322 Exam #3

A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation."

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate?

"I will ask the surgeon to come speak to you about the procedure."

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client?

"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding"

A client has 4000 mL removed via paracentesis. When the nurse weighs the client after the procedure, how many kilograms is an expected weight loss? Record you answer in whole numbers.

4

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?

Apply a hydrocolloidal dressing.

A nurse is talking to a neighbor who asks about reoccurring symptoms of gnawing epigastric pain following meals and heartburn. Recognizing these symptoms, what suggestion could the nurse make?

Avoid alcohol and nonsteroidal anti-inflammatory medications.

The nurse is providing discharge instructions for a client who had an inguinal herniorrhaphy. What information should the nurse give the client?

Avoid lifting items weighing >5 lb (2.3 kg).

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action?

Elevate the ankle.

A nurse asks a client who had abdominal surgery 3 days ago if they have moved their bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate at least three times per day.

A client reports a firm, red nodule with a scaly crust on the back. What is the best nursing intervention?

Notify the healthcare provider.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

A school nurse is examining a student at an elementary school and notes vesicular lesions that ooze, forming crusts on the face and extremities. Which actions by the nurse are most appropriate?

Sending the child home and encourage evaluation by physician.

A client has a newly created colostomy. After participating in a teaching session with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

The client touches the altered body part.

When caring for the client with hepatitis B, which situation would expose the nurse to the virus?

a blood splash into the nurse's eyes

A client with a recent history of rectal bleeding is being prepared for a colonoscopy. The nurse knows that positioning the client lying on the left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will

allow proper visualization of the large intestine.

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note

anorexia, nausea, and vomiting

Which task may a nurse delegate to a nursing assistant?

assisting a client who had surgery to ambulate in the hallway

A nurse is performing a skin assessment on a younger adult who reports frequent sunbathing. Which skin changes should the nurse observe for in this client?

asymmetry, border irregularity, color variation, and diameter

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of

increasing fluid intake to prevent dehydration

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

nothing by mouth

What would be the priority treatment of a client who has reported severe lower right quadrant pain that has now resolved?

preparation for emergency surgery

An adolescent, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention is appropriate?

providing small, frequent meals

A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:

teach children the importance of proper hand washing.

A client is diagnosed with contact dermatitis. Which medication should the nurse expect to be prescribed to treat this disorder?

topical corticosteroid

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note

yellow sclerae.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

A graduate nurse and the nurse's preceptor are establishing priorities for their morning assessments. Which client should they assess first?

The newly admitted client with acute abdominal pain

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

Which statement indicates that a client with esophageal reflux disorder understands the dietary teaching?

"I won't drink any carbonated drinks.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

Which client statement indicates a need for further instruction about a duodenal ulcer?

"I will need to take an antacid before every meal."

A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client's room to review discharge instructions with the client when the client tells the nurse that they want help to quit drinking. How should the nurse respond?

"I'll notify your physician and call the social worker so they can discuss treatment options with you."