MED SURG Assessment 2

a nurse is providing teaching for a client who has GERD about ways to manage his condition. which of the following instructions should the nurse include?

eat 4 small meals each day -4-6 small meals per day

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?

elevated BUN

a nurse is interviewing a client who has acute pancreatitis. which of the following factors should the nurse anticipate finding in the client's history?

gallstones

a nurse is caring for a client with type 1 DM who reports feeling shaky and having palpitations. when the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he shoudl give the client which of the following?

graham crackers -pt having hypoglycemia, nurse should give client about 15g of rapid acting concetrated carbs, such as 4oz fruit juice, 8oz skim milk, 3 tsp sugar/honey, 3 graham crackers, or glucose tablets.

a nurse is assessing a client who has peptic ulcer disease. which of the following findings should the nurse identify as the priority?

hematemesis -massive bleeding

a nurse is reviewing the medical record of a client who has a peptic ulcer. which of the following findings should the nurse recognize as a risk factor for this condition?

history of NSAID use

a nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. then nurse should identify that the client is likely experiencing which of the following conditions?

hypoglycemia

a nurse is caring for a client who is receiving total parenteral nutrition and develops refeeding syndrome. the nurse should expect which of the following laboratory findings?

hypophosphatemia

a nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. which of the following actions is the nurse's priority?

increase the client's IV fluid rate

a nurse is reviewing the laboratory data of a client who has acute pancreatitis. the nurse should expect to find an elevation of which of the following values?

amylase

a nurse is caring for a client who has gastrointestinal bleeding. which of the following actions should the nurse take first?

assess orthostatic blood pressure

a nurse is providing teaching for a client who has experienced an acute episode of gastritis, what instruction should the nurse include in the teaching?

avoid drinking alcohol

a nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. which of the following information should the nurse include?

both are inflammatory

a nurse is providing teaching for a client who has a new diagnosis of GERD. the client asks about foods he should avoid eating. which of the following foods should the nurse tell him to avoid

chocolate -fatty and fried foods, chocolate, caffiene, alc, and carbonated drinks.

a nurse is caring for a client who has an active upper gastrointestinal bleed. after inserting a NG tube into the client, which of the findings should the nurse anticipate?

coffee-ground drainage - blood, effects of methemoglobin on the hemoglobin frothy pink drainage- incorrect tube placement dark amber- presence of gallbladder or bile duct problems greenish yellow- expected finding.

a nurse is providing dietary teaching to a client who has nephropathy secondary to diabetes mellitus and plans to make dietary adjustments. which of the following instructions should the nurse include?

consume less than 0.8 g/kg of body weight of protein per day.

a nurse is caring for a client who has suspected cholecystitis. the nurse should expect the client's urine to appear which of the following colors?

dark and foamy

a nurse is teaching a client who has a prescription of a NG to treat a pyloric obstruction. which of the following rationales for the use of the NGT should the nurse include in the teaching?

decompress the stomach

a nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. which of the following foods should be eliminated in the client's diet?

dried apricots

a nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. which of the following statements by the client indicates an understanding of the teaching?

"I will sleep with the HOB elevated"

a nurse is teaching about disease management for a client who has type 1 diabetes mellitus. which statement made by the client indicates an understanding of the teaching?

"i give the insulin injections in my abdominal area"

a nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. which of the following statements indicates to the nurse that the client understands the instructions?

"i will lie on my right side to sleep at night" -also elevate head about 10.2-30.5 cm(4-12 in)

a nurse is teaching a client about strategies to manage GERD. which of the following statements should the nurse include?

"lie on your right side when sleeping"

a nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. which of the following instructions should the nurse include?

"maintain stable glucose levels"

a nurse is teaching a client who is taking metformin XR for type 2 DM. which of the following instructions should the nurse include in the teaching?

"take the medication with a meal"

a nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. after administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?

0745 - regular insulin should be given 20-30 min before eating because onset action is 30 minutes.

a nurse is providing teaching to a client who has diabetes mellitus about carb intake needs when exercising. which of the following foods should the nurse include as containing a 15 g serving of carb?

1 cup milk

a nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for a client who has GERD. Available is famotidine 40 mg/5mL. How many mL should the nurse administer? (round nearest tenth)

2.5 mL

a nurse is caring for a client who has cancer and is receiving total parenteral nutrition(TPN). which of the following lab values indicates the treatment is effective?

albumin 4.2 g/dL -clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain.

a nurse is caring for a client who has DKA. which of the following manifestations should the nurse expect?

acetone order to breath -lack of insulin, bodys unable to use glucose and instead breaks down fats resulting in excessive ketones. the large amount of ketones causes the body to become acidic and causes a fruity, or acetone order to the breath.

a nurse is planning care for a client who has cirrhosis of the liver. which of the following actions should the nurse include in the plan? SATA

administer furosemide implement a low-sodium diet measure the client's abdominal girth

a nurse admits a client to the ED who reports nausea and vomiting that worsens when he lies down. Antacids do not help. the provider suspects acute pancreatitis. which of the following laboratory test results should the nurse expect to see?

increased serum amylase -rises within 24 hr of symptoms.

a nurse is preparing to administer lispro insulin to a client who has type 1 DM. which of the following actions should the nurse take?

inject the insulin 15 min before a meal

a nurse is caring for a client who has type 1 DM. the nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. which of the following actions is the nurse's priority?

monitor the client for hypoglycemia

a nurse is caring for a client who is postop following abdominal surgery. which of the following findings should indicate to the nurse the client's peristalsis is returning?

passage of flatus

a nurse is assessing a client who has advanced cirrhosis. which of the following manifestations should the nurse expect?

petechiae

a nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the ED confused, flushed, and with an acetone odor on the breath. Diabetic ketacidosis is suspected. the nurse should anticipate using which of the following types of insulin to treat this client?

regular insulin -classified as short-acting insulin. can be givin through IV with an onset action of less than 30 min.

a nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. which of the following actions should the nurse take first?

review the client's electrolyte values.

a nurse is caring for a client who has chronic kidney disease (CKD) and states she has heartburn. the provider prescribes aluminum hydroxide. the client asks, "why can't i just take the antacid magaldrate my husband has at home?" the nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following?

serum phosphorus levels

A nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes mellitus. The nurse should explain that which of the following sweeteners will add calories to the client's carbohydrate count?

sorbitol

a nurse is assessing a client who has cirrhosis. which of the following is an expected finding for this client?

spider angiomas

A nurse is caring for a client who has peptic ulcer disease. The nurse knows the monitor the client for which of the following findings as an indication of the complication of gastrointestinal perforation?

sudden abdominal pain

a nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. which of the following findings should the nurse expect?

weak, irregular pulse

a nurse is caring for a client who has uncontrolled type 1 DM. which of the following findings should the nurse expect?

weight loss