NSG121- FINAL EXAM (UNIT 3)
When administering a hypertonic solution the nurse should closely watch for? A. Signs of dehydration B. Pulmonary Edema C. Fluid volume deficient D. Increased Lactate level
B. Pulmonary Edema
Most patients with diverticulosis are most likely to have diverticula located in the? A. Transverse colon B. Sigmoid Colon C. Rectum D. Ascending Colon
B. Sigmoid Colon
The nurse recognizes that most nutrients and electrolytes are absorbed by which of the following? A. Colon B. Small intestine C. Esophagus D. Stomach
B. Small intestine
A patient is 2 days post-opt from an ileostomy placement. Which finding requires immediate nursing action? A. The stoma is excreting liquid stool. B. The patient's potassium level is 2.0 C. The stoma is bright red and moist. D. The patient reports mucoid drainage from the anus.
B. The patient's potassium level is 2.0
A patient is 8 hours post-opt from a colostomy placement. Which finding requires immediate nursing action? A. The stoma is swollen and large. B. The stoma is black. C. The stoma is not draining any stool. D. The patient states the site is tender.
B. The stoma is black. (Compromised circulation)
Which clinical manifestation should a nurse associate with effective IV fluid replacement therapy for a client diagnosed with fluid volume defiict? A. Temperature of 99.9F B. Urine output of 50 ml/hr C. Blood pressure of 90/50 mmHg D. Jugular venous distention
B. Urine output of 50 ml/hr
A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? SATA A. History of liver disease B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics E. Prescription for insulin
B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics
The client who has fluid overload has been taking a diuretic for the past 2 days and now experiences these changes. Which change indicates to the nurse that the diuretic is effective? A. Morning blood glucose decreased from 142 mg/dL to 110 mg/dL B. Weight loss of 7 pounds C. Respiratory rate decreased from 20 to 16 D. Heart rate increased from 72 to 80
B. Weight loss of 7 pounds
The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? Select all that apply A. fruit juice B. alcohol C. corticosteroids D. caffeine E. nsaids
B. alcohol C. corticosteroids D. caffeine E. nsaids
Which solution below is NOT a hypertonic solution? A. 5% Dextrose in 0.9% Saline B. 5% Saline C. 5% Dextrose in Lactated Ringer's D. 0.33% saline (1/3 NS)
D. 0.33% saline (1/3 NS)
If you were walking across the Sahara Desert with an empty canteen, the amount of Antidiuretic hormone secreted would most likely A. Have no effect B. Increase C. Decrease D. Stay the same
B. Increase
A nurse cares for a patient with ulcerative colitis. The patient states, "I feel like I am tied to the toilet. This disease is controlling my life." How would the nurse respond? A. "Let's discuss potential factors that increase your symptoms." B. "To decrease distress, do not eat anything before you go out." C. "If you take the prescribed medications, you will no longer have diarrhea." D. "You must retake control of your life. I will consult a therapist to help."
A. "Let's discuss potential factors that increase your symptoms."
A patient is newly diagnosed with mild ulcerative colitis. What type of anti-inflammatory medication is typically prescribed as first line treatment for this condition? A. 5-Aminosalicylates (Sulfasalazine) B. Immunomodulators (Adalimumab) C. Corticosteroids (Prednisone) D. Immunosupressors (Azathioprine)
A. 5-Aminosalicylates (Sulfasalazine)
Which patient is at most risk for hypomagnesemia? A. A 55 year old chronic alcoholic B. A 57 year old with hyperthroidism C. A patient reporting overuse of anatacids and laxatives D. A 25 year old suffering from hypoglycemia
A. A 55 year old chronic alcoholic
Which patient is at more risk for an electrolyte imbalance? A. An 8 month old with a fever of 102.3 'F and diarrhea B. A 55 year old diabetic with nausea and vomiting C. A 5 year old with RSV D. A healthy 87 year old with intermittent episodes of gout
A. An 8 month old with a fever of 102.3 'F and diarrhea
The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? A. Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. B. Auscultating bowel sounds in all abdominal quadrants C. Counting the number of bowel sounds in each abdominal quadrant over one minute. D. Observing the abdomen for symmetry and distention
A. Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours.
The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? SATA A. Assess daily weights. B. Encourage consumption of citrus fruits. C. Weigh the client weekly. D. Monitor serum potassium. E. Discourage intake of spinach. F. Monitor for bradycardia.
A. Assess daily weights. B. Encourage consumption of citrus fruits. D. Monitor serum potassium.
A patient with Crohn's Disease is taking corticosteroids. The patient is complaining of extreme thirst, polyuria, and blurred vision. What is your next nursing action? A. Check the patient's blood glucose B. Give the patient a food containing sugar (ex: orange juice) C. Administer oxygen via nasal cannula D. Assess bowel sounds
A. Check the patient's blood glucose
The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A. Client behavior that changes from anxious to lethargic B. Deep furrows on the surface of the tongue C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours
A. Client behavior that changes from anxious to lethargic
Select ALL of the following that are complications associated with Crohn's Disease: A. Cobble-stone appearance of GI lining B. Lead-pipe sign C. Toxic megacolon D. Fistula E. Abscess F. Anal Fissure
A. Cobble-stone appearance of GI lining D. Fistula E. Abscess F. Anal Fissure
A patient asks what type of testing is performed to assess for diverticulosis. As the nurse, you know that which test below is used to assess for diverticulosis? A. Colonoscopy B. Fleets enema C. Bronchoscopy D. Cystoscopy
A. Colonoscopy
A nurse is reviewing a client's laboratory data. Which laboratory data should the nurse associate with the development of fluid volume excess? Select All That Apply. A. Decreased hematocrit B. Decreased Urine Specific Gravity C. Decreased hemoglobin D. Increased hematocrit E. Increased Creatinine
A. Decreased hematocrit B. Decreased Urine Specific Gravity C. Decreased hemoglobin
Which type of colostomy can allow a patient to have bowel continence? A. Descending or Sigmoid Colostomy B. Ascending or Transverse Colostomy C. Transverse or Descending Colostomy D. Ascending or Descending Colostomy
A. Descending or Sigmoid Colostomy
Select ALL the options below that are similarities between ulcerative colitis and Crohn's Disease: A. Each cause inflammation B. Both affect the serosa layer C. Each are found from the mouth to anus D. They both increase colon cancer risk E. The cause of both is unknown D. The cure for both diseases includes total colectomy
A. Each cause inflammation D. They both increase colon cancer risk E. The cause of both is unknown
The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A. Heart rate B. Blood pressure C. Increases in edema D. Sodium level
A. Heart rate (The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range.)
________ fluids remove water from the extracellular space into the intracellular space. A. Hypotonic B. Hypertonic C. Isotonic D. Colloids
A. Hypotonic
You're providing diet teaching to a patient with ulcerative colitis about what types of foods to avoid during a "flare-up". Which foods below should the patient avoid? SELECT-ALL-THAT-APPLY: A. Ice cream B. White Rice C. Fresh apples and pears D. Popcorn E. Cooked carrots
A. Ice cream C. Fresh apples and pears D. Popcorn
Thinking back to the patient with the Ascending colostomy, what type of stool would you expect the stoma to be excreting? A. Liquid stool B. Lose to partly formed stool C. Similar to normal stool D. Semi-solid stool
A. Liquid stool
A patient, who has a colostomy, asks what type of foods they should avoid to decrease odorous gas. You would tell the patient to avoid: A. Onions, alcoholic beverages, eggs, and cabbage B. Beef, fried foods, lettuce, and rice C. Apple, pears, nuts, and wheat D. Potatoes, peas, carrots, and chicken
A. Onions, alcoholic beverages, eggs, and cabbage
A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? SATA A. Place the client on bed rest. B. Evaluate the electrolyte levels C. Administer the ordered diuretic D. Assess for orthostatic hypotension E. Initiate cardiac monitoring
A. Place the client on bed rest. B. Evaluate the electrolyte levels D. Assess for orthostatic hypotension E. Initiate cardiac monitoring
A patient has a double-barrel colostomy of the transverse colon. You note on assessment two stomas, a proximal and distal stoma. What type of stool do you expect to drain from the proximal and distal stomas? A. Proximal: lose to partly formed stool; Distal: mucous B. Proximal: liquid stool; Distal: mucous C. Proximal: mucous; Distal: lose to partly formed stool D. Proximal & Distal: lose to partly formed stool
A. Proximal: lose to partly formed stool; Distal: mucous
A patient with ulcerative colitis is scheduled for ileoanal anastomosis (J-Pouch) surgery. You know that this procedure: A. Removes the colon and rectum which allows a pouch to be created that will attach to the ileum. This will allow stool to pass from the small intestine to the anus. B. Removes the colon and rectum and creates a permanent ileostomy. C. Removes the colon and creates a temporary colostomy. D. Removes the rectum which allows a pouch to be created from the colon. This will allow stool to pass from the colon to the anus.
A. Removes the colon and rectum which allows a pouch to be created that will attach to the ileum. This will allow stool to pass from the small intestine to the anus.
The nurse writes the nursing problem of "fluid volume excess". Which intervention should be included in the plan of care? A. Restrict the client's sodium in the diet B. Change the IV fluid from an isotonic solution to a hypertonic solution C. Prepare the client for hemodialysis D. Monitor blood glucose levels
A. Restrict the client's sodium in the diet
On morning assessment of your patient in room 2502 who has severe burns. You notice that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not changed and his intake and output is equal. What do you suspect? A. Third spacing B. This is normal and expected after a burn and it is benign C. Document this finding as non-pitting abdominal edema. D. Intravascular compartment syndrome
A. Third spacing
A patient has the following symptoms: urgent and frequent bowel movements of diarrhea that contains blood with pus and mucous, low hemoglobin/hematocrit, potassium level of 2.0. Based on the patient's signs and symptoms, which disease does this describe? A. Ulcerative Colitis B. Crohn's Disease
A. Ulcerative Colitis
Which bowel disease starts in the rectum and migrates in a continuous fashion throughout the colon? A. Ulcerative Colitis B. Crohn's Disease
A. Ulcerative Colitis
______________ affects the inner layer of the intestinal lining. A. Ulcerative Colitis B. Crohn's Disease
A. Ulcerative Colitis
A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? SATA A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion C. Infuse at a rate of no more than 10 mEq/hr D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest.
A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion C. Infuse at a rate of no more than 10 mEq/hr
A client presents to an urgent care center after a reported 3-day history of nausea, vomiting, and diarrhea. A nurse suspects this client is severely dehydrated. Which information is most important for the nurse to obtain when assessing this client? A. Vital signs B. BUN and creatinine C. Skin turgor D. Thirst level
A. Vital signs
You're providing education to a patient with severe ulcerative colitis about Adalimumab. Which statement by the patient is CORRECT? A. "This medication is used as first-line treatment for ulcerative colitis." B. "My physician will order a TB skin test before I start taking this medication." C. "This medication works by increasing the tumor necrosis factor protein which helps decrease inflammation." D. "This medication is a corticosteroid. Therefore, I need to monitor my blood glucose levels regularly."
B. "My physician will order a TB skin test before I start taking this medication."
A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid, bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made, and she is started on sulfasalazine (Azulfidine), an aminosalicylate. What does the nurse tell her about why she is receiving this therapy? A. "With this medication, your cramping will be relieved." B. "Your intestinal inflammation will be reduced." C. "It is to stop the diarrhea and bloody stools." D. "This will minimize your GI discomfort."
B. "Your intestinal inflammation will be reduced."
Which patient below would have a potassium level of 5.5? A. A 76 year old who reports taking lasix four times a day B. A patient with Addison's disease C. A 55 year old woman who have been vomiting for 3 days consistently D. A patient with liver failure
B. A patient with Addison's disease (A patient with Addison disease suffers from increased potassium levels due to adrenal insufficiency)
You're educating a group of outpatients about signs and symptoms of ulcerative colitis. Which of the following are NOT typical signs and symptoms of ulcerative colitis? SELECT-ALL-THAT-APPLY: A. Rectal Bleeding B. Abdominal mass C. Bloody diarrhea D. Fistulae E. Extreme Hungry F. Anemia
B. Abdominal mass D. Fistulae E. Extreme Hungry
A patient is admitted to the ER with the following findings: heart rate of 110 (thready upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160. What interventions do you expect the medical doctor to order for this patient? A. Restrict fluid intake and monitor daily weights B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output C. Administer hypotonic IV fluid and administer sodium tablets. D. No interventions are expected
B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and monitor urinary output
A client's IV solution of DNS with 20MeQ KCL is infusing at 150ml/hr as ordered. After 4 hours of infusion, the client reports shortness of breath and develops a cough. Which intervention would be the nurse's priority? A. Continue to only monitor the client B. Assess the client's lung sounds C. Notify the health care provider D. Elevate the client's legs
B. Assess the client's lung sounds
The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? SATA A. Apples B. Bananas C. ACE inhibitors D. Grapes E. Salt substitute
B. Bananas C. ACE inhibitors E. Salt substitute (While taking a potassium-sparing diuretic, the nurse teaches the client to avoid bananas, ACE inhibitors, and salt substitutes. Other foods high in potassium include cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Salt substitutes contain potassium and may predispose the client to hyperkalemia.)
The nurse monitors for which complication in the client who has undergone a barium enema: a. Fluid overload B. Constipation C. Diarrhea D. Dehydration
B. Constipation
You're providing diet teaching to a patient with an ileostomy. Which foods should the patient consume in very small amounts or completely avoid? A. Peanut butter, bananas, rice B. Corn, popcorn, nut and seeds C. Grape juice, bread, and pasta D. Vinegar, soft drinks, and cured meats
B. Corn, popcorn, nut and seeds (These foods are difficult to digest and could block the stoma)
When evaluating a client being treated for fluid volume excess, a nurse determines that the fluid volume excess has not resolved based on which finding? A. Decrease in urine specific gravity and increase in urine output B. Crackles increased bilaterally in anterior and posterior lung fields C. Level of consciousness improved to alert and oriented D. Bilateral lower extremity edema decreased to scant
B. Crackles increased bilaterally in anterior and posterior lung fields
The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? A. Peripheral edema B. Crackles ½ way up the lung fields C. Serum osmolarity of 294 mOsm/kg (294 mmol/kg) D. Urine output of 1300 mL over 24 hours
B. Crackles ½ way up the lung fields
A patient had a colonoscopy which showed a "cobble-stone" appearance of the GI lining. This is found in: A. Ulcerative Colitis B. Crohn's Disease
B. Crohn's Disease
A patient has the following signs and symptoms: abdominal cramping which is mainly located in the right lower side, ulcers in the mouth, bleeding anal fissure, and diarrhea. Based on the patient's signs and symptoms, which disease does this describe? A. Ulcerative Colitis B. Crohn's Disease
B. Crohn's Disease
Which type of bowel disease is most likely to cause severe malnourishment? A. Ulcerative Colitis B. Crohn's Disease
B. Crohn's Disease
______________ is most commonly found in the terminal ileum and beginning of the colon. A. Ulcerative Colitis B. Crohn's Disease
B. Crohn's Disease
Which of the following is not a hypertonic fluid? A. 3% Saline B. D5W C. 10% Dextrose in Water (D10W) D. 5% Dextrose in Lactated Ringer's
B. D5W
A client had a routine sigmoidoscopy with a tissue biopsy. What postprocedure complication would the nurse report to the health care provider? A. Gas and flatulence B. Excessive bleeding C. Nausea and vomiting D. Severe rectal pain
B. Excessive bleeding
Select-ALL-the complications associated with Crohn's Disease: A. Loss of form to the haustra B. Fistulas C. Strictures D. Hemorrhoids E. Anal Fissure
B. Fistulas C. Strictures E. Anal Fissure
What type of fluid would a patient with severe hyponatremia most likely be started on? A. Hypotonic B. Hypertonic C. Isotonic D. Colloid
B. Hypertonic
You're providing nursing education to a group of nursing students about diverticulosis versus diverticulitis. Which statement by the nursing students demonstrate they understand the education provided? A. "Most patients with diverticulitis are asymptomatic." B. "Diverticulosis tends to occur in young women with a family history of diverticulosis." C. "Diverticulitis, if not treated, can lead to abscess formation and peritonitis." D. "Patients with diverticulosis should at all times avoid eating seeds and nuts."
C. "Diverticulitis, if not treated, can lead to abscess formation and peritonitis."
A client has newly diagnosed ulcerative colitis (UC). What does the nurse tell the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "Raw vegetables and high-fiber foods may help to diminish your symptoms." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day."
C. "Lactose-containing foods should be reduced or eliminated from your diet."
The doctor orders an isotonic fluid for a patient. Which of the following is not an isotonic fluid? A. 0.9% Normal Saline B. Lactated Ringer's C. 0.45% Saline D. 5% Dextrose in 0.225% saline
C. 0.45% Saline
Which medications are used in the treatment of Crohn's Disease and ulcerative colitis? SELECT-ALL-THAT-APPLY: A. Guanylate Cyclase-C agonists B. Anticholinergics C. 5-Aminosalicylates D. Antacids E. Corticosteroids F. Immune suppressors
C. 5-Aminosalicylates E. Corticosteroids F. Immune suppressors
A patient is admitted with exacerbation of congestive heart failure. What would you expect to find during your admission assessment? A. Flat neck and hand veins B. Furrowed dry tongue C. Increased blood pressure and crackles throughout the lungs D. Bradycardia and pitting edema in lower extremities
C. Increased blood pressure and crackles throughout the lungs
A physician has prescribed a patient with a severe case of Crohn's Disease to take a drug that works by suppressing the immune system. This medication achieves this by blocking a protein that plays a role the inflammatory process. Which drug does this describe? A. Azathioprine B. Sulfasalazine C. Infliximab D. Prednisone
C. Infliximab
When the cell presents with the same concentration on the inside and outside with no shifting of fluids this is called? A. Hypotonic B. Hypertonic C. Isotonic D. Osmosis
C. Isotonic
A patient, who had a colostomy placed yesterday, calls on the call light to say their surgical dressing "fell off". You will re-apply what type of dressing over the stoma? A. Wet to dressing B. No dressing is needed. You will keep it open to air. C. Petroleum gauze dressing D. Telfa gauze
C. Petroleum gauze dressing
After obtaining an EKG on a patient you notice that ST depression is present along with an inverted T wave and prominent U wave. What lab value would be the cause of this finding? A. Magnesium level of 2.2 B. Potassium level of 5.6 C. Potassium level of 2.2 D. Phoshorus level of 2.0
C. Potassium level of 2.2
The nurse auscultates a client's abdomen and hears a loud bruit near the umbilicus. What is the nurse's best action based on this assessment finding? A. Document the assessment finding in the medical record. B. Place the client in a semi-Fowler's position. C. Report the finding to the health care provider. D. Palpate the abdomen lightly in all four quadrants.
C. Report the finding to the health care provider.
Which of the following is NOT a potential complication associated with ulcerative colitis? A. Toxic megacolon B. Anemia C. Stricture D. Peritonitis
C. Stricture
A patient with Crohn's Disease is MOST likely to have the disease is what part of the GI tract? A. Rectum B. Duodenum of the small intestine C. Terminal Ileum D. Descending colon
C. Terminal Ileum
Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? A. The client's potassium level is 5.1 mEq/L (5.1 mmol/L). B. The client's heart rate is 101 beats per minute. C. The client is free from adventitious breath sounds. D. The client has experienced a weight gain of 1 pound (0.5 kg).
C. The client is free from adventitious breath sounds.
You're providing teaching to a patient with an ileostomy on how to change their pouch drainage system. Which statement is INCORRECT about how to change a pouching system for an ostomy? A. Empty the pouch when it is 1/3 to 1/2 full. B. Change the pouching system every 3-5 days. C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma. D. Keep the skin around the stoma clean and dry at all times.
C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma. (be sure the opening of the skin barrier is a 1/8 inch larger than the stoma)
The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A. I cannot drink alcohol at all B. It is okay to have a serving of sugar-free pudding C. can eat ice cream in moderation. D. I will need to avoid sweetened fruit juice beverages.
C. can eat ice cream in moderation.
The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority?A. Monitoring urine output B. encouraging sodium rich fluids and foods throughout the day C. instructing the client not to ambulate without assistance D. assessing deep tendon reflexes
C. instructing the client not to ambulate without assistance
Why would adrenal insufficiency put a client at risk for hypovolemia/dehydration?
Cant secrete aldosterone, which then causes the body to not be able to increase sodium thus holding onto water
The nurse finds a client vomiting coffee ground-type material. On assessment, the client has blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention will be the nurse's first priority? A. Administering an H2 antagonist B. Initiating enteral nutrition C. Administering antianxiety medication D. Administering intravenous (IV) fluids
D. Administering intravenous (IV) fluids
Which patient is at most risk for fluid volume deficient? A. A patient who has been vomiting and having diarrhea for 2 days. B. A patient with continous nasogastric suction. C. A patient with an abdominal wound vac at intermittent suction. D. All of the above are correct.
D. All of the above are correct.
The nurse suspects that a client is hypovolemic. What data would support this suspicion? A. An elevated urinary output B. A decreased respiratory rate C. A decreased osmolarity D. An elevated pulse rate
D. An elevated pulse rate
On assessment of a patient with a colostomy, you note the stoma is located on the right lower quadrant. Due to its location, this is known as what type of colostomy? A. Descending Colostomy B. Transverse C. Ileostomy D. Ascending Colostomy
D. Ascending Colostomy
Which intervention should a nurse include when planning care for a confused client with fluid volume deficit? A. Explain to the client the rationale for increasing fluid intake B. Provide fluids at the client's bedside at the desired temperature at all times C. Ensure that the certified nursing assistant maintains fresh ice water at the client's bedside at all times D. Assist the client in drinking fluids every hour
D. Assist the client in drinking fluids every hour
The nurse correlates which clinical manifestation as a normal age-related variant in an older adult? A. Diarrhea b. Melena C. Anorexia D. Constipation
D. Constipation
Which of the following factors increases the risk for dehydration in elderly patients? A. Increased body fat content B. Loss of skin elasticity and decreased turgor C. Decreased glomerular filtration rate D. Diminished thirst sensation
D. Diminished thirst sensation
The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? A. Restrict the client's intake of sodium B. Administer a diuretic C. Monitor the serum osmolarity D. Encourage fluid intake
D. Encourage fluid intake
A nurse assesses a patient who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation would the nurse expect to find? A. Dull, hypoactive bowel sounds in the lower abdominal quadrants B. Reports of abdominal cramping that is worse at night C. Positive Murphy's sign with rebound tenderness to palpitation D. High-pitched, rushing bowel sounds in the right lower quadrant
D. High-pitched, rushing bowel sounds in the right lower quadrant
_______ solutions cause cell dehydration and help increase fluid in the extracellular space. A. Hypotonic B. Osmosis C. Isotonic D. Hypertonic
D. Hypertonic
Giving a hypertonic IV solution to a client may cause too much fluid to be A. Pushed out of the bloodstream into the extravascular spaces B. Pulled out of the bloodstream into the extravascular spaces C. Pulled from the cells into the bloodstream which may cause the cells to increase in size D. Pulled from the cells into the bloodstream, which may cause the cells to shrink
D. Pulled from the cells into the bloodstream, which may cause the cells to shrink
A patient experiencing a flare-up with Crohn's Disease is ordered complete bowel rest by the physician. You are administering TPN (total parental nutrition) per physician order. When developing the patient's nursing plan of care, which nursing diagnosis is MOST important to include in the care plan? A. Risk for allergy response B. Risk for unstable blood glucose level C. Risk for imbalance nutrition: more than body requirements D. Risk for imbalanced nutrition: less than body requirements
D. Risk for imbalanced nutrition: less than body requirements
You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true? A. The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure B. This is known as Trousseau's Sign and is present in patients with HYPERcalcemia C. This is known as Chvostek's Sign D. This is known as Trousseau's Sign and is present in patients with hypocalcemia
D. This is known as Trousseau's Sign and is present in patients with hypocalcemia
A patient diagnosed with pancolitis is experiencing extreme abdominal distension, pain 10 on 1-10 scale in the abdomen, temperature of 103.6 'F, HR 120, and profuse diarrhea. What complication due you suspect the pain is experiencing? A. Fistulae B. Stricture C. Bowel obstruction D. Toxic megacolon
D. Toxic megacolon
The nurse places the client in which position for a gastrointestinal assessment to promote relaxation of the abdominal muscles? A. side-lying with arms above the head and knees flexed B. semirecumbent with knees extended and arms at the side C. sitting upright with arms relaxed in the lap and feet on the floor D. supine with arms at the side and knees flexed
D. supine with arms at the side and knees flexed
True or False: An ileostomy is a surgical opening created to bring the large intestine to the surface of the abdomen.
FALSE (An ileostomy is a surgical opening created to bring the SMALL (not large) intestine to the surface of the abdomen.)
True or False: NSAIDs are used as first-line treatment for pain relief with patients with ulcerative colitis.
FALSE (Tylenol should be used instead or a similar medication that isn't an NSAID)
True or False: Crohn's Disease and ulcerative colitis are two forms of IBS (irritable bowel syndrome).
False
True or False: Patients with an ileostomy are at greater risk for dehydration and an electrolyte imbalance.
TRUE
1. Which is a correct statement differentiating CD from UC? a. Clients with CD experience about 20 loose, bloody stools daily. b. Clients with UC may experience hemorrhage c. The peak incidence of UC is between 15 and 40 years of age. d. Very few complications are associated with CD
b. Clients with UC may experience hemorrhage
A patient had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube q4hr d. Taking and recording vital signs
b. Performing frequent oral care (Only a nurse can lavage the tube with ice water and re-position the tube- A UAP can take and record vital signs but this is not a comfort measure)
1. A nurse is caring for a client with a history of multiple chronic illnesses. Which illness should the nurse identify as placing the client at greatest risk for fluid volume excess (FVE)? a. HTN b. MI c. End stage renal disease d. Type 2 diabetes
c. End stage renal disease
1. A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? a. Chemotherapy has increased your blood pressure and fluid was forced out into the tissues b. The fluid is an adverse reaction to chemotherapy c. Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues d. A decrease in activity has allowed extra fluid to accumulate in the tissues.
c. Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues
1. A nurse is assessing a client who has come to the ED with acute abdominal pain. Which assessment finding is of the greatest concern? a. Bowel sounds are hypoactive in all quadrants b. The client reports spasmodic cramping c. The client says, "I have not had a BM in 3 days." d. Bruising is noted around the client's umbilicus.
d. Bruising is noted around the client's umbilicus. (Bruising around the umbilicus (Cullen's sign) is a sign of intra-abdominal bleeding.)
1. A client has vague symptoms that indicate an acute inflammatory bowel disorder (IBD). Which symptom is most indicative of Crohn's Disease (CD)? a. Epigastric cramping b. Hypotension with vomiting c. Abdominal pain relieved by bending the knees d. Chronic diarrhea, abdominal pain, and fever
d. Chronic diarrhea, abdominal pain, and fever (these symptoms are more indicative of CD than of other acute inflammatory bowel disorders).
