Test 3- Elimination and Inflammation

the nurse performs bladder irrigation through an indwelling catheter. the nurse instilled 90mL of sterile normal saline. the catheter drained 710mL. what is the client's output?

620mL

the client diagnosed with renal calculi is scheduled for a 24 hour urine specimen collection. which interventions should the nurse implement? SELECT ALL THAT APPLY a. check for the ordered diet and medication modifications b. instruct the client to urinate, and discard this urine when starting collection c. collect all urine during 24 hours and place in appropriate specimen container d. insert an indwelling catheter in client after having the client empty the bladder e. instruct the nursing assistant to notify the nurse when the client urinates

1, 2, 3

the client returned from surgery after having a TURP and has a P 110, BP 90/40, and cool and clammy skin. which interventions should the nurse implement? SELECT ALL THAT APPLY. a. assess the urine in the continuous irrigation bag b. decrease the irrigation fluid in the continuous irrigation catheter c. lower the head of the bed while raising the foot of the bed d. contact the surgeon to give an update on the client's condition e. check the client's post-op creatinine and BUN

1, 3, 4

the nurse is inserting an indwelling catheter into a female client. which interventions should be implemented? RANK IN THE ORDER OF PERFORMANCE a. explain the procedure to the client b. set up the sterile field c. inflate the catheter bulb d. place absorbent pads under the client e. clean the perineum from clean to dirty with betadine

1, 4, 2, 3, 5

the public health nurse is discussing hepatitis B with a group in the community. which health promotion activities should the nurse discuss with the group? SELECT ALL THAT APPLY a. do not share needles or equipment b. use barrier protection during sex c. get the hepatitis B vaccine d. obtain immune globulin injections e. avoid any kind of hepatotoxic medications

a, b , c

which s/s should the nurse report to the HCP for the client recovering from an open cholecystectomy? SELECT ALL THAT APPLY a. clay colored stools b. yellow tinted sclera c. amber colored urine d. wound approximated e. abdominal pain

a, b , e

the nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. which interventions would the nurse expect to be prescribed for the client? SELECT ALL THAT APPLY a. maintain NPO status b. encourage coughing and deep breathing c. give small, frequent high calorie feedings d. maintain the client in a flat, supine position e. give hydromorphone IV as prescribed for the client f. maintain IV fluids at 10mL/hr to KVO

a, b ,e

the client with an acute exacerbation of chronic pancreatitis has an NG tube. which interventions should the nurse implement? SELECT ALL THAT APPLY a. monitor the client's bowel sounds b. monitor the client's food intake c. assess the client's IV site d. provide oral and nasal care e. monitor the client's blood glucose

a, c, d, e

the nurse is assessing a client who is experiencing an acute episode of cholecystitis. which of these clinical manifestations support this diagnosis? SELECT ALL THAT APPLY a. fever b. positive cullen's sign c. complaints of indigestion d. palpable mass in the LUQ e. pain in the URQ after a fatty meal f. vague LRQ abdominal discomfort

a, c, e

the nurse provides instructions to a client about measures to treat IBS. which statement by the client indicates a need for further teaching? a. "i need to limit my intake of dietary fiber" b. " i need to drink plenty, at least 8-10 cups daily" c. "i need to eat regular meals and chew my food well" d. "i need to take the prescribed medications because they will regulate my bowel patterns"

a. "i need to limit my intake of dietary fiber" rationale: dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits.

The client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? a. This is a normal, expected event. b. The client is experiencing early signs of ischemic bowel. c. The client should not have the nasogastric tube removed. d. This indicates inadequate preoperative bowel preparation.

a. This is a normal, expected event. rationale: as peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. this indicates returning bowel function.

the client two hours post-op laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. which nursing intervention should the nurse implement? a. apply a heating pad to the abdomen for 15-20 minutes b. administer morphine sulfate IV after diluting with saline c. contact the surgeon for an order to x-ray the right shoulder d. apply a sling to the arm, which was injured during surgery

a. apply a heating pad to the abdomen for 15-20 minutes rationale: a heating pad should be applied for 15-20 minutes to assist the migration of CO2 used to insufflate the abdomen. shoulder pain is an expected occurrence.

A client with inflammatory bowel disease is prescribed TPN. which intervention should the nurse implement? a. check the client's glucose level b. administer an oral hypoglycemic c. assess the peripheral IV site d. monitor the client's oral food intake

a. check the client's glucose level rationale: TPN is high in dextrose, which is glucose; therefore the client's glucose level should be monitored closely

the charge nurse is monitoring client lab values. which value is expected in the client with cholecystitis who has chronic inflammation? a. elevated WBC count b. decreased LDH c. elevated alkaline phosphatase d. decreased direct bilirubin level

a. elevated WBC count rationale: the WBC count should be elevated in clients with chronic inflammation

the public health nurse is teaching day-care workers. which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person? a. hep a b. hep b c. hep c d. hep d

a. hep a rationale: the hepatitis A virus is in the stool of infected people and takes up to two weeks before symptoms develop

the client is diagnosed with irritable bowel syndrome. which intervention should the nurse teach the client to reduce symptoms? a. instruct the client to avoid drinking fluids with meals b. explain the need to decrease intake of flatus-forming foods c. teach the client how to perform gentle perianal care d. encourage the client to attend a support group meeting

a. instruct the client to avoid drinking fluids with meals rationale: avoidance of fluids with meals will help prevent abdominal distention, which causes symptoms of IBS. do not confuse IBD with IBS.

a client has developed hepatitis A after eating contaminated oysters. the nurse assesses the client for which expected assessment finding? a. malaise b. dark stools c. weight gain d. LUQ discomfort

a. malaise rationale: hepatitis causes GI problems. fatigue and malaise are common

the client is reporting chills, fever, and left costovertebral pain. which diagnostic test should the nurse expect the HCP to prescribe first? a. a midstream urine for culture b. a sonogram of the kidney c. an IVP for renal calculi d. a CT scan of the kidneys

a. midstream urine for culture rationale: these are all symptoms of a UTI, which requires a urine culture first to confirm the diagnosis.

which client problem has priority for the client diagnosed with acute pancreatitis? a. risk for FVD b. alteration in comfort c. imbalanced nutrition: less than body requirements d. knowledge deficit

b. alteration in comfort rationale: autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness, and muscle guarding

the client diagnosed with renal calculi is admitted to the medical unit. which intervention should the nurse implement first? a. monitor the client's urinary output b. assess the client's pain and rule out complications c. increase the client's oral fluid intake d. use a safety gait belt when ambulating the client

b. assess the client's pain and rule out complications rationale: assessment is the first part of the nursing process and is priority.

the female nurse sticks herself with a contaminated needle. which action should the nurse implement first? a. notify the infection control nurse b. cleanse the area with soap and water c. request post exposure prophylaxis d. check the hepatitis status of the client

b. cleanse the area with soap and water rationale: the nurse should first cleanse the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin

the client is one day post-op TURP. which task should the nurse delegate to the nursing assistant? a. increase the irrigation fluid to clear clots from the tubing b. elevate the scrotum on a towel roll for support c. change the dressing on the first post-op day d. teach the client how to care for the continuous irrigation catheter

b. elevate the scrotum on a towel roll for support

the nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. the client begins to complain of increased abdominal pain and begins to vomit. on assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. which is the most appropriate nursing intervention? a. administer the prescribed pain medication b. notify the PHCP c. call and ask the OR to perform the surgery as soon as possible d. reposition the client and apply a heating pad on the warm setting to the client's abdomen

b. notify the PHCP rationale: on the basis of the s/s presented in the question, the nurse should suspect peritonitis and notify the PHCP

the nurse is providing care for a client with a recent transverse colostomy. which observation requires immediate notification of the PHCP? a. stomy is beefy red and shiny b. purple discoloration of the stoma c. skin excoriation around the stoma d. semiformed stool noted in the ostomy pouch

b. purple discoloration of the stoma rationale: ischemia of the stoma would be associated with a dusky or blueish purple color.

the client is diagnosed with an acute exacerbation of ulcerative colitis. which intervention should the nurse implement? a. provide a low-residue diet b. rest the client's bowel c. assess vital signs daily d. administer antacids orally

b. rest the client's bowel rationale: whenever a client has an acute exacerbation of a GI disorder, the first intervention is to place the bowel on rest. the client should be NPO with IV fluids to prevent dehydration

which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? a. airborne precautions b. standard precautions c. droplet precautions d. exposure precautions

b. standard precautions rationale: standard precautions apply to all blood, body fluid, secretions and excretions (except sweat) regardless of whether they contain visible blood

which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? a. assess the client's neuro status every 2 hours b. strain all urine and send any sediment to the laboratory c. monitor the client's creatinine and BUN levels d. take a 24 hour dietary recall during the client interview

b. strain all urine and send any sediment to the laboratory

the nurse is caring for a client with chronic pyelonephritis. which assessment data support the diagnosis? a. the client has fever, chills, flank pain and dysuria. b. the client complains of fatigue, headache, and increased urination c. the client had a group B beta-hemolytic strep infection last week d. the client has an acute viral pneumonia infection

b. the client complains of fatigue, headache, and increased urination rationale: these are all symptoms of chronic pyelonephritis

the client diagnosed with liver problems asks the nurse, "why are my stools clay-colored?" on which scientific rationale should the nurse base the response? a. there is an increase in serum ammonia level b. the liver is unable to excrete bilirubin c. the liver is unable to metabolize fatty foods d. a damaged liver cannot detoxify vitamins

b. the liver is unable to excrete bilirubin rationale: bilirubin is the by-product of RBC destruction, and is metabolized in the liver and excreted via the feces, which causes the stool to be brown in color. if the liver is damaged, the bilirubin is excreted through the urine and skin

the client who is post-op TURP asks the nurse, "when will i know if i will be able to have sex after my TURP?" which response is most appropriate by the nurse? a. "you seem anxious about your surgery" b. "tell me about your fears of impotency" c. "potency can return in six to eight weeks" d. "did you ask your doctor about your concern?"

c. "potency can return in six to eight weeks" rationale: this is usually the length of time clients need to wait prior to having sexual intercourse

the nurse is caring for the immediate post-op client who had a laparoscopic cholecystectomy. which task could the nurse delegate to the nursing assistant? a. check the abdominal dressings for bleeding b. increase the IV fluid if the BP is low c. ambulate the client to the bathroom d. auscultate the breath sounds in all lobes

c. ambulate the client to the bathroom rationale: a day surgery client can be ambulated to the bathroom

the lab data reveals a calcium phosphate renal stone for a client diagnosed with renal calculi. which discharge teaching intervention should the nurse implement? a. encourage the client to eat a low purine diet and limit foods such as organ meats b. explain the importance of not drinking water 2 hours before bedtime c. discuss the importance of limiting vitamin d enriched foods d. prepare the client for extracorporeal shock wave lithotripsy

c. discuss the importance of limiting vitamin d enriched foods rationale: dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi.

the nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. which instruction should the discuss with the client? a. decrease alcohol intake b. explain the need to avoid all stress c. discuss the importance of stopping smoking d. teach the correct way to take pancreatic enzymes

c. discuss the importance of stopping smoking rationale: smoking stimulates the pancreas to release pancreatic enzymes and should be stopped.

the nurse is assessing a client 24 hours after a cholecystectomy. the nurse notes that the T-tube has drained 750mL of green-brown drainage since the surgery. which nursing intervention is appropriate? a. clamp the T-tube b. irrigate the T-tube c. document the findings d. notify the PHCP

c. document the findings rationale: the drainage color is normal following a cholecystectomy

the nurse is discussing complications of chronic pancreatitis with a client diagnosed with the disease. which complication should the nurse discuss with the client? a. diabetes insipidus b. crohn's disease c. narcotic addiction d. peritonitis

c. narcotic addiction rationale: narcotic addiction is related to the frequent, severe pain episodes often occurring with chronic pancreatitis, which requires narcotics for relief

the client is diagnosed with an acute exacerbation of IBD. which priority intervention should the nurse implement? a. weigh the client daily and document in the client's chart b. teach coping strategies such as dietary modifications c. record the frequency, amount and color of stools d. monitor the client's oral fluid intake every shift

c. record the frequency, amount and color of stools rationale: the severity of diarrhea helps determine the need for fluid replacement. the liquid stool should be measured as part of the total output.

the client is admitted to the medical department with a diagnosis of rule-out acute pancreatitis. which lab values should the nurse monitor to confirm this diagnosis? a. creatinine and BUN b. troponin and (CK-MB) c. serum amylase and lipase d. serum bilirubin and calcium

c. serum amylase and lipase rationale: serum amylase increases within 2-12 hours of the onset of acute pancreatitis to 2-3 times normal and returns to normal in 3-4 days; lipase elevates and remains elevated for 7-14 days

the nurse is discharging a client with a healthcare acquired UTI. which information should the nurse include in the discharge teaching? a. limit fluid intake so the urinary tract can heal b. collect a routine urine specimen for culture c. take all the antibiotics as prescribed d. tell the client to void every five to six hours

c. take all the antibiotics as prescribed rationale: the client should take all the prescribed medication anytime a prescription is written for antibiotics

the client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. which intervention should the nurse discuss with the client? a. take this med on an empty stomach b. notify the HCP if experiencing a moon face c. take the steroid medication as prescribed d. notify the HCP if blood glucose is over 160

c. take the steroid medication as prescribed rationale: this med must be tapered off to prevent adrenal insufficiency; therefore the client must take this med as prescribed

the nurse assesses a large amount of red drainage on the dressing of a client who is six hours post-op open cholecystectomy. which intervention should the nurse implement? a. measure abdominal girth b. palpate the lower abdomen for a mass c. turn the client on the side to assess for further drainage d. remove the dressing to determine the source

c. turn the client on the side to assess for further drainage rationale: turning the client to the side and assessing for further drainage and possible bleeding is important prior to contacting the surgeon

the client is diagnosed with a uric acid stone. which foods should the client eliminate from the diet to help prevent reoccurence? a. beer and colas b. aspargus and cabbage c. venison and sardines d. cheese and eggs

c. venison and sardines rationale: venison and sardines are high purine foods which should be eliminated from the diet to help prevent uric acid stones

the nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. which statement by the parents indicates their understanding of the plan? a. "caution should be used when straddling my infant on a hip" b. "vital signs should be taken daily to check for bladder infection" c. "catheterization will be necessary when my infant does not void" d. "circumcision has been delayed to save tissue for surgical repair"

d. "circumcision has been delayed to save tissue for surgical repair" rationale: the infant should not be circumcised, because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. options 1,2 and 3 are unrelated to this disorder

a client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. which assessment finding indicates the need to notify the PHCP? a. red, bloody urine b. pain rated as 2 on a 0-10 pain scale c. urinary output of 200mL higher than intake d. BP: 100/50, P: 130

d. BP: 100/50, P: 130 rationale: a rapid pulse with a low blood pressure is a potential sign of excessive blood loss.

the client had surgery to remove a kidney stone. which lab assessment data warrant immediate intervention by the nurse? a. a serum potassium level of 3.8 mEq/L b. a urinalysis shows microscopic hematuria c. a creatinine level of 0.8 mg/100mL d. a wbc count of 14,000

d. a wbc count of 14,000 rationale: the wbc count is elevated. normal range is 5,000 to 10,000

the client is diagnosed with an acute episode of ureteral calculi. which client problem is priority when caring for this client? a. fluid volume loss b. knowledge deficit c. impaired urinary elimination d. alteration in comfort

d. alteration in comfort rationale: pain is a priority

the client with possible renal calculi is scheduled for a renal ultrasound. which intervention should the nurse implement for this procedure? a. ask if the client is allergic to shellfish or iodine b. keep the client NPO 8 hours prior to the ultrasound c. ensure the client has a signed informed consent form d. explain the test is noninvasive and there is no discomfort

d. explain the test is noninvasive and there is no discomfort rationale: no special preparation is needed for this noninvasive, nonpainful test.

a client has just had surgery to create an ileostomy. the nurse assesses the client in the immediate post-op period for which most frequent complication of this type of surgery? a. folate deficiency b. malabsorption of fat c. intestinal obstruction d. f&e imbalance

d. f&e imbalance rationale: losses require replacement by IV infusion until the client can tolerate a diet orally.

the clinic nurse reviews the record of an infant and notes that the PHCP has documented a diagnosis of suspected Hirschsprung's disease. the nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek healthcare for the infant? a. diarrhea b. projective vomiting c. regurgitation of feedings d. foul-smelling, ribbon-like stools

d. foul-smelling, ribbon-like stools rationale: options a, b, and c are not related to this disorder

a 7 year old child is seen in a clinic, and the pediatrician documents a diagnosis of nocturnal enuresis. the nurse should provide which information to the parents? a. nocturnal enuresis does not respond to treatment b. nocturnal enuresis is caused by a psychiatric problem c. nocturnal enuresis requires surgical intervention to improve the problem d. nocturnal enuresis is usually outgrown without therapeutic intervention

d. nocturnal enuresis is usually outgrown without therapeutic intervention rationale: the condition is common in children, and most children eventually outgrow bedwetting without therapeutic intervention

the client is 4 hours post-op open cholecystectomy. which data warrant immediate intervention by the nurse? a. absent bowel sounds in all four quadrants b. the T-tube has 60 mL of green drainage c. urine output of 100 mL in the last 3 hours d. refusal to turn, deep breathe, cough

d. refusal to turn, deep breathe, cough rationale: refusing to turn, deep breathe and cough places the client at risk for pneumonia. the client needs immediate intervention to prevent complications

the school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. which action is most important to teach the high school teachers? a. do not allow students to eat or drink after each other b. drink bottled water as much as possible c. encourage protected sexual activity d. sing the happy birthday song while washing hands

d. sing the happy birthday song while washing hands rationale: hepatitis A is transmitted via the fecal-oral route. good handwashing helps prevent its spread. singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands

the nurse emptied 2000mL from the drainage bag of a continuous irrigation of a client who had a TURP. the amount of irrigation in the bag hanging was 3000mL at the beginning of the shift. there was 1800mL left in the bag 8 hours later. what is the correct urine output at the end of the 8 hours?

800mL

the nurse is providing discharge teaching for a client newly diagnosed with Crohn's disease about dietary measures to implement during exacerbation episodes. which statement by the client indicates a need for further instruction? a. "i should increase fiber in my diet" b. " i will need to avoid caffeinated beverages" c. "im going to learn some stress reduction techniques" d. "i can have exacerbations and remissions with Crohn's disease"

a. "i should increase fiber in my diet" rationale: a high fiber, high calorie diet is prescribed during periods of remission. a low fiber diet is prescribed during periods of exacerbation

which statement indicates discharge teaching has been effective for the client who is post-op TURP? a. "i will call the surgeon if i experience any difficulty urinating" b. "I will take my proscar daily, the same as before my surgery" c. "i will continue restricting my oral fluid intake" d. "I will take my pain medication routinely even if I do not hurt"

a. "i will call the surgeon if i experience any difficulty urinating" rationale: this indicates that the teaching was effective

the client is diagnosed with Crohn's disease, also known as regional enteritis. which statement by the client supports this diagnosis? a. "my pain goes away when i have a bowel movement" b. "i have bright red blood in my stool all the time" c. "i have episodes of diarrhea and constipation" d. "my abdomen is hard and rigid and i have a fever"

a. "my pain goes away when i have a bowel movement" rationale: the terminal ileum is the most common site for regional enteritis, which causes RLQ pain that is relieved by defecation

which s/s should the nurse find in a client diagnosed with ulcerative colitis? a. 20 bloody stools per day b. oral temperature of 102 c. hard, rigid abdomen d. urinary stress incontinence

a. 20 bloody stools per day rationale: the colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. 10-20 bloody diarrhea stools is the most common symptom of ulcerative colitis

a client is admitted to the ER following a fall from a horse, and the PHCP prescribes insertion of a urinary catheter. while preparing for the procedure, the nurse notes blood at the urinary meatus. the nurse should take which action? a. notify the PHCP before performing the catheterization b. use a small-sized catheter and an anesthetic gel as a lubricant c. administer parenteral pain medication before inserting the catheter d. clean the meatus with soap and water before opening the catheterization kit

a. notify the PHCP before performing the catheterization rationale: the presence of blood at the urinary meatus may indicate urethral trauma or disruption. a catheter should not be placed until the PHCP is notified and the cause of bleeding is determined.

the nurse writes the problem "imbalanced nutrition: less than body requirements" for the client diagnosed with hepatitis. which intervention should the nurse include in the plan of care? a. provide a high calorie intake diet b. discuss TPN c. instruct the client to decrease salt intake d. encourage the client to increase water intake

a. provide a high calorie intake diet rationale: sufficient energy is required for healing. adequate carb intake can spare protein.

the nurse is caring for a pregnant client diagnosed with acute pyelonephritis. which scientific rationale supports the client being hospitalized for this condition? a. the client must be treated aggressively to prevent maternal/fetal complications b. the nurse can force the client to drink fluids and avoid nausea and vomiting c. the client will be dehydrated and there won't be sufficient blood flow to the baby d. pregnant clients historically are afraid to take the antibiotics prescribed

a. the client must be treated aggressively to prevent maternal/fetal complications rationale: a pregnant client diagnosed with a UTI will be admitted for aggressive IV antibiotic therapy. after symptoms subside, the client will be sent home to complete the course of treatment with oral medications

the nurse is teaching a client recovering from a laparoscopic cholecystectomy. which statement indicates the discharge teaching is effective? a. "i will take my lipid-lowering medicine at the same time every night" b. "i may experience some discomfort when i eat a high fat meal" c. "i need someone to stay with me for about a week after surgery" d. "i should not splint my incision when i deep breathe and cough"

b. "i may experience some discomfort when i eat a high fat meal" rationale: after removal of the gallbladder, some clients experience abdominal discomfort when eating fatty meals

the client diagnosed with acute pancreatitis is being discharged home. which statement by the client indicates the teaching has been effective? a. "i should decrease my intake of coffee, tea and cola" b. "i will eat a low-fat diet and avoid spicy foods" c. "i will check my amylase and lipase levels daily" d. "i will return to work tomorrow but take it easy"

b. "i will eat a low-fat diet and avoid spicy foods" rationale: high fat and spicy foods stimulate gastric and pancreatic secretions and may precipitate an acute pancreatic attack

the client diagnosed with ulcerative colitis has an ileostomy. which statement indicates the client needs more teaching concerning the ileostomy? a. "my stoma should be pink and moist" b. "i will irrigate my ileostomy every morning" c. "if i get a red, bumpy, itchy rash i will call my HCP" d. "i will change my pouch if it starts leaking"

b. "i will irrigate my ileostomy every morning" rationale: an ileostomy will drain liquid all the time and should not routinely be irrigated.

the client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4mEq/L. which action should the nurse implement first? a. notify the HCP b. assess the client for muscle weakness c. request telemetry for the client d. prepare to administer potassium IV

b. assess the client for muscle weakness rationale: muscle weakness may be a sign of hypokalemia, which can lead to cardiac dysrhythmias and can be life threatening. assessment is a priority for a potassium level just below normal range

a client is diagnosed with viral hepatitis, complaining of "no appetite and "losing my taste for food". what instruction should the nurse give the client to provide adequate nutrition? a. select foods high in fat b. increase intake of fluids, including juices c. eat a good supper when anorexia is not as severe d. eat less often, preferably 3 large meals daily

b. increase intake of fluids, including juices

which clinical manifestations should the nurse expect to assess for in the client diagnosed with a ureteral renal stone? a. dull, aching flank pain and microscopic hematuria b. nausea, vomiting, pallor and cool, clammy skin c. gross hematuria and dull suprapubic pain with voiding d. the client will be asymptomatic

b. nausea, vomiting, pallor and cool, clammy skin

the nurse observes red urine and several large clots in the tubing of the NS continuous irrigation catheter for the client who is one day post-op TURP. which intervention should the nurse implement? a. remove the indwelling catheter b. titrate the NS irrigation to run faster c. administer protamine sulphate IVP d. administer vitamin k slowly

b. titrate the NS irrigation to run faster rationale: increasing the irrigation fluid will flush out the clots and blood

the client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when i'm going to get sick and end up in the hospital." which statement is the nurse's best response? a. "I understand how frustrating this must be for you" b. "you must keep thinking about the good things in your life" c. "i can see you are very upset. I'll sit down and we can talk" d. "are you thinking about doing anything like suicide?"

c. "i can see you are very upset. I'll sit down and we can talk" rationale: the client is crying and expressing feelings of powerlessness. the nurse should allow the client to talk

the male client diagnosed with chronic pancreatitis calls and reports to the clinic nurse he has been having a lot of "gas", along with frothy and very foul-smelling stools. which intervention should the nurse implement? a. explain this is common for chronic pancreatitis b. ask the client to bring a stool specimen to the clinic c. arrange an appt with the HCP for today d. discuss the need to decrease fat in the diet so this won't happen

c. arrange an appt with the HCP for today rationale: steatorrhea is caused by a decrease in pancreatic enzyme secretion and indicates impaired digestion and possibly an increase in the severity of pancreatitis. the client should see the HCP

the client is one hour post-ERCP. which intervention should the nurse include in the plan of care? a. instruct the client to cough forcefully b. encourage early ambulation c. assess for return of the gag reflex d. administer held medications

c. assess for return of the gag reflex rationale: the ERCP requires an anesthetic spray be used prior to insertion of the endoscope. if medications, food, or fluid are given orally prior to return of the gag reflex, the client may aspirate

the client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. which instruction should the nurse discuss with the client? a. increase water intake for the next 24 hours b. take 2 tylenol to help decrease the temperature c. come to the clinic and provide a urinalysis specimen d. use a sterile 4x4 gauze to strain the client's urine

c. come to the clinic and provide a urinalysis specimen rationale: a urinalysis can assess for hematuria, WBC, crystal fragments, or all three, which can determine if the client has a UTI or possibly a renal stone

the client diagnosed with acute pancreatitis is in pain. which position should the nurse assist the client to assume to help decrease the pain? a. recommend lying in the prone position with legs extended b. maintain a tripod position over the bed side table c. place in side-lying position with knees flexed d. encourage a supine position with a pillow under the knees

c. place in side-lying position with knees flexed rationale: this fetal position decreases pain caused by the stretching of the peritoneum as a result of edema

a client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. the nurse anticipates which treatment will be done to relieve the obstruction? SELECT ALL THAT APPLY a. peritoneal dialysis b. analysis of the urinary stone c. IV opioid analgesics d. insertion of a nephrostomy tube e. placement of a ureteral stent with ureteroscopy

d, e

a client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. which assessment findings would be consistent with acute pancreatitis? SELECT ALL THAT APPLY a. diarrhea b. black, tarry stools c. hyperactive bowel sounds d. gray-blue color at the flank e. abdominal guarding and tenderness f. LUQ pain with radiation to the back

d, e, f

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? a. Decreased pain management. b. Ambulate first day postoperative. c. No break in skin integrity. d. Knowledge of postoperative care.

d. Knowledge of postoperative care. rationale: this would be an expected outcome for the client scheduled for surgery. this indicates pre-op teaching has been effective.

which problem is highest priority for the nurse to identify in the client who had open cholecystectomy surgery? a. alteration in nutrition b. alteration in skin integrity c. alteration in urinary pattern d. alteration in comfort

d. alteration in comfort rationale: acute pain management is the highest priority client problem after surgery because pain may indicate a life-threatening problem

the client with a TURP who has a continuous irrigation catheter complains of the need to urinate. which intervention should the nurse implement first? a. call the surgeon to inform the HCP of the client's complaint b. administer the client a narcotic medication for pain c. explain to the client this sensation happens frequently d. assess the continuous irrigation catheter for patency

d. assess the continuous irrigation catheter for patency rationale: the nurse should always assess any complaint before dismissing it as a commonly occuring problem

the female client in an outpatient clinic is being sent home with a diagnosis of UTI. which instruction should the nurse teach to prevent a recurrence of UTI? a. clean the perineum from back to front after a bowel movement b. take warm tub baths instead of hot showers daily c. void immediately preceding sexual intercourse d. avoid coffee, tea, colas and alcoholic beverages

d. avoid coffee, tea, colas and alcoholic beverages rationale: these are all urinary tract irritants

the client from a LTC facility is admitted to the med-surg unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. which intervention should the nurse implement first? a. start an IV with a 20-gauge catheter b. initiate antibiotic therapy via IVPB c. collect a urine specimen for culture d. change the indwelling catheter

d. change the indwelling catheter rationale: unless the nurse can determine the catheter has been inserted within a few days, the nurse should replace the catheter and then get a specimen. this will provide the most accurate specimen for analysis.

the nurse is collecting data from a client. which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? a. nocturia b. scrotal edema c. occasional constipation d. decreased force in the stream of urine

d. decreased force in the stream of urine

the client is diagnosed with acute pancreatitis. which HCP's admitting order should the nurse question? a. bedrest with bathroom privileges b. initiate IV therapy of D5W at 125mL/hr c. weigh the client daily d. low-fat, low carb diet

d. low-fat, low carb diet rationale: the client will be NPO, which will decrease stimulation of the pancreatic enzymes, resulting in decreased autodigestion of the pancreas, therefore decreasing pain

which nursing diagnosis is priority for the client who has undergone a TURP? a. potential for sexual dysfunction b. potential for altered body image c. potential for chronic infection d. potential for hemorrhage

d. potential for hemorrhage rationale: this is a potentially life threatening problem