NURS 425 Exam 3 ATI Questions

1. Which condition is NOT a known cause of cirrhosis? A. Obesity B. Alcohol consumption C. Blockage of the bile duct D. Hepatitis C E. All are known causes of Cirrhosis

E.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? a. Client reports feelings of depression b. Dry, raised rash on the face c. Presence of peripheral edema d. Joint pain in hands and knees

- Presence of peripheral edema The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

3. A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply: A. Increase albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficient E. Esophageal varices

B, C, & E

6. Which of the following is NOT a common source of transmission for Hepatitis A? Select all that apply: A. Water B. Food C. Semen D. Blood

C & D

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching? a. "I plan to use nicotine gum to help me quit smoking." b. "I am going to take a stress management class." c. "I will limit myself to only two cups of coffee in the morning." d. "I should not drive in the winter months."

- "I am going to take a stress management class." The nurse should instruct the client that stress can elicit attacks.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? a. "I will wear gloves when removing food from the freezer." b. "I will try to anticipate and avoid stressful situations when possible." c. "I will complete the smoking cessation program I started." d. "I will take my medications at the first sign of an attack."

- "I will take my medications at the first sign of an attack." Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A clinic nurse is performing a physical assessment on a client who has SLE. Which of the following findings should the nurse expect? - A grey colored, non-purpuric papular rash. - A dry, red rash across the bridge of the nose and on the cheeks. - Pitting edema of the hands and fingers. - Subcutaneous nodules on the ulnar side of the arm.

- A dry, red rash across the bridge of the nose and on the cheeks. A "butterfly" rash that is dry, red, and raised is characteristic of SLE.

A nurse is assessing a client who has SLE and is taking hydroxychloroquine. The nurse should report which of the following adverse effects to the provider immediately? a. Diarrhea b. Blurred vision c. Pruritus d. Fatigue

- Blurred vision When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding to report to the provider is blurred vision, as this is a manifestation of hydroxychloroquine toxicity and can be an indication of retinal damage.

A nurse is assessing a client who has SLE. Which of the following findings would the nurse expect? a. Thickened skin b. Chronic back pain c. Iritis d. Facial rash

- Facial rash SLE causes a characteristic facial "butterfly" rash that is dry, scaly, red, and raised.

A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect? a. Symmetric joints affected b. Pain worsens with activity c. Weight loss d. Ulnar deviation

- Pain worsens with activity The typical cycle of pain and relief in a client who has early osteoarthritis consists of pain with activity and pain relief with rest. As the disorder progresses, clients typically experience pain even while the joint is at rest.

A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective? A. WBC 3,500 B. Lymphocyte 1,500 C. Decreased viral load D. Low CD4/CD8 ratio

C.

A nurse is reviewing lab values for a client who has SLE. Which of the following values should give the nurse the best indication of the client's renal function? a. Serum creatinine b. Blood urea nitrogen (BUN) c. serum sodium d. Urine-specific gravity

- Serum creatinine A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function.

A nurse is providing discharge teaching to a client who has SLE. Which of the following instructions should the nurse include? a. Avoid using moisturizing lotions on the skin. b. Wash the hair with a mild protein shampoo. c. Apply powder liberally to sensitive areas. d. Use a sun-blocking agent with a sun protection factor of at least 15.

- Wash the hair with a mild protein shampoo. Clients who have SLE are prone to hair loss. They should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (Select all that apply) -Subcutaneous nodules -Decreased urine output -Renal calculi -Butterfly rash -Joint inflammation

-decreased urine output -butterfly rash -joint inflammation

A nurse is caring for a client who is HIV-Positive who is teaching the client about the earliest manifestations of AIDS. Then nurse explains that they include which of the following? a. persistent fever, swollen glands, diarrhea, weight loss and fatigue b. elevated WBC count c. increased BP, tachycardia, dyspnea and edema d. influenza like symptoms: fatigue, sore throat, muscle pain, headache, swollen glands

A persistent fever, swollen glands, diarrhea, weight loss and fatigue Influenza like symptoms are for HIV

A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following effects should the nurse include? (Select all that apply.) A. Osteoporosis B. Moon-shaped face C. Increased risk of infection D. Hearing loss E. Weight loss

A - Correct - Osteoporosis is an adverse effect of long-term corticosteroid therapy due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause. B - Correct - Long-term corticosteroid therapy causes characteristics of the iatrogenic syndrome characterized by a moon-shaped face, a potbelly, and a buffalo hump. C - Correct - Increased risk of infection is an adverse effect of long-term corticosteroid therapy due to the decrease it causes in the number of circulating lymphocytes. D - Incorrect - Long-term corticosteroid therapy is more likely to cause cloudy or blurred vision than hearing loss. E - Incorrect - Long-term corticosteroid therapy is more likely to cause weight gain due to the fluid retention corticosteroids cause. ...

A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (SATA) A. diuretic B. Beta-blocking agent C. opioid analgesic D. lactulose E. sedative

A, B, & D

A nurse is teaching a client who has hepatitis B about home care. Which of the following instructions should the nurse include in the teaching? (SATA) A. limit physical activity B. avoid alcohol C. take acetaminophen for comfort D. wear a mask in public places E. eat small frequent meals

A, B, & E

4. Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply: A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopenia

A, C, & D

9. You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis. You ask the graduates to list activities that should be avoided by a patient with this condition. Which activities listed are correct: Select all that apply A. Excessive coughing B. Sleeping on the back C. Drinking juice D. Alcohol consumption E. Straining during a bowel movement F. Vomiting

A, D, E, & F

A nurse is reviewing nutrition teaching for a client who has cholecystitis. Which of the following food choices can trigger cholecystitis? A. Brownie with nuts B. Bowl of mixed fruit C. Grilled turkey D. Baked potato

A. Brownie with nuts Foods that are high in fat, such as a brownie with nuts, can cause cholecystitis.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children and young adults B. Older adults C. Women who are pregnant D. Middle-aged men

A. Children and young adults

A nurse is teaching a female client newly diagnosed with systemic lupus erythematosus (SLE) about factors that might trigger an exacerbation of SLE. The nurse determines that the client needs more teaching when she identifies which of the following as a factor? A. Exercise B. Pregnancy C. Infection D. Sunlight

A. Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks normal body tissue. This attack may result in generalized inflammation and the symptoms associated with the specific involved tissues. most clients with SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance.

A nurse is assisting with the care of the client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase B. Alkaline phosphatase C. Serum bilirubin D. Alanine aminotransferase (ALT)

A. Gamma-glutamyl transferase The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs.

A client has been diagnosed with Raynaud's disease, when reinforcing teaching with the client, the nurse should include information about which of the following? A. Protecting against cold with layers of clothing B. Starting a regular exercise program of 2-mile walks daily C. Increasing niacin and pyridoxine in the diet D. Elevating the hands above heart level during an acute attack

A. Protecting against cold with layers of clothing Extreme cold can lead to tissue damage, and clients with Raynaud's are prone to more frequent attacks during cold weather.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

A. Prothrombin time A major complication following a liver biopsy is hemorrgage. Many clients who have liver disease have clotting defects and are at risk for bleeding.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees Celsius (101.1 degrees Fahrenheit)

A. Right shoulder pain

5. A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient? A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts

A. beef tips and broccoli rabe

A nurse is providing teaching for a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following should the nurse include in the teaching? A. Avoid crowds B. Expect symptoms to subside in 1 to 2 weeks C. Increase intake of vitamin D D. Anticipate constipation

A. can decrease WBC and platelet levels, thus increasing risk for infection

3. You're providing an in-service on viral hepatitis to a group of healthcare workers. You are teaching them about the types of viral hepatitis that can turn into chronic infections. Which types are known to cause ACUTE infections ONLY? Select all that apply: A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D E. Hepatitis E

A. hepatitis A E. hepatitis E

A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? A. Small purple-colored skin lesions B. Fever and diarrhea lasting longer than 1 month C. Persistent, generalized lymphadenopathy D. CD4 T-cells decreased to 750

A. means acquired Kaposi's sarcoma, which is an AIDS-defining illness.

When planning to teach a client who is HIV positive, the nurse should inform the client on the following that the virus can be transmitted a. as soon as the client develops manifestations b. to anyone having contact with the clients blood c. via respiratory route through droplets d. only during the active phase of the virus

B to anyone having contact with the clients blood

7. You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply: A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool E. Jaundice of the skin F. Bluish mucous membranes

B, C, & E

A nurse is assessing a client who has advanced cirrhosis. the nurse should identify which of the following findings as indicators of hepatic encephalopathy? (SATA) A. anorexia B. change in orientation C. asterixis D. ascites E. fetor hepaticus

B, C, & E B. change in orientation C. asterixis (asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis & hepatic encephalopathy E. fetor hepaticus (fruity breath odor)

4. Which patients below are at risk for developing complications related to a chronic hepatitis infection, such as cirrhosis, liver cancer, and liver failure? Select all that apply: A. A 55-year-old male with Hepatitis A. B. An infant who contracted Hepatitis B at birth. C. A 32-year-old female with Hepatitis C who reports using IV drugs. D. A 50-year-old male with alcoholism and HepatitisD E. A 30-year-old who contracted Hepatitis E.

B, C, D

1. A nurse is providing discharge teaching to a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Take baths rather than showers. B. Clamp T-tube for 1 to 2 hr before and after meals. C. Keep the drainage system above the level of the gallbladder. D. Expect to have constipation. E. Empty drainage bag every 8 hr.

B, E The T-tube should be clamped 1 to 2 hr before and after meals to assess tolerance to food post-cholecystectomy, and prior to removal. Diarrhea is common and stools will return to brown color in a week. The drainage bag attached to the T-tube should be emptied every 8 hr

A nurse is reinforcing teaching with a group of community resident about hepatitis B. Which of the following statement should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

B. "A hepatitis B immunization is given to infants and children."

A nurse is preparing the family of an infant with acquired immune deficiency syndrome (AIDS) for discharge. which statement by the child's parent should alert the nurse to a need for further instruction? A. "I'll use disposable diapers, discarding them in separate plastic bags" B. "I'll clean up blood spills immediately with hot soapy water" C. "I know that handwashing is an important preventive measure" D. "Anybody changing the baby's diapers must wear gloves"

B. "I'll clean up blood spills immediately with hot soapy water"

A nurse in the health clinic is evaluating the effectiveness of naproxen (naprosyn) following a client's exacerbation of rheumatoid arthritis, which comment by the client requires further intervention with the nurse? A. "I signed up for a swimming class, starting tomorrow" B. "I've been buying an acid reducer to help with the indigestion I've had" C. "I've lost 2 pounds since my last appointment 2 weeks ago" D. "The naprosyn goes down easier when I crush it and put it in applesauce"

B. "I've been buying an acid reducer to help with the indigestion I've had" NSAIDs like naprosyn can cause serious adverse GI reactions such as ulcerations, bleeding, perforation.

A nurse is reinforcing teaching with a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."

B. "This procedure can determine how well the lower part of your esophagus works." An EGD is useful in determining the function of the esophageal lining and the extend of inflammation, potential scarring, and strictures

A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."

B. "You may have shoulder pain after surgery." Shoulder pain occurs due to free air that is introduced into the abdomen during laparoscopic surgery.

A nurse is collecting data from a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

B. Anorexia The early manifestations of hepatitis A and is often severe.

11. The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? Select all that apply: A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis

B. Decrease in fetor hepaticus D. decreased ammonia blood level

10. While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as: A. Metallic Hepatico B. Fetor Hepaticus C. Hepaticoacidosis D. Asterixis

B. Fetor Hepaticus

A nurse is collecting data from a client who has had systemic scleroderma for 5 years. In addition to skin changes, which of the following findings should the nurse expect? A. Excessive salivation B. Finger contractures C. Periorbital edema D. Alopecia

B. Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening or tightening of the skin, blood vessels and internal organs. There are 2 types: localized scleroderma, which mainly affects the skin, and systemic scleroderma which may affect many internal organs. The symptoms include skin changes, Raynaud's disease, arthritis, muscle weakness, and dry mucous membranes. With scleroderma, the body produces and deposits too much collagen, causing thickening and hardening. in addition to the clients skin and subcutaneous tissues becoming increasing hard and rigid, the extremities stiffen and lose mobility. Contractures develop with advanced systemic scleroderma unless clients follow a regimen of range of motion and muscle strengthening exercises

A client with an acute exacerbation of rheumatoid arthritis has an erythrocyte sedimentation rate (ESR) of 65 mm/hr. based on this finding, the nurse anticipates that the client's affected joints will require which of the following? A. Assistive devices B. Heat or cold therapy C. Gentle massage D. Active ROM exercises

B. Heat or cold therapy Elevated ESR indicates an acute inflammatory process. The client will most likely need thermal interventions to control inflammation, as well as activity limitations to rest inflamed joints

2. The liver receives it blood supply from two sources. One of these sources is called the _________________, which is a vessel network that delivers blood _____________ in nutrients but ________ in oxygen. A. hepatic artery, low, high B. hepatic portal vein, high, low C. hepatic lobule, high, low D. hepatic vein, low, high

B. Hepatic portal vein, high, low

A nurse is caring for client who has a percutaneous endoscopic gastronomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in semi-Folwer's position C. Cleanse the skin around the tube site D. Aspirate the tube prior to each feeding

B. Place the client in semi-Folwer's position The nurse should apply the ABC priority-setting framework

A client reports bilateral pain and swelling in her finger joints, with stiffness in the morning. the finger joints are erythematous and warm to touch. the clients tells the nurse she has a long family history of arthritis. to help diagnose this client's condition, the nurse anticipates an order for which laboratory study? A. C-Reactive protein (CRP) B. Rheumatoid factor (RF) C. WBC count D. Erythrocyte sedimentation rate (ESR)

B. Rheumatoid factor (RF) Likely RA; RF is found in the serum of most clients who have RA

When planning to reinforce teaching for a client who is HIV-positive, the nurse should explain to the client that the virus can be transmitted A. As soon as the client develops manifestations B. To anyone having contact with the clients blood C. Via the respiratory route through droplets D. Only during the active phase of the virus

B. To anyone having contact with the clients blood The concentration of the virus is highest in blood and has been isolated in several body fluids; including sputum, saliva, CSF, urine and semen. Clients with HIV are cautioned to practice safer sex, avoid donating blood, and abstain from sharing needles with others

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that the purpose of this procedure is which of the following? A. To visualize colon polyps B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary duct D. To determine the presence of free air in the abdomen

B. To detect an ulceration in the stomach

A nurse is providing discharge teaching for a client who is HIV-positive. Which of the following instructions should the nurse include in the teaching? A. Clean bathroom surfaces with full-strength bleach B. Discard beverages that have been unrefrigerated for 1 hour C. Wash laundry soiled with a body fluid in warm water. D. Work in the garden for exercise

B. b/c they can support bacteria

1. The liver receives blood from two sources. The _____________ is responsible for pumping blood rich in nutrients to the liver. A. hepatic artery B. hepatic portal vein C. mesenteric artery D. hepatic iliac vein

B. hepatic portal vein

A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following lab findings should the nurse expect? A. presence of immunoglobulin G antibodies B. positive EIA test C. aspartate aminotransferase (AST) 35 units/L D. alanine aminotransferase (ALT) 15 IU/L

B. positive EIA test Rationale: a positive EIA test is an expected lab finding in a client who has a new diagnosis of hepatitis C.

A nurse in the emergency department is assessing a newly admitted client. Which of the following places the client at increased risk for contracting hepatitis B? A. Residing in an institutional setting B. Engaging in unprotected sexual intercourse C. Working w/ hazardous chemical waste materials D. Traveling to a foreign country

B. transmitted by sexual contact

****An HIV positive client is admitted to the hospital with a lung infection. which isolation category should the client be placed? a. protective isolation b. droplet precautions c. standard precautions d. contact precautions

C standard precautions

A client diagnosed with systemic lupus erythematosus (SLE) is concerned about skin lesions on the face and neck. the client asks the nurse, "what should I do about these spots?" which of the following nursing responses is appropriate? A. "Keep the lesions covered with a light sterile dressing when going outdoors" B. "There is not much you can do. The lesions will go away when your disease is in remission" C. "Apply moisturizer after bathing the lesions with warm water" D. "Apply antibiotic cream twice a day until scabs form on the lesions"

C. "Apply moisturizer after bathing the lesions with warm water"

A nurse is reinforcing teaching for a female client recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements made by the client indicates an understanding of the teaching? A. "Its best for me to minimize exercise" B. "I shouldn't drink any alcohol" C. "I must not smoke" D. "I'd better not plan to become pregnant"

C. "I must not smoke" Raynauds disease is a disorder of the blood vessels that supply blood to the skin and cause the distal extremities and the tips of the nose and ears to feel numb and cool in response to cold temperatures or stress. During a Raynaud's attack, these arteries narrow, limiting blood circulation to affected areas. Strong emotion or exposure to the cold causes these areas to become white, due to lack of blood flow in the area. They then turn blue, as tiny blood vessels dilate to allow more blood to remain in the tissues. When the flow of blood returns, the area becomes red and then returns to normal color. There may be associated tingling, swelling, and painful throbbing. The attacks may last from minutes to hours. If the condition progresses, blood flow to the area could become permanently decreased causing the fingers to become thin and tapered, with smooth, shiny skin and slow-growing nails. If an artery becomes blocked completely, gangrene or ulceration of the skin may occur. Smoking cessation is an action the client should take to prevent the onset of the manifestations of Raynaud's disease.

A client receives instructions about behaviors that increase the risk of developing Hepatitis A. Which statement by the client indicated to the nurse an accurate understanding of the information? A. "I won't donate blood anymore" B. "I'll get a booster shot of immune serum globulin every year" C. "I'll stop eating raw clams even though I enjoy them" D. "I won't touch another drop of alcohol"

C. "I'll stop eating raw clams even though I enjoy them" Hep A is transmitted via fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, uncooked shellfish. Those who eat raw or steamed shellfish are at an increased risk

********A client who tests positive for the human immmunodeficiency virus (HIV) asks the nurse, " should i tell my partner that I am an HIV positive/" which of the following is appropriate nursing response? A. "That is your decision alone" B. "I would if I were you" C. "You aren't sure what to say to your partner?" D. "We are required by law to notify your partner"

C. "You aren't sure what to say to your partner?"

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

C. Amylase Pancreatitis is the most common diagnosis for marked elevations of serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis.

A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Serum albumin 4.1 g/dL B. WBC 9,511/uL C. Direct bilirubin 2.1 mg/dL D. Serum cholesterol 171 mg/dL

C. Direct bilirubin 2.1 mg/dL An expected finding for a client who has cholelithiasis is a serum cholesterol greater than 200 mg/dL, increased bilirubin, and an increased WBC due to inflammation. This finding is outside the expected reference range and is increased in the client who has cholelithiasis. Serum albumin is not an indicator of cholelithiasis.

A nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attack. Which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories

C. Foods high in fiber

A nurse is assisting with the admission of the client who has fulminant hepatic failure. Which of the following procedures should the nurse expect for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

C. Liver transplant

A nurse is checking who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food

C. Rigid abdomen Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension results

A human immunodeficiency virus (HIV) - positive client is admitted to the hospital with lung infection. which isolation category should the nurse implement to prevent transmission of the HIV virus? A. Protective isolation B. Droplet precautions C. Standard precautions D. Contact precautions

C. Standard precautions - standard precautions Implemented with every client, prevent the spread of infection transmitted by direct or indirect contact with infectious blood or bodily fluids. since this is the mode of transmission of HIV, this is appropriate isolation precaution.

A nurse is assisting with the admission of a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure. It also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varices.

13. Which of the following is NOT a role of the liver? A. Removing hormones from the body B. Producing bile C. Absorbing water D. Producing albumin

C. absorbing water

6. During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level

C. increased ammonia level

A nurse is providing teaching for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I should use a suncreen with an SPF of at least 15" B. "Long-term immunosuppresive therapy could cure this disease" C. " I should wear gloves when it is cold outside" D. "SLE should not affect my lungs or breathing"

C. raynaud's syndrome commonly accompanies SLE and can cause painful vasoconstriction in the fingers when they are exposed to cols temps

A nurse is assisting with the care of a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis

D. Diaphoresis The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution.

When assessing a client with Kaposi's Sarcoma the nurse would expect to see: a. a nonproductive cough with fever and SOB b. lesions on the retina that produce blurred vision c. insidious onset of progressive dementia d. reddish-purplish skin lesions

D reddish-purplish skin lesions

8. A 45 year old male has cirrhosis. The patient reports concern about the development of enlarged breast tissue. You explain to the patient that this is happening because? A. The liver cells are removing too much estrogen from the body which causes the testicles to produce excessive amounts of estrogen, and this leads to gynecomastia. B. The liver is producing too much estrogen due to the damage to the liver cells, which causes the level to increase in the body, and this leads to gynecomastia. C. The liver cells are failing to recycle estrogen into testosterone, which leads to gynecomastia. D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes the level to increase in the body, and this leads to gynecomastia.

D.

A nurse is helping to prepare a client with systemic lupus erythematosus (SLE) for discharge. which of the following instructions should the nurse include in the client's discharge teaching plan? A. "Avoid the use of NSAIDs" B. "Stop taking the corticosteroids when your symptoms are resolved" C. "Exposure to UV light will help control the skin rashes" D. "Monitor your body temperature and report any elevations promptly"

D. "Monitor your body temperature and report any elevations promptly" SLE is a chronic autoimmune disorder that can affect virtually any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack normal tissues and organs, including the skin, joints, kidneys, brain, heart, lungs and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temp and report any elevations as fever could suggest an exacerbation or a potentially life-threatening infection

A nurse is collecting data from a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use

D. Alcohol use Alcohol consumption is one of the major causes of chronic pancreatitis in the US

A nurse is collecting data from a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Decreased heart rate B. Yellowing of the skin C. Increased blood pressure D. Board-like abdomen

D. Board-like abdomen The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids

D. Clear liquids

5. A patient is diagnosed with Hepatitis A. The patient asks how a person can become infected with this condition. You know the most common route of transmission is? A. Blood B. Percutaneous C. Mucosal D. Fecal-oral

D. Fecal-oral

A nurse is providing teaching for a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses by the nurse is appropriate? A. "Take a cool bath in the evening." B. "Exercise every other day" C. "Use pillows to support your joints while in bed" D. "Ask family members to help with household chores"

D. Gives the client an opportunity for rest

A nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 mL/hr. When the nurse checks the client at 0800, which of the following findings requires intervention by the nurse? A. A full pitcher of water sitting on the client's bedside table withing the client's reach B. The disposable feeding bag is from the previous day at 1000 and contains 200mL of feeding C. The client is lying on the right side with a visible dependent loop in the feeding tube D. The head of the bed is elevate 20 degrees

D. The head of the bed is elevate 20 degrees The head of the bed should be at least 30 degrees

A nurse is reviewing a new prescription for ursodiol (Ursodeoxycholic Acid) with a client who has cholelithiasis. Which of the following should be included in the teaching? A. This medication reduces biliary spasms. B. This medication reduces inflammation in the biliary tract. C. This medication dilates the bile duct to promote passage of bile. D. This medication dissolves gall stones.

D. This medication dissolves gall stones. Ursodiol is a bile acid that gradually dissolves cholesterol-based gall stones.

12. ________ reside in the liver and help remove bacteria, debris, and old red blood cells. A. Hepatocytes B. Langerhan cells C. Enterocytes D. Kupffer cells

D. kupffer cells

A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the POC? A. initiate contact precautions B. weigh the client weekly C. measure abdominal girth 7.5 cm (3 in) above the umbilicus D. provide a high-calorie, high-carb diet

D. provide a high-calorie, high-carb diet Rationale: The client who has hepatitis B should have a diet high in calories and carbs

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first? a. administer hydralazine via IV bolus b. loosen the client's clothing c. empty the client's bladder d. elevate the head of the client's bed

d

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? a. glasgow coma scale score of 15 b. intracranial pressure reading of 15 mmHg c. ecchymosis at base of skull d. clear drainage from nose

d

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? a. assess hourly for a spike in BP b. keep the client on bed rest c. keep a padded tongue blade at the bedside d. establish IV access

d

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer? a. tissue plasminogen activator b. recombinant factor VIII c. nitroglycerin d. lidocaine

a

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure? a. restlessness b. dizziness c. hypotension d. fever

a

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? a. maintain a PaCO2 of approx 35 mmHg b. provide small doses of fentanyl via IV bolus for pain management c. measure body temp every 1-2 hr d. reposition the client every 2 hr

a

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions? a. check the client's cheek on the affected side after meals to be sure no food remains there b. encourage the client to sit upright with their head tilted slightly forward during meals c. provide the client with eating utensils that have large handles d. remind the client to look consciously at both sides of their meal tray

d

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect? a. unilateral joint involvement b. ulnar deviation c. fractures of the spine d. decreased sedimentation rate

b

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition? a. encourage the client to use the valsalva maneuver b. stroke the client's inner thigh c. perform the Crede maneuver d. administer a diuretic

b

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? a. aphasia b. right-sided neglect c. impulsive behavior d. inability to read

c

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take? a. assess the client's neurologic status every 8 hr b. initiate droplet precautions c. check cap refill at least every 4 hr d. place the client in a well-lit environment

c

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include? a. apply a pressure dressing to the site for 8 hr b. restrict the client's fluid intake for 24 hr c. ensure that the client lies flat for up to 12 hr d. inform the client that neck stiffness is an expected outcome of the procedure

c

A nurse is planning to teach a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the clients medication teaching plan? a. rinse with antiseptic mouthwash instead of using dental floss b. use an OTC antihistamine if a rash develops c. slowly taper the med after 6 consecutive months without seizure activity d. take meds at a consistent time each day to maintain therapeutic blood levels

d