NSG 211 Exam 1 Unit 2 - Inflammation

The nurse will teach clients that antacids are effective in the treatment of hyperacidity based on which mechanism of action? a. Neutralizes gastric acid b. Decreases gastric pH c. Decreases stomach motility d. Decreases duodenal pH

ANS: A Antacids work by neutralizing gastric acid, which would cause an increase in pH. They do not affect gastric motility.

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

ANS: B Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

Which nursing diagnosis is appropriate for a patient receiving famotidine (Pepcid)? a. Ineffective peripheral tissue perfusion related to hypertension b. Risk for infection related to immunosuppression c. Impaired urinary elimination related to retention d. Risk for injury related to thrombocytopenia

ANS: D A serious side effect of famotidine is thrombocytopenia, which is manifested by a decrease in platelet count and an increased risk of bleeding. The patient receiving famotidine may experience hypotension as an adverse effect, not hypertension. Famotidine does not cause immunosuppression or urinary retention.

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

A patient with extensive muscle atrophy and joint deformity has rheumatoid arthritis. Which stage of rheumatoid arthritis does the nurse determine the patient is experiencing? a. Early stage b. Moderate stage c. Severe stage d. Terminal stage

The severe stage of rheumatoid arthritis is characterized by extensive muscle atrophy, and joint deformities such as subluxation, ulnar deviation, and osteoporosis. The early stage of rheumatoid arthritis is characterized by possible x-ray evidence of osteoporosis, but no destructive changes on x-ray. The terminal stage of rheumatoid arthritis is characterized by fibrous or bony ankylosis and adjacent muscle atrophy. A patient with moderate rheumatoid arthritis will experience adjacent muscle atrophy, possible presence of extraarticular lesions, and osteoporosis with or without bone destruction.

The nurse is preparing to administer a medication that has the action to reduce capillary permeability. What medication will the nurse administer to the patient? a. Aspirin b. Piroxicam c. Ibuprofen d. Acetaminophen

ANS: A Aspirin is an antiinflammatory drug that reduces capillary permeability in the body. Ibuprofen is a nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis. Piroxicam is a nonsteroidal antiinflammatory drug that inhibits the synthesis of prostaglandin. Acetaminophen helps maintain thermoregulation by acting on the heat-regulating center in the hypothalamus.

Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a.Encourage the patient to express concerns and ask questions about IBS. b.Suggest that the patient increase the intake of milk and other dairy products. c.Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d.Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease irritation. d. The patient cleans the perianal area with soap after each stool.

ANS: C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool.

A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a.Encourage the patient to ambulate. b.Instill a mineral oil retention enema. c.Administer the ordered IV morphine sulfate. d.Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

Which term refers to the directional migration of white blood cells to the site of a cellular injury? a. chemotaxis b. cell lysis c. chemical mediation d. shift to the left

ANS: A Chemotaxis refers to the directional migration of white blood cells to an injury site. Cell lysis refers to cell rupture, leading to cell death. Chemical mediation describes the mediation of the inflammatory response by a variety of chemical mediators. A shift to the left refers to the presence of band neutrophils, which are an early sign of inflammation.

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

ANS: A Elevated blood glucose will increase inflammation and have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is also important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.

Which medication used in gastroesophageal reflux disease decreases the conversion of pepsinogen to pepsin? a. famotidine b. misoprostol c. rabeprazole d. metoclopramide

ANS: A Famotidine is a histamine (H 2) receptor blocker that reduces the conversion of pepsinogen into pepsin. Misoprostol is a prostaglandin that increases the production of gastric mucosa. Rabeprazole is a proton pump inhibitor that results in a decrease of hydrochloric acid secretion. Metoclopramide increases gastric motility and emptying.

A 51-year-old male patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about a.medication use. b.fluid restriction. c.enteral nutrition. d.activity restrictions.

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

A client is prescribed monoclonal antibody therapy for the treatment of rheumatoid arthritis. What client condition should alert the nurse to question the prescription for this class of drugs? a. AIDS b. COPD c. Nephrotic Syndrome d. Hypertensive emergency

ANS: A Monoclonal antibody drugs are usually contraindicated in patients with known active infectious processes because of their immunosuppressive qualities. Use of alemtuzumab is also contraindicated in clients with active systemic infections and immunodeficiency conditions, including AIDS.

A specimen is taken from a patient's wound and is found to contain white blood cells, microorganisms, debris, and liquefied dead cells when assessed. What type of exudate does the nurse determine this patient has? a. purulent b. catarrhal c. hemorrhagic d. serosanguineous

ANS: A Purulent exudate consists of white blood cells, microorganisms, debris, and liquefied dead cells. Purulent discharge is observed in furuncles, abscesses, and cellulitis. Catarrhal exudate contains mucus. Hemorrhagic exudate contains red blood cells. Serosanguineous exudate contains red blood cells and serous fluid.

A 51-year-old woman with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? a.Fever b.Nausea c.Joint pain d.Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.

A nurse assesses a 38-year-old patient with joint pain and stiffness who was diagnosed with Stage III rheumatoid arthritis (RA). What characteristics should the nurse expect to observe? (select all that apply) a. Nodules present b. Consistent muscle strength c. Localized disease symptoms d. No destructive changes on x-ray e. Subluxation of joints without fibrous ankylosis

ANS: A, E In Stage III severe RA, there may be extraarticular soft tissue lesions or nodules present, and there is subluxation without fibrous or bony ankylosis. The muscle strength is decreased because there is extensive muscle atrophy. The manifestations are systemic not localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis.

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

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent Helicobacter pylori infection.

A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a.Bacteria in the perianal area can enter the urethra. b.Fistulas can form between the bowel and bladder. c.Drink adequate fluids to maintain normal hydration. d.Empty the bladder before and after sexual intercourse.

ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Cherry gelatin with fruit c. Glass of low-fat milk d. Peanut butter and jelly sandwich

ANS: B Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

The nurse is completing discharge teaching for a patient being released from the emergency department after evaluation of an ankle sprain. The nurse is teaching the patient about the rest, ice, compression, and elevation (RICE) approach to dealing with soft tissue injuries. Using RICE, when should the nurse instruct the patient to use heat? a. Immediately b. After 24 to 48 hours c. After 48 to 72 hours d. After the inflammation has begun to subside

ANS: B Heat should be used after 24 to 48 hours (after cold application) to increase circulation to the inflamed site. Cold is used immediately to promote vasoconstriction and decrease swelling, pain, and congestion at the site. The patient does not need to wait 48 to 72 hours or until the inflammation has begun to subside.

Which cells arrive first at the site of injury during the inflammatory response? a. monocytes b. neutrophils c. lymphocytes d. macrophages

ANS: B Inflammatory response is a sequential reaction to cell injury. Neutrophils are the first leukocytes to arrive at the injury site. They usually reach the site of injury within 6 to 12 hours. They engulf bacteria, other foreign material, and damaged cells. Monocytes are the second type of phagocytic cells that migrate from circulating blood. They usually arrive at the site within 3 to 7 days after the onset of inflammation. Lymphocytes arrive later at the site of injury. Their primary role is related to humoral and cell-mediated immunity. On entering the tissue spaces, monocytes transform into macrophages. Together with the tissue macrophages, these macrophages assist in phagocytosis of the inflammatory debris.

How will the nurse describe the action of proton pump inhibitors (PPIs)? a. They form a protective barrier that can be thought of as a liquid bandage. b. They irreversibly bind to the hydrogen-potassium-ATPase pump. c. They compete with histamine for binding sites on the parietal cells. d. They help to neutralize acid secretions to promote gastric mucosal defensive mechanisms.

ANS: B PPIs work to block the final step in the acid-secreting mechanisms of the proton pump. They do this by irreversibly binding to the ATPase pump, H+/K+ ATPase, the enzyme for this step.

A patient with a systemic bacterial infection feels cold and has a shaking chill.Which assessment finding will the nurse expect next? a. Skin flushing b. Rising body temperature b. Muscle cramps d. Decreasing blood pressure

ANS: B The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.

The patient has inflammation and reports malaise, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? a. local response b. systemic response c. infectious response d. acute inflammatory response

ANS: B The systemic response to inflammation includes the manifestations of a shift to the left in the white blood cell (WBC) count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in two to three weeks and usually leaves no residual damage.

PPIs have the ability to almost totally inhibit gastric acid secretion. Because of this possibility, the use of the medication can lead to what condition? a. Gastric ulcer formation b. Gastroesophageal reflux disease (GERD) c. Achlorhydria d. Diverticulosis

ANS: C Because PPIs stop the final step of acid secretion, they can block up to 90% of acid secretion, leading to achlorhydria (without acid).

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

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

ANS: C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Notify the health care provider. c. Document the assessment. d. Assess the wound every 2 hours.

ANS: C The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a.Patient has not voided for the last 4 hours. b.Skin is dry with poor turgor on all extremities. c.Crackles are heard halfway up the posterior chest. d.Patient has had 5 loose stools over the last 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will also be reported, but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

The nurse obtains a history from a 46-year-old woman with rheumatoid arthritis. It is most important for the nurse to follow up on which patient statement? a. "I perform range of motion exercises at least twice a day." b. "I use a heating pad for 20 minutes to reduce morning stiffness." c. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." d. "I restrict fluids to prevent edema when taking methotrexate (Rheumatrex)."

ANS: D Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

The nurse will anticipate teaching a patient experiencing frequent heartburn abouta. a barium swallow. b. endoscopy procedures. c. radionuclide tests. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

A patient admitted for treatment of a large pressure ulcer on the right heel asks the nurse about new inflammation in the subcutaneous tissue. What term best describes the current issue the patient is experiencing? a. sepsis b. keloid c. fistula d. cellulitis

ANS: D Cellulitis can occur due to untreated pressure ulcers and involves the spreading of inflammation to the subcutaneous (connective) tissue. Sepsis occurs when an infection spreads to the bloodstream. A keloid is a permanent protrusion of scar tissue beyond the edges of the wound or injury. Fistulas are abnormal passages that may occur secondary to a wound.

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for a.oral ferrous sulfate tablets. b.regular blood transfusions. c.iron dextran (Imferon) infusions. d.cobalamin (B12) spray or injections.

ANS: D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

The nurse is preparing to apply heat at the site of inflammation to a patient who sustained an injury to the arm. What is the best explanation to the patient as to the reason for this therapy? a. To decrease congestion b. To promote vasoconstriction c. To prevent further tissue injury d. To localize the inflammatory agents

ANS: D Heat application is used to localize the inflammatory agents and promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Cold application decreases congestion and promotes vasoconstriction at the site of inflammation. Immobilizing the inflamed area with a cast prevents further tissue injury.

A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating rheumatoid arthritis.

The postoperative patient states that he or she has never taken pantoprazole in the past. The patient asks why he or she is getting this medication if the patient has never had heartburn. What is the best response by the nurse? a. "This will prevent gas pains from the excess air in your small intestine." b. "This will prevent the heartburn that occurs as a side effect of your diabetes." c. "The stress of surgery is likely to cause stomach bleeding if you do not receive it." d. "This will reduce the amount of acid in your stomach until you can eat a regular diet again."

ANS: D Pantoprazole is a proton pump inhibitor that decreases acid production in the stomach. It minimizes damage to the gastric mucosa while the patient is on bed rest and hospitalized after surgery. Pantoprazole will not prevent gas pains and will not prevent stomach bleeding from surgery. Heartburn is not a side effect of diabetes.

A nursing student is learning about prostaglandins and their role in vasodilation. What is the source of prostaglandins? a. cytokines b. serotonin c. histamine d. arachidonic acid

ANS: D Prostaglandins are produced from arachidonic acid. When cells are activated by injury, the arachidonic acid in the cell membrane is converted to produce prostaglandins. Cytokines, serotonin, and histamine do not have any role in prostaglandin production. They are mediators of inflammation.

What condition will the nurse monitor for with a client using sodium bicarbonate to treat gastric hyperacidity? a. Hypercalcemia b. Hyperkalemia c. Metabolic acidosis d. Metabolic alkalosis

ANS: D Solutions containing sodium bicarbonate (a base) can cause metabolic alkalosis. Serum potassium and serum calcium would decrease, not increase, with alkalosis.

Which cells release growth factors that initiate the healing process? a. platelets b. monocytes c. neutrophils d. red blood cells

ANS: A Platelets release growth factors that initiate the healing process. Monocytes help clean the area before healing. Neutrophils play an important role in producing inflammatory response. Red blood cells do not release any growth factors that initiate the healing process.

A patient being admitted with an acute exacerbation of ulcerative colitis reports cramping abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to a.administer IV metoclopramide (Reglan). b.discontinue the patient's oral food intake. c.administer cobalamin (vitamin B12) injections. d.teach the patient about total colectomy surgery.

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. breath sounds. c. bowel sounds. d. abdominal girth.

ANS: B Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate four times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

What is the mechanism of action for Famotidine (Pepcid)? a. It forms a protective coating against gastric acid, pepsin, and bile salts. b. It competes with histamine for binding sites on the parietal cells. c. It irreversibly binds to the hydrogen-potassium-adenosine triphosphatase (ATPase) pump. d. It causes a decrease in stomach pH, reducing stomach acidity.

ANS: B Famotidine (Pepcid) is an H2 receptor-blocker. Histamine receptor-blocking drugs decrease gastric acid by competing with histamine for binding sites on the parietal cells.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a.Restrict fluid intake to prevent constant liquid drainage from the stoma. b.Use care when eating high-fiber foods to avoid obstruction of the ileum. c.Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d.Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the excess gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

ANS: B Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

Which enzyme is a potent vasodilator that contributes to edema and increased blood flow? a. arachidonic acid b. prostaglandins c. thromboxane d. leukotrienes

ANS: B The complement system is an enzyme cascade that mediates the inflammatory response. Prostaglandins are potent vasodilators that lead to increased blood flow and edema. After cell injury, arachidonic acid is converted to prostaglandins. Thromboxane leads to brief vasoconstriction and clot formation. The slow-reacting substance of anaphylaxis is formed by leukotrienes.

Which client statement demonstrates understanding of teaching by the nurse regarding the use of histamine2-receptor antagonists? a. "Because I am taking this medication, it is OK for me to eat spicy foods." b. "Smoking decreases the effects of this medication, so I should look into cessation programs." c. "I should take this medication 1 hour after each meal to maximally decrease gastric acidity." d. "I should increase bulk and fluids in my diet to prevent constipation."

ANS: B Clients taking histamine2-receptor-blocking drugs should avoid spicy foods, extremes in temperatures, alcohol, and smoking. Diarrhea, not constipation, is a GI adverse effect. Whereas cimetidine should be taken with meals, famotidine can be taken without regard to meals.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen (Tylenol) prescribed PRN for pain.

ANS: C Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature.Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.

ANS: D The earliest manifestation of an infection may be "just not feeling well." Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive or anti-inflammatory medications such as corticosteroids.

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

For a client with chronic renal failure, the nurse MOST likely will question a prescription for which type of antacid? a. Aluminum-containing antacids b. Calcium-containing antacids c. Sodium-containing antacids d. Magnesium-containing antacids

ANS: D Magnesium-containing antacids can cause hypermagnesemia in clients with chronic renal failure. Aluminum-containing antacids may be used as a phosphate binder in clients with chronic renal failure. Sodium- and aluminum-containing antacids are chemically more easily excreted in clients with renal compromise. Although calcium-containing antacids may accumulate in the bloodstream of clients with renal failure, they may also be appropriate because these patients may be hypocalcemic.

A patient who has an infected abdominal wound develops a temperature of 104°F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]. a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS:A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.