MedSurg Exam #6

The nurse reinforces that the immunization for HBV is believed to provide _____ immunity.

ANS: lifelong lifetime The vaccine for hepatitis B produces immunity in about 95% of vaccinated individuals and is administered in three or four doses for probable lifetime immunity (Buggs, 2012).

The basic functional unit of the kidney is the ________.

ANS: nephron The nephron is the functional unit of the kidney, housing the glomerulus and the collecting tubules. Each kidney has approximately 1 million nephrons.

The nurse explains that the urge to void occurs when the bladder contain as little as ______ mL of urine.

ANS: 150 The bladder will transmit the urge to void with a bladder content as little as 150 mL of urine.

The nurse demonstrates that the person whose recommended weight is 150 pounds based on height, age, and body type would be considered obese if the person weighed a minimum of ______ pounds.

ANS: 180 A person is considered obese if his or her weight exceeds 20% of the recommended weight for his or her height, age, and body type. (Recommended weight of 150 pounds ´ .20 is 30 pounds; 150 pounds + 30 pounds = 180 pounds.)

The nurse is aware that 80% of UTIs in females are the result of contamination from __________.

ANS: Escherichia coli E. coli Proximity of the urethral meatus to the anus makes contamination with Escherichia coli a frequent cause of infections.

The nurse caring for the patient who has diarrhea from taking a protocol of oral amoxicillin will use __________ Precautions in the care.

ANS: Standard The diarrhea caused by medications is not infectious and should be dealt with using Standard Precautions.

The nurse cautions that increased morbidity from hypertension and cardiac disease, even in children, is related to the modifiable risk factor of __________.

ANS: obesity Obesity contributes to the morbidity of hypertension and cardiac disease. There are 300,000 deaths a year attributed to hypertension and cardiac diseases in the obese.

The nurse explains that bile salts deposited in the skin cause jaundice and also cause _____.

ANS: pruritus Bile salts deposited in the skin cause both jaundice and pruritus.

The mechanical bowel obstruction caused when the bowel twists on itself is known as _________.

ANS: volvulus Volvulus, the bowel twisting on itself, causes a mechanical bowel obstruction that must be reduced immediately to prevent necrosis to the bowel from ischemia.

The nurse is educating a group of patients about high-fiber dietary selections. Which patient menu selection indicates that the nurse's teaching has been successful? a. Turkey sandwich on whole wheat toast, pears, and tea b. Grilled chicken, corn, and water c. Cheese pizza, salad, and milk d. Bacon, lettuce, and tomato sandwich on sourdough, blackberry compote, and orange juice

ANS: A A high-fiber diet is encouraged for the patient with diverticular disease. Eating whole-grain cereals and breads, as well as fruits such as apples, seedless berries, peaches, and pears adds fiber. High-fiber vegetables—squash, broccoli, cabbage, and spinach—and legumes, including dried beans, peas, and lentils, provide bulk that decreases constipation and speeds the transit time in the intestine. The meal with a turkey sandwich on whole wheat bread and pears is the only meal choice with multiple high-fiber foods (bread and pears).

The nurse is educating a patient with inflammatory bowel disease (IBD) about recommended nutritional choices. Which statement indicates that the nurse's teaching has been successful? a. "I should try to eat foods like white rice and lean poultry." b. "I should avoid red meats and eat large amounts of whole grains." c. "I should eat food that is mushy in consistency." d. "I should increase my intake of green leafy vegetables."

ANS: A A low-fat, low-fiber, high-protein, high-calorie diet is recommended for the patient with IBD to make up for the loss of fluid and nutrients in the frequent stools. Low-fat, low-fiber, high-protein, high-calorie foods include foods like white grains or starches and lean, tender meats. Whole grains are extremely high in fiber and should be avoided. A soft diet is not indicated. Green leafy vegetables are a rich source not only of vitamin K, but also of fiber.

Which causative agent is the primary cause of Barrett esophagus? a. Gastroesophageal reflux disease (GERD) b. Eating hot, spicy foods c. Anorexia nervosa d. Esophageal polyps

ANS: A A major cause of Barrett esophagus is esophageal reflux.

The nurse is caring for a patient who is postoperative after esophageal resection. Shortly after the nurse starts a feeding, the patient suddenly becomes dyspneic and complains of substernal pain. What should the nurse do first? a. Stop the feeding. b. Ambulate the patient. c. Notify the charge nurse. d. Reassure the patient.

ANS: A After esophageal resection, pain, increased temperature, and dyspnea may indicate leakage of the feeding into the mediastinum. The nurse should immediately discontinue the feeding, then notify the charge nurse and address any patient concerns. Ambulation is not indicated at this time; ambulation is an intervention to address gas pains.

The nurse is caring for a patient who is complaining of postoperative gas pain. What intervention should nurse implement? a. Assist the patient with ambulation. b. Apply a cold compress on the abdomen. c. Offer a cup of coffee or tea. d. Offer chilled vegetable juice.

ANS: A Ambulation is the most effective method for helping a patient expel gas. Hot or cold beverages and cold compresses will increase gas.

The nurse is educating a patient who has gastroesophageal reflux disease (GERD) about dietary modification. Which information is most important for the nurse to include in the teaching plan? a. Avoid highly seasoned or spiced foods. b. Drink ginger ale or lemon lime soda rather than cola. c. Use a straw to drink all fluids. d. Eating three meals spaced evenly apart.

ANS: A Avoiding highly seasoned or spicy food should be incorporated into diet changes for the patient with GERD. The avoidance of carbonated beverages with meals and the use of a straw do not reduce the impact of GERD. The frequency of dietary intake does not influence GERD

The nurse is caring for a 50-year-old female who presented to the emergency department after being involved in a motor vehicle collision. The patient displays marked tenderness and spasm in the suprapubic area and a nonpulsating mass. The nurse anticipates that this patient will undergo additional workup for which complication? a. Bladder trauma b. A damaged kidney c. A urethral tear d. Ruptured spleen

ANS: A Bladder traumas signal themselves with pain, spasm, and a mass in the suprapubic area. These findings are not consistent with a damaged kidney, urethral tear, or splenic rupture.

Which statement best indicates that the patient understands teaching about dietary restrictions in glomerulonephritis? a. "I should avoid canned soups and hot dogs." b. "I should drink more water." c. "I should eat more meat and cheeses." d. "I should not eat fresh produce."

ANS: A Care of the patient with glomerulonephritis may include a sodium-restricted diet if edema is present. Canned soups and processed meats are high in sodium. Fluids may be limited if there is oliguria (diminished urine secretion in relation to intake) or anuria (absence of urine). A low-protein, high-carbohydrate diet also may be ordered, so the patient should not increase meat intake. Fresh produce is not contraindicated for this patient.

The nurse is caring for a patient who received an instillation of doxorubicin (Adriamycin) into the bladder for treatment of cancer in situ. What should the nurse do next? a. Reposition the patient every 15 to 30 minutes. b. Unclamp the catheter. c. Educate the patient about the possibility of false positive tuberculin skin testing. d. Apply nonslip footwear for ambulation.

ANS: A Doxorubicin (Adriamycin) has been found to help patients with bladder carcinoma in situ (site of origin) by reducing tumor recurrence and by eliminating residual malignant cells after surgery. The solution is instilled into the bladder via a urinary catheter. The patient should change position every 15 to 30 minutes, and the catheter is clamped for 2 hours. The nurse should not unclamp the catheter. While it is important to educate the patient about potential for positive PPD tests, education should be done at a time when the patient can focus on the information. Ambulation is not appropriate at this time.

For which patient should the nurse question an order for esomeprazole (Nexium)? a. A 55-year-old female who takes digoxin b. A 52-year-old male who is noncompliant c. A 38-year-old female who has asthma d. A 56-year-old male who has epistaxsis

ANS: A Esomeprazole (Nexium) interferes with the absorption of digoxin, rabeprazole, and iron salts. In addition, the Food and Drug Administration (FDA) has issued a warning that long-term use of the proton pump inhibitors esomeprazole (Nexium) or omeprazole (Prilosec) may increase the risk of heart problems.

The nurse is talking with a patient who has been experiencing nausea and vomiting. The patient indicates an interest in using alternative therapies for the condition. Which product may aid in nausea management? a. Ginger b. Ginseng c. Chamomile d. Soy

ANS: A Ginger has been used for centuries in Asia to combat nausea and vomiting, motion sickness, and dyspepsia. It is available candied in capsules, fluid extract, and tablets, and tincture or as fresh ginger root that can be grated and used to make tea. Ginger may decrease the action of histamine (H2) receptor antagonists and proton pump inhibitors and may increase absorption of medications taken orally. Ginger may decrease the effect of antidiabetic medications. It should not be used during pregnancy or lactation.

The nurse is caring for a child suspected of having acute glomerulonephritis. When reviewing the health history, which finding is most concerning to the nurse? a. Recent upper respiratory infection b. Recent outpatient surgery c. History of asthma d. Recent history of gastroenteritis

ANS: A Glomerulonephritis is primarily seen in children and young adults, and affects males more than females. It most commonly occurs about 2 to 3 weeks after a group A beta-hemolytic streptococcal infection, such as "strep throat" or impetigo; however, it can occur in response to bacterial, viral, or parasitic infections elsewhere in the body. Outpatient surgery, asthma, and gastroenteritis are not risk factors for glomerulonephritis.

The nurse explains that when the kidney suffers an autoimmune inflammatory reaction, the glomeruli lose their ability to function effectively. The nurse is describing the etiology of which problem? a. Glomerulonephritis b. Renal calculi c. Hydronephrosis d. Acute pyelonephritis

ANS: A Glomerulonephritis occurs when the inflammatory process alters the effectiveness of the semipermeable membrane in the glomeruli. Renal calculi are kidney stones; causative factions include urinary infections, inadequate fluid intake, and sluggish urine flow. Hydronephrosis results when flow of urine from the kidney is obstructed, and the kidney dilates and fills with fluid. Acute pyelonephritis an infection of the kidneys thought to occur when bacteria (such as Escherichia coli) from a bladder infection travel up the ureters to infect the kidneys.

The nurse is educating a patient with a hiatal hernia. Which statement indicates that the patient understands the nurse's teaching? a. "I should avoid tea and chocolate." b. "I should wear an abdominal binder for added support. c. "I should sleep flat on a single pillow." d. "I should not eat within an hour of going to bed."

ANS: A Hiatal hernia is diagnosed by an upper gastrointestinal (GI) series. Nutritional modification indicated in patients with hiatal hernias includes limiting intake of alcohol, chocolate, caffeine, and fatty food. Other treatment includes weight reduction, avoidance of tight-fitting clothes around the abdomen, administration of antacids, histamine (H2)-receptor antagonists, or proton pump inhibitors, and elevation of the head of the bed on 6- to 8-inch blocks. The patient is instructed not to eat within 3 hours of going to bed.

The nurse is caring for a patient who is suspected of having oral cancer. When reviewing the patient's health history, which finding provides supportive data for the diagnosis? a. Presence of leukoplakia b. History of oral herpes simplex c. History of an oral yeast infection d. Reports of a dry oral cavity

ANS: A Leukoplakia, a precancerous lesion, may occur on the tongue or mucosa.

The nurse is caring for a patient who is scheduled to undergo hemodialysis. Based on awareness of potential complications, the nurse correctly withholds which medication? a. Lisinopril (Zestril) b. Famotidine (Pepcid) c. Paroxetine (Paxil) d. Ciprofloxacin (Cipro)

ANS: A Lisinopril is an ACE-inhibitor antihypertensive medication. Antihypertensive drugs are not given the morning of dialysis because they can cause severe hypotension during the treatment. Nitroglycerin (NTG) patches, digitalis, and anticoagulants also are held. The nurse should consult with the dialysis nurse to coordinate medication timing, but antacids (Pepcid), antianxeity agents (Paxil), and antibiotics (Cipro) do not need to be withheld.

The nurse is aware that a definitive diagnosis of cirrhosis is made based on the results of which diagnostic or laboratory test? a. Liver biopsy b. Elevated aspartate aminotransferase (AST) c. Elevated alanine aminotransferase (ALT) d. Elevated lactate dehydrogenase (LDH)

ANS: A Liver biopsy is the definitive test. AST, ALT, and LDH tests will be elevated, but they are not specific for cirrhosis.

When assessing a patient's bowel sounds, nurse auscultates loud bowel sounds in each quadrant every 3 seconds. The nurse understands that these findings could indicate that the patient is experiencing which condition? a. Diarrhea b. Paralytic ileus c. Vomiting d. Constipation

ANS: A Loud, rapid bowel sounds are indicative of hypermobility, which could result in diarrhea. Absent bowel sounds are associated with paralytic ileus. Normal bowel sounds present as soft gurgles and clicks every 5 to 15 seconds. Hypoactive bowel sounds indicate decreased motility and could indicate that the patient is constipated?

The nurse is collecting data from a patient who complains of having urinary frequency. The nurse should inquire about which dietary habit? a. Red meat intake b. Caffeine intake c. Complex carbohydrate intake d. Tomato juice intake

ANS: B Caffeine and other diuretics found in foods and drinks, as well as increased fluid intake of fluid, can increase the number of times a person must urinate.

The nurse is caring for a patient who complains, "I don't see why I can't have a CT scan instead of the expensive MRI!" Which response is most appropriate for the nurse to make? a. "The MRI provides better contrast between normal and pathologic tissue." b. "The MRI requires less analysis and is easier to read." c. "The MRI produces a digital image that can be transmitted via e-mail." d. "The MRI exposes the patient to less radiation."

ANS: A Magnetic resonance imaging (MRI) uses radiofrequency signals to determine how hydrogen atoms behave in the magnetic field. In addition, the MRI provides a better contrast than computed tomography (CT) between healthy tissues and pathologic tissues.

The nurse is teaching a group of patients about the process of a mechanical bowel obstruction. Which example should the nurse include in the teaching? a. A tumor obstructs the lumen of the bowel. b. A paralytic ileus causes cessation of peristalsis. c. The bowel is inflamed by diverticulitis. d. The bowel motility is slowed by antidiarrheal drugs.

ANS: A Mechanical obstruction results in blockage of the lumen of the bowel. Examples include tumors, adhesions, strangulated hernia, twisting of the bowel (volvulus), telescoping of one part of the bowel into itself (intussusception), gallstones, barium impaction, and intestinal parasites.

The nurse is caring for a patient who presents to the emergency department with severe nausea and vomiting with stomach pain that radiates to his right scapula. The patient has a temperature of 101.2° F. The nurse anticipates that this patient will undergo workup for which problem? a. Cholecystitis b. Hepatitis c. Pancreatitis d. Gastroenteritis

ANS: A Nausea and vomiting, fever, and leukocytosis occur with cholecystitis. Pain may be referred to the right clavicle, scapula, or shoulder. Hepatitis causes liver dysfunction, including jaundice. Pancreatitis causes abdominal pain that is usually acute, but this can vary among individuals. The pain is steady and is localized to the epigastrium or left upper quadrant. Gastroenteritis causes nausea, vomiting, and diarrhea.

The nurse is caring for a patient with glomerulonephritis. Which finding best leads the nurse to suspect that the patient is developing nephrotic syndrome? a. Ascites b. Anorexia c. Pruritis d. Lethargy

ANS: A Nephrotic syndrome sometimes occurs after the glomeruli have been damaged by glomerulonephritis or some other disease. This damage results in increased membrane permeability and excretion of protein and decreased serum albumin (hypoalbuminemia). Hypoalbuminemia causes fluid to shift out into the body tissues and the result is severe edema (ascites). Patients with nephrotic syndrome may also display lethargy and anorexia but are not hallmark symptoms. Nephrotic syndrome does not cause pruritus (itching), although patients with renal insufficiency with high phosphorus/calcium products may experience itching.

The nurse is reviewing the laboratory results of an assigned patient. The serum bilirubin is 2.8 mg/dL. The nurse anticipates that the patient's urine will display which finding? a. Dark color b. Low specific gravity c. Very scant amount d. Foul odor

ANS: A Normal serum bilirubin is 0.1 to 1.2 mg/dL. Jaundice is present at readings above 2.5 mg/dL. The patient who is jaundiced will have dark, tea-colored urine. Specific gravity refers to the concentration of the urine. The amount and odor of urine will not be directly influenced by the bilirubin level.

The nurse is caring for patient with a urinary tract infection (UTI) who is to receive cefazolin (Ancef). The nurse should carefully monitor the patient for which side effect(s)? (select all that apply.) a. Vaginitis b. Decreased clotting time c. Arrhythmias d. Rash e. Confusion

ANS: A, C, D, E Cefazolin (Ancef) may cause vaginitis, arrhythmias, a sunburn-like rash, and confusion. Cefazolin may increase clotting time

The nurse is caring for a patient diagnosed with acute pancreatitis who complains of significant pain. Which nursing action holds the highest priority for this patient? a. Instruct the patient to sit and lean forward. b. Monitor intake and output. c. Monitor laboratory values and note changes. d. Check blood glucose values frequently.

ANS: A Pancreatitis causes abdominal pain that is usually acute, steady, and localized to the epigastrium or left upper quadrant. As it progresses, it spreads and radiates to the back and flank. Sitting and leaning forward may ease the pain. The severity of the pain may slowly decrease after 24 hours. Eating makes the pain worse. While monitoring intake and output and laboratory values are important actions, none of these actions actively address the patient's pain.

The nurse is percussing a patient's abdomen and hears a dull thud in the right upper quadrant. This sound indicates that nurse is percussing over which location? a. The liver b. The small intestine c. The stomach d. The lungs

ANS: A Percussion is performed by placing the middle finger of one hand on the abdomen and striking the finger lightly below the knuckle and listening for the pitch of sound produced. A dull thud would be heard over the liver. Tympany would be heard over the stomach and intestines, and resonance would be heard over lung tissue.

A patient with glomerulonephritis has an order to undergo plasmapheresis. Which statement indicates that the patient accurately understands teaching about the procedure? a. "This procedure removes my affected plasma and gives me a clean replacement." b. "This procedure will use the IV in my hand." c. "I will need to lie very still while the pictures are taken." d. "I should drink this contrast with a straw to keep it from staining my teeth."

ANS: A Plasmapheresis is a blood cleansing procedure used in autoimmune disorders, such as acute glomerulonephritis or myasthenia gravis (see Chapter 24). Much like hemodialysis, plasmapheresis uses a special filter to remove plasma and "wash" it to eliminate antibodies. If treatment is not successful, the disease will rapidly progress to kidney failure and death. The patient's blood is accessed through a shunt or a CVC, not a peripheral intravenous (IV) line. This procedure does not involve imaging or contrast.

The nurse is caring for a woman suspected of having a vaginal fistula. Which finding supports the potential diagnosis? a. Pneumaturia b. Hematuria c. Oliguria d. Dysuria

ANS: A Pneumaturia, or gas in the urine, can occur if there is an abnormal passage between the bladder and vagina. A fistula would not cause hematuria, oliguria, or dysuria.

A nurse is caring for a patient who is 4 hours postoperative after a laparoscopic cholecystectomy. The patient reports abdominal fullness and mild discomfort. After verifying that the patient's vital signs are stable, what action is most important for the nurse to take next? a. Ambulate the patient. b. Notify the charge nurse. c. Position the patient in high Fowler. d. Administer the ordered PRN analgesic.

ANS: A Retained carbon dioxide (CO2) used during a laparoscopic procedure causes "free air" pain, which may manifest as abdominal fullness and mild discomfort. Early and frequent ambulation helps the CO2 gas dissipate. The charge nurse does not require notification at this time. The nurse should position the patient upright after ambulation. If ambulation does not ease the patient's discomfort, the nurse should then administer the PRN analgesic as ordered.

In caring for a patient with hepatitis B, a nurse would employ which precautions? a. Standard Precautions b. Strict isolation c. Contact Precautions d. Surgical asepsis

ANS: A Standard Precautions are needed to care for a patient with hepatitis B. Isolation and contact precautions are not indicated for this diagnosis unless this patient is experiencing active bleeding. Surgical asepsis is not required.

The nurse is caring for a 90-year-old resident in a long-term care facility who is becoming progressively confused and irritable. What should the nurse do next? a. Request an order for a urinalysis. b. Hold the patient's antihypertensive medications. c. Assess the patient for fecal impaction. d. Notify the charge nurse.

ANS: A Sudden confusion and irritability may indicate a urinary tract infection (UTI) in the older adult. There is no supportive information indicating issues with the patient's antihypertensive medications or the presence of a fecal impaction.

The nurse explains to the patient receiving bevacizumab (Avastin) for a tumor in the colon that the drug slows cancer cell growth by which process? a. Changing the pH of the cell environment b. Reducing blood flow to the tumor c. Overhydrating cells of the tumor, causing them to burst d. Interfering with DNA of tumor cells

ANS: B Bevacizumab (Avastin) is an antiangiogenesis medication that reduces blood flow to the growing tumor cells, depriving them of nutrients needed for replication.

The nurse is caring for a patient who returns to the floor at lunch time after undergoing an upper GI (UGI series). Which action is most important for the nurse to perform first? a. Administer a laxative. b. Educate the patient about the possibility of white stools. c. Offer the patient a small snack. d. Provide oral care.

ANS: A The contrast media used in the series features barium that can harden and lead to an impaction. Patients should have a bowel movement quickly after the procedure to eliminate the medium from the body. While fluids and snacks or meal trays should be given as quickly as possible, patients should be educated about the possibility of white stools for several days postprocedure, and oral care should be provided, these interventions are of lesser importance since they do not directly work to quickly prevent a postprocedure complication.

The nurse calculates the body mass index (BMI) of a man who is 6 feet tall and weighs 150 pounds. Which value is correct? a. 21.0 b. 25.0 c. 43.1 d. 66.3

ANS: A The formula to calculate BMI is: weight in kilograms divided by height in meters squared (68.1 kilograms ÷ 3.24 meters = 21.0).

Which type of hernia can lead to necrosis? a. Strangulated hernia b. Indirect hernia c. Direct hernia d. Irreducible hernia

ANS: A The incarcerated hernia may become strangulated, which cuts off the blood supply and can lead to necrosis of the trapped bowel loop. Hernias are classified as reducible, which means the protruding organ can be returned to its proper place by pressing on the organ, and irreducible, which means that the protruding part of the organ is tightly wedged outside the cavity and cannot be pushed back through the opening. Another name for an irreducible hernia is incarcerated hernia. An indirect hernia protrudes through the inguinal ring. A direct hernia protrudes through the posterior inguinal wall.

The nurse is caring for a young man who has been prescribed ciprofloxacin (Cipro) for pyelonephritis. Which information should the nurse include in order to prevent recurrence? a. Take this medication with a full glass of water. b. Take antacids 2 hours after this medication. c. Take the entire prescription. d. Take this medication on an empty stomach.

ANS: A The most important way to prevent recurrence is to take the entire course of antibiotic therapy. Cipro should be taken at least 2 hours prior to an antacid, but this action does not work to prevent recurrence. Cipro does have to be taken with a full glass of water and may be taken on a full or empty stomach.

During a morning assessment, the nurse observes that a patient displays bulging flanks when supine with the knees flexed. Which action should the nurse take next? a. Measure the patient's abdominal girth. b. Auscultate each quadrant of the abdomen for 5 minutes. c. Document the finding. d. Notify the charge nurse.

ANS: A The nurse's initial assessment indicates fluid accumulation. The nurse needs to obtain more information, first measuring abdominal girth. The nurse can then percuss from the umbilicus to the flanks to detect fluid shifts, and document all findings. The nurse will only auscultate bowel sounds for 5 minutes in each quadrant if bowel sounds are not heard before then. It is unnecessary to notify the charge nurse at this time.

The nurse is caring for patient with a history of a chronic incarcerated hernia. The patient suddenly complains of abdominal pain and vomits dark material with a fecal odor. The nurse recognizes these signs as indications of which complication? a. Complete intestinal obstruction b. Rupture c. Gastroenteritis d. Duodenal ulcer

ANS: A The symptoms of intestinal obstruction vary according to the location of the obstruction. Fecal odor or material in the emesis suggests a complete intestinal obstruction. In this case, the incarcerated hernia has blocked the flow of bowel content. If there is a defect in the muscular wall of the abdomen, the intestine may break through the defect; his protrusion is called a hernia or a rupture. Gastroenteritis is inflammation of the stomach and intestines. A duodenal ulcer occurs in the small intestine (the duodenum).

The nurse explains that the laparoscopic adjustable gastric banding surgery is best described as which type of bariatric surgery? a. Restrictive b. Malabsorptive c. Restrictive/malabsorptive d. Obstructive

ANS: A The three types of bariatric surgery are restrictive, malabsorptive, and restrictive/malabsorptive. Laparoscopic adjustable gastric banding is performed by placing an inflatable band around the fundus of the stomach and is considered restrictive. This procedure may be performed laparoscopically. The band is inflated and deflated via a subcutaneous port to change the size of the stomach as the patient loses weight.

When the patient asks why he has so many urinary tract infections (UTIs), the nurse informs the patient that his recurrent UTIs most likely result from which causative factor? a. Bacteria that colonize in the kidney b. Viral infections generating debris in the bladder c. Carelessness in handwashing d. Spicy foods irritating the bladder wall

ANS: A The urinary tract is very vulnerable to bacterial infection. In the high volume of blood that is filtered by the kidney, there are some bacteria that can colonize in the kidney, causing an infection. Also, bacteria can easily enter the urinary tract through the urethra, and then the infection may spread up into the kidneys. Viral infections do not generate bladder debris. Recurrent UTIs are not likely the result of poor hand hygiene. Spicy foods do not irritate the bladder wall or lead to UTIs.

The nurse is aware that the person with ulcerative colitis is a risk factor for developing which disorder? a. Colon cancer b. Chronic urinary infections c. Intussusception d. Volvulus

ANS: A Ulcerative colitis is an inflammation, with the formation of ulcers, of the mucosa of the colon. It is often a chronic disease, and the patient is usually free from symptoms between acute flare-ups. The person with ulcerative colitis is 10 to 15 times more likely to develop colon cancer than those who do not have the disease.

The nurse is caring for a patient with deteriorating kidney function. Laboratory work indicates 900 mg of uric acid in 24 hours. In addition to administering prescribed medication, which dietary modification should the nurse address? a. Limit servings of beef to 3-ounce portions. b. Increase intake of avocados and liver. c. Avoid yogurt or skim milk. d. Limit intake of potatoes and pasta.

ANS: A Uric acid is an end product of protein metabolism, and levels may be elevated in renal failure and associated with increased dietary intake of purine-containing foods. Normal findings are 250 to 750 mg/24 hr (normal diet). A value of 900 mg/24 hr indicates an elevated uric acid level. Sources of purines include beef, liver, and sardines. Purine-rich foods like beef should be limited to small portions or eliminated completely from the patient's diet. Additionally, fatty foods like avocados aid the kidneys in retaining uric acid. Skim milk, yogurt, potatoes, and pasta are low-purine food choices that the patient can eat.

The nurse is caring for a patient with esophageal varices with a new order for vasopressin (Pitressin). The nurse reviews the patient's history and notes that the patient's comorbidities include coronary artery disease (CAD), type 2 diabetes, gastroesophageal reflux disease (GERD), and fibromyalgia. The nurse should immediately notify the physician about which component of the patient's history? a. CAD b. Diabetes mellitus (DM) type 2 c. GERD d. Fibromyalgia.

ANS: A Vasopressin (Pitressin) is a potent medication that causes vasoconstriction and stops bleeding of esophageal varices. With the use of potent vasoconstrictors such as vasopressin (Pitressin), which constricts all vessels, the possibility of it causing a myocardial infarction (MI) is a very real concern and should be used most cautiously with the patient with CAD.

The student nurse is attempting to irrigate an indwelling catheter. Which action best indicates that the student nurse accurately understands the correct procedure? a. The student nurse irrigates using a steady, gentle stream. b. The student nurse forces solution into the catheter to remove the obstruction. c. The student nurse pulls back on the plunger if fluid will not enter the catheter. d. The student nurse counts the amount of irrigation fluid as output.

ANS: A When irrigating, use the correct amount of sterile solution (according to agency policy, or the amount of solution that may be determined by physician's order for nephrostomy tubes, ureteral tubes, or catheters). When irrigating, use a steady, gentle stream to irrigate. Avoid exerting pressure that may traumatize or cause discomfort. Do not pull back forcefully on an irrigating syringe attached to a urinary catheter or tube as this creates negative pressure that may damage delicate tissues. The amount of irrigation fluid is counted as intake, not output.

Which age-related change(s) occur(s) in the urinary system? (select all that apply.) a. Prostate hypertrophy b. Decreased renin secretion c. Decreased bladder muscle tone d. Enlarged bladder. e. Increased ability to concentrate urine

ANS: A, B, C As the urinary system ages, the prostate hypertrophies, renin secretion decrease, and bladder muscle tone decrease. Age-related changes also include shrinking bladder size and decreased ability to concentrate urine.

Which foods or beverages may trigger an attack of irritable bowel syndromes (IBS)? (select all that apply.) a. Coffee b. Yogurt c. Whole wheat bread d. White rice e. Orange juice

ANS: A, B, C Stress, caffeine, and sensitivity to certain foods such as dairy and wheat products seem to trigger IBS in some people. White rice and orange juice are not considered to be triggers for IBS.

When discussing bladder health with a patient, the nurse emphasizes the importance of regular voiding in a timely manner. Which statement(s) indicate(s) that the patient accurately understands the underlying rationale for this recommendation? (select all that apply.) a. "Urinating regularly will prevent prolonged exposure of the bladder wall to harmful wastes." b. "Allowing my bladder to overfill causes the walls to overstretch." c. "A full bladder can cause undue strain on the urinary sphincters." d. "The characteristics of urine can change after being in the bladder for overly extended periods." e. "Pressure from a distended bladder can cause excessive pressure on my colon."

ANS: A, B, C Urinating regularly helps to prevent prolonged exposure to toxins. Allowing the bladder to overfill can allow the walls to become hyperelastic. A full bladder may also strain the urinary sphincters. Urine does not change character in the bladder and does not press on the colon.

The nurse is caring for a patient immediately following a liver biopsy. Which actions are appropriate for the nurse to take? (select all that apply.) a. Position the patient on the right side. b. Assess the patient's pain. c. Monitor vital signs every 15 minutes for the first hour. d. Instruct patient to cough and deep-breathe. e. Assess for hematoma at puncture site.

ANS: A, B, C, E The liver biopsy is performed under local or general anesthesia. Postprocedural care will include positioning on the right side for the first 2 hours, and assessing pain, vital signs and the puncture site. The patient should not cough as it increases intra-abdominal pressure and may stimulate bleeding.

The nurse is discussing the impact of cirrhosis on liver function with the family of a dying patient. The nurse explains that, when the damage caused by cirrhosis blocks the blood flow through the liver, it can lead to which complication(s)? (select all that apply.) a. Portal hypertension b. Decrease in metabolic processes of the liver c. Decrease in clotting factors d. Increase in ascites e. Decrease in aldosterone

ANS: A, B, C, D Cirrhosis is a progressive, chronic disease of the liver. The destruction of normal hepatic structures and their replacement with necrotic tissue occur. Fibrous bands of connective tissue develop in the organ. The bands eventually constrict and partition the liver tissue into irregular nodules. If this process is halted before too much liver tissue is damaged, the liver tissue will regenerate. Late cirrhosis is considered irreversible. The outcomes of cirrhosis of the liver are failure of its cells to perform their functions and the development of portal hypertension. Aldosterone levels are increased rather than decreased.

Which action(s) should the nurse recommend to promote a patient's bowel health? (select all that apply.) a. Exercise regularly. b. Include adequate bulk in the diet. c. Drink adequate water. d. Defecate at approximately the same time every day. e. Take a laxative to maintain a regular defecation pattern.

ANS: A, B, C, D Daily exercise and intake of adequate bulk and water are contributions to bowel health. Heeding the need to defecate and defecating at the same time daily will help to keep the gastrocolic reflex healthy. Taking daily laxatives is not conducive to good bowel health.

The nurse explains to an obese patient that initial medically supervised weight reduction includes which components(s)? (select all that apply.) a. General health assessment b. Specialized exercise program c. Participation in a support group d. Stress reduction e. Surgery

ANS: A, B, C, D Dietary control and exercise are the main treatments for obesity. A general health assessment should be conducted before a patient is placed on a weight reduction diet. A provider will usually prescribe a lower-calorie diet and exercise. The patient is taught ways to change thinking about food and weight. Those with a BMI over 40 may have surgery to achieve weight reduction if they meet established criteria. Participation in a support group and behavior modification with some sort of reward for weight loss are part of the total treatment plan. Teaching stress reduction and alternate ways of coping are essential to success. Medications that suppress appetite or block fat absorption may be used on a short-term basis. Surgery would be a last resort.

Which statement(s) accurately describe the functions of the kidneys? (select all that apply.) a. Regulation of electrolytes b. Regulation of fluid volume c. Regulation of blood pressure d. Secretion of erythropoietin e. Transportation of urine

ANS: A, B, C, D Kidney functions include regulation of electrolytes, fluid volume, and blood pressure, along with the secretion of erythropoietin. The ureters transport urine from the renal pelvis to the bladder.

Which contributing factor(s) may lead to hernia development? (select all that apply.) a. Heavy lifting b. Chronic cough c. Straining with defecation d. Ascites e. Strenuous sexual activity

ANS: A, B, C, D The most common contributing factors in the development of a hernia are straining to lift heavy objects, chronic cough, straining to void or pass stool, and ascites. Sexual activity is not usually a cause for herniation.

To best assist a patient with dysphagia, the nurse should implement which action(s)? (select all that apply.) a. Encourage "practice swallowing" before the meal. b. Coach the patient to chew thoroughly. c. Assist the patient to sit upright with the head forward and chin tucked. d. Offer fluid during the meal. e. Give the patient thin liquids, such as water.

ANS: A, B, C, D To assist a patient with dysphagia (trouble swallowing), the nurse should encourage practice swallows and visualize the larynx rising. Coaching the patient to chew thoroughly while sitting upright, and offering appropriate liquids are actions that decrease likelihood of aspiration. The nurse should administer thickened liquids.

The home health nurse is caring for a patient with chronic renal failure. Which assessment finding(s) indicate(s) that the patient is experiencing uremic syndrome? (select all that apply.) a. Restless legs b. Dry, scaly skin c. Crystals in the eyebrows d. Muscle cramps e. Hypotension

ANS: A, B, C, D Uremia or uremic syndrome signs generally appear when blood urea nitrogen (BUN) concentration passes 100 mg/dL. Complaints about restless legs syndrome are frequent, and the leg discomfort may interfere with sleep. The skin becomes dry, scaly, and a pallid yellowish gray. Uremic frost (a late sign) appears as evaporated sweat leaves urea crystals on the eyebrows. Calcium is not absorbed from the intestinal tract, and this leads to the loss of calcium from the body and a corresponding drop in serum calcium. If the hypocalcemia is not corrected, the patient will eventually suffer from muscle cramps, twitching, and possibly seizures. The patient is usually hypertensive rather than hypotensive.

The nurse is collecting the health history of a patient who has had multiple episodes of renal calculi formation. Which finding(s) increase(s) the patient's risk for the development of renal calculi? (select all that apply.) a. Uric acid crystals in urine b. Frequent bacterial urinary infections c. Excessive fluid intake d. Prolonged bed rest e. Parathyroid gland tumor

ANS: A, B, C, D, E Risk factors for development of renal calculi include uric acid crystals in urine, frequent bacterial urinary infections, prolonged immobility or bed rest, and a parathyroid gland tumor. Another risk factor includes inadequate fluid intake.

A patient has been admitted to the acute care facility to rule out glomerulonephritis. Which assessment finding(s) is/are supportive of the potential diagnosis? (select all that apply.) a. Flank pain b. Hematuria c. Periorbital edema d. Decrease in blood urea nitrogen (BUN) and creatinine e. Hypertension

ANS: A, B, C, E The patient with acute glomerulonephritis usually becomes suddenly ill with fever, chills, flank pain, widespread edema, puffiness about the eyes, visual disturbances, and marked hypertension. The urine may be smoky and will contain red blood cells and protein, and urine will have an increased specific gravity. Serum creatinine and BUN levels rise above normal rather than decrease. Diagnosis is based on physical findings.

The nurse caring for a patient who has just had an arteriovenous (AV) access created in his right forearm. Which finding(s) is/are important for the nurse to assess? (select all that apply.) a. Presence of bruit on auscultation of the AV site b. Capillary refill in the left hand c. Blood pressure in the right arm d. Adequate elevation of the right arm e. Abdominal incision site

ANS: A, B, D The nurse should auscultate for a bruit, assess capillary refill times in both hands, and ensure that the right arm is elevated properly. The nurse should not take the patient's blood pressure in the affected (right) arm, and this procedure does not result in an abdominal incision.

The nursing is planning care for a patient with an acute exacerbation of inflammatory bowel disease (IBD). Which action(s) is/are most important for the nurse to include in the care plan? (select all that apply.) a. Assess number and character of stools. b. Auscultate bowel sounds. c. Obtain weights each shift. d. Encouraging periods of rest. e. Assess for internal bleeding.

ANS: A, B, D, E For an acute attack of IBD, care includes monitoring the number and character of stools, periodic auscultation of bowel sounds, and checking for signs of internal bleeding, electrolyte imbalances, or anemia. The nurse should carefully monitor intake and output, but daily weights are sufficient.

The nurse points out to a patient recently diagnosed with hepatitis B virus (HBV) that the virus is found which type(s) of body fluid(s) or secretions? (select all that apply.) a. Semen b. Vaginal secretions c. Sweat d. Breast milk e. Human feces

ANS: A, B, D, E HBV, hepatitis C virus (HCV), and hepatitis D virus (HDV) may cause chronic inflammation and necrosis of the tissue. HBV and HCV are transmitted by parenteral routes and sexually as they are present in semen, vaginal secretions, and saliva of carriers, as well as breast milk and human feces. HBV is not transmitted through sweat. Sexual partners of patients who are carriers of HBV and HCV are at high risk for contracting the virus.

The nurse is caring for a 70-year-old patient who was diagnosed with gastroenteritis after returning from a camping trip to Mexico. Which manifestation(s) is/are consistent with this diagnosis? (select all that apply.) a. Positive stool culture for Giardia or Shigella b. Abdominal cramping c. Fat in the stool d. Mucus in stool e. Blood in stool

ANS: A, B, D, E Manifestations associated with gastroenteritis include a positive stool culture for Giardia or Shigella, abdominal cramping, and presence of mucus or blood in the stool. Fat in the stool is not symptomatic of gastroenteritis.

The nurse preparing a teaching plan for a 20-year-old woman who is taking sulfasalazine (Azulfidine) for Crohn disease. Which information should the nurse include in the teaching plan? (select all that apply.) a. Avoid tanning beds or going outside during peak hours of sun while taking sulfasalazine (Azulfidine). b. If taking sulfasalazine (Azulfidine) while on oral contraceptives, use a backup method of birth control. c. Sulfasalazine (Azulfidine) decreases the effect of hypoglycemic agents. d. Be aware that sulfasalazine (Azulfidine) may turn the urine orange. e. Be aware that sulfasalazine (Azulfidine) may cause gastrointestinal (GI) upset.

ANS: A, B, D, E Sulfasalazine (Azulfidine) causes increased photosensitivity, may interfere with effectiveness of oral contraceptives, can tint the urine orange, and may cause GI upset. Sulfasalazine (Azulfidine) increases the effect of hypoglycemic agents.

The nurse is teaching a patient about peristomal skin care. Which information is most important for the nurse to include? (select all that apply.) a. Gently remove the faceplate of the appliance to avoid skin irritation. b. Washing the peristomal area with a scrubbing motion to rid the skin of fecal waste. c. Thoroughly rinse the skin. d. Apply a skin barrier to the peristomal area. e. Cut the faceplate to allow a -inch opening around the stoma.

ANS: A, C, D The faceplate should be removed gently to avoid skin damage; rinsing and drying, and application of a skin barrier, is essential. Washing should be gentle; the patient should avoid scrubbing that could irritate the skin. The faceplate should allow a 1/8-inch opening around the stoma.

The nurse explains that the older adult is prone to digestive disorders related to which age-related change(s)? (select all that apply.) a. Decreased hydrochloric acid b. Increased enzyme levels c. Inadequate chewing d. Diminished intestinal motility e. Gastroesophageal sphincter incompetence

ANS: A, C, D, E Age-related changes that predispose the older adult to digestive disorders include decreased hydrochloric acid, inadequate chewing, diminished intestinal motility, and gastroesophageal sphincter incompetence. Age does not increase digestive enzyme levels.

The nurse is speaking with a patient who has concerns about the development of cholelithiasis. The nurse correctly includes which risk factors for the condition? (select all that apply.) a. Obesity b. Daily exercise regimen c. Diabetes mellitus (DM) d. Taking cholesterol-lowering drugs e. Mexican American ethnicity

ANS: A, C, D, E Cholelithiasis is the presence of gallstones within the gallbladder or in the biliary tract. Obesity, DM, intake of cholesterol-lowering drugs, and Mexican American ethnicity are risk factors for the development of gallstones. A sedentary lifestyle is a risk factor for cholelithiasis.

The nurse caring for a patient recently admitted with acute pancreatitis. Which action(s) should the nurse include in the daily assessments? (select all that apply.) a. Auscultate bowel sounds. b. Carefully evaluate amount of food eaten each meal. c. Measure abdominal girth. d. Monitor for effectiveness of pain control. e. Monitor urine output.

ANS: A, C, D, E The nurse should auscultate bowel sounds, measure abdominal girth to monitor for ascites, monitor for pain and evaluate effectiveness of pain control, and monitor urine output. In early acute pancreatitis, the patient should be kept NPO; measuring food is unnecessary.

The nurse instructs the patient on the weight reduction drug Orlistat (Xenical, Alli) that he may experience which side effect(s)? (select all that apply.) a. Diarrhea b. Hypoglycemia c. Abdominal cramping d. Constipation e. Nausea

ANS: A, C, E Medications that suppress appetite or block fat absorption may be used on a short-term basis. Orlistat (Xenical, Alli) inhibits lipase, causing fats to remain partially undigested and unabsorbed. Gastrointestinal side effects of orlistat include diarrhea (sometimes uncontrolled), abdominal cramping, and nausea.

Which factor(s) increase the risk for developing pancreatic cancer? (select all that apply.) a. Obesity b. Jewish ethnicity c. Diabetes mellitus (DM) d. Hepatitis A e. Smoking

ANS: A, C, E Pancreatic cancer incidence rises steadily with age. Although the cause of pancreatic cancer is not known, the incidence is higher in cigarette smokers. Obesity, chronic pancreatitis, and DM are also risk factors for this cancer. Jewish ethnicity and hepatitis are not contributory to the disease.

The nurse correctly recognizes that esophageal cancer is associated with which risk factor(s)? (select all that apply.) a. Cigarette smoking b. Diabetes c. Hypertension d. Heavy alcohol use e. Smokeless tobacco

ANS: A, D, E Cigarette smoking is a major cause of esophageal cancer in the United States. When combined with heavy alcohol consumption, the risk for esophageal cancer greatly increases. Both substances are irritants to the mucosa of the esophagus. Smokeless tobacco is also associated with esophageal cancer. Diabetes and hypertension do not increase the risk of developing esophageal cancer.

While caring for a patient with an indwelling catheter, which intervention(s) is/are important for the nurse to include in the plan of care? (select all that apply.) a. Observe tube placement and note the level of urine in the collection bag. b. Keep the drainage bag even with the level of the bed. c. Avoid ambulation until the catheter is discontinued. d. Use a syringe to deflate the balloon before discontinuing the catheter. e. Clean the meatus and catheter with soap and water.

ANS: A, D, E The nurse should observe tube placement and urine levels, utilize a syringe to deflate the balloon prior to removing the catheter, and perform catheter care with soap and water. The drainage bag should be kept lower than the bed to prevent backflow of urine into the bag (which could lead to an infection). As long as the bag position is maintained below catheter insertion site, the patient can ambulate unless otherwise contraindicated.

The nurse caring for a patient with acute pancreatitis assesses a bluish tinge around the patient's umbilicus. The nurse recognizes that this finding likely results from which underlying problem? a. Increased amylase b. Retroperitoneal hemorrhage. c. Inflammatory response to a pseudocyst d. Ascites

ANS: B A bluish tinge around the umbilicus or in the flank area indicates a retroperitoneal hemorrhage. Increased amylase levels, inflammatory response to a pseudocyst, and ascites do not result in a bluish tinge around the belly button.

A 25-year-old man comes to the college clinic with fever of 101° F, nausea, and flank pain that radiates into the thigh and genitals. The nurse anticipates that the patient will undergo workup for which infection? a. Urethritis b. Pyelonephritis c. Glomerulonephritis d. Cystitis

ANS: B Acute pyelonephritis is an infection of the kidneys. It is thought to occur when bacteria (such as Escherichia coli) from a bladder infection travel up the ureters to infect the kidneys. A frequent cause of pyelonephritis is an obstruction, causing stasis of urine and stones that cause irritation of the tissue. Both situations provide an environment in which bacteria can grow. When bacteria enter the renal pelvis, inflammation and infection occur. Pyelonephritis causes nausea and vomiting, flank pain, temperature elevation with chills, headache, and malaise. Urethritis and cystitis often cause dysuria. Glomerulonephritis commonly occurs about 2 to 3 weeks after a group A beta-hemolytic streptococcal infection, such as "strep throat" or impetigo. The patient with acute glomerulonephritis usually becomes suddenly ill with fever, chills, flank pain, widespread edema, puffiness about the eyes, visual disturbances, and marked hypertension.

A patient has a kidney stone lodged in the ureter. He questions why it must be removed. What response is most appropriate? a. "If the stone is not promptly removed, you will continue to have blood in your urine." b. "If the stone is not removed, it could block urine flow from the kidney and cause swelling within the kidney." c. "Keeping the stone in your body may result in a condition called glomerulonephritis." d. "You may experience scarring of the renal structures and a condition known as nephrotic syndrome may result."

ANS: B An obstructed ureter will cause urinary reflux into the renal pelvis, causing hydronephrosis and, ultimately, destruction of the kidney.

The nurse is aware that an unresolved intestinal obstruction can lead to which complications? a. Systemic infection and fever b. Intestinal rupture and shock c. Adhesions and pain d. Bloating and expelling gas

ANS: B An unresolved intestinal obstruction can lead to rupture of the intestine, peritonitis, shock, and death.

As chronic glomerulonephritis progresses, how is the kidney usually affected? a. The kidney swells. b. The kidney atrophies. c. The kidney develops "skip lesions." d. The kidney develops multiple cysts.

ANS: B Chronic glomerulonephritis may develop rapidly or progress slowly over 20 to 30 years or longer. The exact cause is unknown; however, in chronic glomerulonephritis, the kidney atrophies, functional nephrons decrease, and eventually the kidneys fail. The kidney does not swell, develop skip lesions, or multiple cysts.

The nurse is caring for patient who is postoperative after a bladder repair. The patient complains of pain. Which independent nursing intervention is best? a. Administer an analgesic medication. b. Apply a cold compress to the surgical site. c. Dim the lights in the room. d. Irrigate the drainage tube.

ANS: B Cold application to the surgical site applies the best independent intervention. Dimming the lights may also help to create a more comfortable environment. Administering an analgesic and irrigating the drainage tube are interventions that require a physician's order.

The nurse is caring for a patient who underwent a cholecystectomy 3 days ago. Which assessment finding best indicates to the nurse that the bile flow is no longer obstructed from entering the bowel? a. Excessive flatus b. Dark brown stool c. Dark urine d. Increased appetite

ANS: B Darkening of stools back to the normal color indicates that the bile has reached the duodenum.

The nurse is caring for a patient with suspected dysphagia. Which action is most appropriate for the nurse to take? a. Encourage incentive spirometry use. b. Instruct the patient to take practice swallows before the meal. c. Encourage patient attempts to communicate, and pay attention to nonverbal cues. d. Encourage the patient to keep a food diary.

ANS: B Dysphagia means difficulty in swallowing. The nurse should have the patient take some "practice swallows" before beginning the meal, and watch to see that the larynx rises with each swallow. Incentive spirometry usage is important or patients with dyspnea, or shortness of breath. Encouraging communication and paying attention to nonverbal cues is an effective intervention for aphasia (inability to use or understand words). Keeping a food diary may be useful in cases of polyphagia (extreme hunger), but it does not evaluate whether or not the patient can swallow effectively.

The nurse caring for the patient who is immediately postoperative with a new ileostomy. Which intervention is most important for the nurse to implement at this time? a. Change the ostomy pouch frequently. b. Provide emotional support. c. Administer a stool softener. d. Offer the patient frequent snacks.

ANS: B Helping the patient adjust to the new ostomy is one of the highest priorities in the immediate postoperative period. In the immediate postoperative period, the pouch should not be changed any more than is necessary to avoid trauma to the skin. A stool softener is not indicated since stools are usually softer and more watery when coming from a stoma. Diet advancement is a gradual process that must coordinate with returning bowel function, and the patient may be NPO for a short time while bowl motility returns.

A patient has reported to the clinic with concerns about contracting hepatitis A from her boyfriend. What response by the nurse is most appropriate? a. "If you are having unprotected sexual intercourse with your partner, there is a relatively high risk for hepatitis A." b. "Hepatitis A is not transmitted as a result of close contact with an infected individual." c. "Hepatitis A transmission is associated with contact with infected body fluids." d. "Hepatitis A is relatively uncommon in our country and seen more in underdeveloped countries."

ANS: B Hepatitis A and hepatitis E viruses are transmitted primarily by the fecal-oral route. They are responsible for the epidemic forms of viral hepatitis. Hepatitis A virus can be transmitted by food handlers to customers or by mollusk shellfish from contaminated waters. Hepatitis B is transmitted via infected blood and body fluids. Hepatitis E virus infection is primarily seen in less developed countries.

The nurse explains that a hernioplasty is a surgery that involves which process? a. Reducing the hernia by manual pressure. b. Sewing synthetic mesh over the abdominal wall defect to reduce the hernia. c. Applying an individualized truss for the reduction of the hernia. d. Reducing the hernia and suturing the defect in the abdominal wall.

ANS: B Hernioplasty is a surgical intervention in which the hernia is reduced and a synthetic mesh is sewn over the defect in the wall to prevent reoccurrence.

The nurse is assessing a patient's bowel sounds. After auscultating each quadrant for 30 seconds, the nurse fails to hear any sounds. How should the nurse document this finding? a. Absent bowel sounds b. Hypoactive bowel sounds c. Active bowel sounds d. Hyperactive bowel sounds

ANS: B Hypoactive bowel sounds can be noted in the medical record when no sounds are heard after listening in each of the four quadrants for 30 seconds. For bowel sounds to be considered absent, it is necessary to verify that no sounds are heard after listening in each of the four quadrants for 5 minutes. If hyperactive, high-pitched sounds are heard in one quadrant, and decreased sounds are heard in another quadrant, assess for nausea and vomiting, as the patient may have an intestinal obstruction.

The nurse is planning care for a patient who has experienced moderate diarrhea for 3 days. Which collaborative intervention is most important to include in the plan of care? a. Place the patient on NPO status. b. Limit the patient's diet to clear liquids. c. Administer parenteral nutrition. d. Restrict the patient's diet to soft foods only.

ANS: B If diarrhea is moderate, only clear liquids are permitted by mouth. If the diarrhea is severe, nothing is given by mouth until it subsides. Severe, long-term diarrhea may require the use of total parenteral nutrition. When diarrhea is caused by infection, stool cultures and antibiotics may be necessary. As the condition improves, the diet is advanced.

The nurse is caring for an older adult patient diagnosed with diverticulitis. Which medication is the best choice to manage the patient's pain? a. Meperidine (Demerol) b. Morphine c. Nalbuphine hydrochloride (Nubain) d. Naloxone (Narcan)

ANS: B Morphine is acceptable for pain management and has fewer side effects than meperidine (Demerol). In earlier recommendations, Demerol was the drug of choice based on a theoretical risk not shown in studies. A metabolite of meperidine (Demerol) is toxic, and the older adult has difficulty metabolizing and eliminating it. The buildup of the toxin in the blood can cause seizures and other mental status changes such as acute confusion. Ask for an alternate analgesic for these patients.

Which age-related change predisposes older adult patients to diverticula? a. Loss of bowel tone reduces motility. b. Chronic constipation increases intra-abdominal pressure and allows herniation. c. The diet may be deficient in bulk. d. Multipharmacy has altered bowel mucosa.

ANS: B Most diverticula are asymptomatic, uncommon in people under age 50, and almost universal in those over 90. Increases in intra-abdominal pressure from constipation and straining to defecate causes herniation of the mucosa through the bowel wall, causing a small pocket in the colon.

How can nephrotoxic drugs such as doxycycline and rifampin cause kidney damage? a. Bacterial destruction of the nephrons b. Chemical alterations of glomeruli c. Necrosis of tubules from reduction of oxygenation d. "Clumping" of cellular debris from killed bacteria

ANS: B Nephrotoxic drugs may chemically alter the glomeruli, which make them ineffective.

The nurse is discussing bariatric surgery complications with a patient. Which statement indicates that the patient accurately understands the nurse's teaching about common procedural side effects? a. "I understand that gastric ulcers frequently occur in patients who have bariatric surgery." b. "Gallstones are a common occurrence in patients who have bariatric surgery." c. "I know an umbilical hernia might happen after I have bariatric surgery." d. "Unfortunately, I may experience gastritis after having bariatric surgery."

ANS: B Nutritional deficiencies caused by the banding result in the formation of gallstones in a large percentage of bariatric surgery patients. About a third of patients who undergo bariatric surgery develop gallstones.

A patient has just returned to the nursing unit after having a renal biopsy. Which intervention is most important to include in the patient's nursing care plan? a. Keep the patient NPO for the first 4 hours after the procedure. b. Instruct the patient to avoid laughing and use a pillow to splint when sneezing. c. Report hematuria immediately. d. Teach the patient about the importance of limiting fluid intake.

ANS: B Postprocedure care for the patient who has undergone a renal biopsy will include monitoring for bleeding, avoiding activities that could increase abdominal pressure, and keeping the patient flat for 6 to 24 hours. Laughing and sneezing increase abdominal pressure and should be avoided; splinting when sneezing will help to decrease abdominal pressure. Oral intake is encouraged. Bloody urine is expected for the first 24 hours after the biopsy. The patient should increase fluid intake unless otherwise contraindicated and drink at least 3000 mL of fluid to flush the urinary system.

The home health nurse is caring for the patient with tuberculosis who is taking rifampin and isoniazid (INH). The nurse should carefully monitor the patient for which potential side effect? a. Gallstones b. Liver disorders c. Bleeding ulcers d. Esophagitis

ANS: B Rifampin and INH are both hepatotoxic.

The patient confides that sneezing makes her "wet her pants." The nurse recognizes this cardinal sign of which type of incontinence? a. Urge incontinence b. Stress incontinence c. Functional incontinence d. Overflow incontinence

ANS: B Stress incontinence occurs when the urethral sphincter fails and there is an increase in intra-abdominal pressure, caused by things such as sneezing, laughing, coughing, or aerobic exercise. Urge incontinence is the involuntary loss of urine when there is a strong urge to urinate (urinary urgency). Functional incontinence is caused by cognitive inability to recognize the urge to urinate or self-care deficit caused by extreme depression. Inability to reach the bathroom due to restraints, side rails, or an out-of-reach walker can also result in functional incontinence. Overflow incontinence occurs when there is poor contractility of the detrusor muscle or obstruction of the urethra, as in prostate hypertrophy in the male or genital prolapse or abnormality in the female.

The nurse is aware that patients who have chronic gastritis from renal failure may present with which first sign of this disorder? a. An increase in the white blood cell count b. Sudden massive hemorrhage c. Asthma-like symptoms d. Extreme dyspnea

ANS: B Sudden massive GI hemorrhage may be the first indication of chronic gastritis. Many of these patients do not have any symptoms at all until the hemorrhage.

While reviewing a patient's medications, the nurse notes that a patient has been prescribed liquid nitrofurantoin (Furadantin). Which intervention should the nurse add to the nursing care plan? a. Administer nitrofurantoin on an empty stomach. b. Provide a straw and instruct the patient to rinse the mouth after taking nitrofurantoin. c. Administer nitrofurantoin early in the morning to avoid insomnia. d. Assess the urine for hematuria.

ANS: B The liquid form of this drug will stain the teeth. The patient should use a straw and rise the mouth after taking this medication. The drug causes drowsiness and should be given at night. Hematuria is not a concern.

The nurse cautions the diabetic patient that diabetes affects the blood flow through the kidney. Which statement indicates that the patient understands the nurse's teaching? a. "Long-term high blood sugars provide an environment for bacteria to grow, which can damage my kidneys." b. "Diabetes causes changes to blood vessels, which impacts blood flow to my kidneys." c. "Diabetes causes an immune response and exposes my kidneys to antibody complexes." d. "Long-term insulin use leads to scarring on the kidneys."

ANS: B The long-term effect of diabetes is generalized vasoconstriction, which leads many diabetic patients to renal insufficiency and renal failure. Diabetes can increase a patient's risk for infection. Diabetes does not cause exposure to antibody complexes. Insulin usage does not scar the kidneys.

The nurse explains which advantage benefits patients with a Kock pouch ileostomy? a. The patient can expel feces from the rectum in the normal fashion. b. The patient does not have to wear a collection device. c. The patient only has to evacuate the pouch once a day. d. The patient can have the pouch reanastomosed to the colon at a later time.

ANS: B The major advantage of the Kock pouch is that the patient does not have to wear a collection device. The feces are collected in the pouch and emptied by the patient inserting a catheter into the pouch every 3 or 4 hours.

The nurse caring for an 80-year-old woman who is undergoing the extensive bowel preparation for a colonoscopy. The nurse should most closely monitor the patient for which potential complication? a. Diarrhea b. Metabolic acidosis c. Fatigue d. Dyspnea

ANS: B The older patient is especially at risk for problems of electrolyte imbalance, fluid overload, or dehydration when undergoing preparation for diagnostic tests that require a fasting state and/or bowel cleansing. Metabolic acidosis can occur when there is a large volume loss of bowel content. Bowel preparation causes diarrhea and may cause fatigue; bowel preparation should not cause dyspnea.

The nurse is caring for a patient who has been diagnosed with Crohn disease. When providing education concerning dietary recommendations, which statement indicates that the nurse's teaching has been successful? a. "I should try to eat as much fiber daily as I can." b. "Reducing dietary fat and fiber will be helpful in managing my condition." c. "I should not have lactose-containing products." d. "Eating a larger breakfast and smaller lunch and dinner portions is recommended."

ANS: B The recommended diet in Crohn disease consists of low-fat, low-fiber foods that are high in protein and calories. Small frequent feedings are best. Lactose avoidance helps some patients.

The nurse is caring for a patient with anorexia nervosa. Which intervention(s) might the nurse use to stimulate appetite? (select all that apply.) a. Offer oral care after meals. b. Arrange for preferred foods to be served. c. Encourage family members to bring food from home. d. Suggest that family members or friends come and socialize during the meal. e. Allow ample time to eat and enjoy the meal.

ANS: B, C, D, E Appetite depends on complex mental processes having to do with memory and mental associations that can be pleasant or extremely unpleasant. Appetite is stimulated by the sight, smell, and thought of food. The physical and social environment in which a person is eating stimulates appetite. The enjoyment of eating can be inhibited by unattractive or unfamiliar food, by unpleasant surroundings, and by emotional states such as anxiety, anger, and fear. By serving food based on patient's preferences, encouraging positive interaction, and allowing ample times for meals, the nurse can stimulate appetite. Oral care should be offered before meals to aid in stimulating the appetite.

The nurse is caring for a patient with cirrhosis. The nurse is educating the patient about nutritional implications related to his diagnosis. Which statement indicates that the nurse's teaching has been successful? a. "I should eat lots of sweet potatoes and carrots for vitamin A." b. "I should choose proteins like cottage cheese and quinoa instead of chicken." c. "I should eat oysters and shellfish for a good source of copper." d. "I should eat red meat and dark, leafy vegetables to boost my iron stores."

ANS: B Traditionally, limitation of dietary protein intake was prescribed; however, this approach is being challenged and the current recommendation is to manage encephalopathy with medications rather than to restrict protein. Vegetable proteins are preferred because they do not contribute to encephalopathy. Substituting meat proteins for protein sources like quinoa and cottage cheese is a good dietary choice. Patients with liver inflammation or cirrhosis should avoid taking large doses of vitamins and minerals. Vitamin A, iron, and copper can worsen the liver damage, so this patient should not try to increase intake of these vitamins and minerals.

The nurse is caring for a frustrated patient reports that she still involuntarily voids despite two surgeries to correct incontinence. Which statement indicates that the patient accurately understands the nurse's teaching about incontinence management after surgery? a. "I will avoid wearing pads that can cause skin breakdown." b. "I will talk to my health care provider about a pessary." c. "I will have to have an indwelling catheter." d. "I will have to have another surgery."

ANS: B When surgical measures do not solve the problem, incontinence may be managed by a variety of measures, including intermittent catheterization, indwelling urethral catheterization, suprapubic catheters, external collection systems (such as condom catheters), protective pads and garments, or pelvic organ support devices such as a pessary. The pessary may be useful in managing this patient's stress incontinence. The patient should utilize protective pads and garments. An indwelling catheter may or may not be necessary for this patient. There is no indication that the patient will require another surgery, especially since the previous two surgeries have not eliminated episodes on incontinence.

The nurse is planning skin care of the patient with ascites. Which actions should the nurse include? (select all that apply.) a. Bathe the patient in hot water. b. Apply emollients to decrease itching. c. Closely trim the patient's fingernails. d. Change the patient's position every 1 to 2 hours. e. Coach the patient in deep-breathing exercises.

ANS: B, C, D Applying emollients, cutting the fingernails short, and changing the patient's position frequently are appropriate interventions. The nurse should bathe the patient in tepid water. Deep breathing, although a good intervention in certain situations, has nothing to do with skin care.

The nurse is presenting a program about bulimia nervosa to a group of student nurses. After the program, the participants correctly identify which method(s) of treatment? (select all that apply.) a. Appetite suppressants b. Antidepressant medications c. Psychotherapy d. Behavior modification e. Increased exercise

ANS: B, C, D Bulimia nervosa is a psychological disorder. The bulimic patient consumes large quantities of food and then induces vomiting to get rid of it so that weight is not gained. Laxatives may be taken to purge the system after an eating binge. Treatment of bulimia includes psychotherapy, antidepressant medication, and behavior modification. Appetite suppressants and exercise are not part of treatment for bulimia nervosa.

In which situation(s) should the nurse question an order for carbenicillin for a patient with a urinary infection? (select all that apply.) a. The patient is older than 80 years of age. b. The patient is allergic to penicillin. c. The patient takes warfarin daily. d. The patient takes oral contraceptives. e. The patient has a history of hypertension.

ANS: B, C, D Carbenicillin is an extended-spectrum penicillin medication. It interferes with the effectiveness of oral birth control medication and warfarin and should not be given to people allergic to penicillin. Age and a history of hypertension are not contraindications to carbenicillin.

Before a nurse can document the presence of diarrhea, which criteria must be met? (select all that apply.) a. One loose stool in a 24-hour period b. Multiple liquid or semiliquid stools in a 24-hour period c. Hyperactive bowel sounds d. Cramping e. Fever

ANS: B, C, D Multiple liquid or semiliquid stools in a 24-hour period with hyperactive bowel sounds with cramping are the criteria for diarrhea. Fever is not a diagnostic criteria for diarrhea, and a single loose stool is merely documented as such.

Conservative treatment of diverticulosis includes which management? (select all that apply.) a. Eating a low-fiber diet b. Increasing fluid intake c. Taking stool softeners d. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) for discomfort e. Taking bulk laxatives

ANS: B, C, D, E A high-fiber diet is indicated for the treatment of diverticulosis. All other options would be part of a conservative, nonsurgical approach to treatment.

The nurse is caring for a patient who is undergoing plasmapheresis. The nurse should carefully monitor the patient for which potential complication(s)? (select all that apply.) a. An allergic reaction b. Bleeding at the puncture site c. A bruit at the shunt site d. Decreasing blood pressure e. Signs of hyperkalemia

ANS: B, C, D, E Plasmapheresis is a therapy used in autoimmune disorders, such as acute glomerulonephritis or myasthenia gravis. It removes the autoantibodies causing the disease. This procedure can be done at the bedside by a trained technician with specialized equipment. The patient's blood is accessed through a shunt or a central IV catheter and the blood components are separated from the plasma by filtration or centrifuge. Then, the cellular components are returned to the patient and the plasma is replaced with a fluid such as normal saline or albumin. Assessment for bleeding at puncture site, bruits, hypotension, and electrolyte imbalances is essential. Allergic reactions are not anticipated.

The nurse is caring for a patient with urinary retention. Which measure(s) should the nurse take when assisting the patient to void? (select all that apply.) a. Accompany the patient to the toilet. b. Offer the patient tea or soda. c. Provide a warm bath. d. Discourage the double void technique. e. Run water in the lavatory.

ANS: B, C, E Acceptable interventions when assisting a patient to void include offering a caffeinated or carbonated beverage, and providing a warm bath or running water in the lavatory to stimulate urination. The patient should be given privacy and adequate time to void. The nurse should instruct the patient to utilize the double void technique (void, sit on the toilet for several minutes, and void again).

The presence of which diagnostic criteria are used to confirm the diagnosis of irritable bowel syndrome (IBS)? (select all that apply.) a. Abdominal pain that increases with defecation b. Abdominal pain with a change in stool consistency c. Mucorrhea d. Clay colored stools that float e. Bloating

ANS: B, C, E Diagnosis of IBS is based on clinical manifestations and ruling out the presence of organic bowel disease. Diagnostic criteria include abdominal pain with a change in stool consistency, mucus in the stool (mucorrhea), and abdominal bloating. IBS pain is relieved with defecation; clay colored stools are associated with problems with the gallbladder.

The nurse is caring for a patient scheduled to have an MRI study. Which instruction(s) should the nurse include in the teaching? (select all that apply.) a. Radiation exposure is extremely minimal. b. All metal objects, including dental bridges, jewelry, and body piercings, must be removed. c. Do not eat or drink for 4 hours before the procedure. d. A radiopaque medium may be injected during the procedure. e. There may be a tingling sensation in metal alloy filling of the teeth.

ANS: B, D, E The MRI places the patient in a magnetic field and uses radiofrequency signals to determine how hydrogen atoms behave in the field. All metal must be removed, contrast medium may be injected, and the patient may have a tingling sensation in the teeth with metal alloy fillings. There is no restriction on food or fluid intake in relation to the test. The test does not expose the patient to radiation.

A patient with advanced cirrhosis develops esophageal varices. The nurse anticipates that this complication will be addressed by which type of medication(s)? (select all that apply.) a. Vasodilators b. Intravenous (IV) vasopressin (Pitressin) c. IV iron d. Beta blockers e. Vitamin K

ANS: B, D, E Treatment options include administration of parenteral vasopressors such as vasopressin (Pitressin) to lower portal pressure, a beta blocker to lower blood pressure, and vitamin K to help rectify clotting factor deficiencies. Vasoconstrictors (not vasodilators) such as somatostatin (Zecnil) and octreotide (Sandostatin) are used to reduce portal blood flow, and iron may exacerbate liver failure.

The nurse is caring for a patient with a peptic ulcer. The patient also has a history of chronic bronchitis, diabetes, and arthritis. Which component of the patient's history is the most likely contributing factor to the patient's ulcer? a. The patient requires insulin to manage his diabetes. b. The patient uses a daily inhaler to decrease incidence of asthma attacks. c. The patient takes ibuprofen daily for arthritis pain. d. The patient takes a multivitamin daily.

ANS: C About 4.5 million people in the United States have experienced a peptic ulcer. H. pylori infection is the major cause. Smoking and the continued use of nonsteroidal anti-inflammatory drugs (NSAIDs) are other causes.

The nurse is educating a patient with Barrett esophagus. Which statement indicates that the patient requires a need for further instruction? a. "I should eat smaller meals and avoid foods that cause reflux." b. "I can still have a small glass of wine with dinner." c. "I should consider switching to smokeless tobacco." d. "I should stay upright after eating."

ANS: C Care of the patient with Barrett esophagus is focused on encouraging measures to prevent GERD and on regular checkups. Patients should be encouraged not to use tobacco products and not to indulge in heavy alcohol use.

The nurse is caring for a patient with a 4-day-old ileostomy. The patient complains of cramping, the nurse notes a drop in the effluent for the ileostomy, and the bowel sounds are rapid with a "tinkling" sound. What action should the nurse take? a. Ambulate the patient to help expel gas. b. Irrigate the ileostomy with 500 mL of warm water. c. Notify the charge nurse immediately. d. Turn the patient on the left side to help drain the ileostomy.

ANS: C Cramping and reduced effluent from a new ileostomy should be reported immediately as these are signs of obstruction, which could lead to perforation. Ileostomies are not irrigated except by the physician or an enterostomal therapist.

The nurse is reviewing a history and physical examination of a 22-year-old man hospitalized for acute glomerulonephritis. Which finding best alerts the nurse to a potential causative agent? a. A recent trip to Mexico b. Unprotected sexual activity c. A recent strep throat infection d. A recent protocol of ciprofloxacin (Cipro)

ANS: C Glomerulonephritis is primarily seen in children and young adults, and affects males more often than females. It most commonly occurs about 2 to 3 weeks after a group A beta-hemolytic streptococcal infection, such as "strep throat" or impetigo; however, it can occur in response to bacterial, viral, or parasitic infections elsewhere in the body. It is an immunologic problem caused by an antigen-antibody reaction. International travel and unprotected sexual activity are not causative agents for glomerulonephritis. While recent cipro therapy does indicate a recent bacterial infection, it does not cause glomerulonephritis.

In order to keep optimal flow through the urinary system, a person should have a minimum daily intake of how many mL of fluid? a. 1000 mL b. 1500 mL c. 2000 mL d. 4000 mL

ANS: C Intake of a minimum of 2000 mL/day is adequate to maintain optimal flow through the urinary system.

The nurse is caring for a patient with a Salem sump tube for decompression. The patient displays dyspnea and reports feeling full and nauseated. What action should the nurse take first? a. Increase suction from low to high. b. Notify the charge nurse. c. Irrigate the tube with normal saline. d. Withdraw the tube about three inches.

ANS: C Irrigation of the tube to restore patency is the first intervention when assessment indicates inadequate decompression. The suction should remain on low. Withdrawing the tube may cause inappropriate placement. Notifying the charge nurse is not necessary at this time. Irrigating an obstructed sump tube is a standard of care.

The nurse is caring for a patient with cholelithiasis who is scheduled to undergo a cholescintigraphy (HIDA scan). Which statement accurately describes the purpose of the HIDA scan? a. To visualize the location of gallstones b. To assess amounts of inflammation and swelling c. To diagnose abnormal contraction of the gallbladder d. To assess composition of gallstones

ANS: C The HIDA scan can diagnose abnormal contractions of the gallbladder, which occur in the presence of gallstones or a gallbladder that is not functioning properly.

The nurse is caring for a patient diagnosed with gallstones who requires a cholecystectomy. The patient is upset and asks the nurse why he cannot have lithotripsy instead. Which response is most appropriate for the nurse to make? a. "Is there a reason that you want to have lithotripsy?" b. "Your doctor decides which procedure will be best." c. "Gallstones are usually treated with surgery. Tell me more about your concerns." d. "I understand that you are upset. Would you like to speak with a chaplain?"

ANS: C Lithotripsy, or "shock wave" therapy, is rarely used for gallstones. The treatment of choice is gallbladder removal. By explaining that surgery is the treatment of choice but also asking the patient to elaborate, the nurse provides information and uses an open-ended statement to acknowledge the patient's feelings. Asking the patient to list the reasons that he wants lithotripsy is not therapeutic or effective since the patient requires a cholecystectomy. While the physician does choose which procedure is best indicated, the nurse should not dismiss the patient's concerns or deflect them and suggest that he speak with someone else.

The nurse is caring for a patient with cirrhosis. Which assessment finding warrants the nurse's immediate attention? a. Shiny, tight abdomen b. Yellow sclera c. Confusion d. Paired horizontal bands on the fingernails

ANS: C Mental confusion and coma result from hepatic encephalopathy. Encephalopathy occurs from liver failure that leads to circulating toxins. This finding is an indicator of deteriorating patient condition. Ascites and jaundice are expected findings in cirrhosis and do not necessarily indicate an urgent change in condition. Fingernails that feature horizontal bands in pairs that alternate with normal nail color occur due to hypoalbuminemia from cirrhosis; this finding does not indicate an urgent change in condition.

A patient with a gastrostomy tube gets a bolus feeding of 200 mL every 4 hours. Before giving the bolus, the nurse aspirates a residual of 100 mL. Which action is most appropriate? a. Give the 200 mL feeding. b. Record the residual and give 100 mL of the feeding. c. Document the residual and hold the feeding. d. Position the patient in high Fowler position and give the feeding.

ANS: C On finding a large residual, the nurse should return the residual to the patient, document the amount of the residual, and hold the feeding to avoid possible aspiration.

The nurse documenting the presence of pain in a patient with possible gastric ulcer would anticipate that the pain would occur at which time? a. In the morning b. Erratically, without pattern c. At bedtime d. With meals

ANS: C Pain occurs at bedtime because the stomach is empty, but the gastric juices are still high. Pain is absent in the morning when the digestive juices are low and when the stomach is filled with food.

The nurse caring for a patient admitted with peritonitis who has developed a paralytic ileus. While auscultating bowel sounds, the nurse assesses flatus. What is the significance of this finding? a. Gas has formed in bowel contents. b. Flatus results from forceful vomiting. c. Flatus indicates returning peristalsis. d. Flatus indicates inadequate decompression.

ANS: C Paralytic ileum is a common complication of peritonitis. The nurse should auscultate at least once a shift for the return of bowel sounds. If the patient passes flatus or feces rectally, it indicates return of peristalsis.

The nurse is caring for a patient who is being treated for a gunshot wound to the abdomen. The patient is receiving total parenteral nutrition (TPN), and the physician has prescribed insulin coverage on a sliding scale. The patient reports he has never had diabetes before. What response is best for the nurse to make? a. "It is likely you have developed diabetes as a result of your illness." b. "Do you have a family history for diabetes?" c. "The TPN you are receiving has high amounts of glucose." d. "Insulin is needed to manage your stomach's inability to adequately metabolize food at this time."

ANS: C People on TPN are prone to hyperglycemia from the high glucose content of the solution.

The physician has prescribed rifaximin (Xifaxan) for a patient with cirrhosis. The patient questions why he must take this medication. Which response by the nurse is most appropriate? a. Rifaximin (Xifaxan) helps prevent infection. b. Rifaximin (Xifaxan) helps reduce straining during a bowel movement. c. Rifaximin (Xifaxan) kills intestinal flora. d. Rifaximin (Xifaxan) aids in reducing ascites.

ANS: C Rifaximin (Xifaxan) decrease the bowel flora, colonic bacteria that breakdown protein. This treatment lowers the formation of ammonia. This medication may cause headaches or flatulence and is taken twice daily with food.

A patient who had gastric bypass surgery 5 weeks ago calls the office to report feelings of nausea, sweating, and diarrhea shortly after eating meals. What response by the nurse is most appropriate? a. "This is common after the type of surgery you had." b. "How much, if any, alcohol do you consume each day?" c. "Avoid large meals, limit sweets, and drink small amounts of liquids between meals." d. "You may be experiencing a postoperative infection."

ANS: C Some patients who have had a gastrectomy experience a complication known as the "dumping syndrome." The patient has nausea, weakness, abdominal pain, and diarrhea and may feel faint and perspire profusely or experience palpitations after eating. These sensations are caused by the rapid passage of large amounts of food and liquid into the jejunum. When a patient experiences dumping syndrome, instruction is given to avoid eating large meals and to drink a minimum of fluids during the meal. Fluids may be taken in small amounts later, between meals. If sweet foods seem to aggravate the condition—and they sometimes do—the patient should try to avoid them. Although this is not an uncommon manifestation after this type of surgery, informing the patient that this is common provides limited information to the patient and is not the best response. This problem is not connected to alcohol consumption and is not a symptom of a postoperative infection.

The nurse cautions that constant stress can cause which alteration to the gastrointestinal (GI) system? a. Slowed GI mobility resulting in constipation b. Reversed peristalsis resulting in projectile vomiting c. Increased digestive juices resulting in a gastric ulcer d. Decreased digestive juices resulting in ineffective metabolism

ANS: C Stress increases the gastric secretions, which irritate and finally ulcerate the gastric mucosal lining.

The nurse is caring for a patient who underwent a right nephrostomy to relieve hydronephrosis. Which intervention is most important for this patient? a. Assist the patient with turning every 2 hours. b. Irrigate the nephrostomy tube once per shift. c. Assess urinary output from the left kidney. d. Keep the nephrostomy tube clamped.

ANS: C The left kidney will take on increased renal metabolism and must be assessed constantly. While it is important for the patient to turn, positioning of the patient depends on the surgeon's orders. Frequent turning and deep breathing may help prevent complications but monitoring the unaffected kidney is most important. A nephrostomy tube should never be irrigated or clamped without a specific provider's order that defines the circumstances and the amount of irrigation fluid.

The nurse is caring for a patient being treated for new onset of gallstones. The patient asks the nurse if he will have to have surgery. How should the nurse respond? a. "You will have to have surgery if you continue to have gallstones." b. "Tell me more about your concern." c. "Treatment for gallstones may include diet modification and weight loss, medications, or surgery." d. "You need to ask the doctor about your concerns."

ANS: C The patient should be aware that treatment varies according to severity and frequency of symptoms in conjunction with the patient's response to various treatments. Conservative therapy includes low-fat diets and weight loss, along with restriction of alcohol intake. Oral medications may be given to dissolve gallstones. If the patient does not respond to this therapy, or if bile obstruction occurs, correction of the obstructed biliary tract is indicated. Gallbladder removal is indicated with patients with ongoing symptoms or complications. The nurse should not tell the patient that surgery is inevitable. The patient has already expressed his concern (whether he will require surgery). The nurse can address the patient's concern and should not deflect them to the physician.

The nurse is educating a patient with diverticulitis. Which statement indicates that the nurse's teaching about the importance of seeking treatment has been successful? a. "If left untreated, the inflamed bowel could spread to the entire bowel." b. "If left untreated, the inflamed bowel could cause ulcers." c. "If left untreated, the inflamed bowel can perforate and cause peritonitis." d. "If left untreated, the inflamed bowel can cause appendicitis."

ANS: C The term diverticulum refers to a small, blind pouch resulting from a protrusion of the mucous membranes of a hollow organ through weakened areas of the organ's muscular wall. Diverticula occur most often in the intestinal tract, especially in the esophagus and colon. The infected diverticula can perforate through the bowel wall and cause peritonitis. Diverticulitis does not result in ulcers or appendicitis.

A 25-year-old woman comes to the emergency department with nonspecific urethritis. Which information is most important for the nurse to obtain? a. "How many servings of green vegetables do eat each day?" b. "How often, if any, do you consume alcohol?" c. "How often do you use bath salts or take bubble baths?" d. "Do you take a daily multivitamin?"

ANS: C Urethritis refers to inflammation of the urethra. The use of bath salts, spermicidal jelly, body powders, and feminine hygiene sprays can cause irritation and lead to urethritis. Green vegetable intake, alcohol consumption, and multivitamin intake do not directly relate to causative factors for urethritis.

The nurse is instructing a patient about use of vaginal weight training. Which technique indicates that the patient accurately understands the nurse's teaching? a. The patient inserts the largest cone and leaves it in place for 4-hour increments. b. The patient inserts the smallest cone and performs 10 Kegel exercises before removing it. c. The patient inserts the smallest cone and holds it in place with muscle tightening for 15 minutes before removing it. d. The patient inserts the largest cone and attempts to expel it with vaginal muscle tightening.

ANS: C Vaginal weight training is done with a set of five small, cone-shaped weights that are used along with pelvic muscle exercise as a therapeutic option for incontinence. The lightest cone, which has a string attached, is inserted into the vagina and held in place by muscle tightening for 15 minutes twice a day. When there is no problem holding this cone in place, the next heaviest cone is used. This continues until the heaviest cone can be held in place for the 15-minute period.

The nurse is discussing alternative therapies with a patient who has cystitis. The patient asks the nurse if there are any dietary changes that might help. What response is most appropriate? a. "Drinking lots of water is the only dietary change that would help." b. "Many rumors exist about dietary prevention of UTIs but none are proven at this time." c. "Vitamin C may help decrease the frequency of cystitis." d. "Increase the amount of leafy green vegetables in your daily diet."

ANS: C Vitamin C can help acidify the urine and decrease the frequency of cystitis. Drinking increased amount of water is very helpful, but it isn't the only intervention to avoid a UTI. Evidence indicates that certain foods and drinks may be helpful preventative measures for UTI, like cranberries or cranberry juice. Leafy green vegetables are not considered a preventative food for UTIs.

The nurse is caring for a patient who has been experiencing severe diarrhea and can now resume solid foods. The nurse educates the patient about appropriate food choices. Which food choice indicates that the nurse's teaching has been successful? a. Whole-grain rice b. Wheat toast c. Applesauce d. Grapes

ANS: C When a patient has severe diarrhea and is allowed to resume solid foods, the foods should be slowly introduced in order to help thicken the stool. Foods such as applesauce, pretzels, bananas, white rice, white toast, and yogurt are beneficial.

The nurse reviewing laboratory reports for a patient admitted for acute pyelenophritis. Which finding is most concerning to the nurse? a. Blood urea nitrogen (BUN) of 10.5 mg/dL b. Sodium of 140 mEq/L c. Potassium of 5.0 mEq/L d. Creatinine of 2.0 mg/dL

ANS: D A creatinine of 2.0 is abnormally high and indicates that kidney function negatively affected. The BUN, sodium, and potassium values are within normal limits. (Laboratory ranges include: BUN 10 to 20 mg/dL, creatinine 0.6 to 1.2 mg/dL, sodium 135 to 145 mEq/L, and potassium 3.5 to 5.5 mEq/L.)

A patient is scheduled to undergo a cystogram. Which statement indicates that the patient accurately understands the nurse's teaching about prevention of potential complications of the test? a. "I can have a clear liquid breakfast in the morning before the test." b. "I will have to have a Foley catheter." c. "The test uses radioactive fluid to help take special images of my bladder." d. "I should drink plenty of fluids after the test is over."

ANS: D A radionuclide cystogram utilizes a sodium iodine solution to obtain images of the bladder. The patient should increase intake postprocedure to flush the solution out of the body quickly to limit potential for damage from the hypertonic solution. While the patient is allowed to have a clear breakfast the morning prior to the test and will require a Foley catheter during the procedure, neither of these actions prevent complications from the test. An understanding of the purpose of the test does not prevent potential complications from the procedure.

A 36-year-old woman who had an ascending colostomy angrily declares, "I don't want this hateful thing on my body! This nasty thing is not me." Which response is most appropriate for the nurse to make? a. "The colostomy is part of you now." b. "Let me change the collection bag so you don't stay nasty." c. "All ostomates feel this way at first. I'll go get a list of support groups you may want to join." d. "What about this colostomy concerns you the most?"

ANS: D Asking the patient to name the specific concerns helps to conceptualize where the adjustment problem lies. All other options negate the patient's feelings, reinforce the patient's negative feelings, and do not offer any therapeutic response.

The nurse is caring for a patient diagnosed with glomerulonephritis. The patient reports feeling "bored and caged," and asks when he can resume normal activities. Which finding indicates that bed rest may be discontinued? a. The patient has been compliant with medication for 2 weeks. b. The serum sodium level is 140 mEq/L. c. The patient's weight returns to preillness baseline. d. The patient's blood pressure is 110/74.

ANS: D Bed rest is enforced until the person with glomerulonephritis no longer exhibits hypertension and hematuria.

Transfer of nutrients from intestine to bloodstream

Absorption

The nurse is preparing to administer liquid laxative to a patient in preparation for a colonoscopy. Which action should the nurse take? a. Offer a small snack. b. Take the patient's temperature. c. Mix the laxative with orange juice. d. Chill the laxative and pour it over ice.

ANS: D Chilling the laxative or pouring it over ice makes the drink more palatable and easier to swallow. The nurse should not offer any food, as the accuracy of the test depends on adequate bowel prep. The laxative does not affect the patient's temperature. Mixing the laxative with another substance can make it difficult to judge how much the patient actually consumed if any liquid is remaining.

The nurse is caring for a patient with hepatitis. The nurse explains that jaundice occurs in conjunction with hepatitis based on which underlying pathophysiology? a. Liver ischemia in hepatitis causes jaundice. b. Increased bile production by the enlarged Kupffer cells causes jaundice. c. The hepatitis virus destroys red blood cells and causes jaundice. d. Hepatitis causes liver congestion that obstructs bile flow.

ANS: D Congestion from the inflammation obstructs the bile from entering the duodenum and keeps it in the circulating volume.

The nurse is preparing a teaching plan for a patient with gastroesophageal reflux disease (GERD) who has been prescribed multi-drug therapy for treatment. Which information is most important for the nurse to obtain? a. "Can you identify triggers for your reflux?" b. "Can you commit to changing your diet?" c. "Do you understand how each type of medication works?" d. "Do you think you can afford these prescriptions?"

ANS: D Drug therapy may include antacids, H2-receptor antagonists, proton pump inhibitors, and prokinetic drugs. Priorities related to education about medication include checking for possible drug interactions with other drugs the patient is taking and verifying that the patient can afford the drugs prescribed. (If the patient cannot afford the medications, compliance is an unrealistic expectation.) While it is important for the patient to attempt to identify triggers, commit to dietary and lifestyle modifications, and understand each medication, those are questions that can be answered over time.

The nurse is caring for a patient admitted with suspected acute viral hepatitis. Which laboratory value would best support this diagnosis? a. Decreased aspartate aminotransferase (AST) b. Decreased alanine aminotransferase (ALT) c. Decreased gamma-glutamyl transpeptidase (GGT) d. Increased prothrombin time

ANS: D During the acute phase of hepatitis, the patient will likely display prolonged prothrombin times. Levels of aspartate aminotransferase (AST), alanine aminotransferase and GGT will be elevated.

When the nurse is caring for a patient who reports he has blood that begins when he initiates the urine stream and then abates. Based on underlying pathophysiology, the nurse concludes that the hematuria is occurring in which location? a. In the kidney b. Above the neck of the bladder c. In the neck of the bladder d. In the urethra

ANS: D Gross hematuria indicates bleeding from some point in the urinary tract. If the blood is noticed as soon as voiding starts, it is likely that the blood is from somewhere in the urethra. Blood that appears at the end of urination probably comes from near the neck of the bladder. Bleeding throughout voiding indicates that the blood is coming from a site above the neck of the bladder because the blood has been well mixed with the urine in the bladder.

A 20-year-old college student who has not been immunized against hepatitis B virus (HBV) comes to the clinic and reports that he has been exposed to hepatitis B. The nurse anticipates that the health care provider will likely recommend which treatment? a. A prescription for a broad-spectrum antibiotic b. A prescription for an antiviral agent c. The first of the three immunizations for HBV d. An injection of hepatitis B immune globulin (HBIG)

ANS: D HBIG will give immediate passive immunity. Immunization for HBV takes too long for immediate coverage. Oral medications are of little value at this stage.

The nurse is caring for a confused patient who requires bladder training. Which component of the bladder training program can the nurse safely delegate to the nursing assistant? a. Teaching the patient about a voiding diary b. Creating a schedule for voiding c. Creating a schedule for fluids d. Recording instances of linen changes and fluids offered

ANS: D In planning and implementing a bladder training program for your confused patient, there are several ways in which the UAP can provide help. The nurse appropriately delegates reporting and recording any fluids offered and consumed, along with frequency of linen changes. The nurse should perform patient teaching about the diary, especially since the patient is confused; the nurse is responsible for determining the patient's level of comprehension. The nurse should create the schedule for voiding and fluids, and once the schedule is established, the nursing assistant can help the patient to follow the schedule.

The nurse is assessing a patient who is being treated for acute pyelonephritis. When finding best indicates to the nurse that the patient is in the early stages of pyelonephritis? a. Smoky-colored urine b. Temperature of 99.4° F c. Weakness d. Flank pain

ANS: D In the acute state of pyelonephritis, symptoms include pain in the flank (lateral abdomen) that radiates to the thigh and genitalia, fever (often 103° F+), chills, headache, malaise, and nausea and vomiting. The urine is cloudy with a foul odor as it is loaded with bacteria, blood, and pus. The chronic phase is often subtle, with low-grade fever, weakness, weight loss, and gradual scarring of the kidney tissues.

The nurse is caring for multiple patients. The nurse determines that which patient has the highest risk for developing gallstones? a. A 37-year-old white man of normal weight on long-term corticosteroids for asthma. b. A 42-year-old African American man of normal weight who has smoked for 25 years. c. A 46-year-old Indonesian woman who is under normal weight and has recently had radiation treatments. d. A 50-year-old obese Mexican American woman who has type 1 diabetes.

ANS: D Obesity, diabetes mellitus (DM), rapid weight loss, and Crohn disease increase the risk for the development of gallstones. Native Americans and Mexican Americans have an ethnic predisposition to gallstones.

An 85-year-old patient who has been NPO since midnight last night for diagnostic testing just completed the procedure. Which intervention is most important? a. Inform the patient about the test results. b. Obtain the patient's weight for comparison to the morning value. c. Turn the patient every 2 hours. d. Offer 4 ounces of water or juice every hour.

ANS: D Offering small amounts of fluid every hour will rehydrate the older adult without resorting to intravenous fluids. The older adult has very little fluid reserve and has lost the ability to concentrate the urine; consequently, a long period without fluid intake can cause dehydration. The doctor should inform the patient about the test results. Weighing the patient again is unnecessary. While prevention of skin breakdown is important, there is no indication that the patient cannot reposition independently.

The nurse is caring for a patient who is being treated for extensive burns. The nurse notes the presence of coffee-ground material in the Salem sump catheter. The nurse correctly recognizes which factor as the likely cause? a. Esophagitis b. Perforated gastric ulcer c. Gastric irritation from the Salem sump tube d. A physiologic stress ulcer

ANS: D Prolonged physiologic stress produces what is known as a physiologic stress ulcer, which is believed to be the result of unrelieved stimulation of the vagus nerves and decreased perfusion to the stomach. A stress ulcer is pathologically and clinically different from a chronic peptic ulcer. It is more acute and more likely to produce hemorrhage. Perforation occurs occasionally, and pain is rare. Stress ulcers are a hazard for patients who are severely ill and in intensive care units for prolonged periods. Patients with multiple trauma, burns, or multisystem disorders are subject to physiologic stress ulcers, which may produce blood that has been in contact with gastric juices.

The nurse is obtaining a history of a patient with hepatitis A. Which question is most appropriate for the nurse to ask? a. "If using drugs, do you share needles?" b. "Do you always practice safe sex?" c. "Have you traveled to Canada in the last month?" d. "Do you eat shellfish or oysters often?"

ANS: D Shellfish and mollusks can be contaminated by living in feces-contaminated water. Drug use and unprotected sex are not part of the etiology of hepatitis A but are for hepatitis B. Travel to Canada is not associated with hepatitis A.

The nurse is reviewing a student nurse's charting and notes that the student has documented absent bowel sounds. The nurse reminds the student that in order to document absent bowel sounds, one must auscultate each quadrant at what period of time? a. 30 seconds b. 1 minute c. 2 minutes d. 5 minutes

ANS: D The criterion for the documentation of absent bowel sounds is that each quadrant is auscultated for 5 minutes.

The nurse is performing preprocedure teaching for a patient scheduled to undergo a liver biopsy. After listening to the information, the patient states, "I am so scared. I just don't know if I can do this procedure." Which response is best? a. "The procedure will only last about 15 minutes." b. "Most patients say it feels similar to a punch in the shoulder." c. "You do not have to have the procedure." d. "I understand that you are afraid. Tell me more about your concerns."

ANS: D The nurse should acknowledge the patient's feelings and promote therapeutic communication. While all of the other statements are true, none of them investigate the underlying cause of the patient's fear. Reassurance about the length of the procedure or the sensation that the patient might experience may be indicated after the patient explains more about specific concerns. While the patient can refuse to have the procedure, dismissing the patient is not an appropriate or therapeutic statement.

The nurse is providing discharge teaching for a patient who underwent a laparoscopic cholecystectomy. Which statement indicates that the nurse's teaching has been successful? a. "I should call my doctor if I have any pain." b. "I should be able to go back to work tomorrow." c. "I should avoid fatty foods for a few weeks." d. "I should let these Steri-Strips fall off on their own."

ANS: D The nurse should teach the patient to remove the bandages from the puncture site(s) the day after surgery and shower, leaving the Steri-Strips intact. Steri-Strips will fall off in 7 to10 days. The patient should notify the physician in cases of severe abdominal pain that is not relieved by medication or is worsening. Return to work is probable at 1 week postsurgery. The patient should adhere to a low-fat diet for several weeks and slowly introduce fattier foods to determine if they cause unpleasant symptoms.

The nurse is caring for a patient 1-day postoperative after a transverse colostomy. When assessing the stoma, which finding requires the nurse's immediate action? a. A wet, glistening stoma b. A stoma with scant marginal bleeding c. An edematous stoma d. A purplish-red stoma

ANS: D The purple hue in the new stoma is an indication of reduced perfusion to the stoma and should be reported immediately. A new stoma should have a pink or beefy red color, be slightly edematous, and have some small bleeding around the stoma.

The nurse is caring for a patient whose home medications include bismuth subsalicylate (Pepto Bismol). The nurse should educate the patient about which side effect of this medication? a. Pink urine b. Sunburn-like rash c. Stained teeth d. Black stools

ANS: D This medication often turns the stool black. It does not cause a rash, or stain the urine or teeth.

The nurse explains that the diagnosis of morbidly obese is reserved for people who exceed which percentage of their recommended weight? a. 50% b. 70% c. 90% d. 100%

ANS: D Those people who weigh 100% over their recommended weight are considered morbidly obese.

The nurse is caring for a patient who recently had abdominal surgery. Which assessment finding requires the nurse's immediate attention? a. Bruising near the surgical incision site b. Report of constipation c. Abdominal pain of 4/10 d. Urine output of 20 mL in the last hour

ANS: D Urine output of 20 mL in an hour is inadequate and could indicate that the patient is not perfusing properly. Bruising is a common occurrence after surgery, from small blood vessels leaking blood under the skin after an incision is made. Constipation is normal after abdominal surgery, as anesthesia, surgery, and pain medications slow bowl motility. Abdominal pain of 4/10 may require an analgesic but does not indicate an emergent or urgent finding.

The nurse is caring for a patient who has been taking a sulfa drug for a urinary tract infection (UTI). Which intervention is most important for the nurse to add to the patient's care plan? a. Ambulate the patient q shift. b. Ask the patient about a penicillin allergy. c. Weigh the patient daily. d. Increase fluid intake to 1.5 L/day.

ANS: D With sulfa drugs, it is most important for the patient to maintain a fluid intake of at least 3000 mL (1.5 L) in order to prevent crystalluria and stone formation. Ambulation does not directly correlate to the sulfa drug in any way. Investigating an allergy is an assessment, not an intervention, and this action should occur prior to administering the first dose. Daily weights are important for tracking inputs and outputs, but it is not the priority intervention.

Repair of body tissue

Anabolism

Absence of urine

Anuria

(Match the types of ostomies with the expected type of effluent.) Liquid and unformed stool

Ascending colostomy

Breaking down larger molecules into smaller molecules

Catabolism

(Match the types of ostomies with the expected type of effluent.) No effluent

Continent ileostomy

(Match the types of ostomies with the expected type of effluent.) Formed stool on relatively regular basis

Descending colostomy

(Match the hepatitis virus (HV) with the characteristics that best describe it.) Fecal-oral transmission, acute onset

HAV

(Match the hepatitis virus (HV) with the characteristics that best describe it.) Transmission by contact with blood and body fluids, perinatal transmission from mother to infant

HBV

(Match the hepatitis virus (HV) with the characteristics that best describe it.) Most likely to lead to cirrhosis

HCV

(Match the hepatitis virus (HV) with the characteristics that best describe it.) Coexists with HBV

HDV

(Match the hepatitis virus (HV) with the characteristics that best describe it.) Prevalent in less developed countries

HEV

Blood in the urine

Hematuria

(Match the types of ostomies with the expected type of effluent.) Extremely watery stool with concentrations of digestive enzymes

Ileostomy

(The nurse associates the types of acute renal failure with their probable cause to enhance the patient's understanding. Match the type of acute renal failure (ARF) with its probable cause) Vascular changes related to diabetes mellitus

Intrarenal ARF

Chemical process to make substances needed by the body

Metabolism

Urination at night

Nocturia

Diminished urine

Oliguria

Rhythmic squeezing action of intestinal tract

Peristalsis

High urinary output

Polyuria

(The nurse associates the types of acute renal failure with their probable cause to enhance the patient's understanding. Match the type of acute renal failure (ARF) with its probable cause) Prostate hypertrophy

Postrenal ARF

(The nurse associates the types of acute renal failure with their probable cause to enhance the patient's understanding. Match the type of acute renal failure (ARF) with its probable cause) Ureteral obstruction

Postrenal ARF

(The nurse associates the types of acute renal failure with their probable cause to enhance the patient's understanding. Match the type of acute renal failure (ARF) with its probable cause) Cardiogenic shock

Prerenal ARF

(The nurse associates the types of acute renal failure with their probable cause to enhance the patient's understanding. Match the type of acute renal failure (ARF) with its probable cause) Hypovolemic shock

Prerenal ARF

(Match the types of ostomies with the expected type of effluent.) Semiliquid stool at unpredictable times

Transverse colostomy