igg exam 3

What is the pH range of the distal esophagus? a. 1.5 to 2.0 b. 3.0 to 4.5 c. 4.5 to 6.0 d. 6.0 to 7.0

ANS: D The pH of the lower esophagus is neutral (normal).

The nurse notes a bulge in a client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. Reducible inguinal hernia b. Indirect umbilical hernia c. Strangulated ventral hernia d. Incarcerated femoral hernia

A In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down.

A client has an anorectal abscess. Which teaching topic does the nurse address as the priority? a. Perineal hygiene b. Comfort measures c. Nutrition therapy d. Antibiotic use

A The priority intervention for a client with an anorectal abscess focuses on maintaining meticulous perineal hygiene to prevent infection. Comfort measures are also important, but are not as high a priority. Nutrition management and antibiotic teaching may or may not be needed.

The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Presence of fatigue with a headache c. Presence of slight nausea and no appetite d. Two diarrhea stools yesterday

A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range, 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

A client with Crohn's disease has a draining fistula. Which finding leads the nurse to intervene most rapidly? a. Serum potassium of 2.6 mEq/L b. The client not wanting to eat anything c. White blood cell count of 8200/mm3 d. The client losing 3 pounds in a week

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

The nurse is caring for a client with Giardia lamblia infection. Which medication does the nurse anticipate teaching the client about? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

A Flagyl is the drug of choice for Giardia lamblia infection. Cipro and Rocephin are antibiotics used for bacterial infections. Azulfidine is used for ulcerative colitis and Crohn's disease.

The nurse reviews a health teaching for a client with Crohn's disease. Which instruction does the nurse provide for the client? a. "You should have a colonoscopy every few years." b. "You should eat a diet that is high in protein and fiber." c. "You should avoid heavy lifting and tight-fitting clothes." d. "You should take the Asacol whenever you have loose stools."

A Long-term inflammatory bowel disease increases the risk of colon cancer, so regular colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohn's disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tight-fitting clothes is not necessary.

The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurse's best response? a. "You are at risk for developing more polyps in the future." b. "You may have other cancerous lesions that could not be seen right now." c. "The doctor can remove only a few of the polyps during each colonoscopy." d. "This test will ensure that you have healed where the polyp was removed."

A Once a person has developed a polyp, risk for occurrence of multiple polyps is present. The physician usually can remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed, or to check for cancerous lesions that were not visible during the first procedure.

The nurse is caring for a client with a parasitic gastrointestinal infection. What statement by the client indicates a need for further teaching? a. "I will have my housekeeper keep my toilet very clean." b. "I need to shower or bathe every day." c. "I need to have my well water tested." d. "My sexual partner needs to have a stool test."

A Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. The other statements are accurate

The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? a. Severe, steady right lower quadrant (RLQ) pain b. Abdominal pain that started a day after vomiting began c. Abdominal pain that increases with knee flexion d. Marked peristalsis and hyperactive bowel sounds

A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel? a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L b. Losing 15 pounds over the last month without dieting c. Reports of crampy abdominal pain across the lower quadrants d. High-pitched, hyperactive bowel sounds in all quadrants

A Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction.

The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching? a. "I will put on the truss before I go to bed each night." b. "I will put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I will let my health care provider know right away."

A The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss.

The nurse is caring for a client who has acute viral gastroenteritis. Which dietary instruction does the nurse provide to the client? a. "Drink plenty of fluids to prevent dehydration." b. "You can have only clear liquids to drink." c. "Milk products will give you extra protein." d. "You can have sips of cola or tea to relieve nausea."

A The client should drink plenty of fluids to prevent dehydration. Clients are not necessarily restricted to clear liquids. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings? a. Bowel obstruction; client should be placed on NPO status. b. Perforation of the bowel; client needs emergency surgery. c. Adhesions in the hernia; client needs elective surgery. d. Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

A The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.

A client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurse's best response? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband.

The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Traces of blood in the stool d. Crampy lower abdominal pain

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

A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse's best response? a. "This is normal for your type of colostomy." b. "I will let the health care provider know, so that it can be assessed." c. "You should add extra fiber to your diet to stop the diarrhea." d. "Your stool will become firmer over the next few weeks."

A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client's abdomen for the presence of an acquired umbilical hernia? a. Body mass index (BMI) of 41.9 b. Cholecystectomy last year c. History of irritable bowel syndrome d. Daily dose of lansoprazole (Prevacid) 30 mg orally

A This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.

A nurse is teaching a community group about food poisoning and gastroenteritis. Which statements by the nurse are accurate? (Select all that apply.) a. Rotavirus is more common among infants and younger children. b. Escherichia coli diarrhea is transmitted by contact with infected animals. c. Don't drink water when swimming to prevent E. coli infection. d. All clients with botulism require hospitalization. e. Parasitic diseases may not show up for 1 to 2 weeks after infection.

A, C, D, E Rotavirus is more common among the youngest of clients, not drinking water while swimming can help prevent E. coli infection, people with botulism need to be hospitalized to monitor for respiratory failure and paralysis, and parasitic diseases may take up to 2 weeks to become symptomatic. The other statements are not accurate.

The client asks the nurse how to avoid becoming ill with Salmonella infection again. Which are appropriate responses from the nurse? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked." f. "When eating outdoors, be sure to keep flies off your food."

A, C, D, E, F Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure eggs and meat are cooked properly, and, because it can be transmitted by flies, keep flies off of food.

A nurse is teaching a community group ways to prevent Escherichia coli infection. Which statements made by the nurse are accurate? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

The nurse is helping a student prepare to insert a nasogastric tube for an adult client with a bowel obstruction. Which actions by the student indicate to the nurse that a review of the procedure is needed? (Select all that apply.) a. Gathering supplies, including an 8 Fr Levin tube, sterile gloves, tape, and water-soluble lubricant b. Performing hand hygiene and positioning the client in high Fowler's position, with pillows behind the head and shoulders c. Attaching a 60-mL irrigation syringe to the end of the nasogastric tube before inserting it into the nose d. Instructing the client to extend the neck against the pillow once the nasogastric tube has reached the oropharynx e. Checking for correct placement by checking the pH of the fluid aspirated from the tube f. Securing the nasogastric tube by taping it to the client's nose and pinning the end to the pillowcase g. Connecting the nasogastric tube to intermittent medium suction with an anti-reflux valve on the air vent

A, D, F An 8 Fr nasogastric tube is too small for drainage of thick stomach contents. Sterile gloves are not needed for the procedure. The tube should be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. The clients head should be flexed forward once the tube has reached the oropharynx. All the other actions are appropriate. A 60-mL irrigation syringe should be attached to the end of the tube before insertion so that gastric fluid does not erupt from the tube when it enters the stomach.

A nurse cares for a client who is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The client weighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters should the nurse administer to this client? (Record your answer using a whole number.) ____ mL

ANS: 25 mL 100 lb = 50 kg. 50 kg ´ 5 mg/kg = 250 mg.

A nurse prepares to administer 12 mg/kg of 5-fluorouracil chemotherapy intravenously to a client who has colon cancer. The client weights 132 lb. How many milligrams should the nurse administer? (Record your answer using a whole number.) _____ mg

ANS: 720 mg 132 lb = 60 kg. 60 kg ´ 12 mg/kg = 720 mg.

A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching? a. "After the operation I can eat anything I want." b. "I will have to eat smaller, more frequent meals." c. "I will take stool softeners for several weeks." d. "This surgery may not totally control my symptoms."

ANS: A Nutritional and lifestyle changes need to continue after surgery as the procedure does not offer a lifetime cure. The other statements show good understanding.

A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the client's neck. What action by the nurse takes priority? a. Assess the client's oxygenation. b. Facilitate a STAT chest x-ray. c. Prepare for immediate surgery. d. Start two large-bore IVs.

ANS: A The priorities of care are airway, breathing, and circulation. The priority option is to assess oxygenation. This occurs before diagnostic or therapeutic procedures. The client needs two large-bore IVs as a trauma client, but oxygenation comes first.

10. The nurse is caring for a client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than in the duodenum? a. Body mass index (BMI) is 16.6. b. Stool is positive for occult blood. c. Client has had four ulcers in the last 5 years. d. Hemoglobin is 13 g/dL and hematocrit is 42%.

ANS: A A BMI of 17.6 indicates that the client is underweight (<18.5 is underweight in adults). This finding is more commonly seen with gastric ulcers than with duodenal ulcers because the pain is made worse with food ingestion. Occult blood and low hemoglobin and hematocrit levels may be seen with both gastric and duodenal ulcers. Recurrence is more commonly seen with duodenal than with gastric ulcers. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

An emergency department nurse triages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

ANS: A A client's medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

When performing an assessment, the nurse detects a fruity odor on the client's breath. What does the nurse do next? a. Assess the client's blood sugar level. b. Assess the client's stool for occult blood. c. Instruct the client in oral hygiene techniques. d. Assess the client for petechiae, itching, and jaundice.

ANS: A A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The client's blood sugar level should be checked immediately for hyperglycemia. The nurse may perform the other assessment tests for the client, but they will not be helpful in determining the cause of the fruity breath.

A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next? a. Immobilize the left arm. b. Assess the client's distal pulse. c. Monitor for signs of infection. d. Administer prescribed steroids.

ANS: A A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.

Which question best assists the nurse in assessing a client with acute diarrhea? a. "Have you traveled outside the country recently?" b. "Have you had a colonoscopy lately?" c. "Do you have any trouble swallowing?" d. "Do you have any allergies?"

ANS: A A history of recent travel may help pinpoint an infectious source for the client's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.

The nurse finds a positive Blumberg's sign in a client with abdominal pain. Which action does the nurse plan? a. Have the client be NPO in preparation for surgery. b. Document this normal finding in the client's record. c. Immediately auscultate the client's abdomen for bowel sounds. d. Repeat the maneuver with the client in a supine position, with the knees flexed.

ANS: A A positive Blumberg's sign (rebound tenderness), an abnormal sign, is indicative of peritoneal inflammation, which commonly accompanies appendicitis. The client should be made NPO in preparation for surgery to remove the appendix. The maneuver should not be repeated with the client in the supine position. The nurse should perform auscultation before percussion for the abdominal assessment.

To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

11. The nurse is caring for a client who has been brought to the emergency department with upper GI bleeding. The client is vomiting copious amounts of bright red blood. Which is the nurses priority action? a. Ensure that the client has a patent airway. b. Start a normal saline IV infusion. c. Gather equipment to start a saline lavage. d. Assess the client for causative factors.

ANS: A Airway always comes first. The client must have a patent airway. The client does need an IV and a saline lavage via nasogastric (NG) tube, but these actions are not as important as maintaining the airway. Assessing for causative factors will be important after the client has stabilized. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination? a. "Are you allergic to shrimp, scallops, or shellfish?" b. "Have you had anything to eat or drink in the past 12 hours?" c. "Did you finish taking all the prescribed laxatives?" d. "Can you tolerate being tilted from side to side?"

ANS: A Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies should be scheduled for CT without contrast to avoid anaphylactic reactions. The client does not need to be NPO for this test and does need not to take laxatives. The client is not tilted during the CT scan.

After teaching a client who is recovering from a vertebroplasty, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I can drive myself home after the procedure." b. "I will monitor the puncture site for signs of infection." c. "I can start walking tomorrow and increase my activity slowly." d. "I will remove the dressing the day after discharge."

ANS: A Before discharge, a client who has a vertebroplasty should be taught to avoid driving or operating machinery for the first 24 hours. The client should monitor the puncture site for signs of infection. Usual activities can resume slowly, including walking and slowly increasing activity over the next few days. The client should keep the dressing dry and remove it the next day.

16. A client has been taking an antacid for several weeks without improvement in symptoms. Which response by the nurse is most helpful? a. Tell me exactly how you take your antacid. b. Would you be willing to try a more expensive medication? c. Are you sure you are taking this exactly as ordered? d. Lets ask the health care provider if the dose can be doubled.

ANS: A Antacids can be effective anywhere from 30 minutes to 3 hours after eating. Their neutralizing effect is eliminated when they are taken on an empty stomach. However some people take them before eating to prevent symptoms. The nurse should first discover how the client takes the medication before suggesting other medications or increasing the dose. Asking the client whether the medication is being taken exactly as ordered is a closed-ended question, which is not a good communication tool. Also, the way the statement is phrased is likely to place the client on the defensive. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation)

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the client's fingers are pale, cool, and slightly swollen. Which action should the nurse take first? a. Raise the arm above the level of the heart. b. Encourage range of motion. c. Apply heat to the affected hand. d. Bivalve the cast to decrease pressure.

ANS: A Arm casts can impair circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Encouraging range of motion would not assist the client as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.

The home care nurse is visiting a client with diabetes who has a new cast on the arm. On assessment, the nurse finds the client's fingers to be pale, cool, and slightly swollen. Which is the nurse's first intervention? a. Elevate the arm above the level of the heart. b. Encourage active and passive range of motion. c. Apply heat to the affected hand. d. Place a window or bivalve the cast.

ANS: A Arm casts can impinge on circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should reassess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Heat would cause increased edema and should not be used. Encouraging range of motion would not assist the client as much as elevating the arm. If the cast is assessed to be too tight, it could be bivalved.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a. Consult with the provider about an x-ray. b. Encourage the client to use ibuprofen (Motrin). c. Have the client perform hip range of motion. d. Place the client in a rigid cervical collar.

ANS: A Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.

An older client is 1 day post-esophagectomy. The nurse finds the client short of breath with a heart rate of 120 beats/min. Which action by the nurse takes priority? a. Assess the client's lungs and oxygen saturation. b. Ask the client to rate pain, and treat if needed. c. Help the client change to a side-lying position. d. Increase the client's supplemental oxygen.

ANS: A Clients can have many complications from this operation, and older clients are especially vulnerable to fluid overload. The nurse should first assess lung sounds and oxygen saturation. Although pain can cause tachycardia, it usually does not cause shortness of breath. If the client has pain, it should be treated, but it is not the priority. The nurse needs to know the client's oxygen saturation before turning up the oxygen. Changing the client's position will not help.

25. The nurse is caring for a client who has received multiple serious injuries in a motor vehicle accident. The client asks the nurse why ranitidine (Zantac) is prescribed because she does not have any abdominal pain. Which is the nurses best response? a. It will help prevent the development of a stomach ulcer from the stress of your injuries. b. It will help prevent aspiration pneumonia when you are anesthetized during surgery tomorrow. c. It will help your throat heal after it was irritated from the nasogastric tube. d. It will help prevent nausea and vomiting from the narcotic pain medications that you are taking.

ANS: A Clients who have sustained traumatic injuries are at risk for development of stress ulcers during recovery. H2-antagonist medications may be prescribed to prevent stress ulcers. Zantac will not prevent aspiration pneumonia, esophageal healing after nasogastric intubation, or nausea from narcotic pain medications. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

Which instruction is most important for the RN to provide to the nursing assistant assigned to care for a client with primary osteoporosis? a. "Clean up clutter in the room." b. "Encourage the client to bathe herself or himself." c. "Monitor urinary output." d. "Perform passive range-of-motion exercises."

ANS: A Clients with osteoporosis are at risk for fracture when they fall. Clutter in the room is a risk factor for falls. The other choices have nothing to do with prevention of bone fracture in a client with primary osteoporosis.

A client is admitted with progressive dysphagia. What intervention by the nurse takes priority? a. Weigh the client daily. b. Instruct the client on a high-protein diet. c. Assess and treat the client's pain. d. Administer antitussive medications.

ANS: A Clients with progressive dysphagia can lose weight as a result of their inability to take adequate nutrition. Weighing the client daily is an important intervention to gauge the effectiveness of interventions designed to meet nutritional needs. Increased protein in the diet is important, but if the client has trouble swallowing, this is not the best option. The other two interventions do not relate to dysphagia.

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

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

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugspossibly to toxic levels. The other options do not accurately explain this age-related change.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.

ANS: A Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.

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

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

What information does the nurse teach a women's group about osteoporosis? a. "For 5 years after menopause you lose 2% of bone mass yearly." b. "Men actually have higher rates of the disease but are underdiagnosed." c. "There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis."

ANS: A For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.

A client is prescribed alendronate (Fosamax). Which statement indicates that the client understands teaching about this drug? a. "I should take this drug with a full glass of water." b. "I need to lie down for 30 minutes after taking it." c. "This drug should be taken after a meal." d. "This drug needs to be taken at the same time as calcium."

ANS: A Fosamax needs to be taken on an empty stomach with a full glass of water for best absorption and to prevent esophagitis. After taking the drug, the client needs to stay upright for 30 minutes. Calcium can be taken, but not at the same time as Fosamax.

8. An older client is admitted to the hospital with acute gastritis. The health care provider orders magnesium hydroxide (Mylanta) 1 hour and 3 hours after meals and at bedtime. Which action by the nurse is most appropriate? a. Check the clients renal function studies before giving the drug. b. Call the health care provider and ask for a different antacid for the client. c. Assess the clients pain and treat pain if present. d. Assist the client in ordering bland food from the menu.

ANS: A Hypermagnesemia can develop if the clients kidneys are not functioning well because Mylanta contains magnesium, which is excreted via the kidneys. Kidney function declines as a normal age-related change, so the nurse should be cautious to check kidney function before administering this medication. The client may be able to take the medication; without further information, the nurse should not yet call the provider. Assessing and treating pain and helping the client choose appropriate foods are good interventions, but they are not specific to ensuring safety regarding the medication ordered. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation) MSC: Integrated Process: Nursing Process (Analysis)

While caring for a client who has chronic osteomyelitis and wound drainage, which intervention is most important for the nurse to implement? a. Cover the wound with a dressing. b. Teach about the cause of the infection. c. Monitor the erythrocyte sedimentation rate (ESR). d. Prepare the client for hyperbaric oxygenation.

ANS: A If an open wound is present in the hospital or long-term care setting, the client's treatment usually includes Standard Precautions for limiting infection by covering the wound. Teaching about the cause of the infection could prevent further episodes of infection, but does not take care of the current problem. The ESR just tells the health care provider that an inflammatory process is going on. Hyperbaric oxygenation is used only for clients with chronic, unremitting osteomyelitis. Covering the wound would be the most important step for the nurse to take first.

Which nursing intervention is most effective in preventing transfer of an organism from the wound of a client with osteomyelitis to other clients? a. Contact Precautions b. Restriction of visitors c. Irrigating the wound as needed d. Leaving the wound open to air

ANS: A In the presence of wound drainage, Contact Precautions may be used to prevent the spread of the offending organism to other clients and health care personnel. Restricting visitors does not prevent transfer. One visitor could possibly transfer the bacteria to another surface. Irrigating the wound would not destroy the organism. The wound should be covered to prevent transfer of the organism.

A client is admitted with a chemical injury to the esophagus after ingestion of an alkaline substance. The client states, "I am having trouble breathing because of these air bubbles in my neck." Which action by the nurse is most appropriate? a. Continue assessing the client while another nurse calls the health care provider. b. Ask the client to rate the pain and prepare to administer pain medication. c. Have the client cough and deep breathe, then assess his or her lung sounds. d. Give the client small sips of water to see whether he or she has dysphagia.

ANS: A Ingestion of alkaline substances is dangerous because of their potential to fully penetrate the esophagus, leading to perforation. "Air bubbles" in the neck (subcutaneous emphysema) would lead the nurse to suspect this complication. The nurse needs to continue assessing the client and must stay with him or her, but because this is an emergency, someone else must notify the provider immediately. The nurse should not administer pain medication at this time. Coughing and deep-breathing exercises will not be beneficial to the client. If the client's esophagus has perforated, having the client drink can cause more problems.

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.

A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety? a. Meperidine 50 mg IV every 4 hours b. Patient-controlled analgesia (PCA) with morphine sulfate c. Percocet 2 tablets orally every 6 hours PRN for pain d. Ibuprofen elixir every 8 hours for first 2 days

ANS: A Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this client's pain management.

A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)

ANS: A Metronidazole is the drug of choice for a Giardia infection. Ciprofloxacin and ceftriaxone are antibiotics used for bacterial infections. Sulfasalazine is used for ulcerative colitis and Crohn's disease.

A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.

ANS: A PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best? a. "Your feet have less blood flow, so healing is slower." b. "The bones in your feet are hard to operate on." c. "The surrounding bones and tissue are damaged." d. "Your feet bear weight so they never really heal."

ANS: A The feet are the most distal to the heart and receive less blood flow than other organs and tissues, prolonging the healing time after surgery. The other explanations are not correct.

Which client is at highest risk for the development of plantar fasciitis? a. Young adult runner b. Adolescent swimmer c. Older adult client who walks with a cane d. Adult client confined to a wheelchair

ANS: A Plantar fasciitis accounts for 10% of running-related injuries. Obesity is also thought to be a factor in the development of plantar fasciitis. It is often seen in middle-aged and older adults who are ambulatory, but plantar fasciitis is most common in athletes, especially runners.

7. The nurse is teaching a health promotion class about preventing cancer. Which statement by a student indicates understanding of gastric cancer development? a. I should skip my morning bacon and egg sandwich to reduce my risk of gastric cancer. b. I have been lactose intolerant for many years, so I should have a yearly test for gastric cancer. c. I should switch from regular to decaffeinated coffee to reduce my risk of gastric cancer. d. I am at low risk for developing gastric cancer because I am a vegetarian and I eat only organic produce.

ANS: A Regular consumption of processed foods with nitrates (including bacon) can increase risk for gastric cancer. Lactose intolerance, coffee intake, and vegetarian diet are not factors in gastric cancer development. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How should the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."

ANS: A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

A client for whom skeletal traction is planned asks for an explanation regarding the purpose of this type of traction. Which is the nurse's best response? a. "It aids in realigning the bone." b. "It prevents low back pain." c. "It decreases muscle spasms that occur with a fracture." d. "It prevents injury to the skin as a result of the fracture."

ANS: A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. The other choices are not primary purposes of skeletal traction.

9. The nurse is caring for a client with chronic gastritis. The client asks the nurse how to prevent another flare-up of gastritis. Which is the nurses best response? a. Join a support group to help you stop smoking. b. Take a multivitamin with iron and folic acid every day. c. Make sure to include plenty of fresh vegetables in your diet. d. Make sure that your weight stays within normal limits.

ANS: A Smoking and stress contribute to the development of gastritis, so the client should join a support group to help him quit smoking. Multivitamins, fiber, and weight management do not help prevent gastritis development. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1221 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning

What does the nurse teach the client with esophageal diverticula about dietary needs? a. "Eat soft foods and smaller meals." b. "Only eat puréed foods." c. "Avoid drinking liquids with meals." d. "Avoid dairy products."

ANS: A Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany diverticula. The client does not have to avoid liquids or dairy products because these do not cause symptoms. The client does not have to eat puréed foods because he or she does not have difficulty swallowing or chewing foods.

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best? a. Ensure the client gets 15 minutes of sun exposure daily. b. Give the client daily vitamin D injections. c. Hide vitamin D supplements in favorite foods. d. Plan to serve foods naturally high in vitamin D.

ANS: A Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.

5. The home care nurse is caring for a client who has recently undergone a subtotal gastrectomy. The nurse notes that the clients tongue is shiny and beefy red. Which assessment question does the nurse ask the client regarding this finding? a. Have you been taking your multivitamin every day? b. How much weight have you lost since your surgery? c. Have you been experiencing heartburn or nausea after eating? d. What kind of mouthwash do you use after you brush your teeth?

ANS: A Symptoms of atrophic glossitis are caused by a decrease in vitamin B12, which results from lack of intrinsic factor secondary to surgical resection of a portion of the stomach. The nurse should check to see whether the client has been taking the prescribed multivitamin every day. The other questions will not help the nurse discover the cause of this finding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

While assessing an older adult client admitted 2 days ago with a fractured hip, the nurse notes that the client is confused, tachypneic, and restless. Which is the nurse's first action? a. Administer oxygen via nasal cannula. b. Apply restraints and ask for a sitter. c. Slow the IV flow rate. d. Discontinue the pain medication.

ANS: A The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Pain medication most likely would not cause the client to be restless. The IV rate is not related.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client's vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowler's position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

ANS: A The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowler's position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.

The nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast. Which instructions does the nurse provide to the client? a. "Drink plenty of fluids over the next few days." b. "Do not eat or drink anything for 6 hours after the test." c. "You may not drive or operate heavy machinery today." d. "Do not take any blood thinners for 24 hours after the test."

ANS: A The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon. Limiting the diet as the barium is being cleared is not necessary. The test will not make the client drowsy, so driving should not be limited. Similarly, blood thinners will not affect the client.

The nurse is teaching a client about self-management of gastroesophageal reflux. Which statement by the nurse is most appropriate? a. "Eat four to six small meals each day." b. "Eat a small evening snack 1 to 2 hours before bed." c. "No specific foods or spices need to be cut from your diet." d. "You may include orange or tomato juice with your breakfast."

ANS: A The client is instructed to eat four to six small meals daily rather than three larger meals to avoid pressure in the stomach and delayed gastric emptying, which can increase reflux. Evening snacks and acidic foods also should be avoided. The client should keep a diary to assess for foods or spices that increase symptoms, and those items need to be avoided.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I should refrigerate the GoLYTELY before use." d. "I will buy a case of Gatorade before the prep."

ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.

After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss.

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 liter of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.

A client diagnosed with primary bone sarcoma of the leg is scheduled for tumor removal. The client expresses fear of loss of function. Which is the nurse's best response? a. "It is normal to feel this way." b. "Physical therapy will assist you to regain function." c. "This surgery is better than an amputation." d. "This surgery is necessary to save your life."

ANS: A The client with bone cancer is expected to adjust to actual or impending loss with help. An expected outcome of nursing care includes the ability of the client to verbalize the reality of the loss and seek social support. The other responses do not reflect therapeutic communication techniques.

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the client's foods. d. Make the client NPO.

ANS: A The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.

A client just experienced an episode of reflux with regurgitation. What assessment by the nurse is the priority? a. Auscultate the lungs for crackles. b. Inspect the oral cavity. c. Check the oxygen saturation. d. Teach the client to sleep sitting up.

ANS: A The client with regurgitation is at risk for aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs for crackles—an indication of aspiration. If abnormalities are found, the nurse can then check the oxygen saturation. The nurse should teach the client to sleep with the head of the bed elevated, however; this is not a priority action. Inspecting the oral cavity probably is not needed.

19. The nurse is caring for a client who recently has undergone a partial gastrectomy. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurses priority action? a. Check the clients blood sugar level. b. Increase the clients IV infusion rate. c. Auscultate the clients bowel sounds. d. Place the client in high Fowlers position.

ANS: A The clients symptoms are consistent with late dumping syndrome, in which hypoglycemia is caused by increased insulin levels. The clients blood sugar level should be checked immediately. The other actions are not necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? a. Assess the client's coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.

ANS: A The first step in the nursing process is assessment. The nurse should assess coping skills and possible support systems that will be helpful in this client's treatment. Explaining that a limb salvage procedure will extend life does not address the client's psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the client.

The nurse is performing an assessment on a client admitted with a fractured left humerus. When the client moves the extremity, the nurse notes the presence of a grating sound. Which is the nurse's best intervention? a. Immobilize the arm. b. Perform range of motion. c. Monitor for other signs of infection. d. Administer steroids.

ANS: A The grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell him or her not to move the arm. The nurse should not move the extremity for range of motion. The grating sound does not indicate infection. Steroids would not be indicated.

A client has been diagnosed with early esophageal cancer. The nurse plans care by implementing measures designed to address which priority concern? a. Nutritional support b. Pulmonary toileting c. Fluid and electrolyte balance d. Educational needs

ANS: A The major concern for a client with esophageal cancer is weight loss secondary to dysphasia. Therefore, nutritional support is required, with intake monitored and weight maintained. The other concerns are important, but they are not the priority.

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output

ANS: A The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

15. The nurse is caring for a client with suspected upper GI bleeding. The nurse inserts a nasogastric (NG) tube for gastric lavage and checks placement of the tube in the stomach. When fluid is aspirated from the tube, the pH is found to be 6. Which is the priority action of the nurse? a. Obtain an order for a stat chest x-ray. b. Auscultate over the lung fields bilaterally. c. Assess whether the tube is coiled in the clients throat. d. Auscultate over the epigastric area while instilling air.

ANS: A The pH of gastric contents should be below 3.5. A stat chest x-ray should be obtained whenever any doubt arises regarding NG tube placement. The other methods are not appropriate for confirming placement. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Assessment)

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

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

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention? a. Assess pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Document the finding.

ANS: A The symptoms represent early warning of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible.

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? a. Assess the pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Loosen the traction.

ANS: A These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a provider's prescription.

A client is in the internal medicine clinic reporting bone pain. The client's alkaline phosphatase level is 180 units/L. What action by the nurse is most appropriate? a. Assess the client for leg bowing. b. Facilitate an oncology workup. c. Instruct the client on fluid restrictions. d. Teach the client about ibuprofen (Motrin).

ANS: A This client has manifestations of Paget's disease. The nurse should assess for other manifestations such as bowing of the legs. Other care measures can be instituted once the client has a confirmed diagnosis.

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best? a. Arrange a home safety evaluation. b. Ensure the client has a walker at home. c. Help the client look into assisted living. d. Refer the client to Meals on Wheels.

ANS: A This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the client's condition at discharge.

Which instruction does the nurse include in the discharge teaching plan of a client who has osteoporosis? a. "Avoid using scatter rugs." b. "Avoid weight-bearing exercises." c. "Use a cane when walking outside." d. "Reduce the amount of protein in your diet."

ANS: A To avoid falls, the client should keep a hazard-free environment, including avoiding scatter rugs, cluttered rooms, and wet floor areas. Weight-bearing exercises help prevent bone resorption. A cane is not needed unless the client has a physical disability. A protein deficiency should be avoided because it might cause a reduction in bone density.

The nurse is caring for a client 3 days after a below-knee amputation. Which is a priority intervention? a. Muscle-strengthening exercises b. Use of a very soft bed mattress c. Placing a pillow between the client's knees d. Placing the client in high Fowler's position

ANS: A To prepare for a prosthesis, the nurse instructs the client in muscle-strengthening exercises, provides the client with a firm mattress, and places the client in a prone position every 3 to 4 hours for 20 to 30 minutes to prevent flexion contractures. A pillow should not be placed between the client's knees.

An older woman is admitted after falling down the stairs. Which assessment findings require immediate intervention? (Select all that apply.) a. Blood pressure, 80/50 mm Hg b. Potassium, 6.0 mEq/L c. Dark brown urine d. Heart rate, 90 beats/min e. Urine output, 50 mL/hr

ANS: A, B, C Low blood pressure could indicate hypovolemia, which occurs with crush syndrome. Hyperkalemia and dark brown urine also may indicate crush syndrome. A heart rate of 90 beats/min is within normal limits; urine output of 50 mL/hr is also a normal finding.

A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.) a. Administer additional opioids as prescribed. b. Elevate the extremity on pillows. c. Apply ice to the fracture site. d. Place a heating pad at the site of the injury. e. Keep the extremity in a dependent position.

ANS: A, B, C The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will increase edema and may increase pain. Dependent positioning will also increase edema.

A client with a new fracture reports pain in the site of the fracture. An opioid pain medication was administered 20 minutes ago. Which is the nurse's best intervention? (Select all that apply.) a. Administration of additional opioids b. Elevation of the extremity c. Application of ice d. Application of heat e. Keeping the extremity in a dependent position

ANS: A, B, C The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Heat will increase edema and may increase pain. Dependent positioning will also increase edema. Administration of an additional opioid within the dosage guidelines may be ordered.

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.) a. "I just joined a gym, so I hope that helps me lose weight." b. "I sure hate to give up my coffee, but I guess I have to." c. "I will eat three small meals and three small snacks a day." d. "Sitting upright and not lying down after meals will help." e. "Smoking a pipe is not a problem and I don't have to stop."

ANS: A, B, C, D Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate, caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals. Tobacco is a risk factor for GERD and should be avoided in all forms.

A client has been discharged to an inpatient rehabilitation center after an esophagogastrectomy. What menu selections by the client at the rehabilitation center indicate a good understanding of dietary instructions? (Select all that apply.) a. Boost™ supplement b. Greek yogurt c. Scrambled eggs d. Whole milk shake e. Whole wheat toast

ANS: A, B, C, D Malnutrition is a serious problem after this procedure. The client needs high-protein, high-calorie foods that are easy to chew and swallow. The Boost supplement, Greek yogurt, scrambled eggs, and whole milk shake are all good choices. The whole wheat bread, while heart healthy, is not a good choice as it is dry and not easy to chew and swallow.

The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity e. Viral infections

ANS: A, B, C, D Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with Helicobacter pylori is.

The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia

ANS: A, B, C, D In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.

The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia

ANS: A, B, C, E Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

ANS: A, B, C, E Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.

The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? (Select all that apply.) a. Client is a white woman with a body mass index (BMI) of 19.4. b. Client fractured her wrist badly in a fall last year. c. Client drinks at least four cans of diet cola every day. d. Client does tai chi exercises for 45 minutes every morning. e. Client has smoked two packs of cigarettes a day for 40 years. f. Client has taken estrogen (Premarin) 0.625 mg daily since menopause.

ANS: A, B, C, E Risk factors for osteoporosis include white race, female gender, small body frame, large intake of caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that the client's bones may be soft and/or thin. Hormone replacement therapy, late onset of menopause, and regular exercise help reduce the risk of osteoporosis.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

The nurse is caring for a client who had an esophagectomy 3 days ago and was extubated yesterday. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assisting with position changes and getting out of bed b. Keeping the head of the bed elevated to at least 30 degrees c. Reminding the client to use the spirometer every 4 hours d. Taking and recording vital signs per hospital protocol e. Titrating oxygen based on the client's oxygen saturations

ANS: A, B, D The UAP can assist with mobility, keep the head of the bed elevated, and take and record vital signs. The client needs to use the spirometer every 1 to 2 hours. The nurse titrates oxygen.

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

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

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the client's patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

ANS: A, B, D Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care.

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.) a. Assess the daily serum calcium level. b. Consult the provider about a loop diuretic. c. Institute seizure precautions for the client. d. Instruct the client to call for help out of bed. e. Place the client on a 1500-mL fluid restriction.

ANS: A, B, D The client is exhibiting manifestations of possible hypercalcemia. This disorder is treated with increased fluids and loop diuretics. The nurse should assess the calcium level, consult with the provider, and instruct the client to call for help getting out of bed due to possible fractures and weakness. The client does not need seizure precautions or fluid restrictions.

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing.

Which interventions can the nurse delegate to unlicensed personnel when caring for a client with esophageal cancer? (Select all that apply.) a. Maintaining intake and output b. Maintaining calorie count c. Administering tube feeding d. Obtaining vital signs e. Teaching changes in daily activities f. Changing the incision dressing

ANS: A, B, D Unlicensed personnel can be responsible for charting fluid intake and output and food intake, keeping the calorie count, and taking/recording vital signs. They are not trained or allowed by law to assess, teach, or provide treatments.

A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client? (Select all that apply.) a. Electromyography b. Muscle biopsy c. Nerve conduction studies d. Serum aldolase e. Serum creatinine kinase

ANS: A, B, D, E Diagnostic testing for muscular dystrophy includes electromyography, muscle biopsy, serum aldolase and creatinine kinase levels. Nerve conduction is not related to this disorder.

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D

ANS: A, B, D, E Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.

A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.

ANS: A, B, D, E Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.

A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.

ANS: A, B, E After gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or iron deficiency. The nurse should provide supplements for all these nutrients. The client does not need enteral feeding or total parenteral nutrition.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures should the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

ANS: A, B, E External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.) a. Frequently assess the ergonomics of the equipment being used. b. Take breaks to stretch fingers and wrists during working hours. c. Do not participate in activities that require repetitive actions. d. Take ibuprofen (Motrin) to decrease pain and swelling in wrists. e. Adjust chair height to allow for good posture.

ANS: A, B, E Health promotion activities to prevent carpal tunnel syndrome include assessing the ergonomics of the equipment being used, taking breaks to stretch fingers and wrists during working hours, and adjusting chair height to allow for good posture. The client should be allowed to participate in activities that require repetitive actions as long as precautions are taken to promote health. Pain medications are not part of health promotion activities.

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

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

A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.

ANS: A, B, E When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed.

A client has a fractured tibia and is asking the nurse about external fixation. What are some advantages for the use of external fixation for the immobilization of fractures? (Select all that apply.) a. Leads to minimal blood loss b. Allows for early ambulation c. Decreases the risk of infection d. Increases blood supply to tissues e. Provides visualization of bone ends f. Promotes healing

ANS: A, B, F Blood loss is less. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does place the client at risk for infection and does not increase the blood supply to tissues, nor does it provide visualization of the ends of the bone.

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

ANS: A, C Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years

ANS: A, C The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.

The nurse is obtaining the history of a client with a sliding hernia. Which symptoms does the nurse expect to see in this client? (Select all that apply.) a. Reflux b. Bleeding c. Dysphagia d. Belching e. Breathlessness f. Vomiting

ANS: A, C, D Clients with sliding hernias often experience symptoms of reflux, pain, dysphagia, and belching. Some clients may experience breathlessness or a feeling of suffocation. Breathlessness after eating is a symptom of paraesophageal hernias. Bleeding should not be seen.

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Edema - Increased capillary permeability b. Pallor - Increased blood blow to the area c. Unequal pulses - Increased production of lactic acid d. Cyanosis - Anaerobic metabolism e. Tingling - A release of histamine

ANS: A, C, D Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.

After teaching a client with an anal fissure, a nurse assesses the client's understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.) a. Taking a warm sitz bath several times each day b. Utilizing a daily enema to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories e. Taking a laxative each morning

ANS: A, C, D Taking warm sitz baths each day, using bulk-producing agents, and administering anti-inflammatory suppositories are all appropriate actions for the client with an anal fissure. The client should not use enemas or laxatives to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil).

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. Chocolate b. Decaffeinated coffee c. Citrus fruits d. Peppermint e. Tomato sauce

ANS: A, C, D, E Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided.

A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Wash leafy vegetables carefully before eating or cooking them." b. "Do not ingest water from the garden hose or the pool." c. "Wash your hands before and after using the bathroom." d. "Be sure meat is cooked to the proper temperature." e. "Avoid eating eggs that are sunny side up or undercooked."

ANS: A, C, D, E Salmonella is usually contracted via contaminated eggs, beef, poultry, and green leafy vegetables. It is not transmitted through water in garden hoses or pools. Clients should wash leafy vegetables well, wash hands before and after using the restroom, make sure meat and eggs are cooked properly, and, because it can be transmitted by flies, keep flies off of food.

A client has jaundice and ascites. Which laboratory values indicate hepatic disease? (Select all that apply.) a. Albumin, 2.0 g/dL b. Potassium, 3.0 mEq/L c. Alanine aminotransferase (ALT), 45 IU/L d. Aspartate aminotransferase (AST), 45 U/L e. Unconjugated (indirect) bilirubin, 1 mg/dL f. Ammonia, 120 mg/dL

ANS: A, C, D, E, F Decreased albumin and increased ALT, AST, unconjugated bilirubin, and ammonia all indicate hepatic disease. When the liver is damaged, albumin is not produced by the hepatic cells. ALT and AST liver enzymes increase with liver disease. Bilirubin, the primary component of bile, can be measured as direct or indirect and, if elevated, can indicate impaired secretion. Elevated levels of ammonia indicate severe hepatocellular damage. Decreased potassium does not indicate possible liver involvement but can be reduced by vomiting and diarrhea.

The nurse performs percussion of a client's abdomen. Which findings may the nurse determine with this assessment technique? (Select all that apply.) a. Hepatomegaly b. Kidney stones c. Ascites d. Large mass below the liver e. Biliary colic f. Ileus

ANS: A, C, D, F Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with percussion.

A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Rotavirus is more common among infants and younger children." b. "Escherichia coli diarrhea is transmitted by contact with infected animals." c. "To prevent E. coli infection, don't drink water when swimming." d. "Clients who have botulism should be quarantined within their home." e. "Parasitic diseases may not show up for 1 to 2 weeks after infection."

ANS: A, C, E Rotavirus is more common among the youngest of clients. Not drinking water while swimming can help prevent E. coli infection. Parasitic diseases may take up to 2 weeks to become symptomatic. People with botulism need to be hospitalized to monitor for respiratory failure and paralysis. Escherichia coli is not transmitted by contact with infected animals.

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

ANS: A, C, E The client going home with chronic osteomyelitis will need long-term antibiotic therapy—first intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli

ANS: A, D Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.

A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this group's teaching? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.

A nurse teaches a client about prosthesis care after amputation. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "The device has been custom made specifically for you." b. "Your prosthetic is good for work but not for exercising." c. "A prosthetist will clean your inserts for you each month." d. "Make sure that you wear the correct liners with your prosthetic." e. "I have scheduled a follow-up appointment for you."

ANS: A, D, E A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the client's level of amputation, lifestyle (including exercise preferences), and occupation. In collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for ongoing assessment.

3. The nurse is caring for a client who will undergo a gastrectomy the following day. Which interventions are included in the postoperative plan of care for the client? (Select all that apply.) a. Monitor and record accurate intake and output (I&O). b. Remind the client to use the incentive spirometer twice daily. c. Change abdominal dressings daily using medical asepsis. d. Remind the client daily to use patient-controlled analgesia (PCA) before pain becomes severe. e. Keep the head of the clients bed elevated whenever possible. f. Irrigate the nasogastric tube with normal saline every 8 hours PRN.

ANS: A, D, E I&O should be recorded to monitor for fluid overload or deficit. Pain medication is most effective when taken before pain becomes severe. Keep the clients head of the bed elevated to prevent reflux. The spirometer should be used at least every hour to prevent atelectasis and pneumonia. Surgical asepsis (sterile technique) must be used for dressing changes and the site must be assessed each shift, necessitating a dressing change each shift.

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction.

A client reports that he has been passing black stools for the last few days. Which findings from the client's health history does the nurse consider as possible causes? (Select all that apply.) a. Cirrhosis b. Cholecystitis c. Hemorrhoids d. Diverticulitis e. Long-term use of NSAIDs f. Use of iron supplements

ANS: A, E, F Cirrhosis may cause black stools when bleeding occurs from esophageal varices. Long-term NSAID use may lead to gastric ulcer development and bleeding. Iron supplements may turn the color of the stool black. Hemorrhoids or diverticulitis would result in stools that are streaked with red. Cholecystitis may result in pale-colored stools if bile flow is obstructed.

A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met? a. Choosing foods that are easy to swallow b. Lungs clear after meals and snacks c. Properly performing swallowing exercises d. Weight unchanged after 2 weeks

ANS: B All these assessment findings are positive for this client. However, this client is at high risk for aspiration. Clear lungs after eating indicates no aspiration has occurred. Choosing easy-to-swallow foods, performing swallowing checks, and having an unchanged weight do not assess aspiration, and therefore do not indicate that the priority goal has been met.

A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best? a. Arrange an intensive care unit tour. b. Assess the client's psychosocial status. c. Document the teaching and response. d. Have the client begin nutritional supplements.

ANS: B Clients facing this long, difficult procedure are often anxious and fearful. The nurse should now assess the client's psychosocial status and provide the care and teaching required based on this assessment. An intensive care unit tour may help decrease stress but is too limited in scope to be the best response. Documentation should be thorough, but the nurse needs to do more than document. The client should begin nutritional supplements prior to the operation, but again this response is too limited in scope.

A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client? a. Enteral tube feeding b. Esophageal dilation c. Nissen fundoplication d. Photodynamic therapy

ANS: B Esophageal dilation can provide immediate relief of esophageal strictures that impair swallowing. Enteral tube feeding is a method of providing nutrition when dysphagia is severe, but esophageal dilation would be attempted before this measure is taken. Nissen fundoplication is performed for severe gastroesophageal reflux disease. Photodynamic therapy is performed for esophageal cancer.

A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective? a. "I can only take this medicine at night." b. "I should take this on a full stomach." c. "This drug decreases stomach acid." d. "This should be taken 1 hour before meals."

ANS: B Gaviscon should be taken with food in the stomach. It can be taken with meals at any time. Its mechanism of action is not to decrease stomach acid.

A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first? a. Notify the surgeon. b. Put on a pair of gloves. c. Reinsert the NG tube. d. Take a set of vital signs.

ANS: B To avoid exposure to blood and body fluids, the nurse first puts on a pair of gloves. Taking vital signs and notifying the surgeon are also appropriate, but the nurse must protect himself or herself first. The surgeon will reinsert the NG tube either at the bedside or in surgery if the client needs to go back to the operating room.

A client has a bone density score of -2.8. What action by the nurse is best? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months

ANS: B A T-score from a bone density scan at or lower than -2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.

A nurse assesses a client who is hospitalized for botulism. The client's vital signs are temperature: 99.8° F (37.6° C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take? a. Decrease stimulation and allow the client to rest. b. Stay with the client while another nurse calls the provider. c. Increase the client's intravenous fluid replacement rate. d. Check the client's blood glucose and administer orange juice.

ANS: B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. The nurse should monitor and document the IV infusion per protocol, but this client does not require additional intravenous fluids. Allowing the client to rest or checking the client's blood glucose and administering orange juice are not appropriate actions.

An adult client's susceptibility to osteoporosis is caused by which aspect of his or her history? a. Fractured arm at age 16 b. Active smoking c. Vitamin D supplements d. Weight lifting

ANS: B A history of smoking has been identified as a risk factor for osteoporosis. A history of low-trauma fracture after the age of 50 has been identified as a risk factor. Vitamin D and weight lifting are measures that can be used to prevent this disease.

The nurse is caring for a client with a lesion in the area of the tibia that is swollen and tender. Which client problem is the highest priority for nursing care? a. Need for increased calories related to increased metabolism b. Pain management related to physical injury c. Compromised self-care related to weakness d. Safety risk related to skeletal impairment

ANS: B A palpable mass and swelling in the area of the tibia are symptoms of osteochondroma, which is a common, benign bone tumor. Pain is the most common manifestation of a benign bone tumor. The other distractors are important, but pain management is the highest priority.

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

ANS: B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

A client who has undergone a fundoplication wrap for hernia repair has returned from the postanesthesia care unit with a nasogastric tube draining dark brown fluid. Which is the nurse's priority action? a. Assess the placement of the tube. b. Document the finding and continue to monitor. c. Clamp the nasogastric tube for 30 minutes. d. Irrigate the nasogastric tube with normal saline.

ANS: B After fundoplication, drainage from the nasogastric tube is initially dark brown with old blood. This finding is expected and requires only documentation. The drainage should become yellow-green within 8 hours after surgery.

An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.

ANS: B All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole.

When providing care for a client who has had a débridement for osteomyelitis, which intervention is most important for the nurse to implement? a. Assess the white blood cell count. b. Assess circulation in the distal extremities. c. Administer pain medication. d. Monitor temperature.

ANS: B All the interventions would be completed during care of this client. However, after resection of infected bone, neurovascular assessments must be done frequently because the client experiences increased swelling, which could cause neurovascular compromise.

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy.

Two hours after limb salvage surgery for a client with left leg bone sarcoma, the nurse notes that the toes of the left foot are more edematous, are cooler to the touch, and have a slower capillary refill. Which action does the nurse take first? a. Apply ice to the distal extremity. b. Check the splint for proper placement. c. Elevate the left foot. d. Loosen the pressure dressing.

ANS: B Assessment of the neurovascular status of the affected extremity should be performed every 1 to 2 hours after surgery. Splinting or casting the limb may cause neurovascular compromise and needs to be checked for proper placement. Applying ice will cause vasoconstriction, which will further impair blood flow. Elevation of the foot will similarly decrease circulation to the area.

An abdominal ultrasound is scheduled for the client. Which statement by the client indicates that the nurse's teaching about the procedure was effective? a. "The IV contrast may burn when it is injected." b. "I will drive myself home after the test is completed." c. "I will empty my bladder completely before the test." d. "I may have to take a laxative to pass the barium afterward."

ANS: B Because sedation is not used for this test, clients may drive themselves home after the abdominal ultrasound is completed. Barium and IV contrast are not needed. The client's bladder should be full for accurate visualization.

A client asks why a plaster cast is not applied to the fractured clavicle. Which is the nurse's best response? a. "Plaster will make the area too heavy for movement." b. "A splint or a bandage is sufficient to keep the bones in alignment." c. "Cloth braces are less likely to disrupt circulation." d. "Fractures to the upper body always heal more quickly."

ANS: B Because upper extremities do not bear weight, cloth splints are usually sufficient to immobilize the fracture. The other responses are not accurate for this type of fracture.

The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food

ANS: B Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the bodys circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.

The nurse is rounding on assigned orthopedic clients. The client with which type of fracture requires immediate interventions to prevent infection? a. Fractured clavicle b. Open fracture of the tibia c. Simple fracture of the wrist d. Compression fracture of a vertebra

ANS: B Bone infection or osteomyelitis is most common in clients with an open fracture because skin integrity is lost and organisms gain access easily. The nurse will remind all those who come into contact with the client to use good handwashing and will observe the wound daily for signs of infection. The other clients do not have extra risk factors for infection.

After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I will let my husband do all of the cooking for my family." b. "I'll take the ciprofloxacin until the diarrhea has resolved." c. "I should wash my hands with antibacterial soap before each meal." d. "I must place my dishes into the dishwasher after each meal."

ANS: B Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Clients can be carriers for up to 1 year.

The mother of a 16-year-old client diagnosed with Ewing's sarcoma expresses concern that her son seems to be angry at everyone in the family. How does the nurse respond? a. "You need to set limits with your son." b. "This is a normal stage in the grieving process." c. "He will be back to normal when he leaves the hospital." d. "This is typical behavior for a teenager."

ANS: B Clients often experience loss of control over their lives when a diagnosis of cancer (e.g., Ewing's sarcoma) is made. Clients may progress through the grieving process, which includes denial, followed by anger. Setting limits without understanding the grieving process can make the client feel that he has no control. The behavior is not typical of a teenager without the disease. It is part of the grieving process. The mother should not expect the son to return to "normal" when he goes home.

A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture

ANS: B Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.

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

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

A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs

ANS: B Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.

23. A client with Zollinger-Ellison syndrome will be admitted to the medical unit. Which intervention does the nurse include in the clients nursing plan of care? a. Performing a urine test for ketones every morning before breakfast b. Performing perineal care and applying a moisture barrier twice daily c. Assessing the abdomen for fluid wave and shifting dullness every 8 hours d. Keeping 2 units of packed red blood cells on hold at all times

ANS: B Clients with Zollinger-Ellison syndrome often experience severe diarrhea and steatorrhea, so the nurse should include careful perineal care in the plan of care. Abdominal fluid wave testing and shifting dullness checks for ascites, which is not seen with Zollinger-Ellison syndrome. Ketones are not associated with this condition either. Blood transfusions are not part of the typical management plan for clients with Zollinger-Ellison syndrome, and blood would not be kept on hand unless the client was bleeding. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortPersonal Hygiene) MSC: Integrated Process: Nursing Process (Planning)

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention should the nurse include in this client's plan of care? a. Place pillows between the client's knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

ANS: B Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.

Which statement indicates that the client understands the management of his or her sliding hiatal hernia? a. "I will lie flat for 30 minutes after each meal." b. "I will remain upright for several hours after each meal." c. "I will have my blood count done in 2 weeks to check for anemia." d. "I will sleep at night while lying on my left side to prevent reflux."

ANS: B Clients with hiatal hernia experience gastroesophageal reflux disease (GERD). Positioning is an important intervention. The client should be taught to sleep with the head of the bed elevated, to remain upright after meals for 2 to 3 hours, and to avoid straining or restrictive clothing. The other actions are not consistent with managing a sliding hiatal hernia.

12. The nurse is caring for a client who has just arrived in the emergency department reporting epigastric pain. The client says that emesis earlier in the day looked like coffee grounds. What does the nurse prepare to do for the client first? a. Check the clients stool for occult blood. b. Insert 18-gauge IV lines with normal saline infusions. c. Insert a nasogastric tube and prepare for gastric lavage. d. Determine whether the client has a history of ulcers.

ANS: B Coffee ground emesis is indicative of bleeding in which the blood has been partially digested by gastric acid. This client is at risk for hemorrhage and severe volume depletion and requires two large-bore IVs immediately. The client next will most likely need a saline lavage. Checking the stool and obtaining a history can be done later when the client is stable. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer? a. Older white client with irritable bowel syndrome b. Middle-aged African-American client who smokes cigars c. Middle-aged Asian client who travels and eats out frequently d. Older American Indian client taking hormone replacement therapy

ANS: B Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.

A nurse cares for an older adult client who has Salmonella food poisoning. The client's vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination.

ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of lower priority than fluid replacement. The nurse should teach the client about proper hand hygiene to prevent the spread of infection, and preparation of food and beverages to prevent contamination.

A client has been prescribed denosumab . What instruction about this drug is most appropriate? a. "Drink at least 8 ounces of water with it." b. "Make appointments to come get your shot." c. "Sit upright for 30 to 60 minutes after taking it." d. "Take the drug on an empty stomach."

ANS: B Denosumab is given by subcutaneous injection twice a year. The client does not need to drink 8 ounces of water with this medication as it is not taken orally. The client does not need to remain upright for 30 to 60 minutes after taking this medication, nor does the client need to take the drug on an empty stomach.

The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the client may have? a. Cirrhosis b. Splenomegaly c. Bowel obstruction d. Abdominal aortic aneurysm

ANS: B Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the client's left upper quadrant, indicating hepatomegaly. The nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic aneurysm.

13. The nurse is caring for a client who presents with chronic epigastric pain, heartburn, and anorexia. The client asks the nurse how the doctor can best determine whether the symptoms are caused by gastritis. Which is the nurses best response? a. You will be asked to drink a barium solution while x-rays are taken of your stomach. b. The doctor will take a look inside your stomach using a tube with a light on the end of it. c. A CT scan of your abdomen will show whether inflammation is present in your stomach. d. A blood sample will be sent to the laboratory to determine whether you have a stomach infection or bleeding.

ANS: B Endoscopy (esophagogastroduodenoscopy) with biopsy is the best method for diagnosing gastritis. Computed tomography (CT) scans, upper GI series, and blood samples are less accurate for making the diagnosis of gastritis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1222 TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning

An obese client has reflux and asks how being overweight could cause this condition. Which response by the nurse is best? a. "You eat more food, more often, than nonobese people do." b. "The weight adds extra pressure, which helps push stomach contents up." c. "Obese people tend to eat more high-fat food, which presents a risk." d. "Obesity is not related to reflux, but losing weight would be healthy."

ANS: B Esophageal reflux can occur when intra-abdominal pressure is elevated, or when the sphincter tone of the lower esophageal sphincter (LES) is decreased. Obesity can increase intra-abdominal pressure. The other statements are not accurate explanations of the connection between obesity and reflux.

A client with esophageal cancer is receiving radiation therapy. Which finding alerts the nurse to a possible complication in this client? a. Redness of the skin at the site of radiation b. Worsening of dysphagia or odynophagia c. Development of nausea or vomiting d. A profound feeling of tiredness

ANS: B Esophageal stricture is a complication of radiation therapy to the esophagus. This would manifest with worsening dysphagia or odynophagia. Redness is an expected result. Nausea and vomiting are common side effects, as is profound fatigue.

The nurse is caring for a client with rheumatoid arthritis. For which condition does the nurse assess most carefully? a. Dupuytren's contracture b. Hallux valgus c. Morton's neuroma d. Plantar fasciitis

ANS: B Hallux valgus deformity is a common foot problem in which the great toe deviates laterally at the first metatarsophalangeal joint. This condition often occurs as a result of poorly fitted shoes, family history, osteoarthritis, and rheumatoid arthritis. The other responses are not applicable to rheumatoid arthritis.

A client has Barrett's esophagus. Which client assessment by the nurse requires consultation with the health care provider? a. Sleeping with the head of the bed elevated b. Coughing when eating or drinking c. Wanting to eat several small meals during the day d. Chewing antacid tablets frequently during the day

ANS: B In Barrett's esophagus (a complication of gastroesophageal reflux disease [GERD]), fibrosis and scarring that accompany the healing process can cause esophageal stricture, leading to difficulty in swallowing. This can be manifested by coughing when the client eats or drinks and requires consultation with the health care team. The other assessments are typical of clients trying to control their GERD.

A client newly diagnosed with Ewing's sarcoma is most likely to exhibit which laboratory finding? a. Elevated red blood cells (RBCs) b. Elevated alkaline phosphatase (ALP) c. Decreased erythrocyte sedimentation rate (ESR) d. Decreased serum lactate dehydrogenase (LDH)

ANS: B In Ewing's sarcoma, laboratory results typically would demonstrate elevated alkaline phosphatase because of higher osteoblastic activity. Red blood cells would be low indicating anemia, the ESR would be elevated owing to tissue inflammation, and the LDH would be elevated as the cancer progresses.

The nurse is working with clients who have esophageal disorders. The nurse should assess the clients for which manifestations? (Select all that apply.) a. Aphasia b. Dysphagia c. Eructation d. Halitosis e. Weight gain

ANS: B, C, D Common signs of esophageal disorders include dysphagia, eructation, halitosis, and weight loss. Aphasia is difficulty with speech, commonly seen after stroke.

A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask? a. "Have you experienced any constipation?" b. "Have you had any stomach pain or indigestion?" c. "Have you had any difficulty swallowing?" d. "Have you noticed any weight loss lately?"

ANS: B Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be assessed for stomach pain or indigestion. This medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this medication

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

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

A client with severe gastroesophageal reflux disease (GERD) is still having symptoms of reflux despite taking omeprazole, (Prilosec) 20 mg daily. What does the nurse do next? a. Document the finding in the client's chart. b. Obtain an order for omeprazole twice daily. c. Instruct the client to double the daily dose. d. Tell the client to take antacids with omeprazole.

ANS: B Omeprazole is a proton pump inhibitor that acts to reduce gastric acid secretion. If once-daily dosing fails to control the client's symptoms, the nurse should obtain an order for the client to take omeprazole twice daily for better symptom control. This finding should be documented, but the nurse should do more than merely record the client's symptoms. Doubling the daily dose and adding antacids will not be as effective as obtaining an order for twice-a-day dosing.

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

A client had an open fundoplication 2 days ago. Which assessment by the nurse indicates that an important National Patient Safety Goal is being met for this client? a. The client uses the spirometer during the shift. b. The client's pain is monitored and treated. c. The client has vital signs taken routinely. d. The client verbalizes understanding of the discharge teaching.

ANS: B Pain must be monitored and aggressively treated after an open fundoplication because the high incision makes breathing very painful. If the client does not participate in deep-breathing exercises and will not use the spirometer, the chance of respiratory complications is quite high. National Patient Safety Goals include goals selected to reduce/prevent health care-related infection. Using the spirometer will help prevent pneumonia and atelectasis, but the client must use it hourly. Taking vital signs may help the nurse notice an infection but will not prevent the infection. Understanding discharge teaching is important, but preventing respiratory complications takes priority.

20. The nurse is caring for a client with advanced gastric cancer who is scheduled for palliative surgery to relieve gastric outlet obstruction. The client asks the nurse why he should bother having the surgery, because he will not be cured. Which is the nurses best response? a. It will allow the doctors to determine more accurately how long you have to live. b. It will relieve the obstruction so you will be more comfortable and able to eat again. c. It will remove much of the tumor so that chemotherapy will be more effective. d. It will help prevent the tumor from spreading to other parts of your body.

ANS: B Palliative surgery will relieve the gastric outlet obstruction and allow the client to eat again, thus improving quality of life. The surgery will not provide physicians with an accurate prognosis, make chemotherapy more effective, or prevent metastasis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications) MSC: Integrated Process: Caring

A client has returned to the nursing unit after a sliding hernia repair. Which action by the nurse is most important in preventing complications? a. Range of motion to the lower extremities b. Elevating the head of the bed to 30 degrees c. Monitoring input and output d. Assessing for bowel sounds

ANS: B Prevention of respiratory complications is the primary focus of postoperative care. The high incision makes taking deep breaths extremely painful for this client. By elevating the head of the bed to at least 30 degrees, the nurse promotes lung expansion in the client. The other activities are important too but do not take priority over preventing respiratory complications.

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

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

A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.

ANS: B Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond? a. "Your friends will be happy that you are alive." b. "Tell me more about your concerns." c. "A therapist can help you resolve your concerns." d. "With time you will accept your new body."

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client's concerns or provide false reassurance.

14. The nurse is caring for a client with a history of heart failure and chronic gastritis. The client tells the nurse about taking 2 teaspoons of sodium bicarbonate every night before going to bed to prevent heartburn. Which is the nurses best response? a. You should let the doctor know right away if you develop diarrhea. b. I will let your doctor know so a safer antacid can be prescribed for you. c. Do not take that with milk, because the combination can cause kidney stones. d. Make sure that you mix the sodium bicarbonate with at least 8 ounces of water.

ANS: B Sodium bicarbonate can cause fluid retention and edema, which can be dangerous for clients with heart failure. The provider should be notified so that an alternative antacid can be prescribed. The other statements do not reflect an accurate concern with sodium bicarbonate. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Implementation)

3. The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the clients abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? a. Place the client in a knee-chest position. b. Prepare the client for emergency surgery. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Assess the clients pain and administer analgesics.

ANS: B Sudden, sharp mid-epigastric pain is indicative of perforation, which is a surgical emergency. Pain medication should not be administered just now because the surgeon will need to assess the clients abdomen, and the client will need to sign an operative permit. The client may assume the knee-chest position in an attempt to relieve pain. The provider may order placement of an NG tube, but this would not take priority over getting the client ready for surgery. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action? a. Keep the client NPO (nothing by mouth). b. Check the client's gag reflex. c. Offer the client sips of clear liquids. d. Provide the client with a few ice chips.

ANS: B The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned.

A client has left-sided weakness. Which action by the client indicates that additional teaching about proper cane use is needed? a. Holding the cane in the right hand b. Advancing the cane while the right leg moves forward c. Stepping forward first with the right leg when ambulating d. Flexing the elbow 15 to 20 degrees when holding the cane

ANS: B The cane should be held on the strong right side so that it provides support for the weaker left side. The cane should be advanced with the opposite affected lower limb (the left leg for this client). The client should step forward with the strong right leg when ambulating. The elbow should be flexed 15 to 20 degrees when the client is holding the cane.

The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence does the nurse palpate the client's abdomen? a. Palpate the lower quadrants only. b. Palpate the upper quadrants last. c. Palpate the upper quadrants only. d. Defer palpation and use percussion only.

ANS: B The client with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the client from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. All quadrants should be palpated. Palpation is an important assessment tool that should not be deferred for this client.

The nurse is caring for a client with a fractured fibula. Which assessment prompts immediate action by the nurse? a. Reported pain of 4 on a scale of 0 to 10 b. Numbness and tingling in the extremity c. Swollen extremity where the injury occurred d. Reports of being cold in bed

ANS: B The client with numbness and tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Pain of 4 on a scale of 0 to 10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

ANS: B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse cares for a client who had a long-leg cast applied last week. The client states, "I cannot seem to catch my breath and I feel a bit light-headed." Which action should the nurse take next? a. Auscultate the client's lung fields anteriorly and posteriorly. b. Administer oxygen to keep saturations greater than 92%. c. Check the client's blood glucose level. d. Ask the client to take deep breaths.

ANS: B The client's symptoms are consistent with the development of pulmonary embolism caused by leg immobility in the long cast. The nurse should check the client's pulse oximetry reading and provide oxygen to keep saturations greater than 92%. Auscultating lung fields, checking blood glucose level, or deep breathing will not assist this client.

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation.

A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action? a. The client's blood pressure is 130/86 mm Hg. b. The traction weights are resting on the floor. c. Slight oozing of clear fluid is noted at the pin site. d. Capillary refill of the extremity is less than 3 seconds.

ANS: B The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. Slight oozing of clear fluid is normal as is the capillary refill time. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture.

A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds

ANS: B The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in bed. The client's blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.

The nurse is in the room of a client who is sleeping in bed. The client experiences an episode of reflux with regurgitation. Which action does the nurse take first? a. Have the client roll to the side. b. Raise the head of the client's bed. c. Auscultate the client's lung sounds. d. Call the Rapid Response Team.

ANS: B The immediate danger for this client is aspiration. The nurse first should raise the head of the bed to reduce this risk. Asking the client to roll to the side will take too much time. The nurse can auscultate the client's lungs after raising the head of the bed. Calling the Rapid Response Team may or may not be necessary but would be done after the client is in a safer position.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure will depress the clients gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the clients readiness for them.

A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. "Do you have family or friends for support?" b. "I'd like to know what you are feeling now." c. "Well, we knew this would probably happen." d. "Would you like me to refer you to hospice?"

ANS: B The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and "yes-or-no" questions are not therapeutic. Stating that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support.

After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best? a. Ask the family why they feel this way. b. Assess family concerns and fears. c. Refuse to go along with the family's wishes. d. Tell the family that such secrets cannot be kept.

ANS: B The nurse should use open-ended questions and statements to fully assess the family's concerns and fears. Asking "why" questions often puts people on the defensive and is considered a barrier to therapeutic communication. Refusing to follow the family's wishes or keep their confidence will not help move this family from their position and will set up an adversarial relationship.

A nurse cares for an older adult client with multiple fractures. Which action should the nurse take to manage this client's pain? a. Meperidine (Demerol) injections every 4 hours around the clock b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain d. Morphine 4 mg intravenous push every 2 hours PRN for pain

ANS: B The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.

The nurse is caring for an older adult client with multiple fractures. How does the nurse manage pain in this client? a. Meperidine (Demerol) injections every 4 hours rather than PRN b. Patient-controlled analgesia (PCA) pump with morphine c. Ibuprofen (Motrin) 600 mg every 4 hours d. IV morphine PRN

ANS: B The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.

The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action? a. Pink and warm to the touch b. Pale and cool to the touch c. Dark pink and dry to the touch d. Pink and slightly moist to the touch

ANS: B The skin flap should appear pink in a light-skinned person and not discolored in a darker-skinned person. The area should feel warm but not hot. Pale and cool skin could indicate inadequate blood flow to the area. The nurse would notify the provider.

A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best? a. "Slippery elm has no benefit for this problem." b. "Slippery elm is often used for this disorder." c. "There is no evidence that this will work." d. "You should not take any herbal remedies."

ANS: B There are several complementary and alternative medicine regimens that are used for gastritis and peptic ulcer disease. Most have been tested on animals but not humans. Slippery elm is a common supplement used for this disorder.

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.

ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority? a. Allow the client to rest in a position of comfort. b. Assess the client's cardiac and respiratory systems. c. Assist the client with ambulating and position changes. d. Position the client on one side propped with pillows.

ANS: B This degree of curvature of the spine affects cardiac and respiratory function. The nurse's priority is to assess those systems. Positioning is up to the client. The client may or may not need assistance with movement.

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size.

ANS: B This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurses priority action is to notify the provider.

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

A client is seen at the clinic with the medical diagnosis of osteomalacia. When taking the client's history, what does the nurse assess for? a. Arm and leg strength b. Dietary intake of vitamin D c. Dietary intake of calcium d. Exercise habits

ANS: B Vitamin D deficiency is the most important factor in the development of osteomalacia. Weak arm and leg strength may be seen, calcium deficiency plays a part in the disease process, and discomfort while exercising may be described. However, the most significant risk factor in this disease process is vitamin D deficiency.

Which exercise does the nurse recommend to a client at risk for osteoporosis? a. High-impact aerobics 45 minutes once weekly b. Walking 30 minutes three times weekly c. Jogging 30 minutes four times weekly d. Bowling for 1 hour twice weekly

ANS: B Weight-bearing, nonjarring exercises have been proved to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a client with osteoporosis. Walking would be the best choice as an exercise.

A female client who is a carrier of the gene for Duchenne's muscular dystrophy asks whether any of her daughters will have this disease. Which is the nurse's best response? a. "Both parents must have the defective gene." b. "Your daughter cannot get the disease." c. "Your daughters have a 50% chance of developing the disease." d. "Your daughters will become carriers of the gene."

ANS: B Women who are carriers have a 50% chance of passing the gene to their daughter, who then are carriers, and to their sons, who then have the disease. This type of muscular dystrophy affects only males. The other responses are not accurate.

A client with Paget's disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering ibuprofen (Motrin) b. Applying a heating pad c. Providing a massage d. Referring the client to a support group e. Using a bed cradle to lift sheets off the feet

ANS: B, C Comfort measures for Paget's disease include heat and massage. Administering medications and referrals are done by the nurse. A bed cradle is not necessary.

After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the client's understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. "I'll have my housekeeper keep my toilet clean." b. "I must take a shower or bathe every day." c. "I should have my well water tested." d. "I will ask my sexual partner to have a stool test." e. "I must only eat raw vegetables from my own garden."

ANS: B, C, D Parasitic infections can be transmitted to other people. The client himself or herself should keep the toilet area clean instead of possibly exposing another person to the disease. Parasites are transmitted via unclean water sources and sexual practices with rectal contact. The client should test his or her well water and ask sexual partners to have their stool examined for parasites. Raw vegetables are not associated with parasitic gastrointestinal infections. The client can eat vegetables from the store or a home garden as long as the water source is clean.

After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I must avoid dairy products to reduce gas and odor in the pouch."

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the client's skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the client's skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.

An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

ANS: B, C, E With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client's heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents.

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

Which referrals does the nurse make for an older adult client who is being discharged with esophageal cancer? (Select all that apply.) a. IV infusionist b. Home health aide c. Medicare or Medicaid d. Meals on Wheels e. Housecleaning service f. Transportation to and from treatment

ANS: B, D, F The outcome is to keep the client as independent as possible. Providing a home health aide will help the client with normal self-care activities, shopping, and light housework, so the client can reserve energy for essential activities. Meals on Wheels will provide nutritious meals within the client's dietary restrictions. It is essential for the client to maintain adequate intake despite dysphagia. Transportation to treatments and the physician's office is essential for maintaining the client's health. The client may or may not need home infusion therapy or full housekeeping services. The client may or may not be eligible for Medicare or Medicaid.

The nurse reviews the health history of a client with acute osteomyelitis. Which findings might have contributed to the diagnosis? (Select all that apply.) a. Recent dental work b. Urinary tract infection c. Pregnancy d. Age e. Hemodialysis f. Gastrointestinal infection

ANS: B, E, F Poor dental hygiene and gum infection (not necessarily recent dental work), urinary tract infection, hemodialysis, and Salmonella infection of the gastrointestinal tract can be sources of infection and, consequently, osteomyelitis. Pregnancy and advancing age are not necessarily precursors to osteomyelitis, even though urinary tract infection leading to osteomyelitis is common in older men.

Which symptom indicates a need for immediate intervention in a client with a rolling hernia? a. Reflux b. Crackles in the lungs c. Distended and firm abdomen d. Two episodes of diarrhea

ANS: C A rolling hernia causes the fundus and portions of the stomach's greater curvature to roll into the thorax next to the esophagus, predisposing the client to volvulus, obstruction, and strangulation. A firm, distended abdomen may indicate a bowel obstruction. This is a serious situation and the provider must be notified immediately. Crackles and diarrhea also warrant intervention, but not as a priority. Reports of reflux would be the lowest-level priority.

2. The nurse is caring for a client with a nasogastric (NG) tube after an episode of GI bleeding. Which interventions are included in the nursing care plan? (Select all that apply.) a. Monitor and record intake and output every 8 hours. b. Monitor hemoglobin and hematocrit laboratory values. c. Ensure that suction is set on high continuous for Levin tubes. d. Measure the clients girth and/or assess for distention daily. e. Pin the tube to the clients gown, so it cannot be dislodged. f. Check vital signs and orthostatic blood pressure every 4 hours and PRN.

ANS: B, E, F The client with an NG tube post-GI bleeding should have his or her hemoglobin and hematocrit monitored and the tube pinned to the clients gown so it cannot be dislodged; also, vital signs should be checked every 4 hours. Intake and output should be assessed and recorded every 4 hours or more often as needed. Suction should be set on low intermittent suction for Levin tubes. The client should be observed for distention when the nurse makes other assessments. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment)

A client is 1 day postoperative after having Zenker's diverticula removed. The client has a nasogastric (NG) tube to suction, and for the last 4 hours there has been no drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate? a. Document the findings as normal. b. Irrigate the NG tube with sterile saline. c. Notify the surgeon about this finding. d. Remove and reinsert the NG tube.

ANS: C NG tubes placed during surgery should not be irrigated or moved unless prescribed by the surgeon. The nurse should notify the surgeon about this finding. Documentation is important, but this finding is not normal.

A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client? a. Famotidine (Pepcid) b. Magnesium hydroxide (Maalox) c. Omeprazole (Prilosec) d. Ranitidine (Zantac)

ANS: C Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid.

A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene? a. Checking tube placement every 4 to 8 hours b. Monitoring and documenting drainage from the NG tube c. Pinning the tube to the gown so the client cannot turn the head d. Providing oral care every 4 to 8 hours

ANS: C The client should be able to turn his or her head to prevent pulling the tube out with movement. The other actions are appropriate.

A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? a. Client who underwent diverticula removal with a pulse of 106/min b. Client who had esophageal dilation and is attempting first postprocedure oral intake c. Client who had an esophagectomy with a respiratory rate of 32/min d. Client who underwent hernia repair, reporting incisional pain of 7/10

ANS: C The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared for.

The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment Vital Signs Physician Orders Skin dry Urine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hour Vital signs every hour Vancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best? a. Administer the prescribed pain medication. b. Consult the surgeon about a different antibiotic. c. Consult the surgeon about increased IV fluids. d. Have respiratory therapy reduce the respiratory rate.

ANS: C This client's vital signs, cardiac output, dry skin, and urine output indicate hypovolemia or possible hypotension resulting from pressure placed on the posterior heart during surgery. The client needs more fluids, so the nurse should consult with the surgeon about increasing the fluid intake. The client may be restless as a result of the hypotension and may not need pain medication at this time. There is no reason to request a different antibiotic. The respiratory rate does not need to be adjusted.

A client's susceptibility to osteomalacia is related to which risk factor? a. Calcium level of 11 mg/dL b. Diet high in milk and soy c. Phosphate level of 1.0 mg/dL d. Taking vitamin D supplements

ANS: C A low serum phosphate level predisposes a client to osteomalacia. The normal range is 2.5 to 4.5 mg/dL. Vitamin D supplements, diets high in vitamin D (e.g., milk and soy), and high calcium levels are not risk factors for osteomalacia.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure."

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider.

A client who had a plaster cast applied to the right arm 3 weeks ago presents to the clinic with an erythrocyte sedimentation rate (ESR) that has increased from 15 to 25 mm/hr. Which is the nurse's best action? a. Repeat this laboratory assessment in 4 hours. b. Have the cast reapplied. c. Evaluate temperature and vital signs. d. Obtain blood for a platelet count.

ANS: C A rise in the ESR during fracture healing suggests a bone infection or a fat embolism. The nurse should collect all other assessment data that can assist in confirming this diagnosis and then should notify the health care provider. Repeating the laboratory assessment, reapplying the cast, and assessing a platelet count would not be indicated.

A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate? a. Assess the client for iodine or shellfish allergies. b. Educate the client on the side effects of sedation. c. Inform the client a second scan may be needed. d. Teach the client about bowel preparation for the scan.

ANS: C A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.

The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client's abdomen, the nurse does not hear any bowel sounds. Which is the nurse's best action? a. Notify the health care provider. b. Percuss the abdomen. c. Document the finding. d. Insert a nasogastric tube.

ANS: C Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the client's record for later reference. The provider does not need to be notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may be performed but may be uncomfortable for the client and will not reveal the cause of the ileus.

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

A hospitalized client is being treated for Ewing's sarcoma. What action by the nurse is most important? a. Assessing and treating the client for pain as needed b. Educating the client on the disease and its treatment c. Handling and disposing of chemotherapeutic agents per policy d. Providing emotional support for the client and family

ANS: C All actions are appropriate for this client. However, for safety, the nurse should place priority on proper handling and disposal of chemotherapeutic agents.

A nurse answers a client's call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? a. Assist the client back to bed. b. Notify the provider immediately. c. Put on a pair of gloves. d. Take a set of vital signs.

ANS: C All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids.

A client has esophageal cancer. Which intervention by the nurse takes priority? a. Maintaining nutritional intake b. Allowing grieving c. Preventing aspiration d. Managing pain relief

ANS: C Although nutrition and pain are both high on the list of priorities, prevention of aspiration is the highest. When a client aspirates, his or her respiratory system is compromised, thereby causing further deterioration, which increases nutritional needs. Grieving, although also important, does not take priority over physical needs and safety.

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

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

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

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

The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure? a. "I may have gas and abdominal cramps after the test." b. "I will take strong laxatives the afternoon before the test." c. "I will take my Coumadin with a sip of water tomorrow morning." d. "I will take nothing by mouth after midnight on the day of the test."

ANS: C Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure.

A client has a metastatic bone tumor. What action by the nurse takes priority? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Handle the affected extremity with caution. d. Place the client on protective precautions.

ANS: C Bones invaded by tumors are very fragile and fracture easily. For client safety, the nurse handles the affected extremity with great care. Pain medication should be given to control pain. Elevation and heat may or may not be helpful. Protective precautions are not needed for this client.

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess? a. Inability to maintain adduction of the affected arm for more than 30 seconds b. Shoulder pain that is relieved with overhead stretches and at night c. Inability to initiate or maintain abduction of the affected arm at the shoulder d. Referred pain to the shoulder and arm opposite the affected shoulder

ANS: C Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience referred pain to the opposite shoulder. Pain is usually more intense at night and with overhead activities.

The client is being assessed for rotator cuff injury. Which physical assessment finding is consistent with this type of injury? a. The client is unable to maintain adduction of the affected arm at the shoulder for longer than 30 seconds. b. The client is able to raise the affected arm to shoulder height but feels pain on doing this maneuver. c. The client is unable to initiate or maintain abduction of the affected arm at the shoulder. d. The client has referred pain to the shoulder and arm opposite the affected shoulder.

ANS: C Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The other options are not descriptive of a rotator cuff injury.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurses first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

21. The nurse is caring for a client who will be discharged from the hospital following surgery for advanced gastric cancer. The clients daughter verbalizes the fear that she will not be able to manage her parents symptoms adequately at home. Which is the nurses best response? a. The nurses have taught you everything you need to know to care for your parent. b. Dont worry, the pain pills will keep your parent comfortable until the end. c. I will ask the social worker to arrange for a hospice nurse to help you at home. d. I will ask the health care provider to review the care instructions with you again.

ANS: C Hospice nurses can assist family members with caring for clients who are terminally ill. The nurse should not belittle the daughters concerns, nor should she ask the provider to review the discharge instructions again. The hospice nurse can provide not only physical care, but support for the family as they care for a loved one at home. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications) MSC: Integrated Process: Caring

Which factor places a client at risk for esophageal cancer? a. High-stress occupation b. Preference for high-fat foods c. 20-pack-year smoking history d. History of myocardial infarction

ANS: C In the United States, the two most important factors for the development of esophageal cancer are tobacco use and alcohol ingestion. The other factors do not increase the risk for developing esophageal cancer.

An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm3 but the client is afebrile. What action does the nurse take first? a. Administer acetaminophen (Tylenol). b. Educate the client on amputation. c. Place the client on contact isolation. d. Refer the client to the wound care nurse.

ANS: C In the presence of a heavily draining wound, the nurse should place the client on contact isolation. If the client has discomfort, acetaminophen can be used, but this client has not reported pain and is afebrile. The client may or may not need an amputation in the future. The wound care nurse may be consulted, but not as the first action.

The nurse is assessing a client with Paget's disease. Which assessment finding leads the nurse to notify the health care provider immediately? a. Client is 5 feet in height and weighs 130 pounds. b. Long bones of the legs and arms are bowing. c. Base of the skull is enlarged with changes in vital signs. d. Mild pain is present in the area of the hips and pelvis.

ANS: C It is common for the client with Paget's disease to be short in stature and to develop bowing of the long bones and mild to moderate pain, which often occurs in weight-bearing joints. When the skull becomes enlarged with basilar invagination, the brainstem may become damaged; this can threaten the vital sign center and life itself.

fter teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 grams of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."

ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. "Aspirin must be avoided." b. "Do not worry about black stools." c. "Report diarrhea to your provider." d. "Take 1 hour before meals."

ANS: C Maalox can cause hypermagnesemia, which causes diarrhea, so the client should be taught to report this to the provider. Aspirin is avoided with bismuth sulfate (Pepto-Bismol). Black stools can be caused by Pepto-Bismol. Maalox should be taken after meals.

For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)? a. Client taking antacids b. Client taking antibiotics c. Client who is pregnant d. Client over 65 years of age

ANS: C Misoprostol can cause abortion, so pregnant women should not take this drug. The other clients have no contraindications to taking misoprostol.

2. The nurse is caring for a female client who has just received a prescription for misoprostol . Which instructions does the nurse provide to the client regarding this medication? a. You may dissolve the contents of the capsule in warm water if it is difficult for you to swallow. b. Take this medication on an empty stomach just before going to bed every evening. c. You will need to stop taking your magnesium hydroxide (Mylanta) now that you are on this drug. d. You should add extra fiber to your diet because this medication may cause constipation.

ANS: C Misoprostol is a prostaglandin analogue. Clients on this medication need to avoid magnesium-containing antacids; Mylanta contains magnesium. Clients should not dissolve the pill, should take misoprostol with food, and do not need to take precautions against constipation while on this drug.

A client is admitted to the cardiac monitoring unit for a suspected myocardial infarction. The client reports long-standing nighttime reflux, and the health care provider orders nizatidine (Axid) 150 mg twice a day. Which action by the nurse is most appropriate? a. Consult with the health care provider because the dose is too high. b. Check the client's kidney function tests before administering the drug. c. Ask the pharmacist to recommend another histamine receptor agonist. d. Give the medication as ordered and monitor for effectiveness.

ANS: C Nizatidine, a histamine receptor agonist, can cause dysrhythmias. Because the client has a heart condition that may cause rhythm problems, the nurse should consult with the pharmacist for another drug in the same class to recommend to the provider. The dose is appropriate. Kidney function does not need to be monitored while on this drug. The nurse should monitor all drugs given for effectiveness, but this drug should not be given as prescribed.

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.

The nurse is teaching a client who has left leg weakness to walk with a cane. Which gait training technique is correct? a. Place the cane in the client's left hand and move the cane forward, followed by moving the left leg one step forward. b. Place the cane in the client's left hand and move the cane forward, followed by moving the right leg one step forward. c. Place the cane in the client's right hand and move the cane forward, followed by moving the left leg one step forward. d. Place the cane in the client's right hand and move the cane forward, followed by moving the right leg one step forward.

ANS: C Placing the cane in the client's left hand does not provide sufficient stability. After the cane in the right hand (stronger side) is moved ahead, the cane and the stronger leg provide a stable base for movement of the weaker leg. The other techniques are not correct.

A client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication? a. Erosion b. Bleeding c. Aspiration d. Odynophagia

ANS: C Regurgitation of stomach contents while the client is recumbent poses a risk of aspiration for the client.

The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which problem does the nurse anticipate for this client? a. Failure to absorb nutrients from the stomach b. Inability to digest protein c. Impaired ability to soften and break down food d. Difficulty swallowing food

ANS: C Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral cavity can result in reduction of saliva production. Radiation to the mouth will not impair swallowing, ability to digest protein, or ability to absorb nutrients from the stomach.

The nurse is caring for a client after arthroscopy surgery. Which intervention is a postoperative priority for this client? a. Passive range of motion on the involved knee b. Active range of motion on the involved knee c. Straight leg raises with the involved leg d. Immobilization of the leg

ANS: C Straight leg raises and quadriceps setting are started immediately after the client awakens from the anesthesia. These exercises are performed to strengthen the leg, prevent venous thromboembolism, and decrease swelling. Bending the affected knee and range of motion should not be done for several days. Immobilization will lead to additional complications.

The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor

ANS: C Sucralfate is a mucosal barrier fortifier (protector). It is not a gastric acid inhibitor, a histamine receptor blocker, or a proton pump inhibitor.

4. The nurse is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food after breakfast. Which intervention does the nurse prepare to provide for the client? a. Administer a soap suds cleansing enema. b. Change the clients diet to clear liquids only. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Administer prochlorperazine (Compazine) 10 mg IM.

ANS: C Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance. The client should remain NPO, and a soap suds cleansing enema is not indicated. Decompressing the stomach should alleviate the nausea, but if antiemetics are ordered, they would not take priority over decompressing the stomach. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation)

A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer? a. Cholesterol b. Serum lipase c. Carcinoembryonic antigen d. Xylose absorption

ANS: C The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine.

The nurse is caring for an older adult client who had leg amputation surgery the previous day. During the admission assessment, the client tells the nurse, "I don't want to live with only one leg, so I should have died during the surgery." Which is the nurse's best response? a. "Your vital signs are good, and you are doing just fine right now." b. "Your children are waiting outside and do not want to lose their parent." c. "Remember that you are still the same person inside, with a missing body part." d. "You will be able to do some of the same things as before you became disabled."

ANS: C The client feels like less of a person following the amputation, so the nurse should remind the client that he is still the same person inside. The nurse should not try to make the client feel guilty by saying that his children do not want to lose their parent. The nurse should not ignore the client's feelings by focusing on vital signs. The nurse should not refer to the client as being "disabled."

A nurse cares for an older adult client who is recovering from a leg amputation surgery. The client states, "I don't want to live with only one leg. I should have died during the surgery." How should the nurse respond? a. "Your vital signs are good, and you are doing just fine right now." b. "Your children are waiting outside. Do you want them to grow up without a father?" c. "This is a big change for you. What support system do you have to help you cope?" d. "You will be able to do some of the same things as before you became disabled."

ANS: C The client feels like less of a person following the amputation. The nurse should help the client to identify coping mechanisms that have worked in the past and current support systems to assist the client with coping. The nurse should not ignore the client's feelings by focusing on vital signs. The nurse should not try to make the client feel guilty by alluding to family members. The nurse should not refer to the client as being "disabled" as this labels the client and may fuel the client's poor body image.

A nurse cares for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication should the nurse administer first? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

ANS: C The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.

A client who has had an above-knee amputation of the right leg reports pain in the right foot. Which priority medication does the nurse administer? a. IV morphine b. 650 mg of acetaminophen c. IV calcitonin d. 600 mg of ibuprofen

ANS: C The client is experiencing phantom limb pain. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. The other medications will not assist in decreasing the client's pain.

A client who has undergone an open fundoplication hernia repair is preparing for discharge. Which information is most important for the nurse to include in discharge instructions? a. "You can take laxatives for constipation." b. "Eat three normal-sized meals daily." c. "Notify your health care provider if you get a cough." d. "You can go back to work in about a week."

ANS: C The client is instructed to report cold or flu-like symptoms because persistent coughing associated with these conditions can cause dehiscence of the incision in the early postoperative stage. Constipation can be caused by narcotic medications, but the client should be instructed to use fiber, water, and stool softeners first before using laxatives. The client must continue eating six small meals a day. After the open procedure, activity restrictions continue for up to 6 weeks.

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first? a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago b. Client taking ibandronate (Boniva) who cannot remember when the last dose was c. Client taking raloxifene (Evista) who reports unilateral calf swelling d. Client taking risedronate (Actonel) who reports occasional dyspepsia

ANS: C The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

A client has been diagnosed with carpal tunnel syndrome. Which intervention does the nurse question in the treatment of this injury? a. Ibuprofen 600 mg three times a day with meals b. Weekly injections of a corticosteroid by the physician c. Morphine 30 mg to be taken orally every 4 hours d. Use of a hand brace or splint during the day

ANS: C The client with carpal tunnel syndrome can be treated nonsurgically by administration of oral NSAIDs and corticosteroid injections. Most clients find relief with taking these medications and the use of a hand brace or splint to immobilize the wrist. The use of opioids such as morphine should not be necessary. NSAIDs and corticosteroids decrease inflammation and pain.

A client who had a long-leg cast applied last week reports to the clinic nurse, "I can't seem to catch my breath and I feel a bit lightheaded." Which is the priority action of the nurse? a. Listen to the client's lungs and check the client's blood glucose level. b. Give the client 2 L of oxygen via nasal cannula and check vital signs. c. Check the client's pulse oximetry and arrange emergency transfer to the hospital. d. Reassure the client that it takes much more effort to move with a long-leg cast.

ANS: C The client's symptoms are consistent with the development of pulmonary embolism (PE) caused by leg immobility in the long cast. The nurse should check the client's pulse oximetry reading and arrange for transfer to the hospital for further testing and treatment. The client should not be reassured that the symptoms are caused by exertion. The nurse can check vital signs, administer oxygen, and check the client's blood glucose level while waiting for transport to the emergency department.

A client is undergoing diagnostic testing for gastroesophageal reflux disease (GERD). Which test does the nurse tell the client is best for diagnosing this condition? a. Endoscopy b. Schilling test c. 24-Hour ambulatory pH monitoring d. Stool testing for occult blood

ANS: C The most accurate method of diagnosing gastroesophageal reflux disease is 24-hour ambulatory pH monitoring.

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

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

While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer, the client begins to cry. Which is the nurse's best response? a. "I am so sorry for making you cry!" b. "I will step out for a few minutes until you feel better." c. "I can see that you are upset about this. It is all right to cry." d. "I can see that I am upsetting you. Let's move on to something else."

ANS: C The nurse should recognize the client's feelings and should allow the client to cry. Moving on to another topic shows disregard for the client's feelings. The nurse should not leave the room but should stay to offer support. Apologizing to the client does not place the focus on the client or acknowledge the client's feelings and emotions in this situation.

nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond? a. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." c. "Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

A client is scheduled for a bone biopsy. What action by the nurse takes priority? a. Administering the preoperative medications b. Answering any questions about the procedure c. Ensuring that informed consent is on the chart d. Showing the client's family where to wait

ANS: C The priority is to ensure that informed consent is on the chart. The preoperative medications should not be administered until the nurse is confident the procedure will occur and the client has already signed the consent, if the medications include anxiolytics or sedatives or opioids. The provider should answer questions about the procedure. The nurse does show the family where to wait, but this is not the priority and could be delegated.

A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.

ANS: C This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT

ANS: C This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.

26. The nurse is to insert a nasogastric (NG) tube for a client with upper GI bleeding. Which instruction does the nurse give to the client before starting the procedure? a. You may take some sips of water when I begin to insert the tube into your nose. b. Please hold your breath when I insert the tube through your nose. c. Tilt your head down to your chest when the tube gets to the back of your throat. d. The distance from the end of your nose to your navel tells me which size tube to use.

ANS: C Tilting the head down toward the chest after the NG tube has reached the back of the throat will facilitate intubation of the esophagus rather than the trachea. The client should be encouraged to mouth-breathe and swallow during the procedure. The tube should be measured from the nose to the earlobe to the xiphoid process. Sips of water should be encouraged once the tube is at the back of the throat, not at the beginning of the procedure.

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. "Assess distal pulses for potential compartment syndrome." b. "Turn the client every 3 to 4 hours to promote cast drying." c. "Use a cloth-covered pillow to elevate the client's leg." d. "Handle the cast with your fingertips to prevent indentations."

ANS: C When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.

The nurse is caring for a client with a pelvic fracture. Which is the nurse's priority action to prevent complications? a. Monitor temperature daily. b. Insert a urethral catheter. c. Monitor blood pressure frequently. d. Turn the client every 2 hours.

ANS: C With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client's vital signs, skin color, and level of consciousness frequently to determine whether shock is occurring. The client may need a urethral catheter inserted at some point in time if voiding is a problem. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. The client should not be turned on his or her side unless the fracture is stabilized.

A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting

ANS: C, D Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk 30 minutes at least 3 times a week.

ANS: C, D, E Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics

ANS: C, D, E Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.

The nurse is caring for a client who has recently undergone a partial gastrectomy. The client asks the nurse which foods would be best for him to have for breakfast. Which menu items does the nurse recommend for the client?(Select all that apply.) a. Blueberry pancakes with maple syrup b. A half-grapefruit with a blueberry muffin c. Plain bagel with margarine or butter d. Raisin bran with milk and artificial sweetener e. Scrambled eggs with cheese and a slice of bacon f. One half cup of cottage cheese with canned pears

ANS: C, E, F Clients who have undergone gastrectomy surgery are at risk for dumping syndrome after meals. To help avoid dumping syndrome, clients should avoid concentrated sweets and fluids at mealtimes. Clients should choose foods that are relatively high in protein and fat, with relatively low carbohydrate content. Good choices are the bagel with butter or margarine, the scrambled egg breakfast, and the cottage cheese with unsweetened canned fruit. The pancakes and syrup are too sweet and have too many carbohydrates. The muffin is high in refined carbohydrates, and fresh fruit should be eaten with caution. Raisin bran is too high in fiber, and beverages (milk) should be taken between meals. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best? a. "Bacteria can often cause ulcers." b. "This operation often causes ulcers." c. "The medication keeps your blood pH low." d. "It prevents stress-related ulcers."

ANS: D After surgery, anti-ulcer medications such as pantoprazole are often given to prevent stress-related ulcers. The other responses are incorrect.

A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first? a. Document the findings in the chart. b. Notify the surgeon immediately. c. Reassess the drainage in 1 hour. d. Take a full set of vital signs.

ANS: D The drainage in the NG tube should initially be brown with old blood. The presence of bright red blood indicates bleeding. The nurse should take a set of vital signs to assess for shock and then notify the surgeon. Documentation should occur but is not the first thing the nurse should do. The nurse should not wait an additional hour to reassess.

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.

A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? a. "I will no longer need any medication for my GERD." b. "I will avoid spicy foods because they can irritate the suture line." c. "I should take anti-reflux medications when I eat a large meal." d. "I will need to continue to watch my diet and may still need medication."

ANS: D A high percentage of recurrence of reflux has been noted after this type of surgery, so clients are encouraged to continue anti-reflux regimens of medication and diet control. These include taking medications, eating small meals, and avoiding spicy or acidic foods.

Which client does the nurse assess most carefully for the development of gastroesophageal reflux disease? a. Client with atrial fibrillation who drinks decaffeinated coffee b. Client who has lost 20 pounds through diet and exercise c. Diabetic client taking oral hypoglycemic agents d. Postoperative client who has a nasogastric (NG) tube

ANS: D A nasogastric tube keeps the cardiac sphincter open, allowing acidic contents from the stomach to enter the esophagus. The other clients do not have increased risk for gastroesophageal reflux.

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2

ANS: D An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.

The nurse is caring for a client with an external fixator in place on the leg. What does the nurse assess for first? a. Alteration in skin integrity b. Impaired motor action c. Acute pain d. Signs of infection

ANS: D As long as the external fixator is in place, a direct connection is present between the external environment and the bone. The risk for infection is high. An expected alteration in skin integrity and a decrease in movement are noted. Acute pain would not be expected, but the client should be medicated for pain if necessary.

Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis? a. Amylase, 129 IU/L; alkaline phosphate, 45 U/L b. Reticulocyte count, 1%; magnesium, 1.5 mEq/L c. Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL d. Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL

ANS: D Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired. The other laboratory values are within normal limits and would not be expected with advanced cirrhosis.

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL b. Client who recently fell and has vertebral compression fractures c. Hypertensive client who takes calcium channel blockers d. Client with a spinal cord injury who cannot tolerate sitting up

ANS: D Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.

After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis

ANS: D Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.

The nurse is caring for several clients with fractures. Which client does the nurse consider at highest risk for developing deep vein thrombosis? a. Middle-aged woman with a fractured ankle taking aspirin for rheumatoid arthritis b. Young adult male athlete with a fractured clavicle c. Female with type 2 diabetes with fractured ribs d. Older man who smokes and has a fractured pelvis

ANS: D Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.

The nurse is performing an assessment of a client with suspected esophageal cancer. Which statement made by the client does the nurse correlate with advanced disease? a. "I have difficulty swallowing solids." b. "I usually have a sticking feeling in my throat." c. "I have difficulty swallowing soft foods." d. "I have difficulty swallowing liquids."

ANS: D Dysphagia is a common sign of esophageal cancer, but it often does not present until late in the disease. Clients first notice swallowing problems with solid foods, then liquids; they can even choke on saliva. Sometimes they have the feeling of food sticking in their throats.

Which client does the nurse assess more carefully for risk of developing primary osteoporosis? a. African-American client b. Resident of a nursing home c. Client who eats meat with every meal d. Client who drinks 6 cups of coffee daily

ANS: D Excessive consumption of caffeine and alcohol has been shown to be a risk factor for primary osteoporosis because of loss of calcium in the urine. Being white or Asian has been identified as causing a higher risk for developing osteoporosis at an earlier age compared with African-American ethnicity. Being a resident of a nursing home who is not exposed to sunlight could be a risk factor, but just being a resident does not predispose to osteoporosis. Meat is high in protein. Protein deficiency has been identified as a risk factor.

Which assessment finding relates most directly to a diagnosis of chronic osteomyelitis? a. Erythema of the affected area b. Swelling around the affected area c. Temperature higher than 101° F (38° C) d. Ulceration of the skin

ANS: D Fever, swelling, and erythema are far less common in chronic osteomyelitis, whereas ulceration, sinus tract formation, and localized pain are more characteristic.

A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.

ANS: D If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

6. The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? a. I will avoid drinking coffee, even if it is decaffeinated. b. I will take a multivitamin every morning with breakfast. c. I will go to my tai chi class to wind down after a busy day. d. I will take my medication every day until my heartburn is gone.

ANS: D Long-term medication compliance is crucial to eradicate Helicobacter pylori and prevent recurrence. The nurse stresses the importance of continuing medications for the entire time prescribed. Decaffeinated coffee is a better choice than caffeinated coffee for the client with peptic ulcer disease. Stress management should also be part of the treatment plan. Good nutrition is always important. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation)

The nurse is caring for a client who is at risk for developing gastritis. Which finding from the clients history leads the nurse to this conclusion? a. Client is lactose intolerant and cannot drink milk. b. Client recently traveled to Mexico and South America. c. Client works at least 60 hours per week in a stressful job. d. Client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.

ANS: D Motrin and other NSAIDs can cause gastritis, even if symptoms are not yet apparent. Stress, travel, and spicy foods do not increase the risk for gastritis. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Analysis)

17. The nurse is caring for a client with gastritis who will undergo a nuclear medicine GI bleeding study in the morning. What instruction for preparation does the nurse give the client? a. You cannot eat anything after midnight. b. You should drink several glasses of water in the morning. c. You must make arrangements for transportation home. d. No special preparations are required for this test.

ANS: D No special preparations are required for this test, so the client is not required to be NPO or to drink several glasses of water. Sedation is not used, so the client does not need to find transportation home. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1229 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Teaching/Learning

A client who had a wrist cast applied 3 days ago calls from home, reporting that the cast is loose enough to slide off. How does the nurse respond? a. "Keep your arm above the level of your heart." b. "As your muscles atrophy, the cast is expected to loosen." c. "Wrap an elastic bandage around the cast to prevent it from slipping." d. "You need a new cast now that the swelling is decreased."

ANS: D Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the client's skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the client's muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.

A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How should the nurse respond? a. "Keep your arm above the level of your heart." b. "As your muscles atrophy, the cast is expected to loosen." c. "I will wrap a bandage around the cast to prevent it from slipping." d. "You need a new cast now that the swelling is decreased."

ANS: D Often the surrounding soft tissues may be swollen considerably when the cast is initially applied. After the swelling has resolved, if the cast is loose enough to permit two or more fingers between the cast and the client's skin, the cast needs to be replaced. Elevating the arm will not solve the problem, and the client's muscles should not atrophy while in a cast for 6 weeks or less. An elastic bandage will not prevent slippage of the cast.

The nurse is performing an abdominal assessment on an older client. Which assessment finding does the nurse expect as a normal consequence of aging? a. Increased salivation and drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric acid production and heartburn d. Impaired sensation to defecate and constipation

ANS: D Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.

A nurse obtains the health history of a client with a fractured femur. Which factor identified in the client's history should the nurse recognize as an aspect that may impede healing of the fracture? a. Sedentary lifestyle b. A 30-pack-year smoking history c. Prescribed oral contraceptives d. Paget's disease

ANS: D Paget's disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.

The nurse is caring for a client with a fractured femur. Which factor in the client's history may impede healing of the fracture? a. A sedentary lifestyle b. A history of smoking c. Oral contraceptive use d. Paget's disease

ANS: D Paget's disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.

When preparing to care for a client with a family history of Paget's disease, it is most important for the nurse to include education in which area? a. Avoidance of infections b. Exercise program c. Nutrition high in vitamin C d. Need for genetic testing

ANS: D Paget's disease has been noted in up to 30% of people with a positive family history. Clients who have a history of this disease in their family should be taught the importance of genetic counseling. An exercise program may be started with the help of a physical therapist, but exercise may be difficult because of pain and danger of fracture. The diet should be rich in calcium and vitamin D.

The nurse has educated a client on Paget's disease. Which statement by the client indicates good understanding of causative factors? a. "It is caused by lack of calcium in my diet." b. "I probably had a fracture that caused it." c. "This disease occurs because of lack of exercise." d. "I may have a genetic predisposition."

ANS: D Paget's disease has been noted in up to 30% of people with a positive family history. The other responses are not accurate as a cause of Paget's disease.

A client 2 hours post-esophageal dilation develops increasing pain in the throat. Which is the best action of the nurse? a. Administer an analgesic. b. Document the finding. c. Reposition the client. d. Assess the client for perforation.

ANS: D Pain may be indicative of perforation, which is a known complication of dilation and requires immediate intervention. An analgesic should not be administered until the problem is diagnosed. Repositioning will not help the nurse determine what is wrong. Documentation should be done after the nurse finishes assessing the client.

22. The nurse is caring for a client who reports persistent epigastric pain, heartburn, and nausea, despite faithfully taking ranitidine (Zantac), aluminum hydroxide (Amphojel), and metronidazole (Flagyl) as prescribed. Which is the nurses best response? a. Is your pain better or worse after you eat? b. Have you tried elevating the head of your bed at night? c. Have you been taking the Amphojel and Flagyl together? d. Have you been experiencing foul-smelling diarrhea lately?

ANS: D Peptic ulcer disease (PUD) symptoms that are not alleviated by medications may indicate Zollinger-Ellison syndrome, a similar condition that is often refractory to treatment. A hallmark of Zollinger-Ellison syndrome is diarrhea and steatorrhea, with frothy, foul-smelling diarrhea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

The health care provider is prescribing medication to treat a client's severe gastroesophageal reflux disease (GERD). Which medication does the nurse anticipate teaching the client about? a. Magnesium hydroxide (Gaviscon) b. Ranitidine (Zantac) c. Nizatidine (Axid) d. Omeprazole (Prilosec)

ANS: D Proton pump inhibitors such as omeprazole are the main treatment for more severe cases of GERD. Gaviscon, Axid, and Zantac can be used to treat less severe cases.

A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse's best response? a. "Elevate your arm on two pillows and apply ice to the cast." b. "Continue to take ibuprofen (Motrin) until the swelling subsides." c. "It is normal for a new cast to feel a little tight for the first few days." d. "Please come to the clinic today to have your arm checked by the health care provider."

ANS: D Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and Motrin are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not just reassure the client that this is normal.

A phone triage nurse speaks with a client who has an arm cast. The client states, "My arm feels really tight and puffy." How should the nurse respond? a. "Elevate your arm on two pillows and get ice to apply to the cast." b. "Continue to take ibuprofen (Motrin) until the swelling subsides." c. "This is normal. A new cast will often feel a little tight for the first few days." d. "Please come to the clinic today to have your arm checked by the provider."

ANS: D Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse should not reassure the client that this is normal.

A client has undergone an esophagogastrostomy for cancer of the esophagus. How will the nurse best support the client's respiratory status? a. Assessing the client's breath sounds every 4 hours b. Performing chest physiotherapy every 6 hours c. Maintaining the client in a supine position d. Administering analgesia regularly

ANS: D Respiratory care is the highest postoperative priority. Incisional support and adequate analgesia are crucial for effective coughing and deep breathing. As long as vital signs are stable, the nurse administers analgesia regularly to assist the client in performing deep breathing, turning, and coughing routines. Assessing breath sounds is a vital nursing assessment but will not help support respiratory function. The client may or may not need chest physiotherapy. The client should not be kept in a supine position, but rather sit up in the chair and ambulate as much as possible.

A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first? a. Heart rate and rhythm b. Bowel sounds c. Urinary output d. Respiratory rate

ANS: D Severe infection with C. botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected C. botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

The RN has assigned a client with severe osteoporosis to an LPN. Which information about the care of the client is most important for the RN to provide the LPN? a. Provide passive range of motion (ROM) to all weight-bearing joints. b. Position the client upright to promote lung expansion. c. Place a pillow between the client's knees when in the side-lying position. d. Use a lift sheet to reposition the client.

ANS: D Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a client. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the client to promote lung expansion and positioning with a pillow for side-lying are important interventions for any client. The most important intervention for this client is to prevent bone fractures.

The nurse is assessing a client with a body cast. Which assessment finding indicates a complication that must be reported to the health care provider? a. Blood pressure, 130/85 mm Hg b. Urinary output, 40 mL/hr c. Redness around the edges of the cast d. Vomiting after meals

ANS: D The client in a body cast is monitored for cast syndrome, which results in intestinal obstruction. Vomiting after meals may indicate that this is occurring. Bowel sounds might be "normal" with this condition. The rest of the assessments are not related to cast syndrome.

24. A client has returned to the nursing unit after esophagogastroduodenoscopy (EGD). Which action by the nurse takes priority? a. Keep the client on strict bedrest for 8 hours. b. Delegate taking vital signs to the nursing assistant. c. Increase the IV rate to flush the kidneys. d. Assess the clients gag reflex.

ANS: D The client will receive moderate sedation and a numbing agent during the procedure. The client may temporarily lose his or her gag reflex; this should be checked before the client is permitted to eat anything by mouth. The client does not require strict bedrest for 8 hours or increased fluid to flush the kidneys. The nurse can delegate the taking of vital signs to unlicensed assistive personnel (UAP) such as the nursing assistant, but this is not the priority. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

A client has a fractured humerus. Which dietary choice indicates that the client understands the nutrition needed to assist in healing the fracture? a. Skim milk, vitamin D supplements, and fish b. Soy milk, vitamin B supplements, and bacon, lettuce, and tomato sandwich c. Whole milk, vitamin A supplements, and vegetable lasagna d. Low-fat milk, vitamin C supplements, and roast beef

ANS: D The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

ANS: D The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

A client with esophageal cancer and dysphagia states that it has become more difficult to swallow, and the client has experienced several choking episodes during meals. Which strategy would the nurse recommend to assist this client in obtaining adequate nutrition? a. Monitor caloric intake and weigh the client daily. b. Instruct the client to drink only clear liquids. c. Tell the client that artificial feeding will now be required. d. Encourage the client to eat semisoft foods and thickened liquids.

ANS: D The client with dysphagia usually is able to tolerate swallowing semisoft foods and/or thickened liquids to obtain adequate intake. Monitoring caloric intake and weighing the client are good for monitoring response to therapy but will not help the client obtain nutrition. Clear liquids alone may not provide enough calories or nutrients. Efforts are made to preserve swallowing ability as long as possible, although in the case of complete obstruction, a feeding tube may be necessary.

18. The nurse is caring for a client who has recently undergone a partial gastrectomy. The client reports becoming dizzy and sweaty with heart palpitations about 2 hours after eating. The client is now afraid to eat anything. Which is the nurses best response? a. Drink at least 6 ounces of fluid before each meal. b. Try a clear liquid diet for the next few days. c. You probably should avoid dairy products. d. Limit carbohydrate intake with meals.

ANS: D The clients symptoms are consistent with late dumping syndrome, which is caused by a rapid rise in insulin secretion in response to increased glucose levels after eating. Eliminating sugary foods and eating low to moderate carbohydrates with meals helps manage this problem. Liquids should be taken between meals. Clear liquids and limited dairy products are not needed. DIF: Cognitive Level: Comprehension/Understanding REF: p. 1236 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning

The nurse is caring for clients with above-knee amputations. Which client does the nurse treat first? a. Client who reports phantom limb pain b. Client who reports cramping c. Client who does not want to move the leg d. Client with regional pain syndrome

ANS: D The first priority in the management of clients with complex regional pain syndrome is pain relief. Pain can be of prolonged duration and will require pharmacologic and nonpharmacologic modalities for control. If this client is not treated immediately, prolonged pain may be triggered. The client with phantom limb pain would be the next priority. The client who does not want to move and the client with cramping would be treated after the clients with pain.

The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days post-esophagogastrostomy. Which is the nurse's priority intervention? a. Irrigate the NG tube with cold saline. b. Document the drainage in the chart. c. Reposition the tube in the opposite nostril. d. Assess the client's vital signs and abdomen.

ANS: D The initial nasogastric drainage appears bloody but should turn yellow-green by the end of the first postoperative day. If the bloody color continues, this may indicate bleeding at the suture line. The nurse should assess the client further, then should notify the provider. If the tube is draining, it is not necessary to irrigate it. Repositioning the tube will not change the drainage. In addition, repositioning the tube might cause more damage to the suture line.

A client is admitted with a large draining wound on the leg. What action does the nurse take first? a. Administer ordered antibiotics. b. Insert an intravenous line. c. Give pain medications if needed. d. Obtain cultures of the leg wound.

ANS: D The nurse first obtains wound cultures prior to administering broad-spectrum antibiotics. The nurse would need to start the IV prior to giving the antibiotics as they will most likely be parenteral. Pain should be treated but that is not the priority.

A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. "The pain you are feeling does not actually exist." b. "This type of pain is common and will eventually go away." c. "Would you like to learn how to use imagery to minimize your pain?" d. "How would you describe the pain that you are feeling?"

ANS: D The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must assess the client's pain before determining the best action.

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet.

A nurse assesses a client with a pelvic fracture. Which assessment finding should the nurse identify as a complication of this injury? a. Hypertension b. Constipation c. Infection d. Hematuria

ANS: D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.

A client has severe Paget's disease. Which factor has the highest priority when the nurse intervenes in the care of this client? a. Dietary education b. Exercise program c. Genetic testing d. Relief of pain

ANS: D The primary intervention for Paget's disease is drug therapy with pain management as a priority. This can be accomplished with various drugs and complementary measures. All the other options are treatments for Paget's disease. Pain management is the priority.

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next? a. Request a prescription to decrease the traction weight. b. Apply an antibiotic ointment and a clean dressing. c. Cleanse the area, scrubbing off the crusty areas. d. Obtain a prescription to culture the drainage.

ANS: D These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.

The nurse notes that the skin around the client's skeletal traction pin site is swollen, red, and crusty, with dried drainage. Which is the nurse's priority intervention? a. Decrease the traction weight. b. Apply a new dressing. c. Cleanse the area, scrubbing off the crusty areas. d. Culture the drainage.

ANS: D These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the client's stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample.

ANS: D To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.

A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the client's risk for infection? a. Wash the traction lines and sockets once a day. b. Release traction tension for 30 minutes twice a day. c. Do not place the traction weights on the floor. d. Schedule for pin care to be provided every shift.

ANS: D To decrease the risk for infection in a client with skeletal traction of external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the client's skin; these do not need to be washed. Although traction weights should not be removed or released for any period of time without a prescription, or placed on the floor, this does not decrease the risk for infection.

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? a. "Remove the traction when re-positioning the client." b. "Inspect the client's skin when performing a bed bath." c. "Provide pin care by using alcohol wipes to clean the sites." d. "Ensure that the weights remain freely hanging at all times."

ANS: D Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client's skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.

A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy

ANS: D Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical.

A client has an ingrown toenail. About what self-management measure does the nurse teach the client? a. Long-term antibiotic use b. Shoe padding c. Toenail trimming d. Warm moist soaks

ANS: D Treatment of an ingrown toenail includes a podiatrist clipping away the ingrown part of the nail, warm moist soaks, and antibiotic ointment if needed. Antibiotics are not used long-term. Padding the shoes will not treat or prevent ingrown toenails. Clients should not attempt to trim ingrown nails themselves.

A client who has been diagnosed with osteomyelitis is beginning antibiotic therapy. Which information does the nurse include in the client's teaching plan? a. Needing a consultation with a surgeon b. Continuing on Contact Isolation at home c. Remaining in the hospital for the rest of the treatment d. Receiving antibiotic treatment at home from the home health nurse

ANS: D Typically, osteomyelitis requires treatment with IV antibiotics for several weeks. The client will leave the hospital with a central IV catheter (PICC) for home infusion of the medication. Oral antibiotics usually follow the IV regimen for several more weeks. Surgical intervention is reserved for clients with chronic osteomyelitis if medication therapy is ineffective. Contact Isolation is needed only if the infection can be transmitted to another person when copious drainage is present.

After the administration of each dose of zoledronic acid (Zometa), it is most important for the nurse to determine which finding? a. Capillary refill b. Pain relief c. Level of consciousness d. Urine output

ANS: D Zoledronic acid is a bisphosphonate that helps protect bones and prevent fractures. Urine output and serum creatinine should be monitored because this drug can be toxic to the kidneys. Zometa does not relieve pain or affect capillary refill or level of consciousness.

A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching? a. Tuna salad on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed green beans, glass of apple juice c. Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon d. Grilled steak, green beans, dinner roll with butter, cup of coffee with cream

B Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

The nurse is caring for an older client with Salmonella food poisoning. Which is the priority action of the nurse? a. Monitor vital signs. b. Maintain IV fluids. c. Provide perineal care. d. Initiate Isolation Precautions.

B Dehydration can occur quickly in older clients with Salmonella food poisoning caused by diarrhea, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions, but are of lower priority than fluid replacement. Contact Isolation is not regularly instituted for Salmonella infection. Standard Precautions are usually sufficient.

A nurse is caring for a client hospitalized with botulism. The nurse obtains the following vital signs: temperature—99.8° F (37.6° C), pulse—100, respiratory rate—10 and shallow, and blood pressure—100/62 mm Hg. What action by the nurse is most appropriate? a. Allow the client rest periods without interruption. b. Stay with the client while another nurse calls the physician. c. Check the client's IV rate and document all findings. d. Help the client order appropriate food items from the menu.

B A client with botulism is at risk for respiratory failure. This client's respiratory rate is slow and shallow, which could indicate impending respiratory distress or failure. The nurse should remain with the client while another nurse notifies the provider. Nothing is allowed by mouth until all respiratory function and swallowing are normal. The nurse should monitor and document the IV infusion per protocol, but this does not take priority. Allowing the client to rest and ordering food items are not appropriate actions.

The nurse is caring for a client with severe ulcerative colitis who has been prescribed adalimumab (Humira). Which client statement indicates that additional teaching about the medication is needed? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with food or milk." c. "Nausea and vomiting are common side effects." d. "I will wash my hands after I play with my dog."

B Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.

The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse's priority action? a. Assess the client's vital signs. b. Determine the last time the client voided. c. Insert a rectal tube to facilitate passage of flatus. d. Document the findings in the client's chart.

B Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The client's vital signs may be checked after the nurse determines the client's last void. The nurse should document all findings and actions in the client's medical record.

The nurse is caring for a client who is having approximately 20 foul-smelling stools each day. Laboratory Gram stain testing indicates the presence of white blood cells (WBCs) and red blood cells (RBCs) in the stool. Which organism does the nurse expect to see in the culture report? a. Helicobacter pylori b. Campylobacter jejuni c. Clostridium botulinum d. Norwalk virus

B Campylobacter gastroenteritis causes foul-smelling diarrhea with up to 20 to 30 stools per day for 7 days. Both RBCs and WBCs are present in a Gram stain of the stools. Infection with Clostridium causes not diarrhea, but constipation, paralysis, and respiratory failure. H. pylori is a common cause of gastric ulcers, not gastroenteritis. Norwalk virus produces milder illness with diarrhea and vomiting.

The nurse provides discharge teaching for a client who was hospitalized for Salmonella food poisoning. Which client statement indicates that additional teaching is needed? a. "I will let my husband do the cooking for my family." b. "I will take the ciprofloxacin (Cipro) until the diarrhea has resolved." c. "I will wash my hands with antibacterial soap before and after each meal." d. "I will make sure that my dishes go straight into the dishwasher after each meal."

B Cipro should be taken for 10 to 14 days to treat Salmonella infection, and should not be stopped once the diarrhea has cleared. Clients should be advised to take the entire course of medication. People with Salmonella should not prepare foods for others because the infection may be spread in this way. Dishes and eating utensils should not be shared and should be cleaned thoroughly. Hands should be washed with antibacterial soap before and after eating to prevent spread of the bacteria. Clients can be carriers for up to 1 year.

The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes concerns that the effluent has not become formed and is still liquid green. Which is the nurse's best response? a. "I will call your health care provider right away because the stool should be semi-solid by now." b. "Your stools will firm up in a few weeks as your body gets used to the ileostomy." c. "You should eat a high-fiber diet to help make the stool bulkier and more solid." d. "You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks."

B Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to loss of the large bowel. This process takes time and the client should be reassured of this. Clients with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process.

A client underwent the first stage of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA). What topic is a high priority for the nurse to teach? a. Perineal care b. Ostomy care c. Nutrition therapy d. Relaxation techniques

B In the first stage of the RPC-IPAA procedure, the temporary ileostomy is created. Because the effluent is caustic, severe skin irritation can occur. The client needs good instruction on ostomy care and comfort measures. Perineal care is not needed because stool drains through the ostomy. Nutrition therapy and relaxation techniques are not as high a priority as preventing skin damage.

A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him? a. "This drug is investigational right now for irritable bowel syndrome." b. "Unfortunately, this drug is approved only for use in women." c. "Lubiprostone works well only in a small fraction of irritable bowel cases." d. "Let's talk to your health care provider about getting you a trial prescription."

B Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate.

The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone who had a similar experience. Which is the nurse's best response? a. "Most people who have had a colostomy are reluctant to talk about it." b. "I will make a referral to the United Ostomy Associations of America." c. "You can get all the information you need from the enterostomal therapist." d. "I do not think that we have any other clients with colostomies on the unit right now."

B Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the client's request by saying that no colostomy clients are present on the unit at the time.

The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Ask whether the client was riding in the front or back seat of the car.

B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

The nurse has taught self-care measures to a client with an anal fissure. Which action by the client requires the nurse to do additional teaching? a. Taking warm sitz baths several times daily b. Administering daily enemas to prevent constipation c. Using bulk-producing agents to aid elimination d. Self-administering anti-inflammatory suppositories

B The client should not use enemas to promote elimination, but rather should rely on bulk-producing agents such as psyllium hydrophilic mucilloid (Metamucil). The other actions are appropriate.

The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client? a. "Eat a low-residue diet for the first week after surgery." b. "Change the dressing every day until the staples are removed." c. "Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain." d. "Cough and deep breathe every 2 hours for the first week after surgery."

B The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line.

A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best? a. Have the client use the bedside commode. b. Stay with the client, providing privacy. c. Make sure toilet paper and the call light are in reach. d. Plan to send a stool sample to the laboratory.

B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation.

The nurse is preparing a client with diverticulitis for discharge from the hospital. Which statement by the client indicates that additional teaching is needed? a. "I will ride my bike or take a long walk at least three times a week." b. "I will try to include at least 25 g of fiber in my diet every day." c. "I will take a senna laxative at bedtime to avoid becoming constipated." d. "I will use my legs rather than my back muscles when I lift heavy objects."

C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.

The nurse has completed the teaching session for a client with a new colostomy. Which feedback statement by the nurse is the most appropriate? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority? a. A "left shift" in the white blood cell count b. White blood cell count, 22,000/mm3 c. Serum sodium, 149 mEq/L d. Serum creatinine, 0.7 mg/dL

B This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider's attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

The nurse is caring for a client with perineal excoriation caused by diarrhea from acute gastroenteritis. Which client statement indicates that additional teaching about perineal care is needed? a. "I will rinse my rectal area with warm water after each stool and then apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I will take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I will clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry.

The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? (Select all that apply.) a. "I will change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I will start bicycling and swimming again once my incision has healed." d. "I will notify the doctor right away if any bleeding from the stoma occurs." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I will avoid dairy products to reduce gas and odor in the pouch." g. "I will cut the flange so it fits snugly around the stoma to avoid skin breakdown."

B, C, G The client should avoid using soap to clean around the stoma because it might prevent effective adhesive of the ostomy appliance. The client should use warm water and a soft washcloth instead. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. Exercise (other than some contact sports) is important for clients with an ostomy.

The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the client's plan of care? a. Understanding colostomy care and lifestyle implications b. Learning how to change the appliance independently c. Demonstrating the correct way to change the appliance by discharge d. Not being afraid to handle the ostomy appliance tomorrow

C Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of "by discharge" is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. "Tomorrow" is a vague time frame.

A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurse's best response? a. "I will call and cancel the test for tomorrow." b. "You need two negative fecal occult blood tests." c. "This does not rule out the possibility of colon cancer." d. "You should wait at least a week to have the colonoscopy."

C A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC).

The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? a. Skin integrity b. Blood pressure c. Heart rate and rhythm d. Abdominal percussion

C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm.

The nurse is caring for an older client with gastroenteritis. Which order does the nurse consult with the health care provider about? a. IV 0.45% NS at 50 mL/hr b. Clear liquids as tolerated c. Diphenoxylate hydrochloride/atropine sulfate (Lomotil) orally, after each loose stool d. Acetaminophen (Tylenol), 325-650 mg orally every 4 hr PRN pain

C Lomotil can cause drowsiness and can increase the older client's risk for falls. The nurse should consult with the provider to see if this medication is really necessary and, if an antidiarrheal medication is warranted, what other options might be available. The other orders are appropriate, although the nurse would have to monitor the client's total 24-hour Tylenol dosage to ensure that the client did not receive more than 4000 mg/24 hr.

A client is brought to the emergency department with an abrupt onset of vomiting, abdominal cramping, and diarrhea 2 hours after eating food at a picnic. Which infectious microorganism does the nurse suspect as the probable cause? a. Salmonella b. Giardia lamblia c. Staphylococcus aureus d. Clostridium botulinum

C Staphylococcus can be found in meat and dairy products and can be transmitted to people. Food poisoning occurs, especially if foods are left unrefrigerated over a period of time. Symptoms of Staphylococcus food poisoning include sudden onset of vomiting, abdominal cramping, and diarrhea within 2 to 4 hours. The client's symptoms are not consistent with infection by the other microorganisms.

The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client? a. "You must fast for 12 hours before the test." b. "You will be given a cleansing enema the morning of the test." c. "You must avoid eating meat for 48 hours before the test." d. "You will be sedated and will require someone to accompany you home."

C The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test.

The nurse is caring for a client who is hospitalized with exacerbation of Crohn's disease. What does the nurse expect to find during the physical assessment? a. Positive Murphy's sign with rebound tenderness b. Dullness in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Abdominal cramping that the client says is worse at night

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

The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time? a. Ask the health care provider for a psychiatric consult for the client. b. Explain the improved prognosis for colon cancer with new treatment. c. Encourage the client to verbalize feelings about the diagnosis. d. Allow the client to remain withdrawn as long as he or she wishes.

C The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the client's withdrawal behavior.

The nurse is preparing to begin teaching the client about how to care for a new ileostomy. Which consideration is the highest priority for the nurse when planning teaching for this client? a. Informing the client about what to expect with basic ostomy care b. Starting the teaching after the client has received pain medication c. Starting the teaching when the client is ready to look at the stoma d. Making sure that all needed supplies are ready at the client's bedside

C The nurse should wait until the client is ready to look at the ostomy and stoma before initiating teaching about ostomy care. The nurse should monitor clues from the client and encourage him or her to start taking an active role in management. Effective learning will occur only when the learner is ready. The other considerations are of lower priority for the client and nurse.

The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that she cannot go to the prom with an ostomy. Which is the nurse's best response? a. "You should get your prom dress one size larger to hide the ostomy appliance." b. "You should avoid broccoli and carbonated drinks so that the pouch won't fill with air under your dress." c. "Let's talk to the enterostomal therapist (ET) about options for ostomy supplies and dress styles so that you can look beautiful for the prom." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings? a. The tumor has metastasized to the liver and biliary tract. b. The tumor has caused an intussusception of the intestine. c. The growing tumor has caused a partial bowel obstruction. d. The client has developed toxic megacolon from the growing tumor.

C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon.

A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse? a. Measure the abdominal girth. b. Place the client in a knee-chest position. c. Medicate the client with an opioid analgesic. d. Assess for bowel sounds and rebound tenderness.

D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.

The nurse is teaching a client how to care for a new ileostomy. Which client statement indicates that additional teaching is needed? a. "I will consult the pharmacist before filling any new prescriptions." b. "I will empty the ostomy pouch when it is half-filled with stool or gas." c. "I will wash my hands with antibacterial soap before and after ostomy care." d. "I will call my health care provider if I have not had ostomy drainage for 3 hours."

D A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6 to 12 hours. The other statements indicate good understanding of self-management.

A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? a. Draw blood for type and crossmatch. b. Start two large IVs for fluid resuscitation. c. Obtain vital signs and assess skin perfusion. d. Assess and maintain a patent airway.

D All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

The nurse is caring for a client who is taking mesalamine (5-aminosalicylic acid) (Asacol, Rowasa) for ulcerative colitis. The client has trouble swallowing the pill. Which action by the nurse is most appropriate? a. Crush the pill carefully and administer it to the client in applesauce or pudding. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Contact the client's health care provider to request an order for Asacol suspension. d. Contact the client's health care provider to request an order for Rowasa enemas instead.

D Asacol is enteric coated and should not be crushed, chewed, or broken. If the client is unable to swallow the Asacol pill, Rowasa enemas may be administered instead, with a provider's order. Asacol is not available as a suspension or elixir.

The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer? a. Young adult who drinks eight cups of coffee every day b. Middle-aged client with a history of irritable bowel syndrome c. Older client with a BMI of 19.2 who works 65 hours per week d. Older client who travels extensively and eats fast food frequently

D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.

The nurse is caring for a client who has food poisoning that may be the result of Clostridium botulinum infection. Which is the priority nursing assessment for this client? a. Heart rate and rhythm b. Bowel sounds and heart tones c. Fluid balance and urine output d. Oxygen saturation and respiratory rate

D Severe infection with Clostridium botulinum can lead to respiratory failure, so assessments of oxygen saturation and respiratory rate are of high priority for clients with suspected Clostridium botulinum infection. The other assessments may be completed after the respiratory system has been assessed.

The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client? a. Instruct the client to use dibucaine (Nupercainal) ointment whenever needed. b. Teach the client to choose low-fiber foods to make bowels move more easily. c. Tell the client to take his or her time on the toilet when needing to defecate. d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

D The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse.

The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? a. Monitor the client's hematocrit and hemoglobin. b. Position the client to allow gravity drainage of the fistula. c. Check and record blood glucose levels every 6 hours. d. Encourage the client to consume a diet high in protein and calories.

D The client with Crohn's disease is already at risk for malabsorption and malnutrition. Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining adequate nutrition is a priority for this client. The client will require 3000 calories per day to promote healing of the fistula. Monitoring the client's blood sugar and hemoglobin levels is important, but less so than encouraging nutritional intake. The client need not be positioned to facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? a. Potassium, 5.5 mEq/L b. Hemoglobin, 14.2 g/dL c. Sodium, 144 mEq/L d. Erythrocyte sedimentation rate (ESR), 55 mm/hr

D The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the client's liver was injured? a. Serum lipase, 49 U/L b. Serum amylase, 68 IU/L c. Serum creatinine, 0.8 mg/dL d. Serum transaminase, 129 IU/L

D The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.

The nurse helps a client with diverticular disease choose appropriate dinner options. Which menu selections are most appropriate? a. Roasted chicken, rice pilaf, cup of coffee with cream b. Spaghetti with meat sauce, fresh fruit cup, hot tea with lemon c. Chicken Caesar salad, cup of bean soup, glass of low-fat milk d. Baked fish with steamed asparagus, dinner roll with butter, glass of apple juice

D Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.