NUR 150 Exam # 1 Review/Study Mode

The nurse is caring for a client with hiatal hernia. The client states that the beverages the client enjoys include ginger ale, skim milk, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? 1 Ginger ale 2 Skim Milk 3 Orange juice 4 Cola beverages

2 Skim Milk Milk is not irritating to the gastric mucosa. Carbonated beverages distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? 1 Femoral pulse 2 Toes for mobility 3 Condition of the pin 4 Range of motion of the knee

2 Toes for mobility Monitoring the mobility of the toes assesses neural integrity distal to the surgical site; this is part of a neurovascular assessment. The femoral artery is not assessed because it is not distal to the surgical site. No pin is present with an open reduction and internal fixation of a fractured hip. A range of motion of the knee assessment may cause flexion of the hip, which is contraindicated.

A client with a hiatal hernia comes to the community health clinic to attend a class about nutrition. The client reports frequently waking up at night with heartburn. Which suggestion by the nurse may help to reduce symptoms of heartburn? 1 Eat a large meal at noontime 2 Take an intestinal sedative at night 3 Raise the head of the bed on blocks 4 Have a light snack with orange juice

3 Raise the head of the bed on blocks Elevating the head of the bed helps prevent reflux of gastric contents into the esophagus, minimizing heartburn. Small, frequent meals relieve symptoms of fullness and minimize gastric stimulation. Taking an intestinal sedative at night will delay emptying of the stomach, which will increase production of gastric secretions and the feeling of fullness. Drinking orange juice stimulates the production of gastric secretions.

A client with a ruptured appendix is scheduled for an appendectomy. Preoperatively, the nurse should place the client in which position? 1 Sims 2 Left-lateral 3 Semi-Fowler 4 Dorsal recumbent

3 Semi-Fowler The semi-Fowler position localizes the spilled contents of the ruptured appendix in the lower part of the abdominal cavity. The Sims and left-lateral positions allow the contents of the bowel exiting the ruptured appendix to disperse throughout the abdominal cavity; also, they exert pressure on the abdomen, which may be uncomfortable for the client. The dorsal recumbent position will not localize spilled intestinal contents in the lower part of the abdomen.

A client develops acute appendicitis. Prior to arrival to the hospital, the client attempted self-care at home. Which self-care measures could potentially lead to rupture of the appendix? 1 Refusing food and liquids 2 Applying an ice pack to the abdomen 3 Taking a small volume enema 4 Taking acetaminophen (Tylenol) for pain

3 Taking a small volume enema Enemas can increase pressure in the intestines and cause rupture of an inflamed appendix. Fasting from food or applying an ice pack will not lead to rupture of the appendix. Taking acetaminophen will not increase the risk of rupture of the appendix.

A nurse is counseling a woman who had recurrent urinary tract infections. What factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection? 1 Altered urinary pH 2 Hormonal secretions 3 Juxtaposition of the bladder 4 Proximity of the urethra to the anus

4 Proximity of the urethra to the anus Because the female's urethra is closer to the anus than the male's, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both males and females. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in males and females.

A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine? 1 Clarity 2 Viscosity 3 Glucose level 4 Specific gravity

1 Clarity Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. Viscosity is a characteristic that is not measurable. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

A client is admitted via the emergency department with the tentative diagnosis of diverticulitis. Which test commonly is prescribed to assess for this problem? 1 Computed tomography (CT) scan 2 Gastroscopy 3 Colonoscopy 4 Barium enema

1 Computed tomography (CT) scan A CT scan with contrast is the test of choice for diverticulitis because it effectively reflects the involved colon. An endoscopy assesses the upper, not lower, gastrointestinal tract. Colonoscopy is contraindicated because of the possibility of perforation and peritonitis. Barium enema is contraindicated because of the possibility of perforation and peritonitis.

A female client with the diagnosis of Crohn's disease tells the nurse that her boyfriend dates other women. She believes that this behavior causes an increase in her symptoms. What should the nurse do first when counseling this client? 1 Help the client explore attitudes about herself. 2 Educate the client's boyfriend about her illness. 3 Suggest the client should not see her boyfriend for a while. 4 Schedule the client and her boyfriend for a counseling session.

1 Help the client explore attitudes about herself. Because emotional stress can influence the progress of Crohn's disease, initially the nurse should help the client to explore self-attitudes to aid in better understanding the feelings engendered by her boyfriend dating others. Initially the nurse should help the client explore the situation and the feelings it engenders rather than involve the boyfriend. The client should make the decision about seeing her boyfriend. Scheduling the client and her boyfriend for a counseling session is premature; the client is not ready for a joint counseling session.

A client will be taking nitrofurantoin (Macrobid) 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client? 1 Increase the intake of fluids. 2 Strain the urine for crystals and stones. 3 Stop the drug if urinary output increases. 4 Maintain the exact time schedule for taking the drug.

1 Increase the intake of fluids. To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug. Straining urine is not indicated when the client is taking a urinary antiinfective. Urinary decrease is of concern because it may indicate renal failure. If fluids are encouraged, the client's output should increase. The drug need not be taken at a strict time daily.

A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the nurse discusses prevention of esophageal reflux, what should be included? 1 "Increase your intake of fat with each meal." 2 "Lie down after eating to help your digestion." 3 "Reduce your caloric intake to foster weight reduction." 4 "Drink several glasses of fluid during each of your meals.

3 "Reduce your caloric intake to foster weight reduction." Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase pressure; fluid should be discouraged with meals.

A nurse is caring for a client who had emergency surgery for a ruptured appendix. What action should the nurse take when the client manifests signs and symptoms of shock? 1 Prepare for a blood transfusion 2 Elevate the head of the bed 30 degrees 3 Administer 2 L oxygen via nasal cannula 4 Notify the health care provider immediately

4 Notify the health care provider immediately Peritonitis and shock are potentially life-threatening complications that may occur after abdominal surgery; prompt, rigorous treatment is necessary. Fluids, not blood, will be needed to expand and maintain the circulating blood volume. The head of the bed should be flat to increase tissue perfusion and oxygenation to vital organs. Two liters of oxygen is inadequate; a higher flow rate is necessary.

The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the client to experience increased pain and limited movement of the joints? 1 After assistive exercise 2 When the room is cool 3 In the morning on awakening 4 When the latex fixation test is positive

3 In the morning on awakening Inactivity over an extended time increases stiffness and pain in joints. Assistive exercises help maintain joint mobility. Whether the room is cool is not a factor; cold applications may decrease joint discomfort. The latex fixation test is positive when the rheumatoid factor is found in blood serum; this factor is present in many conditions, including rheumatoid arthritis, aging, narcotic addiction, and systemic lupus erythematosus (SLE).

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: 1 Increase oral fluid intake to 2 to 3 L per day. 2 Maintain bed rest after discharge. 3 Limit fluid intake to 1 L/day. 4 Void at least every hour.

1 Increase oral fluid intake to 2 to 3 L per day. Increasing oral fluid intake to 2 to 3 L per day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin resistant entercoccus (VRE). After notifying the health care provider, which action should the nurse take to decrease the risk of transmission to others? 1 Move the client to a private room 2 Initiate droplet precautions 3 Insert a Foley catheter 4 Use a HEPA respirator when entering the room

1 Move the client to a private room Clients with VRE should be moved to a private room to decrease transmission to others. VRE has been identified in the urine, not respiratory secretions. A Foley catheter should not be inserted as it will predispose the client to develop an additional infection. A HEPA respirator is not required when entering the room. Contact isolation should be implemented.

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? 1 Receives long-term steroid therapy 2 Has a history of hypoparathyroidism 3 Engages in strenuous physical activity 4 Consumes high doses of the hormone estrogen

1 Receives long-term steroid therapy Increased levels of steroids will accelerate bone demineralization. Hyperparathyroidism, not hypoparathyroidism, accelerates bone demineralization. Weight-bearing that occurs with strenuous activity promotes bone integrity by preventing bone demineralization. Although estrogen promotes deposition of calcium into bone, high levels will not be prescribed for osteoporosis; hormone replacement therapy is associated with an increased risk for breast cancer.

A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in Buck's extension. What explanation does the nurse give the client for why the traction is being used? 1 Reduces muscle spasms 2 Prevents soft tissue edema 3 Reduces the need for cast application 4 Prevents damage to the surrounding nerves

1 Reduces muscle spasms Buck's extension is used to reduce the fracture, align the bone, and temporarily reduce muscle spasm. Edema occurs because of tissue trauma and will not be prevented by Buck's extension. A fractured head of the femur is repaired via internal fixation; a cast is unnecessary. Damage already has occurred at the time of trauma and is not prevented by Buck's extension.

The nurse is caring for a 76-year-old obese client with a history of epigastric distress, esophageal burning, binge drinking, and frequent episodes of bronchitis. A diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1 Aging 2 Obesity 3 Bronchitis 4 Alcoholism 5 Esophagitis

1 Aging 2 Obesity 4 Alcoholism Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. Alcoholism can cause relaxation of the lower esophageal sphincter (LES) and upper esophageal sphincter (UES), causing risk for aspiration and potentially causing the bronchitis, which can exacerbate the hiatal hernia. Inflammation of the bronchi will not weaken the diaphragm. Esophagitis does not cause a hiatal hernia.

A nurse teaches a client with calcium-based renal calculi about foods that can be eaten on a low-calcium diet (400 mg/day). The nurse concludes that the teaching was effective when the client selects what food items from the menu? Select all that apply. 1 Baked chicken 2 Chocolate pudding 3 Salmon loaf with cheese sauce 4 Roast beef with mashed potato 5 Vanilla ice cream with chocolate syrup

1 Baked chicken 4 Roast beef with mashed potato Baked chicken is relatively low in calcium. Roast beef and mashed potato have moderate amounts of calcium. Pudding is made with milk and is high in calcium. Cheese is high in calcium. Ice cream is made with milk and is high in calcium.

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. 1 Fever 2 Tachypnea 3 Hypertension 4 Abdominal rigidity 5 Increased bowel sounds

1 Fever 2 Tachypnea 4 Abdominal rigidity The metabolic rate will be increased and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intraabdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and therefore hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intraabdominal pressure.

A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply. 1 Fever 2 Hyperactivity 3 Extreme hunger 4 Urinary retention 5 Abdominal muscle rigidity

1 Fever 5 Abdominal muscle rigidity A moderate fever is associated with inflammation of the peritoneal membrane. Muscular rigidity over the affected area is a classic sign of peritonitis. Malaise, rather than hyperactivity, is often associated with peritonitis. Nausea, not hunger, is a common occurrence with peritonitis. Urinary retention may occur following surgery as a complication of anesthesia, not peritonitis.

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. 1 Hips 2 Knees 3 Ankles 4 Shoulders 5 Metacarpals

1 Hips 2 Knees Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage. Although the ankles are weight-bearing joints and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus, there is less degeneration. Shoulder joints are not the most likely to be involved first because these are not weight-bearing joints. Although the distal interphalangeal joints are affected frequently, the remaining interphalangeal joints and metacarpals are not.

A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamins have to be given intravenously (IV) rather than by mouth. What rationales for this route should the nurse include in a response to the question? Select all that apply. 1 More rapid action results. 2 They are ineffective orally. 3 They decrease colon irritability. 4 Intestinal absorption may be inadequate. 5 Allergic responses are less likely to occur.

1 More rapid action results. 2 They are ineffective orally. 4 Intestinal absorption may be inadequate. Absorption through the gastrointestinal (GI) tract is impaired and parenteral administration goes directly into the intravascular compartment. Disease of the GI tract hampers absorption. Because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired. IV vitamins do not decrease colonic irritability. Route of administration does not affect allergic response.

An obese client with a hiatal hernia asks the nurse how to prevent esophageal reflux. What is the nurse's best response? 1 "Lie down after eating." 2 "Eat less food at each meal." 3 "Increase your intake of fat." 4 "Drink more fluid with each meal."

2 "Eat less food at each meal." Eating less food not only relieves intraabdominal pressure, but it promotes weight loss, which helps to decrease the tendency of gastric contents to reflux into the esophagus. The response "Lie down after eating" increases pressure against the diaphragmatic hernia, thereby increasing symptoms. Fats decrease emptying of the stomach, extending the period during which reflux can occur; fats should be decreased. The response "Drink more fluid with each meal" will increase intraabdominal pressure; fluid should be discouraged with meals.

What should the nurse take into consideration when planning nursing care for a client experiencing an acute episode of rheumatoid arthritis? 1 Inflammation of the synovial membrane rarely occurs. 2 Bony ankylosis of a joint is irreversible and causes immobility. 3 Complete immobility is desired during the acute phase of inflammation. 4 Redness and swelling of a joint signify that irreversible damage has occurred.

2 Bony ankylosis of a joint is irreversible and causes immobility. Ossification of cartilage, particularly of the spine, causes fixation of the involved joints. Inflammation and thickening of the synovial membrane are characteristics of arthritis. Although rest is essential, complete immobility will result in loss of joint motion. Redness and swelling are symptoms of local inflammation; they do not indicate irreversible damage.

A health care provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management? 1 Ingest foods while they are hot. 2 Divide food into four to six meals a day. 3 Eat the last of three daily meals by 8 pm. 4 Suck a peppermint candy after each meal.

2 Divide food into four to six meals a day. The volume of food in the stomach should be kept small to limit pressure on the cardiac sphincter. Foods should be neither cold nor hot; foods should be tepid when ingested. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the cardiac sphincter (lower esophageal sphincter), allowing food to be regurgitated into the esophagus.

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the health care provider. What should the nurse do to help prevent the client from developing a urinary tract infection? 1 Assess urine specific gravity 2 Maintain the prescribed hydration 3 Collect a weekly urine specimen 4 Empty the drainage bag frequently

2 Maintain the prescribed hydration Promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection. Although assessing urine specific gravity may help identify a urinary tract infection, it will not prevent it. Although collecting a weekly urine specimen for culture and sensitivity may help identify a urinary tract infection, it will not prevent it. The collection bag is emptied once every shift unless the bag is full and needs to be emptied sooner; changing the bag periodically, not emptying it, may help prevent infection.

A client with severe Crohn's disease develops a small bowel obstruction. Which clinical finding should the nurse expect the client to report? 1 Bloody vomitus 2 Projectile vomiting 3 Bleeding with defecation 4 Pain in the left lower quadrant

2 Projectile vomiting Nausea and vomiting, accompanied by diffuse abdominal pain, commonly occur in clients with small bowel obstruction; the vomiting may be projectile and may contain bile or fecal material. Hematemesis is associated more closely with peptic ulcer disease. Bleeding with defecation is associated with hemorrhoids and anal fissures. Pain in the left lower quadrant is associated with diverticulitis. Pain associated with a small bowel obstruction usually is more diffuse.

A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day? 1 Paresthesias of the feet 2 Shortening of the muscles 3 Development of osteoblasts 4 Loss of muscular coordination

2 Shortening of the muscles Flexion and extension prevent tightening of muscles and tendons. Abnormal sensations (paresthesias) are related to neurological, not musculoskeletal, alterations. Weight bearing, not exercise, promotes the development of osteoblasts. Loss of muscular coordination is the result of cerebellar changes; it is not related to immobility. Study Tip: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

A client is diagnosed with calcium oxalate renal calculi. Which foods should the nurse teach the client to avoid? Select all that apply. 1 Milk 2 Nuts 3 Liver 4 Spinach 5 Rhubarb

2 Nuts 4 Spinach 5 Rhubarb Nuts, especially peanuts, almonds, and pecans, should be avoided. Clients with struvite stones (staghorn stones) also should avoid nuts. Rhubarb and spinach are high in calcium oxalate. Other examples include beets, wheat bran, tea, chocolate, and coffee. Limiting oxalate-rich foods limits oxalate absorption and the formation of calcium oxalate calculi. Milk is an acceptable calcium-rich protein. Research indicates that it reduces oxalate absorption. Liver is a purine-rich food that may be eaten. All meats, especially organ meats, anchovies, sardines, fish roes, herring, meat extracts, and broths, are purine-rich foods.

A client, experiencing an exacerbation of Crohn's disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? 1 Pancreatitis 2 Thrombophlebitis 3 Bacterial meningitis 4 Acute cholecystitis

3 Bacterial meningitis The bacteria that cause meningitis are transmitted via air currents; the client should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh? 1 Palpate the femoral artery of the affected leg. 2 Assess for a positive Homan sign of the affected leg . 3 Compress and release the toenails of the affected foot. 4 Instruct the client to flex and extend the knee of the affected leg.

3 Compress and release the toenails of the affected foot. Capillary refill based on the blanch test is an accurate assessment for neurovascular integrity; immediate refill is expected. Palpation of the pedal pulse, which is distal to the injury, is more appropriate than palpation of the femoral artery. The pain associated with Homan sign indicates thrombophlebitis, not compromise of blood flow or innervation. Flexion and extension of the affected knee is impossible with this cast.

A client with a history of Crohn's disease develops an intestinal obstruction. An enteric catheter is inserted and connected to low continuous suction. The nurse monitors the client for fluid volume deficit. What clinical finding does the nurse expect if the client becomes dehydrated? 1 Restlessness 2 Constipation 3 Inelastic tissue turgor 4 Increased blood pressure

3 Inelastic tissue turgor When there is a fluid volume deficit, fluid moves from the intracellular and interstitial compartments into the intravascular compartment in an attempt to maintain blood volume. Cellular dehydration is manifested by poor tissue turgor; tissue turgor is assessed by the rapidity with which skin returns to its original position after being pinched. Lethargy and fatigue, not restlessness, are expected with dehydration. With an intestinal obstruction, there is an absence of bowel movements (obstipation); clients with Crohn's disease frequently have watery stools. Hypotension, not hypertension, is associated with hypovolemia.

A client with a femoral fracture associated with osteomyelitis is immobilized for three weeks. Why does the nurse anticipate that the client may develop renal calculi? 1 The client's dietary patterns have changed since admission. 2 The client has more difficulty urinating in a supine position. 3 Lack of weight-bearing activity promotes bone demineralization. 4 Fracture healing requires more calcium, which increases total calcium metabolism.

3 Lack of weight-bearing activity promotes bone demineralization. All clients who are confined to bed for any considerable period risk losing calcium from bones. Calcium precipitates in the urine, resulting in formation of calculi. There is no indication that the client's diet has changed. Although the client may have more difficulty urinating in a supine position resulting from an inability to assume the preferred anatomic position and the emotional impact of using a urinal, it usually does not predispose the client to developing renal calculi, unless fluid intake is low or stasis occurs. The presence of a healing fracture does not increase total calcium metabolism; however, deposition of bone at the fracture site will be increased.

A regimen of rest, exercise, and physical therapy is prescribed for a client with rheumatoid arthritis. The nurse should explain that the intended purpose of the regimen is to: 1 Prevent arthritic pain. 2 Halt the inflammatory process. 3 Prevent the crippling effects of the disease. 4 Provide for the return of joint motion after prolonged loss.

3 Prevent the crippling effects of the disease. Range-of-motion exercises are instituted to maintain mobility of joints. Balanced activity and rest will promote resolution of the inflammation. Pain may persist but cannot be allowed to legitimize inactivity. Activity will not prevent the inflammatory process; it may aggravate it. Severely damaged joints may require prosthetic replacement.

When comparing ulcerative colitis and Crohn's disease, a nurse considers that they are similar yet dissimilar in many ways. What clinical manifestation is common to clients with Crohn's disease and not to clients with ulcerative colitis? 1 Diarrhea 2 Weight loss 3 Right lower quadrant pain 4 Decreased hematocrit

3 Right lower quadrant pain Right lower quadrant pain is typical with Crohn's disease; left lower quadrant pain is typical with ulcerative colitis. Diarrhea is common to both conditions to varying degrees. Weight loss is common to both conditions to varying degrees. Decreased hematocrit is common to both conditions to varying degrees.

One month after abdominal surgery a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in what position? 1 Supine 2 Right Sims 3 Semi-Fowler 4 The position that the client prefers

3 Semi-Fowler Semi-Fowler position promotes localization of purulent material and inflammation and prevents an ascending infection. The risk of an ascending infection may be increased in the supine position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. The risk of an ascending infection may be increased in the right Sims position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. The client may prefer a position that increases the risk of an ascending infection.

A nurse is providing client teaching to a woman who has recurrent urinary tract infections. Which information should the nurse include concerning the reason why women are more susceptible to urinary tract infections than men? 1 Inadequate fluid intake 2 Poor hygienic practices 3 The length of the urethra 4 The continuity of mucous membranes

3 The length of the urethra The length of the urethra is shorter in females than in males; therefore, microorganisms have a shorter distance to travel to reach the bladder. The proximity of the meatus to the anus in females also increases the incidence of urinary tract infections. Fluid intake may or may not be adequate in both males and females and does not account for the difference. Hygienic practices can be inadequate in males or females. Mucous membranes are continuous in both males and females.

A client with a fractured head of the right femur and osteoporosis is placed in Buck's extension before surgical repair. What should the nurse do when caring for this client until surgery is performed? 1 Remove the weights from the traction every 2 hours to promote comfort. 2 Turn the client from side to side every 2 hours to prevent pressure on the coccyx. 3 Raise the knee gatch on the bed every 2 hours to limit the shearing force of traction. 4 Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion.

4 Assess the circulation of the affected leg every 2 hours to ensure adequate tissue perfusion. Arterial perfusion and the presence of hemorrhage must be assessed at least every 2 hours to prevent complications or to identify problems early. Removing the weights will interfere with the pull of traction. Turning the client from side to side will interfere with the pull of traction. Raising the knee gatch on the bed will interfere with the pull of traction.

A client is admitted to the hospital with gastrointestinal bleeding and a nasogastric tube is inserted. The health care provider prescribes the nasogastric tube to be irrigated with normal saline whenever necessary to maintain patency. What should the nurse do first when it is determined that the nasogastric tube is not patent? 1 Instill normal saline. 2 Assess breath sounds. 3 Auscultate for bowel sounds. 4 Check the tube for placement.

4 Check the tube for placement. Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant.

A nurse is assessing a client with Crohn's disease who is to have an upper gastrointestinal series. Which condition necessitates the cancellation of the upper gastrointestinal series? 1 Hemorrhoids 2 Hyperkalemia 3 Inflamed colon 4 Colon perforation

4 Colon perforation When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. Although hemorrhoids may be irritating, they do not contraindicate barium studies. Serum potassium is unaffected; barium is insoluble and will not affect blood content. Barium studies are not contraindicated when the bowel is inflamed. An upper gastrointestinal series is useful in diagnosing ulcerative colitis and Crohn's disease.

A nurse is caring for a postoperative client who has a nasogastric tube attached to low continuous suction. What clinical findings indicate that the client may be experiencing hypokalemia? 1 Tingling of the fingertips and toes 2 Dry and sticky mucous membranes 3 Abdominal cramping and irritability 4 Muscle weakness and cardiac dysrhythmias

4 Muscle weakness and cardiac dysrhythmias Muscle weakness and cardiac dysrhythmias are related to potassium depletion in the skeletal and cardiac muscles; the sodium-potassium pump facilitates conduction of nerve impulses and muscle activity. Tingling of the fingertips and toes is related to hypocalcemia, not hypokalemia. Dry and sticky mucous membranes are related to hypernatremia, not hypokalemia. Abdominal cramping and irritability are related to hyperkalemia, not hypokalemia.

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the health care provider? 1 Passage of pink-tinged urine 2 Pink drainage on the dressing 3 Intake of 1750 mL in 24 hours 4 Urine output of 20 to 30 mL/hr

4 Urine output of 20 to 30 mL/hr Output should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).

A client with osteoarthritis who had a left total hip replacement returns to the unit after surgery. The nurse should place the client in which position? 1 Maintain the left leg in an adduction position. 2 Place the client in a right-lying position. 3 Place the left leg in an internal rotation. 4 Use pillows to keep the client's legs abducted.

4 Use pillows to keep the client's legs abducted. Abduction reduces stress on the joint capsule incision, preventing the prosthesis from becoming dislocated. Adduction strains the posterior joint capsule, fostering dislocation. A right-lying position would not allow the heels to be kept off the bed and would not allow proper abduction. Internal rotation strains the posterior joint capsule.