NURS 111 Final

When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately? a) Anorexia and dyspepsia b) Change in mental status c) Fatigue and weight loss d) Diarrhea or constipation

b) Change in mental status

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure? a) "A capsule will be inserted into your rectum." b) "An x-ray machine will use a capsule ray to follow your intestinal tract." c) "You will need to swallow a capsule." d) "The physician will use a scope called a capsule to view your intestine."

c) "You will need to swallow a capsule."

When preparing a client for a scheduled colonoscopy, the nurse should tell the client that this procedure will involve: a) placing the client on a full-liquid diet 48 hours before the procedure. b) administering an antibiotic to decrease the risk of infection. c) cleansing the bowel with laxatives or enemas. d) administering meperidine IM to prevent pain during the procedure.

cleansing the bowel with laxatives or enemas.

Frequently, what is the earliest symptom of left-sided heart failure? a) Confusion b) Chest pain c) Anxiety d) Dyspnea on exertion

d) Dyspnea on exertion

To assess subjective data related to a client's elimination pattern, the nurse a) Asks the client about changes in elimination patterns b) Reviews the latest laboratory report of the urine c) Palpates the abdomen for pain or distention d) Notes the frequency, amount, and time the client voids

Asks the client about changes in elimination patterns

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? a) Palmar erythema b) Fetor hepaticus c) Asterixis d) Constructional apraxia

C) Asterixis The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? a) Every 45 minutes b) Every hour c) Every 15 minutes d) Every 30 minutes

Every 15 minutes Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a) Weakness on one side of the body and difficulty with speech b) Severe headache and early change in level of consciousness c) Footdrop and external hip rotation d) Vomiting and seizures

Preload is the amount of blood presented to the ventricle just before systole. The patient is positioned or taught how to assume a position that facilitates breathing. The number of pillows may be increased, the head of the bed may be elevated, or the patient may sit in a recliner. In these positions, the venous return to the heart (preload) is reduced, pulmonary congestion is alleviated, and pressure on the diaphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient's weight on the shoulder muscles.

A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action? a) Obtain an order for calcium gluconate 2 g IV push over 2-5 minutes. b) Obtain an order for furosemide 80 mg IV push. c) Arrange for an emergency hemodialysis session. d) Increase the rate of the client's IV fluid to 150 ml/hour.

a) Obtain an order for calcium gluconate 2 g IV push over 2-5 minutes.

The nurse caring for a patient with diverticulitis is preparing to administer the patient's medications. The nurse anticipates administration of which category of medications due to the patient's diverticulitis? a) Antispasmodic b) Antiemetic c) Antianxiety d) Anti-inflammatory

a) Antispasmodic

A systolic blood pressure of 135 mm Hg would be classified as which of the following? a) Prehypertension b) Stage 2 hypertension c) Normal d) Stage 1 hypertension

a) Prehypertension A systolic blood pressure of 135 mm Hg is classified as prehypertension. A systolic BP of less than 120 mm Hg is normal. A systolic BP of 140 to 159 mm Hg is stage I hypertension. A systolic BP of greater than or equal to 160 is classified as stage II hypertension.

Connie, a 60-year-old retired financial planner, is recently diagnosed with carcinoma of the pancreas. She has just met with her surgeon and feels overwhelmed by all the information she was given. She tells you that she is having the head of the pancreas removed; additionally, the surgeon is also removing the duodenum and stomach and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is Connie having performed? a) Radical pancreatoduodenectomy b) Total pancreatectomy c) Distal pancreatectomy d) Cholecystojejunostomy

a) Radical pancreatoduodenectomy This surgical procedure involves removing the head of the pancreas, resecting the duodenum and stomach, and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum. This surgical procedure is a rerouting of the pancreatic and biliary drainage systems, which may be done to relieve obstructive jaundice. This measure is considered palliative only. A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A distal pancreatectomy is a surgical procedure to remove the bottom half of the pancreas.

A patient comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out possible acute pancreatitis. The nurse would expect the diagnosis to be confirmed with which of the following elevated laboratory tests? a) Serum amylase b) Serum potassium c) Serum bilirubin d) Serum calcium

a) Serum amylase

Which of the following is a manifestation of right-sided heart failure? a) Systemic venous congestion b) Accumulation of blood in the lungs c) Reduction in forward flow d) Reduction in cardiac output

a) Systemic venous congestion

The physician has written the following orders: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) for a new patient admitted with pancreatitis. The nurse attributes which of the following as the cause for NPO status? a) To avoid inflammation of the pancreas b) To prevent the occurrence of fibrosis c) To aid opening up of pancreatic duct d) To drain the pancreatic bed

a) To avoid inflammation of the pancreas

The most common cause of hypothyroidism is which of the following? a) Antithyroid medications b) Autoimmune thyroiditis c) Thyroidectomy d) Radioiodine therapy

b) Autoimmune thyroiditis

A patient is admitted to the hospital and is being evaluated for heart failure. Which diagnostic study is usually performed to confirm the diagnosis of heart failure? a) Electrocardiogram (ECG) b) Echocardiogram c) Blood urea nitrogen (BUN) d) Serum electrolytes

b) Echocardiogram

Which of the following would be the least important assessment in a patient diagnosed with ascites? a) Weight b) Foul-smelling breath c) Palpation of abdomen for a fluid shift d) Measurement of abdominal girth

b) Foul-smelling breath

Which of the following is the hallmark of systolic heart failure? a) Limitation of activities of daily living (ADLs) b) Low ejection fraction (EF) c) Basilar crackles d) Pulmonary congestion

b) Low ejection fraction (EF)

A patient comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out possible acute pancreatitis. The nurse would expect the diagnosis to be confirmed with which of the following elevated laboratory tests? a) Serum bilirubin b) Serum amylase c) Serum calcium d) Serum potassium

b) Serum amylase Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis. Serum amylase and lipase levels are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase. Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels.

A client is diagnosed with gallstones in the bile ducts. The nurse knows to review the results of blood work for a a) Serum ammonia concentration of 90 mg/dL b) Serum bilirubin level greater than 1.0 mg/dL c) Serum globulin concentration of 2.0 g/dL d) Serum albumin concentration of 4.0 g/dL

b) Serum bilirubin level greater than 1.0 mg/dL

Which of the following are signs/symptoms of perforation? a) Soft abdomen b) Sudden, severe upper abdominal pain c) Hypertension d) Bradycardia

b) Sudden, severe upper abdominal pain

Dilutional hyponatremia occurs in which disorder? a) (Diabetes insipidus) DI b) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) c) Pheochromocytoma d) Addison's disease

b) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate? a) Insulin has an adverse effect of constipation. b) The pancreas secretes digestive enzymes. c) Elevated glucose levels cause bacteria overgrowth in the large intestine. d) The nerve fibers of the intestinal lining are experiencing neuropathy.

b) The pancreas secretes digestive enzymes.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? a) Instruct the client to cough only when necessary. b) Use incentive spirometry every hour. c) Monitor pulse oximetry every hour. d) Withhold analgesics unless necessary.

b) Use incentive spirometry every hour.

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to betachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of conscious, what would be a priority nursing action for this patient? a) Prepare for the insertion of an NG tube. b) Notify the physician. c) Place the patient in a prone position. d) Provide the patient with ice water to slow any GI bleeding.

b)Notify the physician.

A female client, aged 82 years, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine? a) Take the medicine on an empty stomach. b) There are no adverse effects from blood pressure medicine. c) A possible adverse effect of blood pressure medicine is dizziness when you stand. d) A severe drop in blood pressure is possible.

c) A possible adverse effect of blood pressure medicine is dizziness when you stand.

Which of the following is an important assessment parameter for the patient diagnosed with congestive heart failure? a) Photosensitivity b) Crepitus c) Distended veins d) Excess tears

c) Distended veins

Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? a) Laser hyperthermia b) Cryosurgery c) Lobectomy d) Liver transplantation

c) Lobectomy

A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals? a) Relieving the patient's anxiety b) Controlling bleeding c) Maintaining the airway d) Maintaining fluid volume

c) Maintaining the airway

Which of the following procedures are performed to examine and visualize the lumen of the small bowel? a) Panendoscopy b) Colonoscopy c) Small bowel enteroscopy d) Peritoneoscopy

c) Small bowel enteroscopy Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? a) Both tests need to be done before breakfast. b) The upper GI should be scheduled before the ultrasonography. c) The ultrasonography should be scheduled before the GI procedure. d) The client may eat a light meal before either test.

c) The ultrasonography should be scheduled before the GI procedure. Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

A patient discharged following a laparoscopic cholecystectomy calls the surgeon's office complaining of severe right shoulder pain 24 hours after surgery. Which of the following statements is the correct information for the nurse to provide to this patient? a) This pain may be caused by a bile duct injury. You will need to go to the hospital immediately to have this evaluated. b) This may be the beginning symptoms of an infection. You need to come to see the surgeon today for an evaluation. c) This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort. d) This pain is caused from your incision. Take analgesics as needed and as prescribed and report to surgeon if pain is unrelieved even with analgesic use.

c) This pain is caused from the gas used to inflate your abdominal area during surgery. Sitting upright in a chair, walking, or using a heating pad may ease the discomfort. If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke for best functional outcome? a) 6 hours b) 9 hours c) 12 hours d) 3 hours

d) 3 hours

On his return to the cardiac step-down unit after his diagnostic procedure, a client awaits the report from his cardiologist. As the client's nurse, you review the process of measuring ejection fraction and explain to the client that it measures the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects? a) 50% b) 45% c) 40% d) 55%

d) 55%

A patient has had a 12-lead -ECG completed as part of an annual physical examination. The nurse notes an abnormal Q wave on an otherwise unremarkable ECG. The nurse recognizes this finding indicates which of the following? a) A cardiac dysrhythmia b) An evolving MI c) Variant angina d) A past MI

d) A past MI An abnormal Q wave may be present without ST-segment and T-wave changes, which indicates an old, not acute, MI.

What is the most common cause of small-bowel obstruction? a) Neoplasms b) Volvulus c) Hernias d) Adhesions

d) Adhesions Adhesions are scar tissue that forms as a result of inflammation and infection. Adhesions are the most common cause of small-bowel obstruction, followed by hernias and neoplasms. Other causes include intussusceptions, volvulus, and paralytic ileus

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause decreased preload. The student correctly answers which of the following? a) Application of antiembolytic stockings b) Maintaining the client's legs elevated c) Ambulation d) Administration of a vasodilating drug (as ordered by a physician)

d) Administration of a vasodilating drug (as ordered by a physician)

The nurse is a preparing a patient for a barium enema. The nurse should place the patient on which of the following prior to the procedure? a) Soft diet 1 day prior b) Nothing by mouth (NPO) 2 days prior c) High-fiber diet 1 to 2 days prior d) Clear liquids day before

d) Clear liquids day before

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes? a) Renal failure b) Inability for the liver to reabsorb serum glucose c) Ingestion of foods high in sugar d) Dysfunction of the pancreatic islet cells

d) Dysfunction of the pancreatic islet cells

A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? a) Place the consent form in the patient's medical record. b) Answer the patient's questions. c) Notify the nurse manager of the patient's questions. d) Request that the surgeon come and answer the questions.

d) Request that the surgeon come and answer the questions.

A patient has a nasogastric (NG) tube for suction and is NPO following a pancreaticoduodenectomy. Which of the following explanations made by the nurse is the major purpose of this treatment? a) The tube will help control fluid and electrolyte imbalance. b) The tube will provide relief from nausea and vomiting. c) The tube will allow the removal of toxins. d) The tube will allow the gastrointestinal (GI) tract to rest.

d) The tube will allow the gastrointestinal (GI) tract to rest.

The physician has written the following orders: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) for a new patient admitted with pancreatitis. The nurse attributes which of the following as the cause for NPO status? a) To drain the pancreatic bed b) To aid opening up of pancreatic duct c) To prevent the occurrence of fibrosis d) To avoid inflammation of the pancreas

d) To avoid inflammation of the pancreas

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech

d) Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

A nurse is caring for a client with acute pancreatitis. His physical examination reveals that he has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, his lab results indicate that he is hypovolemic. Which of the following will his healthcare provider consider ordering to treat the large amount of protein-rich fluid that has been released into his tissues and peritoneal cavity? a) Diuretics b) Dextrose solution c) Albumin d) Sodium

• Diuretics • Albumin Explanation: Diuretics are given if circulating fluid is excessive. IV albumin may be given to pull fluid trapped in the peritoneum back into the circulation. Sodium would not be used to treat excessive fluid accumulation. Blood glucose levels can be elevated in clients with acute pancreatitis; therefore, glucose solutions would not be administered nor would they be used to treat excessive fluid accumulation.

A nurse is preparing a patient for an endoscopic retrograde cholangiopancreatography (ERCP). The patient asks what this test is used for. Which of the following statements made by the nurse explains how an ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply. a) It can evaluate the presence and location of ductal stones and aid in stone removal. b) It can assess the anatomy of the pancreas and the pancreatic and biliary ducts. c) It is used in the diagnostic evaluation of acute pancreatitis. d) It can assess for ecchymosis in the body. e) It can detects unhealthy tissues in the pancreas and assess for abscesses and pseudocysts.

• It can evaluate the presence and location of ductal stones and aid in stone removal. • It can assess the anatomy of the pancreas and the pancreatic and biliary ducts. • It can detects unhealthy tissues in the pancreas and assess for abscesses and pseudocysts. An ERCP can determine the difference between pancreatitis and other biliary disorders and is generally used in chronic pancreatitis. It is particularly useful in diagnosis and treatment of patients who have symptoms after biliary tract surgery, patients with intact gallbladders, and patients for whom surgery is particularly hazardous. It can be used to assist with the removal of stones. An ERCP is a useful tool in providing anatomic details about the pancreas and biliary ducts. It can evaluate the presence and location of ductal stones and detect changes in the anatomy of the patient with pancreatitis such as obstruction in the pancreatic duct, tissue necrosis due to premature release of pancreatic enzymes, and assess for abscesses and pseudocysts and atrophy of the glands in the body. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the patient is acutely ill; however, it may be valuable in treating gallstone pancreatitis.

A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply. a) Irritating foods b) DASH diet c) Participation in highly competitive sports d) Overuse of aspirin e) Ingestion of strong acids

• Overuse of aspirin • Irritating foods • Ingestion of strong acids

The mode of transmission of hepatitis A virus (HAV) includes which of the following? a) Fecal-oral b) Semen c) Saliva d) Blood

a) Fecal-oral

Which of the following is the most common motor dysfunction seen in patients diagnosed with stroke? a) Hemiplegia b) Hemiparesis c) Ataxia d) Diplopia

a) Hemiplegia

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a) Hemolytic b) Obstructive c) Hepatocellular d) Nonobstructive

a) Hemolytic

Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Encourage the patient to repeat sounds of the alphabet b) Speak clearly to the patient in simple sentences, use gestures or pictures when able c) Speak slowly and clearly to assist the patient in forming the sounds d) Frequently reorient the patient to time, place, and situation

a) Encourage the patient to repeat sounds of the alphabet

A patient asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: a) "It indicates if a cancer is present." b) "It determines functionality of the liver." c) "It tells the physician what type of cancer is present." d) "It detects a protein normally found in the blood."

a) "It indicates if a cancer is present." The CEA blood test detects the presence of cancer by detecting the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch gap at the lower end of the incision. The nurse concludes which of the following conditions exists? a) Dehiscence b) Normal healing by primary intention. c) Evisceration d) Hemorrhage

a) Dehiscence

The nurse is caring for a patient after a gastroscopy for which the patient received sedation. The nurse should report which of the following findings to the physician? a) Difficulty swallowing b) Loss of gag reflex c) Drowsiness d) Minor throat pain

a) Difficulty swallowing

A patient is being treated for diverticulosis. Which of the following information should the nurse include in this patient's teaching plan? a) Drink at least 8 to 10 large glasses of fluid every day b) Avoid unprocessed bran in the diet c) Use laxatives or enemas at least once a week d) Avoid daily exercise; indulge only in mild activity

a) Drink at least 8 to 10 large glasses of fluid every day

A student nurse is preparing a plan of care for a client with chronic pancreatitis. What nursing diagnosis related to the care of a client with chronic pancreatitis is the priority? a) Impaired nutrition: less than body requirements b) Disturbed body image c) Nausea d) Anxiety

a) Impaired nutrition: less than body requirements

Crohn's disease is a condition of malabsorption caused by which of the following pathophysiological processes? a) Inflammation of all layers of intestinal mucosa b) Disaccharidase deficiency c) Infectious disease d) Gastric resection

a) Inflammation of all layers of intestinal mucosa

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care? a) Intermittent pain and bloody stool b) Unexplained bowel incontinence and fatty stools c) Abdominal bloating and recurrent constipation d) Hematemesis and persistent sensation of fullness

a) Intermittent pain and bloody stool When the patient is symptomatic from a tumor of the small intestine, benign tumors often present with intermittent pain. The next most common presentation is occult bleeding. The other listed signs and symptoms are not normally associated with the presentation of small intestinal tumors.

Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. a) Intracranial hemorrhage b) Major abdominal surgery within 10 days c) Systolic BP less than or equal to 185 mm Hg d) Age 18 years or older e) Ischemic stroke

a) Intracranial hemorrhage

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? a) Ischemic b) Hemorrhagic c) Left-sided d) Right-sided

a) Ischemic

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? a) Limited attention span and forgetfulness b) Visual and auditory agnosia c) Hemiplegia or hemiparesis d) Lack of deep tendon reflexes

a) Limited attention span and forgetfulness

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system? a) Maintain the client in a semi-Fowler's position. b) Administer enteral or parenteral nutrition. c) Withhold oral feedings. d) Carry out wound care as prescribed.

a) Maintain the client in a semi-Fowler's position. The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care? a) Referral for bereavement counseling b) Decreased need for nutritional supplementation c) Decreased need for pain medications d) Decreased need for antidepressant medication

a) Referral for bereavement counseling

Which of the following are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. a) Systolic BP less than or equal to 185 mm Hg b) Age 18 years or older c) Intracranial hemorrhage d) Ischemic stroke e) Major abdominal surgery within 10 days

a) Systolic BP less than or equal to 185 mm Hg b) Age 18 years or older

The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification? a) The client has an absence of bowel sounds. b) The client states a moderate amount of pain at the incisional site. c) The client's lungs reveal rales in the bases. d) A moderate amount of serous drainage is noted on the operative dressing.

a) The client has an absence of bowel sounds. If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend using a heating pad for 15 to 20 minutes hourly, sitting up in a bed or chair, or walking.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: a) eat food on only half of the plate. b) not be able to swallow liquids. c) forget the names of foods. d) have a preference for foods high in salt.

a) eat food on only half of the plate.

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should: a) teach the client to put on clothing on the affected side first. b) encourage the client to wear clothing designed especially for people who have had a CVA. c) advise the client to ask for help when dressing. d) dress the client, explaining each step of the process as it is completed.

a) teach the client to put on clothing on the affected side first.

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement? a) "The head of your bed must remain flat for 24 hours after surgery." b) "You must avoid hyperextending your neck after surgery." c) "You should avoid deep breathing and coughing after surgery." d) "You won't be able to swallow for the first day or two."

b) "You must avoid hyperextending your neck after surgery." To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing

A patient undergoes induction for general anesthesia at 8:30 a.m. and is being assessed continuously for the development of malignant hyperthermia. At which time would the patient be most likely to exhibit manifestations of this condition? a) 9:00 to 9:10 a.m. b) 8:40 to 8:50 a.m. c) 9:30 to 9:40 a.m. d) 10:00 to 10:10 a.m.

b) 8:40 to 8:50 a.m. Malignant hyperthermia usually manifests about 10 to 20 minutes after the induction of anesthesia, which in this case would 8:40 to 8:50 a.m.

Which of the following characteristics should the nurse include when teaching the client about moderate sedation? a) Loss of consciousness b) Ability to respond to verbal commands c) Paralysis of the lower extremities d) Unable to maintain airway

b) Ability to respond to verbal commands

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Apraxia b) Agnosia c) Perseveration d) Agraphia

b) Agnosia

Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agnosia b) Apraxia c) Agraphia d) Perseveration

b) Apraxia

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Hypertension b) Bleeding c) Increased intracranial pressure (ICP) d) Headache

b) Bleeding

Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin? a) Felodipine (Plendil) b) Clopidogrel (Plavix) c) Diltiazem (Cardizem) d) Amlodipine (Norvasc)

b) Clopidogrel (Plavix)

The nurse in the ED is admitting a patient with bloody stools. The nurse documents this finding as being which of the following? a) Steatorrhea b) Hematochezia c) Melena d) Tarry stools

b) Hematochezia The nurse should document the finding of bloody stools as hematochezia. Melena is the term used for tarry black stools with occult blood. Steatorrhea is the term utilized for fatty stools that have an oily appearance and float in water

The nurse is reinforcing diet teaching for a patient s diagnosed with IBS. The nurse instructs the patient to include which of the following in his diet? a) Spicy foods b) High-fiber diet c) Fluids with meals d) Caffeinated products

b) High-fiber diet

Which disturbance results in loss of half of the visual field? a) Diplopia b) Homonymous hemianopsia c) Nystagmus d) Anisocoria

b) Homonymous hemianopsia Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? a) Left-sided b) Ischemic c) Right-sided d) Hemorrhagic

b) Ischemic

Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) Main presenting symptom is an "exploding headache." c) One of the main presenting symptoms is numbness or weakness of the face. d) Functional recovery usually plateaus at 6 months.

b) Main presenting symptom is an "exploding headache."

A 76-year-old client has a significant history of congestive heart failure. During his semiannual cardiology examination, for what should you, as his nurse, specifically assess? Select all that apply. a) Examine the client's eyes for excess tears. b) Monitor the client for signs of lethargy or confusion. c) Examine the client's joints for crepitus. d) Examine the client's neck for distended veins.

b) Monitor the client for signs of lethargy or confusion. d) Examine the client's neck for distended veins.

A patient is suspected of having had a stroke. Which of the following is the initial diagnostic test for a stroke? a) Transcranial Doppler studies b) Noncontrast CT scan c) ECG d) Carotid Doppler

b) Noncontrast CT scan

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? a) Reduced peripheral edema and ascites. b) Reduced serum ammonia levels. c) Stimulation of peristalsis of the bowel. d) Prevention of hemorrhage.

b) Reduced serum ammonia levels. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage

A nurse is instructing the wife of a patient who suffered a stroke about the use of eating devices her husband will be using. During the teaching, the wife starts to cry and states "One minute my husband is laughing, and the next he's crying; I just don't understand what's wrong with him." The nurse's best response is which of the following? a) "You sound stressed; maybe using some stress management techniques will help." b) "You seem upset, and it may be hard for you to focus on the teaching, I'll come back later." c) "Following a stroke, emotional lability is common, and it usually improves with time." d) "This behavior is common in stroke patients. Which does your husband do more often? Laugh or cry?"

c) "Following a stroke, emotional lability is common, and it usually improves with time."

The nurse is planning care for a patient following an incisional cholecystectomy for cholelithiasis. Which of the following interventions is the highest nursing priority for this patient? a) Performing range-of-motion (ROM) leg exercises hourly while the patient is awake b) Assisting the patient to ambulate the evening of the operative day c) Assisting the patient to turn, cough, and deep breathe every 2 hours d) Teaching the patient to choose low-fat foods from the menu

c) Assisting the patient to turn, cough, and deep breathe every 2 hours Assessment should focus on the patient's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client? a) Lack of deep tendon reflexes b) Limited attention span and forgetfulness c) Auditory agnosia d) Hemiplegia or hemiparesis

c) Auditory agnosia

Which of the following is a key diagnostic indicator of heart failure (HF)? a) Creatinine b) Complete blood count (CBC) c) Brain natriuretic peptide (BNP) d) Blood urea nitrogen (BUN)

c) Brain natriuretic peptide (BNP)

A patient diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as which of the following? a) Dysphagia b) Diplopia c) Dysarthria d) Receptive aphasia

c) Dysarthria

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Avoiding the use of hand gestures b) Speaking in complete sentences c) Establishing eye contact d) Speaking loudly

c) Establishing eye contact

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)? a) Every 30 minutes b) Every hour c) Every 15 minutes d) Every 45 minutes

c) Every 15 minutes

A nurse is caring for a client with hypoparathyroidism. During her assessment, the nurse elicits a positive Trousseau's sign. What does the nurse observe to verify this finding? a) Moon face and buffalo hump b) Bulging forehead c) Hand flexing inward d) Cardiac dysrhythmia

c) Hand flexing inward

Which type of jaundice seen in adults is the result of increased destruction of red blood cells? a) Hepatocellular b) Obstructive c) Hemolytic d) Nonobstructive

c) Hemolytic Hemolytic jaundice results because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.

The nurse caring for an elderly patient diagnosed with diarrhea is administering and monitoring the patient's medications. Because one of the patient's medications is digitalis (digoxin [Lanoxin]), the nurse monitors the patient closely for which of the following? a) Hyponatremia b) Hypernatremia c) Hypokalemia d) Hyperkalemia

c) Hypokalemia The older person taking digoxin must be aware of how quickly dehydration and hypokalemia can occur with diarrhea. The nurse teaches the patient to recognize the symptoms of hypokalemia because low levels of potassium intensify the action of digitalis, leading to digitalis toxicity.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Cardiac disease b) Hypertension c) Impaired cerebral circulation d) Diabetes insipidus

c) Impaired cerebral circulation

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? a) Respiratory alkalosis b) Respiratory acidosis c) Metabolic acidosis d) Metabolic alkalosis

c) Metabolic acidosis

A male patient with CVA is prescribed medication to treat the disorder. The patient wants to know what other measures may help reduce CVA. Which of the following is an accurate suggestion for the patient? a) Increase the intake of proteins and carbohydrates b) Increase the fluids and hydration c) Reduce hypertension and high blood cholesterol levels d) Increase body weight moderately

c) Reduce hypertension and high blood cholesterol levels

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is taking digoxin. b) She is not within the treatment time window. c) She is taking coumadin. d) She had surgery 6 weeks ago.

c) She is taking coumadin. To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? a) Three meals and three snacks and 120 mL fluid daily b) Three meals and 120 ml fluid daily c) Six small meals daily with 120 mL fluid between meals d) Six small meals and 120 mL fluid daily

c) Six small meals daily with 120 mL fluid between meals

The presence of mucus and pus in the stools suggests which of the following conditions? a) Intestinal malabsorption b) Small bowel disease c) Ulcerative colitis d) Disorders of the colon

c) Ulcerative colitis

A client with cholecystitis is taking propantheline bromide. The expected outcome of this drug is: a) relief from nausea. b) absence of infection. c) decreased biliary spasm. d) increased bile production.

c) decreased biliary spasm.

A 43-year-old man is seen in the office where you work with complaints of severe pain and bleeding while having a bowel movement. Upon inspection, his healthcare provider notes a linear tear in the anal canal tissue. While reviewing with him the medical management for his condition, he asks you to repeat the name of the condition. The nurse will most likely tell him that he has been diagnosed with a ________. a) pilonidal cyst b) fistula c) fissure d) hemorrhoid

c) fissure An anal fissure (fissure in ano) is a linear tear in the anal canal tissue. An anal fistula (fistula in ano) is a tract that forms in the anal canal. The condition described is known as a fissure. Hemorrhoids are dilated veins outside or inside the anal sphincter. The condition described is known as a fissure. A pilonidal sinus is an infection in the hair follicles in the sacrococcygeal area above the anus. The condition described is known as a fissure.

A 70-year-old patient is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which of the following gerontologic considerations associated with the pancreas? a) Increases in the rate of pancreatic secretion b) Development of local complications c) Increases in the bicarbonate output by the kidneys d) Decreases in the physiologic function of major organs

d) Decreases in the physiologic function of major organs

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which of the following nursing interventions is advised for this patient? a) The client's fluid output should be measured for at least 24 hours after the procedure. b) The client should be monitored for cramping or abdominal distention. c) The client should be monitored for any breathing-related disorder or discomforts. d) The client should not be given any food and fluids until the gag reflex returns

d) The client should not be given any food and fluids until the gag reflex returns

A nurse is caring for a patient who experienced an MI. The patient is ordered metoprolol (Lopressor). The nurse understands that the therapeutic effect of this medication is which of the following? a) Increases cardiac output b) Decreases cholesterol level c) Decreases platelet aggregation d) Decreases resting heart rate

d) Decreases resting heart rate The therapeutic effects of beta-adrenergic blocking agents such as metoprolol are to reduce the myocardial oxygen consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced heart rate, slowed conduction of impulses through the conduction system, decreased blood pressure, and reduced myocardial contractility to balance the myocardial oxygen needs and amount of oxygen available. This helps to control chest pain and delays the onset of ischemia during work or exercise. This classification of medication also reduces the incidence of recurrent angina, infarction, and cardiac mortality. Generally the dosage of medication is titrated to achieve a resting heart rate of 50-60 bpm. Metoprolol is not administered to decrease cholesterol levels, increase cardiac output, or decrease platelet aggregation.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? a) Vanilla pudding b) Mashed potatoes c) White rice d) Hot roast beef sandwich with gravy

d) Hot roast beef sandwich with gravy The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, because fatty foods may bring on an episode of cholecystitis.

Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) Functional recovery usually plateaus at 6 months. c) One of the main presenting symptoms is numbness or weakness of the face. d) Main presenting symptom is an "exploding headache."

d) Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.

The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? a) Monitoring for seizure activity b) Administering a stool softener c) Elevating the head of the bed at 30 degrees d) Maintaining a patent airway

d) Maintaining a patent airway

After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time? a) C-reactive protein b) Troponin I c) WBC (white blood cell) count d) Myoglobin

d) Myoglobin Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart damage, but troponin I levels due not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not until about day 3.

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis? a) Administering oral analgesics around the clock b) Allowiing a clear liquid diet during the acute phase c) Maintaining a high-Fowler's position d) Providing intensive insulin therapy

d) Providing intensive insulin therapy Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

A client who is legally blind must undergo a colonoscopy. The nurse is helping the physician obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? a) Document on the consent form that the client is unable to sign the consent because he is legally blind. b) Encourage the client to read the form. c) Make sure the client's family is present when he signs the consent form. d) Read the consent form to the client and ask him if he has any questions.

d) Read the consent form to the client and ask him if he has any questions.

A nurse is teaching a patient about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the patient correctly identifies which of the following conditions as a cause of acute pancreatitis? a) Use of loop diuretics to increase the incidence of pancreatitis b) Fibrosis and atrophy of the pancreatic gland c) Calcification of the pancreatic duct leading to its blockage d) Self-digestion of the pancreas by its own proteolytic enzymes

d) Self-digestion of the pancreas by its own proteolytic enzymes

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Weakness on one side of the body and difficulty with speech b) Footdrop and external hip rotation c) Confusion or change in mental status d) Severe headache and early change in level of consciousness

d) Severe headache and early change in level of consciousness

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? a) Hemorrhage b) Laryngeal nerve damage c) Thyroid storm d) Tetany

d) Tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction

At 0800, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:

evaluate the tube for patency.

Antithyroid medications are contraindicated in late pregnancy due to the fact that which of the following may occur? Select all that apply. a) Cretinism b) Fetal tachycardia c) Goiter d) Fetal bradycardia e) Fetal hypothyroidism

• Fetal hypothyroidism • Fetal bradycardia • Goiter • Cretinism