SATA Final

A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this client's evaluation? (Select all that apply.)

Examination of mucous membranes and nail bed. Measurement of rate, depth, and rhythm of respirations. Determine the client's need and use of oxygen. Ability to perform activities of daily living.

A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms would the nurse be aware of? (Select all that apply.)

Gynecomastia in male patients Frequent shaking and sweating relieved by eating "Moon" face and "buffalo" hump General edema

After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.)

I will take enzymes between meals Enzymes should be taken with high protein foods

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.)

Infection GI bleed Constipation Hypovolemia

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.)

Jaundice Clay-colored stools Icterus Ascites Petechiae Dark urine

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.)

"Apply lotion to the client's dry skin areas." "For the patient's oral care, use a soft toothbrush." "Provide clippers so the patient can trim the fingernails."

The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.)

"Avoid alcohol ingestion." "Be sure and balance rest with activity." "Avoid caffeinated beverages." "Eat small meals and high-calorie snacks."

The nurse is preparing to teach a community group about warning signs of lung cancer. What information does the nurse include? (Select all that apply.)

Persistent coughing Rusty or blood-tinged sputum Dyspnea Hoarseness

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.)

Polyarthritis Heart disease Myalgia

The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.)

Registered dietitian nutritionist Clinical pharmacist Primary HCP

A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment finding(s) alert(s) the nurse to a complication from this surgery? (Select all that apply.)

Substernal chest pain SOB Lack of bowel sounds or flatus Urine output of 20mL/6 hr

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this client's teaching? (Select all that apply.)

"Avoid drinking fluids just before and during meals." "Rest before meals if you have dyspnea." "Have about six small meals a day." "Use pursed-lip breathing during meals." "Choose soft, high-calorie, high-protein foods."

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.)

"Do you have any difficulty sleeping?" "How long does it take to perform your morning routine?" "Have you lost any weight lately?" "How does your activity compare to this time last year?"

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.)

"How old are you?" "Do you work in health care?" Are you receiving hemodialysis?" "Do you use IV drugs?" "Did you receive blood before 1992?" "Have you even been in prison or jail?"

The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group's teaching? (Select all that apply.)

"Wash your hands after any contact with animals." "Use separate cutting boards for meat and vegetables."

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions by the nurse are best? (Select all that apply.)

Administer oxygen and place client on an oximeter. Administer prescribed albuterol inhaler. Assess the client's lung sounds after administering the inhaler.

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.)

Administer pain medications as prescribed. Palpate the abdomen for distention.Assess for sudden changes in mental status. Evaluate stools for occult blood.

A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.)

Anorexia Constipation Abdominal pain

The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.)

Ascites Steatorrhea Jaundice Polydipsia Polyuria

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this client's plan of care? (Select all that apply.)

Ask client to drink 2 L of fluids daily. Add humidity to prescribed oxygen .Use a vibrating chest physiotherapy device. Administer ordered mucolytic agent.

After teaching a patient who has a permanent ileostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.)

Corn String Beans Wheat rice

The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What factors present risks for developing this type of cancer? (Select all that apply.)

Diabetes Mellitus Cirrhosis Smoking Fam history Older age

A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.)

Does your gym provide yoga classes? When should you contact your provider? What do you plan to eat for dinner? How many bathrooms are in your home?

The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.)

Elevated amylase Elevated lipase Elevated glucose Decreased calcium Elevated bilirubin Elevated leukocyte count

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.)

Elevated international normalized ratio (INR) Elevated serum ammonia Elevated prothrombin time (PT)

A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary artery hypertension. What actions would the nurse take to ensure the client's safety while on this medication? (Select all that apply.)

Keep an intravenous line dedicated strictly to the infusion. Ensure there is always a backup drug cassette available. Use strict aseptic technique when using drug delivery system.

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)

Lower gastrointestinal bleeding—erosion of the bowel wall Abscess formation—localized pockets of infection develop in the ulcerated bowel lining Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.)

Nausea Vomiting Abdominal pain Bradycardia Decreased urinary output Fever

The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.)

Need to have drug administered by primary HCP. Need to avoid crowds & individuals who have infection. Awareness of a rare but potentially fatal drug complication. Need to report any s/s of infection immediately.

The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.)

Oxygen therapy Feet elevated on pillows Daily weights Respiratory therapy

A client, who has become increasingly dyspneic over a year, has been diagnosed with pulmonary fibrosis. What information would the nurse plan to include in teaching this client? (Select all that apply.)

The need to avoid large crowds and people who are ill. Safety measures to take if home oxygen is needed. Information about appropriate use of the drug nintedanib. Measures to avoid fatigue during the day.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.)

Tracheal deviation Sudden onset of shortness of breath Drainage greater than 70 mL/hr Disconnection at Y site

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.)

Use medicated wipes instead of tp. Apply thin coat of aloe cream to perineum. Gently pat perineum dry after cleansing.

A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.)

Use your abdominal muscles to squeeze air out of your lungs. Breathe out slowly without puffing your cheeks. Exhale at least twice the amount of time it took to breathe in