method for the nurse manager to assist in the conflict between the nurses? Use your position of power to resolve the conflict. You decide who will work Christmas Day. Rely on centralized staffing to resolve the issue. Try to arrange a compromise. Have one employee work the first half of the shift and have the other work the second half. Meet with both employees at the same time. Engage them in the problem-solving process.

D

A new staff nurse discovers two of the certified nursing assistants (CNAs) in the utility room speaking loudly and pointing at each other. What is the MOST appropriate action by the nurse? A)Continue walking down the hall, believing they will work it out. B)Walk into the utility room and tell them to stop or they will be reported to HR. C)Make an observation about their behavior and ask them what's going on. D)Get the nurse manager and take her to the utility room.

D

A patients potassium level has returned to normal. She will be discharged with a prescription for oral potassium supplementation in addition to the previously prescribed lanoxin and furosemide. Which comment by the patient indicates understanding of the discharge instructions? A) "I may get black stools" B) "I'll start using a salt substitute" C) "I can take an extra pill if I forget to take one" D) "I will call my doctor if I suddenly get weak"

D

The health care provider prescribes a continuous intravenous (IV) infusion of 250 mL of normal saline solution with 40 mEq (40mmol) of potassium chloride to be infused at a rate of 50 mL/hour by way of an infusion device. Which laboratory result is most important for the nurse to check before administering the infusion? A) Sodium B) Hematocrit C) Hemoglobin D) Blood urea nitrogen (BUN)

D

A patient with the potassium level of 5.8 mEq/L (5.8 mmol/L), what finding on the cardiac monitor would the nurse expect to find? A) Inverted T waves B) Prominent U wave C) ST- segment depression D) Widened QRS complexes

D The client is experiencing hyperkalemia. ECG findings noted in hyperkalemia including tall , peaked T waves; widened QRS complexes; prolonged PR intervals; and flat P waves. Inverted T waves, prominent U wave, and ST segment depression are found in hypokalemia.

A nurse performs an assessment of a client with a serum clacium level of 8.0 mg/dL(2.0 mmol/L). Which clinical manifestations of this electrolyte imbalance would the nurse expect to note? Select all that apply. A) Tachycardia B) Hypertension C) Bounding peripheral pulses D) Presence of the Trousseau sign E) Hyperactive deep tendon reflexes

D & E

The nurse has provided education for a client at risk for hypokalemia about foods that are high in potassium. The nurse determines teaching is effective if the client states that she will increase her intake of which of the following? Select all that apply. A) Egg B) Cocoa C) Cheese D) Spinach E) Tomatoes F) Strawberries

D, E, F Foods containing significant amounts of potassium include vegetables, especially dark green leafy ones, dried fruits, oranges and orange juice, bananas, whole grains, beef, legumes, strawberries, tomatoes, potatoes, and milk

Asessment PHYSCIAL finding of a client with Hypokalemia

Hyporeflexia Weak, irregular pulse Tachycardia, tachypnea Orthostatic hypotension Decreased bowel sounds Hyperglycemia Lab values of <3.5

Diagnostic Test Results of a client with hypokalemia

Serum potassium level is less than 3.5 mEq/L. Bicarbonate and pH levels are elevated. Serum glucose level is slightly elevated. Urine potassium level below 20 mEq/L suggests poor intake, intracellular shifting, or GI loss. Serum magnesium levels may be decreased (severe hypokalemia). Urine potassium level may be decreased; 24-hour urine potassium level may be greater than 20 mEq/24 hours. Urine potassium to creatinine ratio is less than 13 mEq/L.

Sulfasalazine (Azulfidine)

is used for ulcerative colitis and Crohns disease.

Assessment HISTORY findings of a client with Hypokalemia

mild Muscle weakness, cramps Paresthesia Abdominal cramps Anorexia Nausea, vomiting Constipation Polyuria, nocturia Excessive thirst Fatigue Palpitations