Quiz 4

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (Select all that apply.)

-Perform leg exercises every 2 hr. -Encourage hourly use of an incentive spirometer while awake. -Document the color, consistency, and amount of nasogastric drainage.

A patient is to receive ampicillin (Unasyn) IV piggyback in 100 mL of fluid every 8 hours. The main intravenous (IV) line of D5W is running at 80 mL/hr and is on time. A nurse's responsibility is to calculate the total 24-hour intake. At the end of the 24-hour shift, how much IV intake should the nurse document that the patient has received?

2220 mL

A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient's blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse's first action?

Check the dressing for bleeding

The nurse should reinforce in the discharge teaching to have the client drink milk as a snack to help maintain nutritional intake.

Consume a glucose-electrolyte solution.

A patient who has just undergone a colon resection complains to a nurse that he felt something pop under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. What nursing action should be implemented first?

Cover the wound with sterile dressings saturated with normal saline.

A nurse is constructing a teaching plan for a patient with a hiatal hernia. What should be included in this plan to help reduce the complaints of heartburn, regurgitation, and eructation?

Eating nothing for several hours before bedtime

A nurse identifies a risk factor in an older man that places him at risk for developing diverticulosis. What patient information indicates such a risk factor?

Eats a low-fiber diet

A resident in a nursing home requests information on how to reduce problems with constipation. What would be some teaching techniques to help regulate stool frequency? (Select all that apply.)

Exercise daily. Drink more water. Eat more high-fiber foods.

To reduce the pain experienced by a patient with acute appendicitis, the nurse should assist the patient into what position?

Semi-Fowler

The nurse is assessing a patient's mouth and notes bluish-white lesions on the mucous membranes. Which condition is present?

Thrush

A nurse provides education to a patient after a hemorrhoidectomy. Which statement by the patient demonstrates the need for further instruction?

"Fluids are restricted."

A charge nurse is reinforcing teaching with a newly licensed nurse about the common link between ulcerative colitis and Crohn's disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Both illnesses are inflammatory in nature."

A nurse is reinforcing teaching with a client who has Crohn's Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?

"Increase your caloric intake by eating foods high in protein."

Inflammatory bowel disease (IBD) includes which conditions? (Select all that apply.)

-Crohn disease -Ulcerative colitis

A nurse is preparing to administer a bisacodyl 10 mg suppository for a client. Which of the following actions should the nurse take? (Select all that apply.)

-Lubricate index finger. -Insert suppository just beyond internal sphincter.

The nurse is caring for a newly admitted patient who complains of a smooth lump in their lower abdomen. When placing the patient in a supine position for assessment, the nurse noted that the lump was no longer visible. What diagnosis will the nurse anticipate for this patient?

Abdominal hernia

Which potential problem will be emphasized in the plan of care for a patient who has gastroesophageal reflux disease (GERD)?

Aspiration risk

A nurse is reinforcing teaching with a client who reports constipation and wants to use an herbal supplement. The nurse should identify that the client can use which of the following herbal supplements to treat constipation?

Flaxseed

A nurse is caring for a 34-year-old patient admitted with severe diarrhea that has been going on for 2 weeks. What assessment should the nurse anticipate?

Hypotension and fatigue

A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?

Increased urine specific gravity

A patient with the diagnosis of Clostridium difficile infection asks what has caused the diarrhea. What is the best response by the nurse?

It is caused by a long-term antibiotic therapy.

A nurse is reviewing medications for a client who has just been diagnosed with a small bowel obstruction. The nurse should withhold senna prescribed orally based on understanding of which of the following?

Laxatives are contraindicated in clients who have a small bowel obstruction.

A nurse is reinforcing discharge teaching with a client who has acute gastritis. Which of the following instructions should the nurse include in the teaching?

Limit drinking milk.

The nurse is assessing a patient with abdominal pain for possible appendicitis. When locating McBurney's point to assess for pain, the nurse knows to assess in which of the following locations?

Midway between the umbilicus and the iliac crest

A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan?

Place the client in a high Fowler's position.

Which set of findings best indicates that a patient with intestinal obstruction has achieved normal hydration?

Pulse and blood pressure are within the patient's norms, mucous membranes are moist, and fluid intake and output are equal.

The nurse is caring for a patient diagnosed with appendicitis. On assessment, the nurse notes that the patient has a temperature of 102 degrees F and that their abdomen has become rigid. What should the nurse anticipate is the cause of these changes?

The appendix has ruptured