ATI Challenge 6

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Fatigue

A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?

Pasta

A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD). Which of the following statements should the nurse include?

"Avoid eating 2 to 3 hours before bedtime."

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

"Excessive laxative use may cause an electrolyte imbalance."

A nurse is providing teaching to a client with gastroesophageal reflux. Which of the following statements by the client indicates a need for further teaching?

"I drink no more than 4 cups of coffee a day."

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

"I will consume less caffeine and fewer spicy foods" is correct. I will sleep with the head of my bed elevated" is correct. "I will try not to gain weight" is correct.

A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates a need for further teaching?

"I will use dried spices to season my food."

A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching?

"I'll splint my incision with a pillow to cough."

A nurse is providing teaching to a client who has peptic ulcer disease and a new prescription for sucralfate tablets. Which of the following information should the nurse provide?

"Take sucralfate 1 hr before meals."

A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make?

"The tube will remove gas and fluid from your stomach."

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

"You may experience a small amount of bleeding around the stoma."

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position.

A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client?

Autonomy

A nurse is providing teaching for a client who has experienced an acute episode of gastritis. Which of the following instructions should the nurse include in the teaching?

Avoid drinking alcohol.

A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?

Avoid eating within 3 hr of bedtime.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Explaining the operative procedure, risks, and benefits

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Before initiating an abdominal assessment, the nurse should inquire if the client has a history of abdominal pain. The nurse should begin the assessment with an inspection of the client's abdomen, noting skin integrity, contour, and symmetry. Next, the nurse should auscultate for bowel sounds, vascular sounds, and peritoneal friction rubs. Auscultation precedes palpation and percussion because movement or stimulation of the bowel can increase bowel motility and create false results from heightened bowel sounds. After auscultation, the nurse should percuss the abdomen using a systematic pattern beginning in the lower right quadrant and proceeding to the upper right quadrant, the upper left quadrant, and then the lower left quadrant to determine the presence of tympany and dullness. The final step the nurse should take is to palpate the abdomen, beginning with light palpation, to detect any area of tenderness or muscle guarding.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Blood

A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Determine what the client knows about the surgery.

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following?

Determining the client's level of understanding about the procedure

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

Chocolate

A nurse is caring for a client who is about to have a colonoscopy. The client states, "I am so nervous about what the doctor might find during the test." The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" With this question, the nurse is using which of the following communication techniques?

Clarification

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

Decompress the stomach.

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)

Discontinue suction when assessing for peristalsis is correct. Irrigate the NG tube with 0.9% sodium chloride irrigation solution is correct. Place sequential compression devices on the bilateral lower extremities is correct. Reposition the client from side to side every 2 hr is correct.

A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings?

Document the findings in the client's medical record.

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet?

Dried apricots

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

Dull, aching calf pain

A nurse is reviewing laboratory data on a client who is recovering from surgery. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Dysrhythmias is correct. Potassium level is correct.

A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include?

Empty the pouch when it is 1/2 full.

A nurse is planning care for a client who states he is anxious concerning abdominal surgery. Which of the following actions should the nurse take?

Encourage the client to express negative emotions.

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority?

Gag reflex

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

Grilled chicken breast with white rice

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?

History of NSAID use

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

Lower left quadrant

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container.

A nurse is caring for an older adult client who has had a total hip arthroplasty. For each potential precaution, click to specify if the precaution is indicated or contraindicated for a client who has had a total hip arthroplasty.

Obtain a culture of the drainage from the surgical site is indicated Encourage client to cough and deep breathe every 2 hr is indicated. Ensure an abductor pillow is in place while the client is in bed is indicated Request an antiemetic medication is contraindicated. Anticipate the administration of antibiotics is anticipated.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Obtain vital signs for both clients.

A nurse is caring for a 64-year-old client who has a small bowel obstruction. For each potential prescription from the provider, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Oxygen 2 L per nasal cannula is nonessential. Unless the client's oxygenation is compromised, oxygen therapy is not required. Salem Sump NG tube is anticipated. A NG tube is inserted and connected to low continuous suction to decompress the bowel. Chest x-ray on admission is nonessential. Once the NG tube is placed if the tube becomes displaced and the tube requires repositioning an abdominal x-ray will be obtained. Morphine 4 mg IV PRN pain every 2 hr is contraindicated. Opioid analgesics can slow intestinal motility, which can cause vomiting. 0.9% sodium chloride at 150 mL/hr is anticipated. Isotonic solutions are ordered because the client with a small bowel obstruction is placed on an NPO status and is losing fluid and electrolytes through the nasogastric suctioning. 2000 mg gm sodium diet is contraindicated. The client who has a small bowel obstruction should not have anything by mouth due to the obstruction and an NG tube connected to suction is placed to decompress the bowel until the obstruction is resolved.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

Paralytic ileus

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

Passage of flatus

A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?

Platelet count 60,000/mm3

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Purplish-colored stoma

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

Relief of heartburn

A nurse is providing teaching to a client who has gastroesophageal reflux disease and a new prescription for omeprazole. Which of the following instructions should the nurse provide?

Report diarrhea to the provider.

A nurse is assessing a client who returned to the unit 4 hr ago after a partial colectomy. Which of the following findings should the nurse attend to first?

Report of severe incisional pain

A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child?

Rice

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Rigid abdomen

A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the client's diet?

Roast turkey

A nurse is preparing a client for a colonoscopy. The client has a family history of colon cancer. Which of the following types of prevention is the nurse demonstrating?

Secondary

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

Senna

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

Skim milk

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

Sudden abdominal pain

A nurse is caring for a client. A nurse is caring for a 26-year-old client who has abdominal pain. Click to highlight the findings below that the nurses should report to the provider. To deselect a finding, click on the finding again.

The client reports abdominal pain for the last two days that is now moving to the right lower quadrant is correct. Respiratory rate 22/min is correct. Heart rate 110/min is correct. Blood pressure 88/58 mm Hg while lying down is correct.

A nurse is caring for a client who is 3 hr postoperative following abdominal surgery. Which of the following assessment data should the nurse report to the provider?

The client urine output has been 50 mL since surgery

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

The surgical dressing

A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for clients who have Crohn's disease?

Toast with jelly

A nurse is caring for a client on the medical surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Upon recognizing and analyzing the client cues of abdominal pain and acute onset of diarrhea after the administration of a high dose IV antibiotics, the nurse's priority hypotheses is that this client is most likely experiencing C. difficile colitis. It is important to generate solutions and take actions that will protect others from infection and treat the symptoms of volume depletion caused by diarrhea. Therefore, the nurse should prepare to start IV fluids and place the client on contact precautions. To evaluate therapy, the nurse should monitor the client's serum potassium and for signs of volume depletion (hypotension) as these can be a consequence of severe diarrhea.

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should recognize that which of the following findings are associated with this condition? (Select all that apply.)

Vomiting, weight loss, and wheezing

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values?

WBC 17,000/mm3

A nurse is caring for a client who is 2 days postoperative following a small bowel resection. A nurse is reviewing the client's assessment findings and information. Complete the following sentence by using the list of options.

WBC count Incisional pain

A nurse is caring for a client who is 2 days postoperative following a small bowel resection. A nurse is reviewing the client's assessment findings and information. Complete the following sentence by using the list of options.

WBC count is correct Incisional pain is correct

A nurse is caring for a client who is 2 days postoperative following a small bowel resection. The nurse is reviewing the client's assessment findings and information. Complete the following sentence by using the list of options.

WBC count is correct. Incisional pain is correct.

A nurse is caring for a client who had abdominal surgery 3 days ago. Drag words from the choices below to fill in each blank in the following sentence.

Wound infection is correct Dehiscence is correct.

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision

A nurse is planning care for a client who has diverticulitis. The nurse should plan to monitor the client for which of the following complications of diverticulitis?

peritonitis