General and Enteric
The nurse is auscultating heart sounds at the base, over the aortic and pulmonic valves. Which normal heart sounds would the nurse expect to hear louder over these valves? A. S2 B. S1 C. S3 D. S4
A. S2
A 28 year old female comes into the clinic with reports of copious, foul-smelling vaginal discharge. The nurse is correct in suspecting A. A vaginal infection B. a pilonidal cyst C. poor hygiene D. carcinoma
A. a vaginal infection
Which of the following disorders will the nurse observe documented on a chart for a patient who cannot digest fat, carbohydrates, and protein? A. pancreatic insufficiency B. gluten-sensitive enteropathy C. Bile salt deficiency D. lactase deficiency
A. pancreatic insufficiency
A nurse is providing teaching to a patient who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the patient to report immediately? A. a feeling of fullness B. persistent coughing C. discomfort in the naris D. postfeeding belching
B. persistent coughing
Which symptom will surprise the nurse when assessing a patient with cachexia? A. anorexia B. weight loss C. heart murmur D. weakness
C. heart murmur
A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's A. competence B. perception C. judgment D. intellect
C. judgment
The most reliable method for verifying initial placement of a small-bore feeding tube is by A. measuring the pH of gastric aspirate B. auscultating the epigastric area while injecting air C. obtaining an abdominal x-ray D. placing the open end of the tube in a cup of water
C. obtaining an abdominal x-ray
Which disease/condition will increase the risk of colorectal cancer in a person? A. duodenal ulcers B. cirrhosis C. ulcerative colitis D. dumping syndrome
C. ulcerative colitis
Aphasia is best described as A. the impaired ability to recognize or identify objects despite intact sensory function B. the impaired ability to carry out motor activities despite intact motor function. C. a disturbance in executive functioning (planning, organizing, sequencing, abstracting). D. a language disturbance in speaking, writing, or understanding
D. a language disturbance in speaking, writing, or understanding
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A. required that a respiratory therapist discuss the technique for incentive spirometry B. Administer a pain medication to the client C. chart the client's refusal to participate in health restorative activities D. determine the reasons why the client is refusing to use the incentive spirometer.
D. determine the reasons why the client is refusing to use the incentive spirometer.
A nurse is providing education for a client who is experiencing nausea due radiation therapy for cancer. Which of the following instructions should the nurse include in the teaching? A. take prescribed antiemetic 15 min. before meals B. rest while supine after mealtime C. add sauces and gravies to moisten foods. D. eat foods at room temperature
D. eat foods at room temperature
A patient has dysphagia. Which activity does the nurse assess? A. speaking B. hiccupping C. burping D. eating
D. eating
Which of the following complications should the nurse assess for in a patient with gastroesophageal reflux disease (GERD)? A. Zollinger-Ellison syndrome B. Nonalcoholic fatty liver disease (NAFLD) C. Crohn disease (CD) D. Esophageal cancer
D. esophageal cancer
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? A. lemon-lime sports drinks B. ginger ale C. black coffee D. orange sherbet
D. orange sherbet
A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse? A. "We should restrict your visitors so that you can get more rest." B. "shortness of breath is temporary and should subside." C. "I will be able to give you a medication to help your breathing." D. "Fatigue is a common experience among hospice clients."
C. "I will be able to give you a medication to help your breathing."
A client who was diagnosed with clostridium difficile calls the clinic and says, "I'm still have diarrhea so I started taking over the counter medication to stop it." How should you respond? A. "Which antidiarrheal are you taking?" B. "How many doses have you taken?" C. "Stop taking the medicine and come to the clinic." D. "Is it stopping your diarrhea?"
C. "Stop taking the medicine and come to the clinic."
A nurse is caring for a client who has an NG tube that is irrigated every 8 hours. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? A. tap water B. sterile water C. 0.9% sodium chloride D. 0.45% sodium chloride
C. 0.9% sodium chloride
A nurse is caring for a client who has taken in 2,600 mL of fluids in 24 hours. Which of the following is an expected output for the client? A. 1,800 mL B. 2,100 mL C. 2,500 mL D. 3,200 mL
C. 2,500
A nurse is asked what causes reflux esophagitis. How should the nurse respond? Reflux esophagitis is defined as: A. the autoimmune destruction of the esophageal lining B. dysplasia of the epithelial lining of the esophagus C. A congenital anomaly of the esophagus D. an inflammatory response to gastroesophageal reflux
C. A congenital anomaly of the esophagus
During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that the patient must have which of the following types of tubes? A. Levin B. Sengstaken-Blakemore C. Salem Sump D. Ewald
C. Salem Sump
A nurse should recognize that nasogastric intubation is indicated to relieve gastric distension for which of the following patients? A. a 6-year old child who drank a toxic substance B. a 60-year old patient admitted with gastrointestinal hemorrhage C. a 40-year old patient with a postoperative bowel obstruction D. a 20-year old patient with malabsorption syndrome
C. a 40-year old patient with a postoperative bowel obstruction
A nurse is asked what causes pancreatitis. How should the nurse respond? The most common cause of chronic pancreatitis is: A. narcotic addiction B. gall stones C. alcohol abuse D. diabetes mellitus
C. alcohol abuse
A nurse is describing the pathophysiology of duodenal ulcers. Which information should the nurse include? Non-steroidal anti-inflammatory agents (NSAIDs) can cause duodenal ulcers by: A. increasing gastric bicarbonate production B. accelerating the proton pump in parietal cells C. inhibiting mucosal prostaglandin synthesis D. reducing mucosal blood flow.
C. inhibiting mucosal prostaglandin synthesis
Which of the following formulas is appropriate to administer to a patient who has a dysfunctional gastrointestinal tract? A. modular B. elemental C. polymeric D. specialty
C. polymeric
The primary goal in treatment of gastroesophageal reflux disease is to: A. promote ulcer healing B. prevent infection C. reduce gastric acid secretions D. decreases stomach pain
C. reduce gastric acid secretions
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse recognize as infiltration? A. purulent exudate B. warmth C. skin blanching D. bleeding
C. skin blanching
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A. to measure the rate of lymphatic drainage B. to evaluate the adequacy of capillary patency before venous blood draws C. to evaluate the adequacy of collateral circulation before cannulating the radial artery D. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
C. to evaluate the adequacy of collateral circulation before cannulating the radial artery
Which assessment finding is common in a patient with Crohn disease? A. significant blood loss in diarrhea B. gastroesophageal reflux C. vitamin B12 deficiency D. mucosal erosions of the rectum
C. vitamin B12 deficiency
Which of the following risk factors should the nurse discuss that can increase a person's chance of developing esophageal cancer? A. nonsmoker B. dietary salt C. chronic pancreatitis D. gastroesophageal reflux
D. gastroesophageal reflux
Nasogastric tube feedings are an appropriate choice for a patient who A. has a paralytic ileus B. has recently experienced facial trauma C. is postoperative following laryngectomy D. has pancreatitis
D. has pancreatitis
After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to: A. empty the bladder B. completely disrobe C. sit in a chair D. walk around the room
A. empty the bladder
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movements? A. flexion and extension B. supination and pronation C. circumduction D. inversion and eversion
A. flexion and extension
A nurse is implementing a plan of care for an older adult client who is at risk for falls. Which of the following is an appropriate nursing action? A. implement a regular toileting schedule B. encourage the client to wear athletic socks when ambulating C. place all 4 bed rails in the upright position D. require a family member to remain at the bedside
A. implement a regular toileting schedule
Which of the following should indicate to a nurse the need to suction a client's tracheostomy? A. irritability b. hypotension C. flushing D. bradycardia
A. irritability
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? A. place a warm compress over the skin. B. record the findings in the client's chart C. notify the client's primary care provider D. prepare to insert a new IV catheter
A. place a warm compress over the skin.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) A. place the client in a negative pressure room B. wear gloves when assisting the client with oral care C. limit each visitor to 2 hours increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene
A. place the client in a negative pressure room B. wear gloves when assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene
A nurse is describing the pathophysiology of hiatal hernias. Which information should the nurse include? A hiatal hernia is a protrusion of the ___ through the ___. A. stomach, diaphragm B. duodenum, pyloric sphincter C. small intestine, inguinal canal D. rectum, anus
A. stomach, diaphragm
A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? A. x-ray examination of the chest and abdomen B. auscultation of injected air C. pH measurement of gastric aspirate D. color of gastric contents
A. x-ray examination of the chest and abdomen
Which of the following would NOT be appropriate to assist a female patient in preparing for a vaginal examination? A. have the patient empty her bladder B. Assume that the patient has had a vaginal exam before and has no questions C. ask the patient if she would like a family member, friend or chaperone present D. instruct the patient to inform you of any pain or discomfort during the exam
B. Assume that the patient has had a vaginal exam before and has no questions
A burn patient develops a stress ulcer. Which type of diagnosis will the nurse observe documented on the chart? A. Addison B. Cushing C. Curling D. restropertoneal E. hide feedback
B. Cushing
Which of the following typical symptoms will the nurse find upon assessment of a patient with colon cancer? A. nausea and jaundice B. abdominal pain and hematochezia C. epigastric pain and vomiting D. heartburn and dysphagia
B. abdominal pain and hematochezia
Which of the following patients should the nurse assess for a paralytic ileus? In a patient: A. when gastroesophagal reflux resolves B. after abdominal surgery C. who is pregnant D. that is vomiting
B. after abdominal surgery
Which of the following diets is most prone to cause diverticulosis in a patient? A. lactose deficiency B. diet high in refined foods C. iron deficiency D. high fiber intake
B. diet high in refined foods
Which of the following formulas is appropriate to administer to a patient who has a dysfunctional gastrointestinal tract? A. modular B. elemental C. polymeric D. specialty
B. elemental
Pancreatic enzyme replacement is most commonly used for acute pancreatitis A. True B. false
B. false
A nurse recalls jaundice related to biliary duct obstruction is manifested by which of the following laboratory alterations? A. decreased unconjugated bilirubin B. increased unconjugated bilirubin C. decreased conjugated bilirubin D. increased conjugated bilirubin
B. increased unconjugated bilirubin
A nurse is asked to describe diverticula. How should the nurse respond? Diverticula are: A. ulcers that form in the colon B. outpouchings of the colon's mucosa C. performations of the colon wall D. areas where the colon wall is hypertrophied
B. outpoudhings of the colon's mucosa
A nurse is planning care for a client who has dysphagia following a stroke. The nurse should initiate a referral for which of the following therapies? A. physical therapy B. speech therapy C. occupational therapy D. respiratory therapy
B. speech therapy
A nurse is caring for a patient experiencing respiratory difficulty. Oral suctioning is completed. The nurse knows that purpose of oral suctioning is: A. to deliver more oxygen to the lungs than an endotracheal tube can provide B. to manage a patient requiring immediate airway management C. to provide a shorter distance for the air to get into the lungs more effectively than any other artificial airway D. to assist with removal of nasal tracheal secretion
B. to manage a patient requiring immediate airway management
The most common site of cancerous breast tumors is in the: A. upper inner quadrant B. upper outer quadrant C. lower inner quadrant D. lower outer quadrant
B. upper outer quadrnt
A patient has hepatitis. Which of the following does the nurse suspect most likely caused the hepatitis? A. bacterial infection B. viral infection C. prescription drug toxicity D. street drug toxicity
B. viral infection
A patient has a small bowel obstruction. Which classic symptoms should the nurse assess for in this patient? A. Nausea, dyspnea, and mid-back pain B. vomiting, colicky abdominal pain, and abdominal distention C. diarrhea, pelvic pain, and dysuria D. fever, heartburn, and mouth ulcers
B. vomiting, colicky abdominal pain, and abdominal distention
Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? A. have the client wear a mask when receiving visitors. B. wash hands before and after client contact. C. assign the client to a room with negative pressure airflow exchange D. instruct all visitors to limit time with the client
B. wash hands before and after client contact.
A nurse is reviewing the medical records for a client who has a pressure ulcer. Which of the following is an expected finding? A. Serum albumin level of 3 g/dL B. HDL level of 90 mg/dL C. Norton scale score of 18 D. Braden scale score of 20
A. Serum albumin level of 3 g/dL
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? A. Thread the IV catheter so that the hub rests at the insertion site. B. Shave excess hair from around the insertion site. C. Cleanse the site with hydrogen peroxide before IV catheter insertion D. palpate the site carefully just before inserting the IV catheter.
A. Thread the IV catheter so that the hub rests at the insertion site.
A nurse is asked what can cause liver cirrhosis. What is the nurse's best response? Common causes of liver cirrhosis are hepatitis C and: A. alcoholism B. cocaine abuse C. overdose of antibiotic medications D. liver cancer
A. alcoholism
A nurse is performing an assessment on an uncircumcised male patient. She retracts the foreskin and remembers to return the skin to its original position in order to prevent all of the following except: A. an erection B. tissue loss C. decreased circulation D. amputation
A. an erection
A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by A. closing off the glottis B. preventing curling of the tube in the mouth C. allowing the patient to breath through her mouth D. opening the lower esophageal sphincter
A. closing off the glottis
A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching? A. consume a light snack of carbohydrates at bedtime B. drink warm tea at bedtime D. watch TV in bed until drowsy E. exercise 1 hour before bedtime
A. consume a light snack of carbohydrates at bedtime
An older adult patient in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient? A. encourage him to go to the dining room at meal times to talk with other patients B. Suggest that he watch television while his feedings are being administered C. remind him that he can have visitors after his feeding administration times D. Ask the facility chaplain to speak with the patient
A. encourage him to go to the dining room at meal times to talk with other patients
An older adult patient in a long-term care facility is receiving intermittent enteral feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. Which of the following interventions is appropriate for this patient? A. encourage him to go to the dining room at meal times to talk with other patients B. suggest that he watch television while his feedings are being administered C. remind him that he can have visitors after his feeding administration times D. ask the facility chaplain to speak with the patient
A. encourage him to go to the dining room at meal times to talk with other patients
A patient presents with fever, abdominal pain, and jaundice from ingesting contaminated food. Which of the following types of hepatitis does the nurse suspect the patient has? A. hepatitis A B. hepatitis B C. hepatitis C D. hepatitis I
A. hepatitis A
A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A. inspect the oropharynx with a penlight and a tongue blade. B. obtain an x-ray examination of the chest and abdomen C. tape the tube securely with a tube holder device D. aspirate gastric contents
A. inspect the oropharynx with a penlight and a tongue blade.
A patient has occult gastrointestinal bleeding. Which complication should the nurse monitor for in this patient? A. iron deficiency anemia B. polyps C. hypertension D. ascites
A. iron deficiency anemia
Which information should the nurse include when describing the pathophysiology of acute pancreatitis? Tissue damage in acute pancreatitis is caused by: A. leakage of pancreatic enzymes into pancreatic tissue B. hydrochloric acid reflux into the pancreatic duct C. autoimmune destruction of the pancreas D. insulin toxicity
A. leakage of pancreatic enzymes into pancreatic tissue
To prevent a common complication of continuous enteral tube feedings, a nurse should A. limit the time the formula hangs to 4 hr. B. chill the formula prior to administration C. deliver the formula at a brisk rate D. allow the feeding bag to empty before refilling it
A. limit the time the formula hangs to 4 hrs.
A nurse is preparing to transfer a client from the bed to the stretcher using a slide board. Which of the following actions should the nurse take? A. lower the head of the bed B. instruct the client to place both arms down by his sides C. position the bed slightly lower than the stretcher D. remind the client to extend his neck during transfer.
A. lower the head of the bed
A patient has digested dark blood in the stool. Which term should the nurse use to describe this condition? A. melena B. hematochezia C. hematemesis D. occult bleeding
A. melena
A known risk factor for breast cancer includes: A. menstruation before age 12 or menopause after age 55. B. physical activity C. breastfeeding an infant for more than 6 months D. low cholesterol diet.
A. menstruation before age 12 or menopause after age 55.
The nurse designs a plan of care for the client with peptic ulcer disease (PUD) who is taking omeprazole (Prilosec) for the management of his illness. What will the best plan by the nurse include? (select all that apply) A. omeprazole (Prilosec) should not be crushed or chewed B. omeprazole (Prilosec) is best taken with yogurt C. omeprazole (Prilosec) should be administered before breakfast on an empty stomach if possible D. omeprazole (Prilosec) should be administered after meals.
A. omeprazole (Prilosec) should not be crushed or chewed C. omeprazole (Prilosec) should be administered before breakfast on an empty stomach if possible
Which complication will the nurse monitor for in a patient with intestinal obstruction? A. peritonitis B. hypervolemia C. hepatic failure D. elevated potassium
A. peritonitis
Which assessment should cause a nurse to be concerned when administering an isotonic intravenous solution to a patient with dehydration? A. pitting edema B. dry mucous membranes C. poor skin turgor D. B/P 108/64
A. pitting edema
A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia? A. storing food in the mouth B. sipping warm liquids C. chewing excessively D. refusing soft foods
A. storing food in the mouth
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to this client? A. use a bed exit alarm system B. raise 4 side rails while client is in bed C. apply one soft wrist restraint D. dim the lights in the client's room
A. use a bed exit alarm system
The nurse is describing how to perform a testicular self-examination to a patient. Which of these statements is most appropriate? A. "A good time to examine your testicles is just before you take a shower." B. "If you notice an enlarged testicle or a painless lump, call your health care provider." C. "The testicle is pear-shaped and immovable. It feels firm and has a lumpy consistency." D. "Perform a testicular exam at least once a week to detect the early stages of testicular cancer."
B. "If you notice an enlarged testicle or a painless lump, call your health care provider."
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? A. "The transfer of your family member is being done because it is in his best interest." B. "have a seat and let me tell you what has happened." C. "Why are you so concerned about this transfer?" D. "I know how you feel. My father had to be sent to a long-term care facility."
B. "have a seat and let me tell you what has happened."
A client has been prescribed ranitidine (Zantac). The nurse plans to include which information in the teaching plan for this client? (Select all that apply) A. You should experience symptom relief almost immediately after taking this medication B. This medication will decrease the acid production in your stomach, but not completely eliminate acid C. Take this medication before or after your meal. D. This drug will not work as well if you continue smoking.
B. This medication will decrease the acid production in your stomach, but not completely eliminate acid D. This drug will not work as well if you continue smoking.
Spirituality is defined as A. participating in religious services on a regular basis B. a personal effort to find meaning and purpose is life. C. an organized system of beliefs concerning the cause, nature, and purpose of the universe
B. a personal effort to find meaning and purpose is life.
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? A. inert the suction catheter while the client is swallowing B. apply intermittent suction when withdrawing the catheter C. place the catheter in a location that is clean and dry for later use D. hold the suction catheter with the clean, nondominant hand.
B. apply intermittent suction when withdrawing the catheter
A nurse is asked what causes chronic gastritis. What is the nurses best response? The most common cause of chronic (antral) gastritis is: A. viral infection B. bacterial infection C. parasitic infection D. fungal infection
B. bacterial infection
When percussing the right upper quadrant of the abdomen where the liver is located, you would expect to hear what sound? A. tympany B. dullness C. resonance D. hyperresonance
B. dullness
When using chilled normal saline solution during gastric lavage, the nurse should watch for which of the following complications? A. rapid influx of electrolytes B. hypothermia C. hyponatremia D. increased heart rate
B. hypothermia
A client has developed N/V. What is the nurse's primary treatment? A. change the patient's diet to clear liquids B. identifying and eliminating the cause C. encouraging the client to lie still D. providing the client with soft foods
B. identifying and eliminating the cause
A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient? A. nasogastric tube B. nasointestinal tube C. percutaneous endoscopic gastrostomy tube D. percutaneous endoscopic jejunostomy tube
B. nasointestinal tube
The nurse has just completed a lymph node assessment on a 60-year old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally A. shotty B. not palpable C. large, firm, and fixed to the tissue D. rubbery, discrete, and mobile
B. not palpable
A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by A. closing off the glottis B. preventing curling of the tube in the mouth C. allowing the patient to breathe through her mouth D. opening the lower esophageal sphincter
B. preventing curling of the tube in the mouth
A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A. allow the patient to suck on ice chips B. provide frequent mouth care C. apply petroleum jelly to the patient's naris D. offer throat lozenges for the patient to use
B. provide frequent mouth care
A dietary practice to restrict meat on certain days such as Ash Wednesday and Fridays during Lent is an example of what type of nutritional influence? A. ethnic B. religious C. economic D. cultural
B. religious
A nurse is obtaining a health history from a client who has hearing loss. Which of the following actions by the nurse is appropriate? A. speak loudly with the mouth close to the client's ear. B. rephrase rather than repeat misunderstood information C. ask a family member about the client's health history use a high tone of voice instead of a low voice
B. rephrase rather than repeat misunderstood information
When the nurse is performing a pain assessment on a patient with appendicitis, which abdominal quadrant is most typically affected? A. right upper B. right lower C. left upper D. left lower
B. right lower
A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheostomy. Which of the following is an appropriate action for the nurse to take? A. use a resuscitation bag with 80% oxygen prior to the procedure. B. select a suction catheter that is half the size of the lumen C. place the end of the suction catheter in water-soluble lubricant D. adjust the wall suction apparatus to a pressure of 170 mm Hg.
B. select a suction catheter that is half the size of the lumen
The nurse is calling the health care provider about a patient's changing condition. Which of the following would included in the SBAR communication? A. subjective information, background, assessment, and revisions needed B. situation, background, assessment and recommendation C. situation, background, all vitals, and review of orders D. summary, better plan, accurate diagnosis, and rights
B. situation, background, assessment and recommendation
A nurse is describing the pathophysiology of ulcerative colitis. Which information should the nurse include? A characteristic of ulcerative colitis is: A. the disease has "skip" lesions. B. the disease begins in the rectum and may advance back through the colon in continuous manner C. It has a cobblestone appearance that increases the risk for colon cancer. D. it has a beginning in the small intestines and advances to the large intestines
B. the disease begins in the rectum and may advance back through the colon in continuous manner
Obesity in adults is defined as: A. excess body fat placed predominately within the hips and thighs. B. excessive body fat leading to body weight 5% above ideal. C. a body mass index of 30 or greater. D. overnourished
C. a body mass index of 30 or greater
Which statement indicates the patient needs more teaching regarding constipation? One common cause of constipation includes: A. inadequate fluid intake B. laxative use C. a low fiber diet D. opioid medications
C. a low fiber diet
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? A. limit the adolescent's visitors B. select the adolescent's food choices C. allow the adolescent to make decisions regarding his daily routine D. encourage the adolescent's parent to assist with personal hygiene.
C. allow the adolescent to make decisions regarding his daily routine
A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take? A. flush the tubing with 100 mL of water. B. Dilute the formula with sterile water. C. aspirate for residual D. place the client in the supine position
C. aspirate for residual
Which of the following pulses should the nurse assess bilaterally, but separate or one at a time? A. ulnar B. posterior tibial C. carotid D. radial
C. carotid
Which of the following disorders does the nurse suspect when the patient has lower gastrointestinal bleeding? A. Mallory-Weiss tear B. peptic ulcers C. colorectal cancer D. hernia
C. colorectal cancer
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? A. touch the face with a cotton ball B. apply a vibrating tuning fork to the client's forehead C. have the client stand with arms at side and feet together D. perform direct percussion over the area of the kidneys
C. have the client stand with arms at side and feet together
A patient has gastroesophageal reflux disease (GERD). Which common manifestations should the nurse assess for in this patient? A. N/V and weight loss B. diarrhea, abdominal cramping, and fever C. heartburn, dysphagia, and pain within one hour of eating D. back pain, ascites, and anorexia
C. heartburn, dysphagia, and pain within one hour of eating
A patient has gastroesophageal reflux disease (GERD). Which common manifestations should the nurse assess for in this patient? A. nausea, vomiting, and weight loss B. diarrhea, abdominal cramping and fever C. heartburn, dysphagia, and pain within one hour of eating D. back pain, ascites, and anorexia
C. heartburn, dysphagia, and pain within one hour of eating
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? A. request an occupational therapy consult to determine the need for assistive devices B. assign assistive personnel to perform self-care tasks for the client C. instruct the client to focus on gradually resuming self-care tasks D. ask the client if a family member is available to assist him with his care
C. instruct the client to focus on gradually resuming self-care tasks
Nasogastric tube feedings are an appropriate choice for a patient who: A. has a paralytic ileus B. has recently experienced facial trauma C. is postoperative following laryngectomy D. has pancreatitis
C. is postoperative following laryngectomy
The most reliable method for verifying initial placement of a small-bore feeding tube is by A. measuring the pH of gastric aspirate B. auscultating the epigastric area while injecting air C. obtaining an abdominal x-ray D. placing the open end of the tube is a cup of water
C. obtaining an abdominal x-ray
Which of the following symptoms is greatly influenced by a person's cultural heritage? A. hearing loss B. food intolerance C. pain D. breast lump
C. pain
Which principle should the nurse remember when providing nursing care to a patient who has a gastric ulcer? Gastric ulcers are characterized by: A. increased acid secretion B. weight gain C. pain immediately after eating D. bloody diarrhrea
C. pain immediately after eating
To determine if a dark-skinned patient in pale, the nurse should access the color of the A. conjunctivae B. ear lobes C. palms of the hands D. skin in the antcubital space
C. palms of the hands
A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient? A. nasogastric tube B. nasointestianl tube C. percutaneous endoscopic gastronomy tube D. percutaneous endoscopic jejunostomy tube
C. percutaneous endoscopic gastronomy tube
What should the nurse assess before entering the patient's room on morning rounds? A. patient's input and output chart from the previous shift B. patient's general appearance C. posted conditions, such as isolation precautions D. presence of any visitors in the room
C. posted conditions, such as isolation precautions
A nurse is teaching a class about healthy eating. The nurse explains to the group that some fat is needed in the diet to maintain which of the following functions? A. regulate compensatory mechanisms B. repair body tissue C. provide energy D. enhance visual acuity
C. provide energy
A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions maximizes the effectiveness of incentive spirometry? A. side-lying B. supine C. semi-Fowler's D. trendelenburg
C. semi-Fowler's
A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care? A. critical pathway B. transfer document C. situation, background, assessment, and recommendation (SBAR) D. medication administration report (MAR)
C. situation, background, assessment, and recommendation (SBAR)
A nurse begins performing tracheostomy care on a hospitalized patient admitted with pneumonia who requires continuous oxygen therapy. While performing the tracheostomy care the most important safety measure for the nurse to remember is: A. to follow clean procedure guidelines B. the entire tracheostomy tube should be removed and then replaced. C. the tracheostomy ties should not be cut unless new ones are secured D. care should never be performed more than once a day.
C. the tracheostomy ties should not be cut unless new ones are secured
A nurse in a long-term facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A. "When do you usually bathe, in the morning or in the evening?" B. "Do you prefer a bath or a shower?" C. "At what temperature do you prefer your bath water?" D. "Are you able to help with your hygiene care?"
D. "Are you able to help with your hygiene care?"
A nurse is speaking with the parent of an infant who has a cardiac defect. After the parent expresses concern, which o the following is an appropriate response? A. "Do any of your other children have congenital defects?" B. "Is anything concerning you that I can explain?" C. "She is going to grow up to be a healthy child." D. "Tell me about your baby while I bathe her."
D. "Tell me about your baby while I bathe her."
A nurse is caring for a client who reports pain. When documenting the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "the pain makes me feel nauseous." C. "I notice that the pain gets worse after I eat." D. "The pain is life a dull ache in my stomach."
D. "The pain is life a dull ache in my stomach."
A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding? A. a male client who has diaphragmatic breathing B. A female client who has thoracic muscle movement when breathing C. an infant who has an irregular breathing pattern D. An adolescent who has visible accessory muscle movement when breathing
D. An adolescent who has visible accessory muscle movement when breathing
A nurse is describing the pathophysiology of duodenal ulcers. Which information should the nurse include? A. Chronic inflammation inhibits the proton pumps in the gastric lining to decreased acid levels B. presence of bacteria in the stomach causes the pyloric sphincter to open slowly C. H. pylori inhibits prostaglandins, leading to decreased mucus production D. H. pylori releases toxins and enzyme that promote inflammation
D. H. pylori releases toxins and enzyme that promote inflammation
While assessing a patient with pain which individual response to pain should the nurse monitor? A. cultural B. psychologic C. physiologic D. all of the above
D. all of the above
Which complication should the nurse assess for in a patient with chronic gastritis? A. excessive intrinsic factor B. polyachlorhydria C. liver failure D. gastric cancer
D. gastric cancer
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridum difficile. Which of the following information should the nurse include in the teaching? A. assign the client to a room with a negative air-flow system B. use alcohol-based hand sanitizer when leaving the client's room C. clean contaminated surfaces in the client's room with a phenol solution D. have family members wear a gown and gloves when visiting.
D. have family members wear a gown and gloves when visiting.
A nurse is caring for a client for whom a nasogastric tube is ordered for stomach decompression. Which of the following actions is appropriate when inserting the NG tube? A. position the client with the head of the bed elevated to 30 degree prior to insertion of the tube B. Remove the NG tube if the client begins to gag or choke C. apply suction to the NG tube prior to insertion D. have the client take sips of water to promote insertion of the NG tube into the esophagus
D. have the client take sips of water to promote insertion of the NG tube into the esophagus
The nurse is aware that the four areas in the body that the lymph nodes are accessible are the: A. head, breasts, groin, and abdomen B. arms, breasts, inguinal area, and legs C. head and neck, arms, breasts, and axillae D. head and neck, arms, inguinal area, and axillae
D. head and neck, arms, inguinal area, and axillae
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions falls within the RN scope of practice? A. insert an implanted port B. close a laceration with sutures. C. place an endotracheal tube. D. initiate an enteral feeding through a PEG tube
D. initiate an enteral feeding through a PEG tube
When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the apex of the heart are: A. tricuspid and aortic B. aortic and pulmonic C. mitral and pulmonic D. mitral and tricuspid
D. mitral and tricuspid
A nurse is assisting a client with range of motion exercises of the neck. Which of the following should the nurse suggest to promote neck rotation? A. move her head backward B. touch her chin to her chest C. touch her ear to her shoulder D. move her head from side to side
D. move her head from side to side
Which statement indicates the patient needs more teaching regarding constipation? One common cause of constipation includes: A. inadequate fluid intake B. laxative use C. a low-fiber diet D. opioid medications
D. opioid medications
A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that tube has become occluded? A. active bowel sounds B. passing flatus C. increase in gastric secretions D. patient's report of nausea
D. patient's report of nausea
To prevent aspiration during the administration of an enteral tube feeding a nurse should A. flush the feeding tube with 30 mL of water B. add blue food coloring to the enteral formula C. ensure the formula is at room temperature D. place the patient in Fowler's position
D. place the patient in Fowler's position
To prevent aspiration during the administration of an enteral tube feeding, a nurse should A. flush the feeding tube with 30 mL of water B. add blue food coloring to the enteral formula C. ensure the formula is at room temperature D. place the patient in the Fowler's position
D. place the patient in the Fowler's position
Methods to enhance abdominal wall relaxation during examination include: A. a cool environment B. having the patient place arms above the head C. examining painful areas first D. positioning the patient with the knees bent
D. positioning the patient with the knees bent
Which patient is most at risk for peptic ulcer disease? One who: A. takes Tylenol B. exercises 5 times/week C. has a sedentary lifestyle. D. smokes and drinks alcohol
D. smokes and drinks alcohol
A nurse observes cholelithiasis documented on the chart. The nurse will be caring for a patient with: A. an infection of the gallbladder B. gallbladder atrophy C. hypersecretion of bile by the liver D. the accumulation of gallstones in the gallbladder
D. the accumulation of gallstones in the gallbladder
A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following factors is most important for the nurse to consider before delegating care? A. The AP's previous training B. other tasks assigned to the AP C. the amount of supervision the AP requires D. the facility's job description for the AP
D. the facility's job description for the AP
Which of the following patients in most prone to ulcerative colitis? A patient A. taking aspirin B. taking non-steroidal anti-inflammatory drugs C. who has a head injury D. who has a family member with ulcerative colitis
D. who has a family member with ulcerative colitis
A nurse is caring for a client who is refusing a scheduled blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A. ask the client to consider a direct donation B. ask the client's family to intervene C. request a consultation with the ethics committee D. withhold the scheduled blood transfusion
D. withhold the scheduled blood transfusion
To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patient's nose to the earlobe and from the earlobe to the A. umbilicus B. xiphoid process C. manubrium plus 10 to 20 cm more. D. xiphoid process plus 20 to 30 cm more.
D. xiphoid process plus 20 to 30 cm more.
To determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the patient's nose to the earlobe and from the earlobe to the A. umbilicus B. xiphoid process C. manubrium plus 10-20 cm more D. xiphoid process plus 20-30 cm more
D. xiphoid process plus 20-30 cm more