FINAL

A patient who has blunt abdominal trauma after an automobile accident is complaining of severe pain. A peritoneal lavage returns brown drainage with fecal material. Which action will the nurse plan to take next? a. Check the patient's oral temperature. b. Prepare the patient for surgery. c. Obtain information about the accident. d. Auscultate the bowel sounds

b. Prepare the patient for surgery.

Which action will the nurse anticipate taking for an otherwise healthy 50 year-old who has just been diagnosed with Stage 1 renal cell carcinoma? a. Prepare patient for a renal biopsy. b. Provide preoperative teaching about nephrectomy. c. Teach the patient about chemotherapy medications. d. Schedule for a follow-up appointment in 3 months.

b. Provide preoperative teaching about nephrectomy.

A 56 year old female patient is admitted to the hospital with new onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

b. Recent weight gain

When the nurse is caring for a patient who has been admitted with a severe crushing injury after an industrial accident, which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL

b. Serum potassium level 6.5 mEq/L

A client has been diagnosed with early alcoholic cirrhosis. The client should be taught that changing which of the following behaviors could potentially reverse the pathologic changes occurring in the liver? a. Eliminate smoking. b. Eat a high-carbohydrate, low-fat diet. c. Avoid overexertion and fatigue. d. Avoid drinking alcohol.

d. Avoid drinking alcohol.

After the nurse has completed teaching a patient with newly diagnosed celiac disease, which breakfast choice by the patient indicates good understanding of the information? a. Bagel with cream cheese b. Oatmeal with nonfat milk c. Whole wheat toast with butter d. Corn tortilla with eggs

d. Corn tortilla with eggs

A client who has a history of an inguinal hernia is admitted to the hospital with complaints of sudden, severe abdominal pain, vomiting and abdominal distention. Based on these assessment findings, the nurse suspects that which of the following complications has developed? a. Intestinal perforation b. Strangulated hernia c. Incarcerated hernia d. Peritonitis

b. Strangulated hernia

The nurse performs a physical assessment on a pt with type 2 diabetes. Her findings include a fasting blood glucose of 124, temp 101, pulse 88, respirations 22, and a BP of 140/86. Which of those findings would be of most concern to the nurse? a. Respirations b. Temperature c.Pulse d.BP

b. Temperature

A patient who is receiving chemotherapy develops a Candida albicans oral infection. The nurse will anticipate the need for: a. Referral to a dentist for professional tooth cleaning b. Hydrogen peroxide rinses c. The use of antiviral agents d. Administration of nystatin (Mycostatin) oral suspension

d. Administration of nystatin (Mycostatin) oral suspension

The patient is diagnosed with an acute episode of ureteral calculi. Which patient problem is priority when caring for this patient? a. Fluid volume loss. b. Knowledge deficit. c. Impaired urinary elimination. d. Alteration in comfort.

d. Alteration in comfort.

Two days after an exploratory laparotomy with a resection of a short segment of small bowel, a patient complains of gas pains and abdominal distention. Which nursing action is best to take at this time? a. Administer the ordered IV morphine sulfate. b. Insert the ordered promethazine (Phenergan) suppository. c. Give a return-flow enema. d. Assist the patient to ambulate.

d. Assist the patient to ambulate.

A patient in the oliguric phase after an acute kidney injury has had a 250 ml urine output and an emesis of 100 ml in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?

950 ml (previous day's total losses plus 600 ml)

A patient is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority. 1. insert a nasogastric tube 2.begin iced saline lavage 3. type and crossmatch for a blood transfusion 4.start an IV with an 18-gauge needle 5.assess the patient's vital signs

1. assess the patient's vital signs 2. start an IV with an 18-gauge needle 3. type and crossmatch for a blood transfusion 4. insert a nasogastric tube 5. begin iced saline lavage

Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "It will be helpful to keep the head of your bed elevated on blocks." b. "Peppermint tea may be helpful in reducing your symptoms." c. "Vigorous physical activities may increase the incidence of reflux." d. "You should avoid eating between meals to reduce acid secretion."

a. "It will be helpful to keep the head of your bed elevated on blocks."

Which of these conditions occurs as a result of excess glucocorticoids (cortisol)? a. Cushing's syndrome b. Addison's disease c. primary aldosteronism d. pheochromocytoma

a. Cushing's syndrome

A pt's T3 and T4 levels are decreased. The nurse understands that the cause of the low thyroid hormone levels is the primary hypothyroidism, further diagnostic testing would reveal a. Increased I131 uptake b. Increased TSH levels c. Increased serum Iodine levels d.hypoalbuminemia

b. Increased TSH levels

What is grave's diasease?

An autoimmune disorder in which immunoglobulin G produces thyroid antibodies that exert a similar effect as TSH

Interventions for prostatitis

Antibiotic therapy Anti infammatory agents for pain Warm sitz bath Teach- avoid sexual intercourse in acute, encourage sexual intercourse with chronic, also encourage high fiber diet and fluid intake

A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurse's most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurse's most appropriate response? A) Assess the patient for further signs or symptoms of rejection. B) Recognize this as an expected finding. C) Inform the primary care provider of this finding. D) Administer exogenous antidiuretic hormone as ordered.

B) Recognize this as an expected finding.

What are the risks of having a TURP?

Bleeding, clot, retention, dilutional hyponatremia, and retrograde ejaculation

Which nursing action will the nurse include in the plan of care when admitting a patient with an exacerbation of inflammatory bowel disease (IBD)? a. Ambulate four times daily. b. Monitor stools for blood. c. Increase dietary fiber intake. d. Restrict oral fluid intake.

b. Monitor stools for blood.

Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Bilirubin b. Calcium c. Potassium d. Amylase

D. Amylase

What is cholecystitis?

Inflammation of the gall bladder. Almost always associated with cholelithiasis

What is prostatitis?

Inflammation of the prostate. Caused by a bacterial infection ascending from urethra or descending from bladder. May be acute or chronic

When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will plan to: (Select all that apply.) a. Order a diet high in fiber and fluids. b. Monitor the WBC count c. Give IV antibiotics d. Teach to avoid bending and heavy lifting e. Place on NPO status.

b. Monitor the WBC count c. Give IV antibiotics e. Place on NPO status.

What is TURP?

Transurethral resection of Prostate. Insertion of a resectoscope to remove prostate tissue. Will have a 3 way indwelling catheter with 30 ml balloon. Will have continuous irrigation to prevent obstruction from mucus and clots for first 24 hours.

Diagnostics for prostatitis

UA, C&S, CBC, prostatic secretions

What are the clinical manifestations of prostatitis?

Urinary burning, urgency, or frequency Urethral discharge Low back or perineal pain Pain when ejaculating or voiding

A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take first? a. Irrigate the NG tube. b. Obtain the vital signs. c. Listen for bowel sounds. d. Give the ordered antacid.

b. Obtain the vital signs

A patient is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Do you use any over-the-counter (OTC) drugs?" b. "Are you taking corticosteroids for any reason?" c. "Is there any history of IV drug use?" d. "Have you recently traveled to a foreign country?"

a. "Do you use any over-the-counter (OTC) drugs?"

The nurse notes several small bandages covering cuts on the hands of a client with diabetes. The client says "I'm so clumsy. I'm always cutting or burning myself in the kitchen." The nurse's most appropriate response would be a. "Even small cutscan be serious for persons with diabetes" b. "Don't worry about it. Keep all your cuts clean and covered." c. "Why do you think you injure yourself so frequently?" d. "I'm sure they will heal without complications"

a. "Even small cutscan be serious for persons with diabetes"

The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I eat small meals throughout the day and have a bedtime snack." b. "I take antacids between meals and at bedtime each night." c. "I sleep with the head of the bed elevated on 4-inch blocks." d. "I quit smoking several years ago, but I still chew a lot of gum."

a. "I eat small meals throughout the day and have a bedtime snack."

Which statement indicates the patient diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? a. "I should increase my fluid intake, especially in warm weather." b. "I should eat foods containing cocoa and chocolate." c. "I will walk about a mile every week and not exercise often." d. "I should take one (1) vitamin a day with extra calcium."

a. "I should increase my fluid intake, especially in warm weather."

When the nurse is obtaining a history from a patient who is admitted with jaundice, which statement is most indicative of a need for patient teaching? a. "I use acetaminophen (Tylenol) every four hours for chronic pain. b. "I take a baby aspirin every day to prevent strokes." c. "I used cough syrup several times a day last week." d. "I need to take an antacid for indigestion several times a week."

a. "I use acetaminophen (Tylenol) every four hours for chronic pain.

After the nurse has finished teaching a patient with ulcerative colitis about sulfasalazine (Azulfidine), which patient statement indicates that the teaching has been effective? a. "I will need to use a sunscreen when I am outdoors." b. "The medication will prevent infections that cause the diarrhea." c. "The medication will need to be tapered if I need surgery." d. "I will need to avoid contact with people who are sick."

a. "I will need to use a sunscreen when I am outdoors."

A client asks the nurse, "What are the advantages of peritoneal dialysis over hemodialysis?" Which response by the nurse is accurate? (Select all that apply) a. "It will give you greater freedom in your scheduling." b. "You have less chance of getting an infection." c. "You only need to do it three times/week." d. "You do not need a machine to do it." e. "You will have fewer dietary restrictions."

a. "It will give you greater freedom in your scheduling." d. "You do not need a machine to do it." e. "You will have fewer dietary restrictions."

Cobalamin (Vitamin B12) injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states: a. "The cobalamin injections will prevent me from becoming anemic." b. "The cobalamin injections need to be taken until my inflamed stomach heals." c. "These injections will decrease my risk for developing stomach cancer." d. "These injections will increase the hydrochloric acid in my stomach."

a. "The cobalamin injections will prevent me from becoming anemic."

A pt recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. "an insulin deficit promotes metabolism of triglycerides, which produces large amounts of acidic ketones" b. "when an insulin deficit causes hyperglycemia, then proteins are deanimated by the liver, causing acidic byproducts" c. "excess glucose in the blood is metabolized by the liver into acetone, which is acidic in nature" d. "insufficient insulin leads to cellular starvation and as cells rupture, they release organic acids into the blood."

a. "an insulin deficit promotes metabolism of triglycerides, which produces large amounts of acidic ketones"

A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A popsicle b. A glass of orange juice c. A bowl of oatmeal d. A cup of coffee with cream

a. A popsicle

A patient with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. The nurse will teach the patient: a. About fistula formation between the bowel and bladder. b. About the effects of corticosteroid use on immune function. c. To clean the perianal area carefully after any stools. d. To empty the bladder before and after sexual intercourse.

a. About fistula formation between the bowel and bladder.

When the nurse is listening to a patient's abdomen, which finding indicates a need for a focused abdominal assessment? a. Absent bowel sounds b. High-pitched gurgles c. Loud gurgles d. Frequent clicking sounds

a. Absent bowel sounds

A patient with peptic ulcer disease associated with the presence of Helicobacter pylori is treated with triple drug therapy. The nurse will plan to teach the patient about: a. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec). b. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix). c. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol). d. Metoclopramide (Reglan), bethanechol (UIrecholine), and promethazine (Phenergan).

a. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec).

A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal: a. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). b. Hepatitis B surface antigen (HBsAg). c. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. Antibody to hepatitis D (anti-HDV).

a. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)

Which patient education will the nurse provide before discharge for a patient who has had a herniorrhaphy to repair an incarcerated inguinal hernia? a. Apply a scrotal support and ice to reduce swelling. b. Provide sitz baths several times a day. c. Encourage the patient to cough. d. Avoid use of acetaminophen (Tylenol) for pain.

a. Apply a scrotal support and ice to reduce swelling.

Which action should the nurse take first when a patient calls the clinic complaining of diarrhea of 24 hours duration? a. Ask the patient to describe the character of the stools and any associated symptoms. b. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. c. Inform the patient that laboratory testing of blood and stool specimens will be necessary. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

a. Ask the patient to describe the character of the stools and any associated symptoms.

A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." Which action should the nurse take first? a. Assess the patient about individual risk factors for constipation. b. Suggest that the patient increase dietary intake of high-fiber foods. c. Inform the patient that a daily bowel movement is unnecessary, d. Encourage the patient to increase oral fluid intake.

a. Assess the patient about individual risk factors for constipation.

The patient in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement? Select all that apply. a. Avoid rectal temperatures b. Monitor the platelet count c. Assess for asterixis d. Use only a soft toothbrush e. Use small-gauge needles

a. Avoid rectal temperatures b. Monitor the platelet count d. Use only a soft toothbrush e. Use small-gauge needles

Nurses have a major role in prevention of urinary tract infections (UTIs). Which guidelines can help prevent hospital-acquired UTIs? (Select all that apply). a. Avoid unnecessary catheterization. b. Intermittent catheterization every four hours. c. Wash hands before and after contact with each patient d. Wash around catheter insertion site with betadine daily. e. Routine and thorough perineal hygiene for all hospitalized patients

a. Avoid unnecessary catheterization. c. Wash hands before and after contact with each patient e. Routine and thorough perineal hygiene for all hospitalized patients

Which client is most at risk for developing postrenal, acute kidney injury? a. Client diagnosed with renal calculi b. Client with congestive heart failure c. Client taking nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis pain d. Client recovering from glomerulonephritis

a. Client diagnosed with renal calculi

A patient calls the clinic and reports having severe and frequent diarrhea. The nurse anticipates that the patient will need to a. Collect a stool specimen. b. Schedule a barium enema. c. Have blood cultures drawn. d. Prepare for colonoscopy.

a. Collect a stool specimen.

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patient's diet to maximize the therapeutic effect and minimize the risks of complications. The patient's diet should include which of the following modifications? (Select all that apply) a. Decreased protein intake b. Decreased sodium intake c. Increased potassium intake d. Fluid restriction e. Vitamin D supplementation

a. Decreased protein intake b. Decreased sodium intake d. Fluid restriction

Which nursing action will be included in the plan of care for a patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express feelings and ask questions about IBS. b. Teach the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs). c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Suggest that the patient increase the intake of milk and other dairy products.

a. Encourage the patient to express feelings and ask questions about IBS.

During a hot summer day, an older adult client tells the clinic nurse, "I am not drinking or voiding that much these days." The nurse notes a heart rate of 100 beats/min and a blood pressure of 100/60 mm Hg. Which action does the nurse take first? a. Give the client something to drink. b. Insert an intravenous catheter. c. Teach the client to drink 2 to 3 liters a day. d. Perform a bladder scan to assess urine volume.

a. Give the client something to drink.

The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's preferred recommendation for the early detection of colon cancer? a. Have a colonoscopy at age 50 and then once every ten years. b. A flexible sigmoidoscopy should be done yearly after age 40. c. Beginning at age 60, a digital rectal examination should be done yearly. d. After reaching middle age, a yearly fecal occult blood test should be done.

a. Have a colonoscopy at age 50 and then once every ten years.

The nurse is preparing education materials on colon cancer to present at a health fair. The following should be included as being risk factors: (Select all that apply.) a. History of inflammatory bowel disease b. Daily alcohol intake c. Low fat diet d. Use of daily NSAIDs e. Diet high in red or processed meat

a. History of inflammatory bowel disease b. Daily alcohol intake e. Diet high in red or processed meat

John is a 58 year old newly diagnosed with type 1 diabetes. His physician told John to exercise. Which of the following means John needs more teaching? a. John plans to ride his bike for 12 miles on Saturday b. John eats a apple before he rides his bike c. John rides his bike for 2 miles 4 times a week d. John carries a concentrated sweet with him at all times

a. John plans to ride his bike for 12 miles on Saturday

A 32-year-old patient is diagnosed with early alcoholic cirrhosis. Which topic is most important to include in patient teaching? a. Need to abstain from alcohol b. Treatment with lactulose (Cephulac) c. Maintenance of a nutritious diet d. Use of vitamin B supplements

a. Need to abstain from alcohol

A patient with a body mass index (BMI) of 17 kg/m2 and a low albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? a. Pitting edema b. Hypertension c. Food allergies d. Restlessness

a. Pitting edema

Which nursing action will be included in the plan of care for a patient with cirrhosis who has severe ascites and 4+ edema of the feet and legs? a. Use a pressure-relieving mattress. b. Reposition the patient every 4 hours. c. Restrict dietary protein intake. d. Administer cholestyramine (Questran) every 8 hours

a. Use a pressure-relieving mattress.

You have a fiver year old diabetic pt. Which of the following physician's orders do you question? a. administration of oral hypoglycemic agents b. serum glucose in AM c. activity ad lib d. diet may include fresh fruit

a. administration of oral hypoglycemic agents

A 60 year old client comes to the diabetic clinic. Type 2 diabetes mellitus is suspected. When obtaining a nursing history, the nurse would expect this older client to indicate a. an insidious onset with fatigue b. a recent episode of ketosis c. "sweet tooth" but no obesity d. rapid onset of symptoms

a. an insidious onset with fatigue

Following a thyroidectomy, the pt develops hypoparathyroidism. The nurse teaches the pt that maintenance therapy for the hypoparathyroidism will include a. calcium supplements b. diet high in oxalic acid c. parenteral parathyroid hormone d. phosphorus supplements

a. calcium supplements

Your pt has been diagnosed with having a deficiency of growth hormone. Prior to administration of somatotropin (growth hormone), the nurse should check for documentation of a. evidence of open bone varices b.adequate urine output c.retarded growth state d.ability of the pt of understand treatment

a. evidence of open bone varices

A client had an ileostomy created three days ago. The nurse assesses the client in the postoperative period for which most frequent complication of this surgery? a. fluid and electrolyte imbalance b. folate deficiency c. intestinal obstruction d. malabsorption of fat

a. fluid and electrolyte imbalance

The physician prescribes glyburide (micronase), a sulfonylurea, for a pt when her type 2 diabetes has not been controlled with diet and exercise. When teaching the pt about glyburide, the nurse explains that a. glyburide is thought to stimulate insulin release from the pancreas making more insulin available at receptor sites b. glyburide, like all oral antidiabetes agents, does not cause the hypoglycemic reactions that may occur with insulin use c. glyburide and other sulfonylureas lower blood sugar by decreasing the rate of hepatic glucose production, preventing gluconeogenesis d. glyburide is a substitute for insulin and acts by directly stimulating glucose uptake into the cell

a. glyburide is thought to stimulate insulin release from the pancreas making more insulin available at receptor sites

A patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. Monitors arterial blood gas values on a daily basis. b. Periodically aspirates and tests gastric pH. c. Measures the amount of residual stomach contents hourly. d. Checks each stool for the presence of occult blood.

b. Periodically aspirates and tests gastric pH.

A pt with a 20 year history of type 2 diabetes has symmetrical peripheral neuropathy of his feet and legs with almost total loss of sensitivity to touch and temperature. He also has peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. To prevent injury and infection to the feet and legs, the nurse teaches the pt that a. he should not go barefoot and should always wear shoes with soles b. the use of commercial keratolytic agent to remove corns with calluses is preferred to cutting off corns and calluses c. he should use a heating pad to warm his feet when they feel cool to the touch d. he should soak his feet in warm water every day

a. he should not go barefoot and should always wear shoes with soles

A pt screened for diabetes at a clinic has a fasting plasma glucose of 120. The nurse knows that this indicates a. impaired fasting glucose b. impaired glucose tolerance c. diabetes mellitus d. a normal finding

a. impaired fasting glucose

A pt with type 2 diabetes that is controlled with diet and metformin (glucophage) also has severe RA. During an acute exacerbation of the patient's arthritis, the HCP prescribes corticosteroids to control inflammation. The nurse monitors the pt's condition closely, recognizing that this situation may cause a. increased blood glucose levels b. increased production of glucagons c. an increased effect on the glucophage d. reduced effectiveness of the corticosteroids

a. increased blood glucose levels

The most important factor for the nurse to consider in caring for a hospitalized client receiving prednisone is the client's a. increased susceptibility for infections b. tendency to retain potassium and secrete sodium c. need for extra glucose and fluids d. need for more exercise

a. increased susceptibility for infections

A diabetic client would most likely plan to eat a. meals and snack at fairly consistent times b. a large breakfast, moderate lunch, and minimal dinner c. two large meals daily d. every 1 to 2 hours

a. meals and snack at fairly consistent times

A 34 year old female is admitted via the emergency room complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who has been well managed at home with 30 U NPH insulin every morning and a 1200 calorie ADA diet. Her glucose in the ER was 700. Regular insulin was given and a repeat glucose was drawn 1 hour ago. Results were not available upon transfer to the floor. Given the above information, which nursing activities should be the first priority? a. perform a finger stick and check blood glucose b. monitoring the urine output c. assess skin turgor d. asses pedal pulses and feet

a. perform a finger stick and check blood glucose

A pt with possible pheochromocytoma is admitted to the hospital for evaluation and diagnostic testing. During an attack, the nurse would expect the pt to experience (select all that apply) a. severe hypertension and sweating b. severe bradycardia refractory to drug therapy c. severe pounding headache, tachycardia, and markedly elevated BP d. persistent hypoglycemia

a. severe hypertension and sweating c. severe pounding headache, tachycardia, and markedly elevated BP

When working with a pt who is newly diagnosed with type 2 diabetes, the nurse stressed the importance of management of the disease because diabetes is a leading cause of (select all that apply) a. stroke b. dementia c. adult blindness d. end stage renal disease e.non traumatic lower limb amputation

a. stroke c. adult blindness d. end stage renal disease e.non traumatic lower limb amputation

A pt is being aggressively treated for diabetic ketoacidosis. A common, immediate complication that should be monitored closely is: a.dehydration b.pulmonary infarction c.ventricular tachycardia d.respiratory infection

a.dehydration

A 34 year old female is admitted via the emergency room complaining of abdominal pain, fatigue, anorexia, muscle cramping, and nausea. She is a diabetic who has been well managed at home with 30 U NPH insulin every morning and a 1200 calorie ADA diet. Her glucose in the ER was 700. Regular insulin was given and a repeat glucose was drawn 1 hour ago. Results were not available upon transfer to the floor. You receive the lab results from the ER. Her glucose is now 100. But her WBC count is 25,000. What conclusion can you draw based on this information? a.infection has increased her need for insulin b.lab results are within normal limits, no action necessary c.her diabetes is out of control d.insulin administration increased WBC count

a.infection has increased her need for insulin

When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

b. Place the patient on a cardiac monitor.

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? a. "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." b. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels." c. "He must have forgotten to take his daily water pill." d. "He must have been eating too many foods with salt in them. Salt pulls water with it."

b. "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."

A patient in the emergency department reports extreme dry mouth, constipation, and an inability to void. The client's history includes incontinence. Which question by the nurse is most important? a. "Are you drinking plenty of water?" b. "Do you take anticholinergic medication?" c. "Have you tried laxatives or enemas?" d. "Has this type of thing ever happened before?"

b. "Do you take anticholinergic medication?"

Your pt is on an insulin sliding scale as follows: 0-150 0 units, 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, over 350 call HCP. Your morning glucose stick is 253. How many units will you administer to your pt? a. 2 b. 6 c. 8 d. 4

b. 6

Which of the following outcomes would be appropriate for the client with hepatitis B? The client will: a. Adhere to a low-sodium, low-protein diet. b. Adhere to measures to prevent the spread of infection to others. c. Verbalize the importance of using sedatives to provide adequate rest. d. Avoid social activities with friends after discharge from the hospital.

b. Adhere to measures to prevent the spread of infection to others.

A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.0 mEq/L (3.0 mmol/L). Which action should the nurse take? a. Withhold both drugs until talking with the healthcare provider. b. Administer the spironolactone. c. Give both drugs as scheduled. d. Administer the furosemide and withhold the spironolactone.

b. Administer the spironolactone.

The RN and nursing assistive personnel (NAP) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to NAP? a. Irrigation of the nasogastric (NG) tube with saline b. Applying petroleum jelly to the lips c. Assessment of the nose for irritation d. Auscultation for bowel sounds

b. Applying petroleum jelly to the lips

To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take? a. Instruct the patient to perform the Valsalva maneuver. b. Ask the patient to extend both arms to the front. c. Have the patient walk a few steps with the eyes closed. d. Request that the patient stand on one foot.

b. Ask the patient to extend both arms to the front.

Which information will the nurse plan to include in discharge teaching for a patient after gastric bypass surgery? a. Choose high-fat foods for at least 30% of intake. b. Avoid drinking fluids with meals. c. Development of flabby skin can be prevented by daily exercise. d. Choose foods that are high in carbohydrates for increased energy

b. Avoid drinking fluids with meals.

While conducting a physical assessment of a patient, which of the following skin findings would alert the nurse to the possibility of liver problems? (Select all that apply) a. Cyanosis of the lips b. Ecchymoses c. Aphthous stomatitis d. Petechiae e. Jaundice

b. Ecchymoses d. Petechiae e. Jaundice

A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of "disturbed body image." How can the nurse best address the effects of this urinary diversion on the patient's body image? a. Emphasize that the diversion is an integral part of successful cancer treatment. b. Encourage the patient to speak openly and frankly about the diversion. c. Allow the patient to initiate the process of providing care for the diversion. d. Provide the patient with detailed written materials about the diversion at the time of discharge

b. Encourage the patient to speak openly and frankly about the diversion.

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 C b. Hepatitis A c. Hepatitis D d. Hepatitis B

b. Hepatitis A

The nurse in the dialysis center is initiating the morning dialysis schedule. Which patient should the nurse assess first? a. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. b. The client who does not have a palpable thrill or auscultated bruit. c. The client who is complaining of being exhausted and is sleeping. d. The client who did not take antihypertensive medication this morning.

b. The client who does not have a palpable thrill or auscultated bruit.

The nurse who is interviewing a 40-year-old obtains information about the following patient problems. Which information is most important to communicate to the healthcare provider? a. The patient had an appendectomy at age 17. b. The patient has recently noticed blood in the stools. c. The patient has a history of frequent constipation. d. The patient smokes a pack/day of cigarettes.

b. The patient has recently noticed blood in the stools.

Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? a. The patient has been vomiting several times a day for the last four days. b. The patient is lethargic and difficult to arouse. c. The patient's chart indicates a recent resection of the small intestine. d. The patient has taken only sips of water.

b. The patient is lethargic and difficult to arouse.

When the nurse is taking a health history, which information given by the patient, indicates that screening for hepatitis C should be done? a. The patient eats frequent meals in fast-food restaurants. b. The patient reports a one-time use of IV drugs 20 years ago. c. The patient had a blood transfusion after surgery in 1998. d. The patient recently traveled to an undeveloped country.

b. The patient reports a one-time use of IV drugs 20 years ago.

A client presents to the emergency department with complaints of acute GI distress, bloody diarrhea, weight loss, and fever. Which condition in the family history is most pertinent to the client's current health problem? a. Hypertension b. Ulcerative colitis c. Gastroesophageal reflux disease d. Appendicitis

b. Ulcerative colitis

A 58 year old patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle accident. Which postoperative assessment finding is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Urine output is 20 mL/hr for 2 hours. c. Incisional pain level is reported as 9/10. d. Crackles are heard at bilateral lung bases

b. Urine output is 20 mL/hr for 2 hours.

A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. The amount of fat in the diet. b. Use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. History of recent weight gain or loss. d. Any family history of gastric problems.

b. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).

When educating a patient with chronic pancreatitis about the prescribed pancrelipase (Viokase), the nurse will teach the patient to take the medication: a. Upon arising in the morning b. With every meal c. As soon as abdominal pain occurs d. At bedtime

b. With every meal

The nurse will plan to teach a 27 year-old female who smokes 2 packs of cigarettes daily about the increased risk for a. kidney stones. b. bladder cancer. c. bladder infection. d. interstitial cystitis.

b. bladder cancer.

A female client with diabetes was recently discharged from the hospital. She calls the nursing unit to report that she is ill and cannot remember what she is to do. The nurse should remind the client that the first thing the client should do is to a. omit her insulin unless she is able to comply with her dietary prescription b. check her blood glucose level c. review the material she was given at the hospital d. call the physician

b. check her blood glucose level

During a clinical visit 3 months following a diagnosis of type 2 diabetes, the pt reports that she has been following her reduced-calorie diet but she has not lost any weight, and she has neglected to bring her record of glucose monitoring results. The nurse recognizes that the best indicator of the pt's control of her diabetes since her initial diagnosis and instruction is a. analysis for microalbuminura b. glycosylated hemoglobin level (A1C) c. the pt's verbal report of her symptoms d. a fasting glucose level

b. glycosylated hemoglobin level (A1C)

Which outcome goal for the client's care should take priority during the initial hospitalization for an exacerbation of ulcerative colitis? a. promoting self-care and independence b. managing diarrhea c. maintaining adequate nutrition d. alleviating stress

b. managing diarrhea

A 20 year old college student who has type 1 diabetes normally walks each evening as part of her exercise regimen. She now plans to enroll in a swimming class to meet her physical education requirement. The nurse teaches the pt that adjustments to her treatment plan should include a. timing her morning insulin injection so that the peak action will occur during her swimming class b. monitoring her glucose level before, during, after swimming to determine the need for alterations in food or insulin c. adding 10 units of regular insulin to her usual morning dose on the days she plans to swim d. delaying the normal meal before the swimming class until the session is over

b. monitoring her glucose level before, during, after swimming to determine the need for alterations in food or insulin

When teaching a pt with newly diagnosed hypothyroisim about management of the condition, the nurse should a. schedule daily home visits by home care nurses to repeat the necessary instructions b. provide written handouts of all instructions for continued reference as the pt improves c. designate a family member to teach the pt about the condition when forgetfulness has improved d. delay teaching about the condition until the pt has responded to replacement therapy

b. provide written handouts of all instructions for continued reference as the pt improves

The nurse is educating a client with a new sigmoid colostomy on how to regain bowel control. Which of the following would the nurse emphasize as a priority? a. a high-protein diet b. regular irrigation of the colostomy c. a soft low-residue diet that will allow three formed bowel movements per day d. managing fluid intake to control the number of bowel movements

b. regular irrigation of the colostomy

Type 2 diabetics who are placed on oral hypoglycemic medications should be taught that most of these medications work by a. decreasing the gastrointestinal tract's ability to absorb simple and complex carbohydrates b. stimulating the pancreas to release more insulin, increasing the effectiveness of receptor sites, and enhancing the action of insulin at receptor sites c. providing actual insulin for those pt's who are capable of absorbing the hormone from the gastrointestinal tract d. both slowing the rate of release and decreasing the body's ability to release glucose into the blood

b. stimulating the pancreas to release more insulin, increasing the effectiveness of receptor sites, and enhancing the action of insulin at receptor sites

A 16 year old with diabetes mellitus develops DKA. The nurse realizes that the condition can be caused by a. taking too much insulin b. taking too little insulin c. skipping a meal d. increasing daily exercise

b. taking too little insulin

A 74 year-old who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best? a."It depends on which type of dialysis you are considering." b."Tell me more about what you are thinking regarding dialysis." c."You are the only one who can make the decision about dialysis." d."Many people your age use dialysis and have a good quality of life."

b."Tell me more about what you are thinking regarding dialysis."

A 14 year old girl has recently been diagnosed with type 1 diabetes mellitus. She visits the diabetes clinic for insulin management and teaching. Glargine (Lantus) 10 units HS and aspart (novolog) 5 units with each meal is prescribed. The nurse should explain that after taking the aspart (Novolog), she is at risk for hypoglycemia for the next ___ hours a.24 hours b.4 hours c.1 hour d.8 hours

b.4 hours

A client is scheduled to have dialysis in 30 minutes and is due for the following medications: vitamin C, B-complex vitamin, and cimetidine (Tagamet). Which action by the nurse is best? a.Give medications with a small sip of water. b.Hold all medications until after dialysis. c.Give the supplements, but hold the Tagamet. d.Give the Tagamet, but hold the supplements.

b.Hold all medications until after dialysis

The nurse is caring for an elderly patient who has an indwelling catheter. Which data warrant further investigation? a.The client's temperature is 98.0˚F. b.The client has become confused and irritable. c.The client's urine is clear and light yellow. d.The client feels the need to urinate.

b.The client has become confused and irritable.

When a pt is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, the nurse would expect the pt to experience a.increased serum sodium levels b.increased serum potassium levels c.decreased urinary output d.increased vascular fluid volume

b.increased serum potassium levels

A 38 year old pt has been on long term steroid therapy (Prednisone) and is being admitted for exacerbation of a disease. During your assessment, which one of the following objective signs relates to chronic steroid use? a.muscle wasting in torso b.thin easily damaged skin c.dry flaky skin d.limited night vision

b.thin easily damaged skin

Your pt is a 50 year old male admitted to your unit with a history of weight loss, nervousness, and insomnia. A diagnosis of hyperthyroidsim is made. The nurse may note the following signs of hyperthyroidism when assessing the pt a.anorexia b.weight loss with increased appetite c.exopthalamus d.constipation

b.weight loss with increased appetite c.exopthalamus

Which information will be best for the nurse to include when teaching a patient with peptic ulcer disease (PUD) about dietary management of the disease? a. "You will need to remain on a bland diet indefinitely." b. "You should avoid eating many raw fruits and vegetables." c. "Avoid foods that cause pain after you eat them." d. "High-protein foods are least likely to cause pain."

c. "Avoid foods that cause pain after you eat them."

After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. a. "With careful attention to my diet, my diverticulosis can be cured." b. "Using a cathartic laxative weekly is okay to control bowel movements." c. "I should follow a diet that's high in fiber." d. "It is important for me to drink at least 2,000 ml of fluid every day." e. "I should exercise regularly."

c. "I should follow a diet that's high in fiber." d. "It is important for me to drink at least 2,000 ml of fluid every day." e. "I should exercise regularly."

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective? a. "I will buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will clean the catheter carefully before and after each catheterization." d. "I will need to take prophylactic antibiotics to prevent any urinary tract infections."

c. "I will clean the catheter carefully before and after each catheterization."

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

c. "I will measure my urinary output each day to help calculate the amount I can drink."

A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse her concern that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best? a. "I promise I won't tell anyone." b. "I'll avoid any questions." c. "I'm not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so." d. "I can't lie to them if they ask me."

c. "I'm not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so."

Which patient should the nurse assess first after receiving change of shift report? a. 50 year old patient with familial adenomatous polyposis who has occult blood in the stool b. 40 year old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours c. 30 year old patient who has abdominal distention and an apical heart rate of 136 beats/minute d. 60 year old patient whose new ileostomy has drained 800 ml over the previous 8 hours

c. 30 year old patient who has abdominal distention and an apical heart rate of 136 beats/minute

After receiving change-of-shift report, which patient should the nurse assess first? a. A patient who is crying after receiving a diagnosis of esophageal cancer b. A patient with nausea who has a dose of metoclopramide (Reglan) scheduled c. A patient with esophageal varices who has a blood pressure of 90/54 mm Hg d. A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena

c. A patient with esophageal varices who has a blood pressure of 90/54 mm Hg

A patient has a large bowel obstruction that occurred as a result of diverticulosis. When assessing the patient, the nurse will plan to monitor for: a. Projectile vomiting b. Metabolic alkalosis c. Abdominal distention d. Stomatitis

c. Abdominal distention

A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient's: a. Temperature b. Hemoglobin c. Albumin level d. Activity level

c. Albumin level

When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of: a. Diabetes mellitus b. High-protein diet c. Alcohol use d. Cigarette smoking

c. Alcohol use

The healthcare provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse a. Places the patient on NPO status. b. Assists the patient to lie flat in bed. c. Asks the patient to empty the bladder. d. Positions the patient on the right side.

c. Asks the patient to empty the bladder.

When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's: a. Apical pulse b. Abdominal girth c. Breath sounds d. Bowel sounds

c. Breath sounds

When a patient has a history of a total gastrectomy, the nurse will monitor for clinical manifestations of: a. Elevated total cholesterol b. Dehydration c. Cobalamin (vitamin B12 deficiency) d. Constipation

c. Cobalamin (vitamin B12 deficiency)

Cardiac monitoring is initiated for a pt in DKA. The nurse recognizes that this measure is important to identify a. fluid overload resulting from aggressive fluid replacement b. the presence of hypovolemic shock related to osmotic disease c. ECG changes and dysrhythmias related to hypokalemia d. cardiovascular collapse resulting from the effects of excess glucose on cardiac muscle

c. ECG changes and dysrhythmias related to hypokalemia

A client has end-stage kidney disease (ESKD). Which food selection by the client demonstrates understanding of a low-sodium, low-potassium diet? a. Bananas b. Ham c. Herbs and spices d. Salt substitutes

c. Herbs and spices

A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. Initially the nurse will plan to: a. Teach the patient to turn, cough, and deep breathe. b. Administer IV metoclopramide (Reglan). c. Implement the NPO order d. Teach the patient about total colectomy surgery.

c. Implement the NPO order

The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will: a. Lower the chance for H. pylori infection. b. Decrease the risk for nausea and vomiting. c. Inhibit the development of stress ulcers. d. Prevent aspiration of gastric contents.

c. Inhibit the development of stress ulcers.

The nurse is performing peristomal skin care and changing the stoma pouch on a patient with a descending colostomy. The most appropriate nursing action is to: a. Apply liquid deodorant to mucous membrane of protruding stoma. b. Empty the ostomy pouch when it is full. c. Leave 1/8 inch of skin exposed around stoma when determining size to cut new skin barrier. d. Pull flange and pouch off together to prevent spillage of stoma pouch contents.

c. Leave 1/8 inch of skin exposed around stoma when determining size to cut new skin barrier.

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. Which intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply) a. Assess and document vital signs every 4 hours b. Monitor number of bowel movements per day c. Perform daily weights d. Measure abdominal girth daily e. record intake and output each shift

c. Perform daily weights d. Measure abdominal girth daily e. record intake and output each shift

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? a. CO2 b. Chloride c. Potassium d. Sodium

c. Potassium

A 22-year-old who is hospitalized with anorexia nervosa is 5 ft. 5 in. (163 cm) tall and weighs 90 pounds (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which nursing diagnosis has the highest priority for the patient? a. Risk for activity intolerance related to anemia and weakness. b. Fatigue related to malnutrition c. Risk for electrolyte imbalance related to poor eating patterns. d. Ineffective health maintenance related to obsession with body image.

c. Risk for electrolyte imbalance related to poor eating patterns.

When performing an admission assessment for a patient with abdominal pain, the nurse palpates the left lower quadrant and the patient complains of right lower quadrant pain. The nurse will document this as: a. Pain 8/10. b. Cullen sign. c. Rovsing sign. d. McBurney point.

c. Rovsing sign.

Which nursing measure would be most effective in helping the client cough and deep breathe after an open cholecystectomy? a. Having the client take rapid, shallow breaths to decrease pain. b. Having the client lie on the left side while coughing and deep breathing. c. Teaching the client to use a folded blanket or pillow to splint the incision. d. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.

c. Teaching the client to use a folded blanket or pillow to splint the incision

In a patient who had a total gastrectomy 12 hours previously, which assessment finding is most important to report to the healthcare provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Temperature 102.1° F (38.9° C) d. Complaints of incisional pain

c. Temperature 102.1° F (38.9° C)

A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention? a. The client states he has been passing gas. b. The client complains of pain at the surgical site. c. The client's right lower leg is red and swollen. d. The client states he is nauseated.

c. The client's right lower leg is red and swollen.

A patient with acute gastrointestinal (GI) bleeding is receiving normal saline IV at a rate of 500 mL/hr. Which assessment finding obtained by the nurse is most important to communicate immediately to the health care provider? a. The bowel sounds are very hyperactive in all four quadrants. b. The nasogastric (NG) suction is returning coffee-ground material. c. The patient's lungs have crackles audible to the midline. d. The patient's blood pressure (BP) has increased to 142/94 mm Hg.

c. The patient's lungs have crackles audible to the midline.

A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug: a. Reduces the reflux of gastric acid by increasing the rate of gastric emptying. b. Coats and protects the lining of the stomach and esophagus from gastric acid. c. Treats gastroesophageal reflux disease by decreasing stomach acid production. d. Neutralizes stomach acid and provides relief of symptoms in a few minutes

c. Treats gastroesophageal reflux disease by decreasing stomach acid production.

A 32-year-old client has a history of neurogenic bladder and presents with fever, burning, and suprapubic pain. What would you suspect is the problem? a. Urethral strictures b. Urinary incontinence c. Urinary tract infection d. Urinary retention

c. Urinary tract infection

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes. Which nursing action is most appropriate? a. Monitor the patient's intake and output over night. b. Have the patient drink small amounts of fluid frequently. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that this is normal after rectal surgery because of anesthesia.

c. Use an ultrasound scanner to check the postvoiding residual volume.

The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which nursing intervention has the greatest priority when a dialysis exchange is performed? a. Adding potassium and antibiotic to the dialysate bags b. Positioning the client on his side c. Using sterile technique when hooking up dialysate bags d. Warming the dialysate fluid in a microwave oven

c. Using sterile technique when hooking up dialysate bags

The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent a. Pressure on the diaphragm with poor lung expansion during surgery. b. Gas pains and distention during the immediate postoperative period. c. Vomiting and possible aspiration of vomitus during surgery. d. Constipation during the immediate postoperative period.

c. Vomiting and possible aspiration of vomitus during surgery.

A nurse is teaching her diabetic client about proper nutrition. The nurse would most likely tell the client that a. type 2 diabetics are generally of normal weight and should maintain their current level of caloric intake b. exercise generally elevates blood glucose levels c. alcohol increases the risk of hypoglycemia in clients on insulin or sulfonylureas d. type 1 diabetics are generally overweight and should decrease their caloric intake

c. alcohol increases the risk of hypoglycemia in clients on insulin or sulfonylureas

The plan of care for the diabetic pt includes all of the following interventions. Which intervention could you not delegate to the nursing assistant? a. Discuss community resources for diabetic outpatient care b. check to make sure that the pt's bath water is not too hot c. check the pt's technique for drawing up insulin into a syringe d. instruct the pt to perform daily foot inspections

c. check the pt's technique for drawing up insulin into a syringe

A 9 year old boy is diagnosed with type 1 diabetes. The physician orders NPH and regular insulin daily on a sliding scale. The nurse teaches the boy and his parents about his care after discharge. If the boy should suddenly become unconscious, the nurse would tell the parents to a. give him 8 oz of orange juice to drink b. inject regular insulin according to sliding scale c. inject glucagon according to package instructions d. take him to the hospital

c. inject glucagon according to package instructions

A pt is admitted to the ED with a diagnosis of myxedema coma. Which action would the nurse carry out initially? a. warm the pt b. administer thyroid hormone c. maintain an airway d. administer fluid replacement

c. maintain an airway

The major manifestation of DKA that differs from HHS is a. coma b. dehydration c. metabolic acidosis d. tachycardia

c. metabolic acidosis

A patient's renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid eating a. milk and dairy products. b. legumes and dried fruits. c. organ meats and sardines. d. spinach, chocolate, and tea.

c. organ meats and sardines.

The nurse is caring for a pt with type 1 diabetes mellitus. Which pt complaint would alert the nurse to the presence of possible hypoglycemic reaction a. muscle cramps b. anorexia c. tremors d. hot dry skin

c. tremors

Which of these nursing actions should the RN delegate to nursing assistive personnel, who help with the care of a patient admitted with nausea and vomiting? a. Auscultate the bowel sounds. b. Ask the patient what precipitated the nausea. c. Assess for signs of dehydration. d. Assist the patient with oral care after vomiting.

d. Assist the patient with oral care after vomiting.

A middle-aged client with diabetes mellitus is being treated for the third episode of acute pyelonephritis in the past year and asks what can be done to help prevent these infections. Which is the nurse's best response? a."Test your urine daily for the presence of ketone bodies and proteins." b."Use tampons rather than sanitary napkins during your menstrual period." c."Drink more water and empty your bladder every 2 to 3 hours during the day." d."Keep your hemoglobin A1c under 9% by keeping your blood sugar controlled."

c."Drink more water and empty your bladder every 2 to 3 hours during the day."

A pt with type 1 diabetes has received diet instruction as part of his treatment plan. The nurse determines the need for additional instruction when the pt says a."I should eat meals as scheduled even if I am not hungry to prevent hypoglycemia" b."I will need a bedtime snack because I take an evening dose of NPH insulin" c."I may eat whatever I want as long as I cover the calories with sufficient insulin" d."I may have an occasional alcoholic drink if I include it in my meal plan"

c."I may eat whatever I want as long as I cover the calories with sufficient insulin"

The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following? a."I should stop having coffee and orange juice for breakfast." b."I will buy calcium glycerophosphate (Prelief) at the pharmacy." c."I will start taking high potency multiple vitamins every morning." d."I should call the doctor about increased bladder pain or odorous urine."

c."I will start taking high potency multiple vitamins every morning."

A 28 year-old male patient is diagnosed with polycystic kidney disease (PKD). Which information is most appropriate for the nurse to include in teaching at this time? a.Complications of renal transplantation b.Methods for treating severe chronic pain c.Discussion of options for genetic counseling d.Differences between hemodialysis and peritoneal dialysis

c.Discussion of options for genetic counseling

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a.Postural hypotension b.Recurrent tachycardia c.Knee and hip joint pain d.Increased serum creatinine

c.Knee and hip joint pain

Which assessment of a 62 year old patient who has just had an intravenous pyelogram (IVP) requires immediate action by the nurse? a.The heart rate is 58 beats/minute. b.The patient complains of a dry mouth. c.The respiratory rate is 38 breaths/minute. d.The urine output is 400 mL after 2 hours.

c.The respiratory rate is 38 breaths/minute.

Your pt has a primary tumor of the adrenal medulla. The nurse should anticipate that the patient will have which symptom? a. immunodeficiency b.infertility c.hypertension d.exopthalamus

c.hypertension

When assessing the pt experiencing classic symptoms of diabetes, the nurse recognizes that the symptom directly related to inadequate uptake of glucose due to insufficient insulin is a. polyuria b. glucosuria c.polyphagia d. polydipsia

c.polyphagia

A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient. When evaluating for adverse effects of the medication, the nurse will plan to monitor which of the following? a.blood glucose. b.urine osmolality. c.serum creatinine. d.serum potassium.

c.serum creatinine.

The nurse is obtaining a history for a 45-year-old woman who is being evaluated for acute lower abdominal pain and vomiting. Which question will be most useful in determining the cause of the patient's symptoms? a. "What is your usual elimination pattern?" b. "Is it possible that you are pregnant?" c. "What type of foods do you usually eat?" d. "Can you tell me more about the pain?"

d. "Can you tell me more about the pain?"

Which of the following statements indicates that the client with peptic ulcer disease understands how to effectively adjust the response to work-related stress? a. "Well, I guess this ulcer means I won't be able to work toward a promotion." b. "I don't have any control over my stressors at work. My coworkers are difficult to work with." c. "My job is stressful. I will have to choose another career." d. "I will have to improve my ability to cope with stress."

d. "I will have to improve my ability to cope with stress."

Which statement by a client who has undergone kidney transplantation indicates a need for more teaching? a. "I will need to continue to take insulin for my diabetes." b. "I will have to take my cyclosporine for the rest of my life." c. "I will take the antibiotics three times daily until the medication is finished." d. "My new kidney is working fine. I do not need to take medications any longer."

d. "My new kidney is working fine. I do not need to take medications any longer."

A nurse is administering medications to a client diagnosed with hepatitis B. When the nurse hands the client his medications, the client says, "I'd rather not take that pill or any others. I know there is no cure for hepatitis B." The nurse recognizes that the client is expressing feelings of hopelessness about his diagnosis. Which response by the nurse respects the client's rights concerning medication administration? a. "You seem frustrated; however, you still must take this medication, it will help you." b. "Legally, I have to give you this medication." c. "I will document that you are noncompliant with your treatment regimen." d. "You have the right to refuse any medication. Would you like to discuss your feelings about this disease?"

d. "You have the right to refuse any medication. Would you like to discuss your feelings about this disease?"

Your pt is admitted to the ICU with a diagnosis of DKA. His blood chemistry values are: Glucose 843, K+ 2.9, Na+ 120. ABGs are pH 7.26, CO2 64, HCO3 28. Vital signs are BP 78/48, P 122, R 28, and Temp 99.3. Which of the following IV solutions would likely be adminstered first? a. 5% dextrose in water b. 0.45% sodium chloride solution c. 10% dextrose solution d. 0.9% sodium chloride solution

d. 0.9% sodium chloride solution

Your pt is an 18 year old type 1 diabetic. Her daily dose of insulin had been 32 units of NPH each morning. Today she was found unconscious. Of the following blood glucose levels which would best explain her unconscious state? a. 90 b. 70 c. 110 d. 40

d. 40

Which nursing action is a priority when the nurse is caring for a patient with pancreatic cancer? a. Offer psychologic support for anxiety or depression. b. Educate about the need to avoid scratching pruritic areas. c. Offer high-calorie, high-protein dietary choices. d. Administer prescribed opioids to relieve pain as needed.

d. Administer prescribed opioids to relieve pain as needed.

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a foley catheter. Which action requires that the nurse intervene? a. Taping the catheter to the skin on the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Using an alcohol-based hand cleaner before performing catheter care d. Disconnecting the catheter from the drainage tube to obtain a specimen

d. Disconnecting the catheter from the drainage tube to obtain a specimen

A nurse would most likely expect the following assessment in a pt with DKA a. sudden pallor b. oliguria c. frothy breath d. Kussmaul's respirations

d. Kussmaul's respirations

Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to: a. Identify the extent of cancer spread or metastasis. b. Determine the need for postoperative chemotherapy. c. Confirm the diagnosis of colon cancer. d. Monitor for recurrence of cancer after surgery

d. Monitor for recurrence of cancer after surgery

Which assessment finding in a patient with acute pancreatitis, would the nurse need to report most quickly to the healthcare provider? a. Hypotonic bowel sounds b. Abdominal tenderness and guarding c. Nausea and vomiting d. Muscle twitching and finger numbness

d. Muscle twitching and finger numbness

When caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD), which action by the nursing assistant requires that the RN intervene? a. Positioning the patient on the right side b. Swabbing the patient's mouth with cold water c. Checking the vital signs every 30 minutes d. Offering the patient a glass of water

d. Offering the patient a glass of water

A patient who is hospitalized with watery, incontinent diarrhea is diagnosed with Clostridium difficile. Which action will the nurse include in the plan of care? a. Order a diet with no dairy products for the patient. b. Teach the patient about why antibiotics are not being used. c. Educate the patient about proper food handling and storage. d. Place the patient in a private room with contact isolation.

d. Place the patient in a private room with contact isolation.

When caring for a patient following a needle biopsy of the liver at the bedside, the nurse should: a. Check the patient's postbiopsy coagulation studies. b. Put pressure on the biopsy site using a sandbag. c. Elevate the head of the bed to facilitate breathing. d. Place the patient on the right side with the bed flat

d. Place the patient on the right side with the bed flat

When caring for a patient following a needle biopsy of the liver at the bedside, the nurse should: a. Check the patient's postbiopsy coagulation studies. b. Put pressure on the biopsy site using a sandbag. c. Elevate the head of the bed to facilitate breathing. d. Place the patient on the right side with the bed flat.

d. Place the patient on the right side with the bed flat.

A patient with protein calorie malnutrition who has had abdominal surgery is receiving parenteral nutrition (PN). Which assessment information obtained by the nurse is the best indicator that the patient is receiving adequate nutrition? a. Fluid intake and output are balanced. b. Serum albumin level is 3.5 mg/dL. c. Blood glucose is 110 mg/dL. d. Surgical incision is healing normally.

d. Surgical incision is healing normally.

An elderly client asks the nurse how to prevent chronic constipation. What is the best recommendation the nurse can make? a. Administer a phospho-soda (Fleet) enema when necessary. b. Take a mild laxative such as magnesium citrate when necessary. c. Administer a tap-water enema weekly. d. Take a bulk-forming laxative such as psyllium (Metamucil)) daily.

d. Take a bulk-forming laxative such as psyllium (Metamucil)) daily.

Which instructions are most important for the nurse to include in discharge teaching, for a patient who has had a hemorrhoidectomy? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Delay having a bowel movement for several days until healing has occurred. d. Take prescribed pain medications before a bowel movement is expected.

d. Take prescribed pain medications before a bowel movement is expected.

While caring for a patient who has just arrived in the recovery area after an upper endoscopy, which information is most important to communicate to the healthcare provider? a. The patient complains of a sore throat. b. The apical pulse is 104 beats/minute. c. The patient is very sleepy. d. The oral temperature is 101.6° F.

d. The oral temperature is 101.6° F.

A patient who has advanced cirrhosis is receiving lactulose (Caphulac). Which finding by the nurse indicates that the medication is effective? a. The patient has at least one stool daily. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient is alert and oriented.

d. The patient is alert and oriented.

The nurse evaluates the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the health care provider? a. The stoma does not expel stool b. The stoma is slightly edematous c. The stoma oozes a small amount of blood d. The stoma is dark red to purple

d. The stoma is dark red to purple

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis? a. beginning a weight training program b. walking two miles every day c. changing to a modified vegetarian diet d. a demanding and stressful job

d. a demanding and stressful job

A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing action should be included in the postoperative plan of care? a. reposition NG tube if drainage stops or decreases b. notify HCP immediately about bloody NG drainage c. start oral fluids when patient has active bowel sounds d. elevate the head of bed to at least 30 degrees

d. elevate the head of bed to at least 30 degrees

In evaluating the lab results for a pt with DKA, the nurse expects all of the following to indicate acidosis except a. elevated blood glucose level b. decreased serum bicarbonate level c. decreased BUN d. increased pH

d. increased pH

A patient in the ED has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. send the patient for a CT scan b. place a nasogastric (NG) tube to intermittent low suction c. insert a urinary catheter to drainage d. infuse metronidazole (Flagyl) 500 mg IV

d. infuse metronidazole (Flagyl) 500 mg IV

A diagnosis of HHS is made for a pt with type 2 diabetes who is brought to the ER in an unresponsive state. The nurse anticipates that treatment on the pt will focus on adminstering a. oxygen by nasal cannula b. IV dextran as a source of complex carbohydrates c. long-acting IV insulin d. large amounts of IV fluids

d. large amounts of IV fluids

Thyroid replacement therapy is indicated for the treatment of a. acute thyrotoxicosis b. obesity c. Grave's disease d. myxedema

d. myxedema

In assessing a client recently diagnosed with acute glomerulonephritis, the nurse asks which question to determine potential contributing factors? a."Are you sexually active?" b."Do you have pain or burning on urination?" c."Has anyone in your family had chronic kidney problems?" d."Have you had a cold or sore throat within the last 2 weeks?"

d."Have you had a cold or sore throat within the last 2 weeks?"

In assessing a client 6 hours after a radical nephrectomy for renal cell carcinoma, the nurse notes that the client's blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for the past hour. Which is the nurse's best action? a.Position the client so that the remaining kidney is not dependent. b.Measure the specific gravity of the client's urine. c.Document the findings in the client's record. d.Assess the pulse rate and quality, and then notify the provider.

d.Assess the pulse rate and quality, and then notify the provider.

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy (ESWL), which assessment finding is most important to report to the health care provider? a.Blood in urine b.Left flank bruising c.Left flank discomfort d.Decreased urine output

d.Decreased urine output

Which of these assessment findings in a patient with a hiatal hernia, who returned from a laparoscopic Nissen fundoplication four hours ago, is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 6/10 (0 to 10 scale) abdominal pain. c. The patient has decreased bowel sounds in all four quadrants. d.The patient has absent breath sounds throughout the left lung.

d.The patient has absent breath sounds throughout the left lung.

Which finding by the nurse for a patient admitted with acute glomerulonephritis indicates that treatment has been effective? a.The patient denies pain with voiding. b.The urine dipstick is negative for nitrites. c.The antistreptolysin-O (ASO) titer is decreased. d.The periorbital and peripheral edema is resolved.

d.The periorbital and peripheral edema is resolved.