Chronic

A nurse is teaching a client with Crohn's disease (CD) about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."

A. "Avoid large crowds and anyone who is sick." Rationale A. The client should avoid being around large crowds to avoid developing an infection. B. The client should not take the medication if he or she is allergic to certain proteins. C. Although immune suppression may occur to some degree, the client should not experience difficulty with wound healing while taking this particular medication. D. The client should not experience a decrease in blood pressure from taking this drug.

Situation: A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made. She is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does a nurse include in the teaching about this medication? A. "Be aware of the symptoms (as we discussed) of toxic megacolon." B. "If diarrhea increases, you should let your health care provider know." C. "Pregnancy should be avoided." D. "You will need to decrease the dose of sulfasalazine (Azulfidine)."

A. "Be aware of the symptoms (as we discussed) of toxic megacolon." Rationale A. Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia. B. Loperamide (Imodium) will decrease diarrhea rather than increase it. Constipation is sometimes a problem. C. No contraindication for pregnancy is noted. D. The administration of sulfasalazine (Azulfidine) continues. It is usually used on a long-term basis.

A client has a history of gastroesophageal reflux disease and is worried about getting cancer of the esophagus. What health teaching about ways to decrease the risk for cancer will the nurse provide? Select all that apply. A. "Consider dieting and exercise because you are overweight." B. "Drink a glass of red wine every night because it provides antioxidants." C. "Join a good smoking-cessation program as soon as possible." D. "Eat plenty of fruits and vegetables instead of so much junk food." E. "Sleep with two pillows every night to prevent reflux when sleeping."

A. "Consider dieting and exercise because you are overweight." C. "Join a good smoking-cessation program as soon as possible." D. "Eat plenty of fruits and vegetables instead of so much junk food." E. "Sleep with two pillows every night to prevent reflux when sleeping." Rationale For most clients, GERD can be controlled by nutrition therapy, lifestyle changes, and drug therapy. Weight reduction may be helpful because decreased intra-abdominal pressure often reduces reflux symptoms. Smoking cessation and limiting fatty junk food can positively affect lower esophageal sphincter pressure, decreasing reflux. Using two pillows to elevate the head 6 to 12 inches in bed can help prevent nighttime reflux. Red wine is acidic and can contribute to the symptoms associated with GERD.

A nursing assistant asks a rehabilitation nurse for assistance in transferring a 320-pound client from the bed to a wheelchair. How does the nurse respond? A. "First, I want to check the physical therapy care plan." B. "OK, but let's get the mechanical patient lift device." C. "Sure, but we need to ask additional staff members for assistance." D. "Yes, I would be happy to help you transfer the client."

A. "First, I want to check the physical therapy care plan." Rationale A. The physical (PT) or occupational therapist (OT) is usually responsible for assessing a client's ability to transfer and for specifying the type of transfer. This plan needs to be consulted before the client is moved. B. The use of a mechanical lifting device by the nurse may be appropriate, depending on the physical therapy care plan, but the PT or OT should be consulted before the nurse goes ahead with this plan. C. Getting more staff to help may be the appropriate action for the nurse to take, depending on the physical therapy care plan. D. Before agreeing to help, the nurse needs to consult the PT or OT care plan. This action ensures client safety and coordination of all staff efforts.

A client in rehabilitation says, "This is too hard. My life will never be the same again!" How does the nurse respond? A. "How did you handle challenges before you were injured?" B. "Should I call a family member to help?" C. "Why don't you try a relaxation exercise?" D. "You will be fine, don't worry so much."

A. "How did you handle challenges before you were injured?" Rationale A. Assess the client's previous coping strategies and support systems so that they can be used during rehabilitation, if needed. This open-ended question allows the client to problem-solve and explore plausible ways to cope. B. Suggesting that a family member be called provides a supportive environment for the client but does not build coping skills. This is a "closed" question that requires a "yes" or "no" response. It does not explore coping mechanisms for the client. C. Suggesting a relaxation exercise minimizes the client's current situation. "Why" questions are not therapeutic because they place the client in a defensive mode. Relaxation may be an option but is one that has to be learned. D. Telling the client that he or she will be fine minimizes the client's current situation. Giving reassurances is not considered a therapeutic response. It closes communication.

A nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed? A. "I can drive my car in about 2 weeks." B. "I should avoid drinking carbonated sodas." C. "It may take 6 weeks to see the effects of some foods on my bowel patterns." D. "Stool softeners will help me to avoid straining."

A. "I can drive my car in about 2 weeks." Rationale A. The client who has had a bowel resection and colostomy should avoid driving for 4 to 6 weeks. B. The client who has had a bowel resection and colostomy should avoid drinking sodas and other carbonated drinks because of the gas they produce. C. The client who has had a bowel resection and colostomy may not be able to see the effect of certain foods on bowel patterns for several weeks. D. The client who has had a bowel resection and colostomy should avoid straining at stool.

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileoanal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." B. "This is something that you will have to discuss with your health care provider." C. "The period of time is indefinite—I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal."

A. "It is usually ready to be closed in about 1 to 2 months." Rationale A. The RPC-IPAA has become the most effective method of creating an alternate method for UC clients who have surgery to remove diseased portions of intestines. Stage 1 creates an ileostomy while the internally created pouch is healing. Stage 2 closes the ileostomy, and the client begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months. B. This answer evades the question. The nurse can give generalities to the client based on past practice and available data. C. The time that the client has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. D. The pouch should heal in 1 to 2 months, not 6 months. This estimate is not based on the expected outcome.

What roles does the rehabilitation nurse have in the functioning of the rehabilitation team? Select all that apply. A. Coordinates holistic care B. Coordinates rehabilitation team activities C. Develops the client's fine motor skills D. Plans continuity of care for discharge E. Retrains clients with swallowing challenges

A. Coordinates holistic care B. Coordinates rehabilitation team activities D. Plans continuity of care for discharge Rationale Providing holistic care and coordinating all activities of the team is a role for the rehabilitation nurse, perhaps the primary role.

The nurse is teaching the client with peptic ulcer disease (PUD) about the prescribed drug regimen. Which statement made by the client indicates a need for further teaching before discharge? A. "Nizatidine (Axid) needs to be taken three times a day to be effective." B. "Taking ranitidine (Zantac) at bedtime should decrease acid production at night." C. "Sucralfate (Carafate) should be taken 1 hour before and 2 hours after meals." D. "Omeprazole (Prilosec) should be swallowed whole and not crushed."

A. "Nizatidine (Axid) needs to be taken three times a day to be effective." Rationale A. Nizatidine (Axid) is most effective if administered twice daily. B. A dose of ranitidine (Zantac) at bedtime should decrease acid production throughout the night. C. This is an appropriate administration schedule for sucralfate (Carafate). D. Because omeprazole (Prilosec) is a delayed-release capsule, it should be swallowed whole and not crushed.

The client is an older woman diagnosed with Zollinger-Ellison syndrome. Which statement made by the client's family demonstrates correct understanding of the disorder? A. "She may have to be treated with chemotherapy drugs." B. "This is going to be a chronic problem that cannot be cured." C. "At least this is not an inherited ailment." D. "Thank goodness she won't have to undergo surgery."

A. "She may have to be treated with chemotherapy drugs." Rationale A. The client may undergo treatment with chemotherapeutic agents to reduce the tumor before further treatment can commence. B. Zollinger-Ellison syndrome is curable. C. A familial tendency to develop Zollinger-Ellison syndrome has been noted. D. The only way to cure Zollinger-Ellison syndrome is with surgery.

Situation: A 38-year-old male is admitted with severe gastroenteritis. He states, "I've had watery diarrhea and frequent vomiting for the past couple of days; I am becoming very weak." A health care provider prescribes an IV for him. What fluid does the nurse expect to be administered? A. 0.45% normal saline B. 0.9% normal saline C. D10W (10% dextrose and water) D. Lactated Ringer's solution

A. 0.45% normal saline Rationale A. Hypotonic fluids such as 0.45% normal saline, with or without potassium supplements, are usually infused, as prescribed.

A nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A. A slice of 5-grain bread B. Chuck steak patty (6 ounces) C. Strawberries (1 cup) D. Tomato (1 medium)

A. A slice of 5-grain bread Rationale A. Whole-grain breads are recommended to be included in the diet of clients with diverticular disease. Cellulose and hemicellulose types of fiber are found in them. B. Dietary fat should be reduced in clients with diverticular disease. If the client wants to eat beef, it should be of a leaner cut. C. Foods containing seeds, such as strawberries, should be avoided. D. Tomatoes should be avoided, unless the seeds are removed. The seeds may block diverticula in the client and present problems leading to diverticulitis.

A client has a total colectomy, and a continent ileostomy is created. Which postoperative instruction does the nurse emphasize to this client? A. A small dressing must be worn over the stoma at all times. B. The client must always wear an external pouch system. C. The ileostomy must be drained once a day. D. No sensation will indicate when the ileostomy needs emptying.

A. A small dressing must be worn over the stoma at all times. Rationale A. The client will need to wear a small dressing over the stoma to keep it moist. B. The client will not require an external pouch system. C. The client will need to drain the ileostomy several times a day. D. The client will have a sensation of fullness when the ileostomy needs to be emptied.

A nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? Select all that apply. A. Acupuncture B. Decreasing physical activities C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga

A. Acupuncture C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga

A hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements does the nurse include? Select all that apply. A. Allowing time for clients to practice self-management skills B. Encouraging clients and providing emotional support C. Keeping to a structured hospital schedule (e.g., medication administration) D. Making the inpatient unit a more home-like environment E. Carefully monitoring fluid and dietary intake F. Protecting clients from embarrassment (e.g., bowel training)

A. Allowing time for clients to practice self-management skills B. Encouraging clients and providing emotional support D. Making the inpatient unit a more home-like environment F. Protecting clients from embarrassment (e.g., bowel training) Rationale As clients undergo rehabilitation, they must learn skills to function independently after they are discharged. Incorporating self-management skills in the environment is crucial.

Situation: The client is a 66-year-old man with colorectal cancer. He has been started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to his treatment regimen. He reports peripheral sensory neuropathy. What other medications does the nurse expect to administer to clients with advanced colorectal cancer for relief of symptoms? A. Analgesics and antiemetics B. Analgesics and benzodiazepines C. Steroids and analgesics D. Steroids and anti-inflammatory medications

A. Analgesics and antiemetics

A nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What does the nurse tell the client to report to the health care provider? Select all that apply. A. Anorexia B. Depression C. Drowsiness D. Frequent urination E. Headache F. Vomiting

A. Anorexia E. Headache F. Vomiting

A paraplegic client is being discharged home from rehabilitation. What primary concerns does the nurse include in the client's discharge plan? Select all that apply. A. Assistive and adaptive devices B. Cast care C. Depression prevention D. Range-of-motion (ROM) exercises E. Wheelchair accessibility

A. Assistive and adaptive devices C. Depression prevention D. Range-of-motion (ROM) exercises E. Wheelchair accessibility

Situation: A 38-year-old male is admitted with severe gastroenteritis. He states, "I've had watery diarrhea and frequent vomiting for the past couple of days; I am becoming very weak." A health care provider prescribes an IV for him. The IV has been started, but the client continues with excessive diarrhea. He is given the maximum amount of an antispasmodic agent and yet continues to have diarrhea. What is additionally prescribed to decrease the watery volume of his stools? A. Bismuth subsalicylate (Pepto-Bismol) B. Loperamide (Imodium) C. Olsalazine (Dipentum) D. Sulfasalazine (Azulfidine)

A. Bismuth subsalicylate (Pepto-Bismol)

An older adult has a perforated appendix and is scheduled for emergent surgery. What assessment findings will the nurse expect the client to have before surgery? Select all that apply. A. Bradycardia B. Dizziness C. Distended abdomen D. Fever E. Diarrhea F. Fistulas G. Incontinence

A. BradycardiaC. Distended abdomen D. Fever

A nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? Select all that apply. A. Broccoli B. Buttermilk C. Mushrooms D. Onions E. Peas F. Yogurt

A. Broccoli C. Mushrooms D. Onions E. Peas

Situation: A 28-year-old comes to the clinic with a history of recurrent episodes of diarrhea or constipation and abdominal pain with bloating. The client is diagnosed with irritable bowel syndrome (IBS). What does the nurse advise the client to take during the periods of constipation? A. Bulk-forming laxatives B. Saline laxatives C. Stimulant laxatives D. Stool-softening agents

A. Bulk-forming laxatives Rationale A. For treatment of constipation-predominant IBS, bulk-forming laxatives are generally taken at mealtimes with a glass of water. B. Saline laxatives are not used for the treatment of constipation-predominant IBS. C. Stimulant laxatives will not be used for the treatment of constipation-predominant IBS. D. Stool-softening agents are not effective in the treatment of constipation-predominant IBS.

A client with CRC had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem to be overwhelming." What does the nurse do first for this client? A. Encourages the client to look at and touch the colostomy stoma B. Instructs the client about complete care of the colostomy C. Schedules a visit from a client who has a colostomy and is successfully caring for it D. Suggests that the client involve family members in care of the colostomy

A. Encourages the client to look at and touch the colostomy stoma Rationale A. The initial intervention is to get the client comfortable looking at and touching the stoma—before providing instructions on its care. B. Instructing the client about colostomy care will be much more effective after the client's anxiety level has stabilized. C. Talking with someone who has gone through a similar experience may be helpful to the client only after her or his anxiety level has stabilized. D. The client has begun to express feelings regarding the colostomy and its care. It is too soon to involve others in the care of it. The client needs to get comfortable with this body image change first.

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? A. Having a home health consultation for wound care B. Requesting an antianxiety medication C. Requesting pain medication for the client's osteoarthritis D. Placing the client in a skilled nursing facility for rehabilitation

A. Having a home health consultation for wound care Rationale A. Home health services are most appropriate for this client because wound care will be extensive and the client's mobility may be limited. B. No indication suggests that the client is experiencing anxiety regarding postoperative care. C. Pain medication may be needed for the client's osteoarthritis, but this is not the highest priority. D. A skilled nursing facility is not necessary if the client can remain in his or her home with sufficient support services.

The nurse is caring for an older adult male client who reports stomach pain and heartburn. Which syndrome is most significant in determining whether the client's ulceration is gastric or duodenal in origin? A. Pain occurs 1 1/2 to 3 hours after a meal, usually at night. B. Pain is worsened by the ingestion of food. C. The client has a malnourished appearance. D. The client is a man older than 50 years.

A. Pain occurs 1 1/2 to 3 hours after a meal, usually at night. Rationale A. A key symptom characteristic of duodenal ulcers is that pain usually awakens the client between 1 AM and 2 AM, occurring 1 1/2 to 3 hours after a meal. B. Pain that is worsened with ingestion of food is a key feature of gastric ulcers. C. A malnourished appearance is a key feature of gastric ulcers. D. This is a finding that could apply to either type of ulcer.

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to the client diagnosed with esophageal cancer. Which instruction to the client is the highest priority? A. Place the food at the back of the mouth as you eat. B. Do not be overly concerned with tongue or lip movements. C. Before swallowing, tilt your head back to straighten the esophagus. D. Do not attempt to reach food particles that are on your lips or around your mouth.

A. Place the food at the back of the mouth as you eat. Rationale A. Placing the food at the back of the mouth when eating will help the client avoid aspirating. B. Both tongue movements and sealing of the lips should be monitored in this client. C. The client's head should be tilted forward into the chin tuck position. D. The client should be able to reach food particles on her or his lips and around the mouth with the tongue.

The client is scheduled to be discharged after a gastrectomy. The client's spouse expresses concern that the client will be unable to change the surgical dressing adequately. What is the nurse's highest priority intervention? A. Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the physician B. Asking the physician for a referral for home health services to assist with dressing changes C. Asking the spouse whether other family members could be taught how to change the dressing D. Trying to determine specific concerns that the spouse has regarding dressing changes

A. Providing both oral and written instructions on changing the dressing and on symptoms of infection that must be reported to the physician Rationale A. Providing the spouse with both oral and written instructions on symptoms to report to the physician, as well as on how to perform the dressing change, will reinforce important points and boost the spouse's confidence. B. Obtaining a referral prevents the client and spouse from taking responsibility for the client's care. C. Recruiting other family members prevents the client and spouse from taking responsibility for the client's care. D. The spouse's concerns have already been clearly expressed.

The client has been discharged home after surgery for gastric cancer, and a case manager will follow up with the client. To ensure a smooth transition from the hospital to the home setting, which information provided by the hospital nurse to the case manager is given the highest priority? A. Schedule of the client's follow-up examinations and x-ray assessments B. Information on family members' progress in learning how to perform dressing changes C. Copy of the diet plan prepared for the client by the hospital dietitian D. Detailed account of what occurred during the client's surgical procedure

A. Schedule of the client's follow-up examinations and x-ray assessments Rationale A. Because recurrence of gastric cancer is common, it will be a priority for the client to have follow-up examinations and x-rays, so that a recurrence can be detected quickly. B. It may take family members a long time to become proficient at tasks such as dressing changes. C. Although the case manager should be aware of the diet, family members will likely be preparing the client's daily diet, and they should be provided with this information. D. It is not necessary for the case manager to have details of the client's surgical procedure unless a significant event has occurred during the procedure.

The client is experiencing bleeding related to peptic ulcer disease (PUD). Which nursing intervention is the highest priority? A. Starting a large-bore intravenous (IV) B. Administering intravenous (IV) pain medication C. Preparing equipment for intubation D. Monitoring the client's anxiety level Rationale A. A large-bore IV should be placed as requested, so that blood products can be administered. B. IV pain medication is not a recommended treatment for gastrointestinal bleeding. C. Intubation is not a recommended treatment for bleeding related to PUD. D. The mental status of the client should be monitored, but it is not necessary to monitor the anxiety level of the client.

A. Starting a large-bore intravenous (IV) Rationale A. A large-bore IV should be placed as requested, so that blood products can be administered. B. IV pain medication is not a recommended treatment for gastrointestinal bleeding. C. Intubation is not a recommended treatment for bleeding related to PUD. D. The mental status of the client should be monitored, but it is not necessary to monitor the anxiety level of the client.

A nurse is assigned to care for a client who had a partial colectomy and ascending colostomy yesterday. What assessment findings are expected for the client? Select all that apply. A. The colostomy stoma is pinkish red and moist. B. The nasogastric tube is draining bright red blood. C. The client has pain that is controlled by analgesics. D. The colostomy is draining solid brown stool. E. The perineal incision is covered with a surgical dressing.

A. The colostomy stoma is pinkish red and moist. C. The client has pain that is controlled by analgesics.

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? A. "Be sure to maintain an exclusive low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." Rationale A. An exclusive low-fiber diet will not effectively manage diverticulitis. B. The most effective way to manage diverticulitis is with a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. C. An exclusively high-fiber diet will not effectively manage diverticulitis. D. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

The client has been diagnosed recently with esophageal cancer. The client states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? A. "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." B. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed." C. "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." D. "You need to talk to your doctor about your concerns. The doctor may recommend that you enter a support group for cancer victims."

B. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed." Rationale A. This response is evasive and unhelpful. It is used to placate the client and does not address the client's concerns. B. This response provides psychosocial support to the client and assists the client with finding a solution to the problem. C. The client should use problem-solving and coping skills before resorting to the use of medication. D. This response is evasive and unhelpful. It is used to placate the client and does not address the client's concerns.

A rehabilitation nurse is teaching a client with a spastic bladder to perform intermittent catheterizations. Which client statement shows the need for further education? A. "Before I catheterize myself, I will try to urinate." B. "I can wait from 9 AM until 6 PM between catheterizations." C. "I will use the Valsalva and Credé maneuvers before trying to urinate." D. "You can teach my son to help me with the catheterizations."

B. "I can wait from 9 AM until 6 PM between catheterizations." Rationale A. The client with a spastic bladder needs to attempt to void before the catheterization is performed. B. The client should not go beyond 8 hours between catheterizations. The time between catheterizations in this scenario is 9 hours. This concept needs to be retaught to the client. C. These maneuvers should be used to attempt voiding before self-catheterization in clients with spastic or flaccid bladders. D. If the client cannot catheterize himself or herself, a family member can be taught to do it.

A nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates correct understanding of the nurse's instructions? A. "I should take Ex-Lax after the surgery to keep 'things' moving." B. "I will need to eat a diet high in fiber." C. "Limiting my fluids will help me with constipation." D. "To help with the pain, I'll apply ice to the surgical area."

B. "I will need to eat a diet high in fiber." Rationale A. Stimulant laxatives are discouraged because they are habit forming. B. A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. C. Increased amounts of fluids are needed to prevent constipation. D. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications. Cold therapy is sometimes recommended and useful before surgery for inflamed hemorrhoids.

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure? A. "I may have trouble urinating immediately after the surgery." B. "I will need to stay in the hospital overnight." C. "I should not eat after midnight the day of the surgery." D. "My chances of having complications after this procedure are slim."

B. "I will need to stay in the hospital overnight." Rationale A. Male clients who have difficulty urinating after the procedure should be encouraged to push fluids and to assume a natural position when voiding. B. Usually, the client is discharged 3 to 5 hours after MIIHR surgery. C. Clients undergoing MIIHR surgery must be NPO after midnight before the surgery. D. Most clients who have MIIHR surgery have an uneventful recovery.

The nurse is teaching the client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? A. "Sweetened fruit juice beverages will need to be avoided." B. "Ice cream can be eaten in moderation." C. "I cannot drink alcohol at all." D. "It is okay to have a serving of sugar-free pudding."

B. "Ice cream can be eaten in moderation." Rationale A. The client with dumping syndrome can no longer consume sweetened drinks. B. Milk products such as ice cream must be eliminated from the diet of the client with dumping syndrome. C. Alcohol must be eliminated from the diet of the client with dumping syndrome. D. The client with dumping syndrome can eat sugar-free pudding, custard, and gelatin with caution.

The client with peptic ulcer disease (PUD) asks the nurse whether a maternal history of ovarian cancer will cause the client to develop gastric cancer. What is the nurse's best response? A. "Yes, it is known that a family history of ovarian cancer will cause someone to develop gastric cancer." B. "If you are concerned that you are at high risk to develop gastric cancer, I would recommend that you speak to your physician about the possibility of genetic testing." C. "Have you spoken to your physician about your concerns?" D. "I wouldn't be too concerned about that as long as your diet limits pickled, salted, and processed food."

B. "If you are concerned that you are at high risk to develop gastric cancer, I would recommend that you speak to your physician about the possibility of genetic testing."

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test? A. "During the test, you will drink small amounts of an antacid as directed by the technician." B. "If you have IBS, hydrogen levels will be increased in your breath samples." C. "The test will take between 30 and 45 minutes to complete." D. "You must have nothing to drink (except water) for 24 hours before the test."

B. "If you have IBS, hydrogen levels will be increased in your breath samples."

A client with right-sided weakness is receiving antihypertensive medications. What does the RN communicate to the physical therapist (PT), who is planning to help the client walk? A. "Monitor the client for weakness and fatigue during exercise." B. "Move the client from lying to standing slowly." C. "Remind the client to use the left side to grip." D. "Use a gait belt when ambulating the client."

B. "Move the client from lying to standing slowly." Rationale A. The PT will not need instruction about how to safely exercise (monitor for weakness) or ambulate the client, because these activities are included in the role of the PT in rehabilitation. B. Because the PT may not be aware of the client's medications or that antihypertensives can cause orthostatic hypotension, the nurse should discuss this with the PT before the client is ambulated. C. The PT will not need instruction about how to safely exercise (use his or her "strong" side) or ambulate the client, because these activities are included in the role of the PT in rehabilitation. D. The PT will not need instruction about how to safely exercise or ambulate (with a gait belt) the client, because these activities are included in the role of the PT in rehabilitation.

The client has a long-term history of Crohn's disease and has recently developed acute gastritis. The client asks the nurse whether Crohn's disease was a direct cause of the gastritis. What is the nurse's best response? A. "Yes, Crohn's disease is known to be a direct cause of the development of chronic gastritis." B. "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." C. "What has your doctor told you about how your gastritis developed?" D. "Yes, a familial tendency to inherit Crohn's disease as well as gastritis has been reported. Have your other family members been tested for Crohn's disease?"

B. "We know that there can be an association between Crohn's disease and chronic gastritis, but Crohn's does not directly cause acute gastritis to develop." Rationale A. Crohn's disease may be an underlying disease process associated with gastritis, but it is not known to be a direct cause of the disease. B. This is the only accurate statement. Crohn's disease may be an underlying disease process when chronic gastritis develops, but not when acute gastritis occurs. C. This is an evasive response on the part of the nurse and does not help answer the client's question. D. Although Crohn's disease tends to run in families, gastritis is a symptom of other disease processes and is not a disease process in and of itself.

Which client does the charge nurse assign to an experienced LPN/LVN? A. 28-year-old who needs teaching about how to catheterize a Kock's ileostomy B. 30-year-old who needs to receive neomycin sulfate (Mycifradin) before colectomy C. 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 D. 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

B. 30-year-old who needs to receive neomycin sulfate (Mycifradin) before colectomy Rationale A. Teaching about how to catheterize a Kock's ileostomy is a complex problem that requires assessment or intervention by an RN. B. The LPN/LVN should be familiar with the purpose, adverse effects, and client teaching required for neomycin. C. A client with UC who has a white blood cell count of 23,000/mm3 presents a complex problem that requires assessment or intervention by an RN. D. The client with gastroenteritis who is receiving IV fluids at 250 mL/hr presents a complex problem that requires assessment or intervention by an RN.

Which client does the RN in the rehabilitation unit plan to assess first? A. 45-year-old client with multiple sclerosis complaining of constipation B. 56-year-old client with a spinal cord injury and new-onset redness over the sacral area C. 63-year-old client who has had a myocardial infarction and is expressing anxiety about walking D. 70-year-old client with a joint replacement who needs to be medicated before exercising

B. 56-year-old client with a spinal cord injury and new-onset redness over the sacral area Rationale A. This client also needs assessment and intervention (laxative or enema) but is not as at high a risk for acute physiologic complications. B. Because new redness over a bony area may indicate the presence of a stage I pressure ulcer, the nurse assesses this client's skin as soon as possible and implements interventions to improve skin integrity. C. This client also needs assessment and intervention (antianxiety medications or therapeutic communication) but is not as at high a risk for acute physiologic complications. D. This client also needs assessment and intervention (analgesic administration) but is not as at high a risk for acute physiologic complications. NEW ONSET!!!!!

A nurse has been effectively using digital stimulation in older adult clients with constipation problems. For which client is this practice unsafe? A. 68-year-old client with a long history of multiple sclerosis (MS) B. 70-year-old client with recently diagnosed atrial fibrillation C. 74-year-old client who is 4 months post cerebrovascular accident (CVA) with left-sided weakness D. 84-year-old client with progressive dementia and confusion Rationale A. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. The MS client is a safe risk. B. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. This client should not have digital stimulation to induce stool passage. Another method of treatment for constipation should be used—diet, fluids, or laxatives. C. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. The post-CVA client is a safe risk. D. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. A confused client is not at risk for this

B. 70-year-old client with recently diagnosed atrial fibrillation

A client in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action will the nurse take first? A. Teach the client about antacid effects and side effects. B. Ask the client about medications and dietary intake. C. Suggest that the client sleep with the head elevated 6 inches. D. Tell the client to avoid drinking alcohol late in the evening.

B. Ask the client about medications and dietary intake. Rationale A. Before client teaching can begin, the nurse needs to elicit more information about the client's symptoms. B. The nurse's initial action should be further assessment of the client's risk factors for GERD. C. Before suggesting interventions, the nurse needs to gather additional data about the client's symptoms. D. The nurse needs additional data before making this determination.

A male client in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing the client's incision for signs of infection B. Assisting the client to stand to void C. Instructing the client in how to deep-breathe D. Monitoring the client's pain level

B. Assisting the client to stand to void

A client has newly diagnosed ulcerative colitis (UC). What does the nurse tell the client about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

C. "Lactose-containing foods should be reduced or eliminated from your diet."

An 80-year-old client is bedridden after having a cerebrovascular accident (CVA). Which nursing intervention is used to help prevent skin breakdown? A. Applying moist packs to the skin every shift. B. Assuring the client's skin remains dry and clean. C. Decreasing calories consumed; avoiding weight gain. D. Turning and repositioning at least every 4 hours.

B. Assuring the client's skin remains dry and clean. Rationale A. Moisture is contraindicated because it can cause further skin breakdown. B. Assuring that the client's skin stays clean and dry will insure early detection and prevention of the problem of skin breakdown in this client. C. Decreasing calories is contraindicated because nutrition is needed for good skin turgor; weight gain is likely not an issue for this client. D. The client should be repositioned at least every 2 hours to prevent skin breakdown.

A client has vague symptoms that indicate an acute inflammatory bowel disorder (IBD). Which symptom is most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees B. Chronic diarrhea, abdominal pain, and fever C. Epigastric cramping D. Hypotension with vomiting

B. Chronic diarrhea, abdominal pain, and fever Rationale A. Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. B. Chronic diarrhea, abdominal pain, and fever are symptoms more indicative of Crohn's disease (CD) than of other acute inflammatory bowel disorders. C. Epigastric cramping is a symptom more indicative of appendicitis. D. Hypotension with vomiting is not characteristic of Crohn's disease (CD).

A medical-surgical nurse is coordinating transfer from acute care to community-based care for a client who requires rehabilitation. Which interdisciplinary team member receives highest priority for decision making in this transition? A. Case manager B. Client C. Medical-surgical nurse D. Rehabilitation nurse

B. Client Rationale A. The case manager is an important member of the interdisciplinary team but is not the most important member. B. Clients in a rehabilitation setting are managed by an interdisciplinary team of health care professionals, but the client is at the center of the team and should be the primary decision maker. C. The medical-surgical nurse is an important member of the interdisciplinary team but is not the most important member. D. The rehabilitation nurse is an important member of the interdisciplinary team but is not the most important member.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Clients with CD experience about 20 loose, bloody stools daily. B. Clients with UC may experience hemorrhage. C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.

B. Clients with UC may experience hemorrhage.

The nurse is caring for a client with esophageal cancer who has received photodynamic therapy (PDT) using porfimer sodium (Photofrin). What instructions will the nurse include in teaching the client about porfimer sodium? Select all that apply. A. Avoid sunlight for 2 weeks. B. Cover all exposed body areas. C. Follow a full liquid diet for 3 to 5 days after the procedure. D. Monitor for hypertension. E. Tissue particles may be found in the sputum.

B. Cover all exposed body areas. C. Follow a full liquid diet for 3 to 5 days after the procedure. E. Tissue particles may be found in the sputum. Rationale Sunlight should be avoided for 1 to 3 months.

The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings will the nurse expect to observe? Select all that apply. A. Blood-tinged sputum B. Dyspepsia C. Excessive salivation D. Flatulence E. Regurgitation

B. Dyspepsia D. Flatulence E. Regurgitation

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? A. Decrease in liver function test results B. Elevated carcinoembryonic antigen C. Elevated hemoglobin levels D. Negative test for occult blood

B. Elevated carcinoembryonic antigen

A rehabilitation nurse in a medical-surgical setting is assessing a client's ability to perform ADLs. Which test does the nurse use? A. ADL Ability Test B. Functional Independence Measure C. Minimum Data Set D. Shift change assessment

B. Functional Independence Measure Rationale A. There is no such test as the ADL Ability Test. B. Functional assessment tools are used to assess a client's abilities. The most commonly used is the Functional Independence Measure. C. The Minimum Data Set is used in long-term care settings. D. Shift change in the medical-surgical setting is not the correct venue for assessing ADLs, which takes more time than this opportunity allows.

A client with a recent, surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the client whether family members could be trained in stoma care B. Has another client with a stoma—who performs self-care—come and talk with the client C. Requests that the health care provider request antidepressants and a psychiatric consult for the client D. Suggests that the health care provider request a home health consultation for the client, so that stoma care can be performed by a home health nurse

B. Has another client with a stoma—who performs self-care—come and talk with the client Rationale A. If at all possible, the client should perform her or his own stoma care so that he or she can be as independent as possible. B. Talking with another client who successfully cares for his or her stoma may give the client the confidence to begin his or her own self-care. C. Although the client may need medication for depression, the priority is to encourage the client to look at, touch, and begin caring for the stoma. D. The client must perform his or her own stoma care, if at all possible. A home health nurse can be a support but cannot provide all of the care that the client will need.

After a cerebrovascular accident (CVA), a client with right-sided hemiplegia is in a rehabilitation unit. Which nursing intervention is effective in promoting the client's independence? A. Assisting the client with all of his or her ADLs B. Instructing the client step-by-step on how to put on his or her robe C. Telling the client to do the "best" that he or she can do D. Sending the client to a long-term care facility

B. Instructing the client step-by-step on how to put on his or her robe Rationale A. Assisting the client with all of the ADLs will not support the client's independence. B. Instructing the client (step-by-step) on how to put on a garment provides direct teaching of skills, which promotes independence for the client. C. Telling the client to do her or his best does not help teach new skills and may even add to the client's frustration. D. Sending the client to a long-term care facility will not support the client in gaining independence.

Situation: A 28-year-old comes to the clinic with a history of recurrent episodes of diarrhea or constipation and abdominal pain with bloating. The client is diagnosed with irritable bowel syndrome (IBS). The client is discharged home with a variety of medications for the symptoms of IBS. Upon returning to the clinic, the client states, "Most of my symptoms have improved—except for the diarrhea." What does the health care provider prescribe for this client? A. Antidiarrheal agent B. Muscarinic receptor agonist C. Serotonin antagonist D. Tricyclic antidepressant

B. Muscarinic receptor agonist Rationale A. Antidiarrheal agents are not the most effective choices for this client. B. A muscarinic (M3)-receptor antagonist can also inhibit intestinal motility. C. Serotonin antagonists will not be the most effective choices for the client's diarrhea. D. A tricyclic antidepressant is not going to be effective for this client's diarrhea.

A client is struggling with the use of eating utensils. Which rehabilitation team member is brought in to help the client with this problem? A. Activity therapist B. Occupational therapist C. Physiatrist D. Physical therapist

B. Occupational therapist Rationale A. The recreational or activity therapist works to help the client continue or develop hobbies or interests. B. The occupational therapist works to develop the client's fine motor skills used for ADLs, such as those required for eating, maintaining hygiene, dressing, and driving. C. The physiatrist is a physician who specializes in rehabilitative medicine. This rehabilitation team member is not the best resource for this situation. D. The physical therapist helps the client achieve mobility (e.g., by facilitating ambulation and teaching the client to use a walker).

A client with a recent diagnosis of acute gastritis needs health teaching about nutrition therapy. Which foods and beverages should the nurse teach the client to avoid? Select all that apply. A. Potatoes B. Onions C. Apples D. Milk E. Orange juice F. Tomato juice

B. Onions E. Orange juice F. Tomato juice

Situation: An 82-year-old woman is admitted to the transitional care unit at your institution for stroke rehabilitation with a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her blood pressure (BP) is currently controlled with antihypertensive medications. The unlicensed nursing personnel (UAP) reports that the client's systolic blood pressure drops by 20 mm Hg when she gets her out of bed. What is the cause of the change in blood pressure? A. Her stroke is worsening—becoming more acute. B. Orthostatic hypotension is exacerbated by antihypertensive medications. C. The dose of her antihypertensive medication is too high. D. The dose of her antihypertensive medication is too

B. Orthostatic hypotension is exacerbated by antihypertensive medications. Rationale A. Worsening of the client's cerebrovascular accident (CVA) would be characterized by an increase, rather than a decrease, in BP. The client is experiencing orthostatic hypotension. B. If the client moves from a lying to a sitting position too quickly, her blood pressure drops. This problem is worsened by antihypertensive medications, especially in older adults. C. The situation does not supply the dosage or the type of antihypertensive medication that the client is receiving, so it is impossible to determine whether it is too high. The client is experiencing orthostatic hypotension. D. The situation does not supply the dosage or the type of antihypertensive medication that the client is receiving, so it is impossible to determine whether it is too low. If it were too low, the client's BP would be higher, not lower. The client is experiencing orthostatic hypotension.

The nurse is reviewing admitting requests for a client admitted to the intensive care unit with perforation of a duodenal ulcer. Which request will the nurse implement first? A. Apply antiembolism stockings. B. Place nasogastric (NG) tube, and connect to suction. C. Insert an indwelling catheter, and check output hourly. D. Give famotidine (Pepcid) 20 mg IV every 12 hours.

B. Place nasogastric (NG) tube, and connect to suction. Rationale A. Antiembolism stockings will need to be applied to prevent thromboembolism, but the nurse's immediate priority is to minimize the risk for peritonitis. B. To decrease spillage of duodenal contents into the peritoneum, NG suction should be rapidly initiated. This will minimize the risk for peritonitis. C. Monitoring output is important, but the nurse's first priority is to minimize the risk for peritonitis. D. Famotidine (Pepcid) will need to be administered, but the nurse's immediate priority is to minimize the risk for peritonitis.

Which nursing action is best for the charge nurse to delegate to an experienced licensed practical nurse/vocational nurse (LPN/LVN)? A. Re-tape the nasogastric tube for a client who has had a subtotal gastrectomy and vagotomy. B. Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis. C. Document instructions for a client with chronic gastritis about how to use "triple therapy." D. Assess the gag reflex for a client who has arrived from the postanesthesia care unit (PACU) after a laparoscopic gastrectomy.

B. Reinforce the teaching about avoiding alcohol and caffeine for a client with chronic gastritis.

A paraplegic client with injury to the sixth thoracic vertebra has urinary incontinence that is assessed as "sudden and gushing." When catheterized after being incontinent, urine remains in the client's bladder. Which bladder training technique does the nurse recommend for this client? A. Providing a high-fiber diet B. Scheduling intermittent catheterizations C. Taking an antispasmodic medication as prescribed D. Using the Valsalva and Credé maneuvers

B. Scheduling intermittent catheterizations Rationale A. A high-fiber diet is used for bowel, not bladder, training. B. Intermittent catheterization may be used for disorders that involve a flaccid or spastic bladder. C. Antispasmodics may be used for mild overactive bladder, but they would not be an effective choice for the client with residual urine in the bladder. D. Valsalva and Credé maneuvers are best used for the client with a flaccid bladder.

An 88-year-old woman is admitted for cardiac rehabilitation after an insertion of two coronary artery stents. While ambulating with her walker, the client reports chest pain. What is the nurse's first action? A. Take her heart rate and blood pressure. B. Stop her activity and provide a rest period. C. Call her health care provider immediately. D. Perform a stat electrocardiogram.

B. Stop her activity and provide a rest period. Rationale A. After having the client cease activity, the nurse should check the client's vital signs. The client may be experiencing a decrease in cardiac output, and her activity tolerance has been reached. The nurse should check the client's heart rate and blood pressure after assisting her into a comfortable position for rest. Reference: p. 94, Physiological Integrity B. The nurse should instruct the client to stop ambulating and allow her to rest. Reference: p. 94, Physiological Integrity C. Additional assessment data, such as vital signs, will need to be collected before calling the health care provider. Reference: p. 94, Physiological Integrity D. Obtaining an electrocardiogram will be part of the assessment data collected by the nurse. The electrocardiogram should be performed only after the client has stopped ambulating and vital signs are assessed. Reference: p. 94, Physiological Integrity

A nurse is reinforcing the physical therapist's teaching on gait training for a client who had a total knee replacement 6 weeks ago. Which ambulatory aid does the nurse expect the client to be using? A. Crutches B. Straight cane C. Walker with a built-in seat D. Walker with rollers

B. Straight cane Rationale A. After 6 weeks, the client should be weight-bearing on the affected knee. Crutches would have been used earlier in the rehabilitation process. B. A straight cane is the most likely ambulatory aid for a client who is 6 weeks post surgery from a knee replacement. The client should be weight-bearing, with some assistance, on the affected leg. C. Clients who need assistance with both weight bearing and balance would be using a walker. Specialized walkers with a seat (for resting) are especially helpful for clients who tire easily. No indication suggests that this client has those needs. D. Clients who need assistance with both weight bearing and balance would be using a walker. No indication suggests that this client has those needs.

A client attending a summer camp develops an Escherichia coli infection. What does the camp nurse tell campers about how to prevent this infection? A. "Do not touch other campers' towels or bed linens." B. "Don't use dishes or eating utensils that are not disposable." C. "If you are swimming, avoid swallowing the water." D. "You should avoid drinking pasteurized dairy products."

C. "If you are swimming, avoid swallowing the water."

Situation: The client is a 66-year-old man with colorectal cancer (CRC). He was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to his treatment regimen. He also reports peripheral sensory neuropathy. What does the nurse tell him about his diarrhea and mouth ulcers? A. "A combination of chemotherapeutic agents has caused them." B. "GI problems are symptoms of the advanced stage of your disease." C. "5-FU cannot discriminate between your cancer and your healthy cells." D. "You have these as a result of the radiation treatment."

C. "5-FU cannot discriminate between your cancer and your healthy cells."

A home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates correct understanding of the instructions? A. "A dark or purplish-looking stoma is normal and should not concern me." B. "If the skin around the stoma is red or scratched, it will heal soon." C. "I need to check for leakage underneath my colostomy." D. "I should strive for a very tight fit when applying the barrier around the stoma."

C. "I need to check for leakage underneath my colostomy."

The partner of a newly diagnosed paraplegic client says, "I don't know how I am going to manage a job, care for my partner, and take care of the family." How does the nurse respond? A. "Can you quit your job?" B. "How did you handle challenges before your partner was injured?" C. "Let's see what resources are available to help." D. "Things will get better and you will be fine."

C. "Let's see what resources are available to help." Rationale A. Quitting a job is typically not an option. This is a closed question that requires a "yes" or "no" answer, so it does not encourage problem solving. B. The partner's previous stressors most likely were not as overwhelming as this one. Therefore this response is irrelevant. C. Suggesting helpful resources is the most effective response. The partner will know that support is available and can access it. D. Telling the client's partner that he or she will "be fine" minimizes the current situation. It is giving false reassurance and is a nontherapeutic response.

The nurse is mentoring a nursing student about best practices for safe patient handling (SPH). What practice does the nurse teach the student? A. "Keep the client at arm's length to maximize your leverage in moving him or her." B. "Place your feet at right angles to the client's feet to stabilize yourself." C. "Put the bed at the correct height-waist level for care and hip level for movement of the client." D. "Try to keep the client positioned to your side so that you can benefit from a rotating motion when moving him or her."

C. "Put the bed at the correct height-waist level for care and hip level for movement of the client." Rationale A. The client is kept as close to the body of the person transferring as possible. B. A wide base of support should be maintained from a position in front of the client, not at right angles. C. Positioning the bed at the proper height keeps the student from straining or injuring the back. D. The client should be positioned in front of the student to prevent the student's spine from rotating.

Situation: An 82-year-old woman is admitted to the transitional care unit institution for stroke rehabilitation. She has a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her bladder and bowel patterns are altered as a result of an uninhibited bowel and bladder. Her bowel training program has been successful. She now regularly takes psyllium hydrophilic mucilloid (Metamucil) daily. What does the nurse teach the client about taking her medications? A. "Do not take your Metamucil within 12 hours of any other medication." B. "Take the Metamucil with only two other medications." C. "Take your Metamucil at least 3 hours apart from other medications." D. "You can take your Metamucil with other medications with no problems."

C. "Take your Metamucil at least 3 hours apart from other medications." Rationale A. The client needs to wait only 3 hours from taking other mediations when taking Metamucil. B. Because Metamucil can interfere with drug absorption, taking it with two other medications would not be a therapeutic practice. C. Metamucil may bind with some drugs, such as anticoagulants, thyroid replacements, and digoxin, preventing their absorption. Timing of this drug is best when it is separated from other prescribed drugs by at least 3 hours. D. Because Metamucil can interfere with drug absorption, taking it with other medications would not be a therapeutic practice.

Situation: An 82-year-old woman is admitted to the transitional care unit for stroke rehabilitation with a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her bladder and bowel patterns are altered as a result of an uninhibited bowel and bladder. Bowel training has been unsuccessful despite consistent toileting and dietary modification. This client has just received a glycerin suppository. How soon after administration would you expect results to be evident? A. 5 to 10 minutes B. 10 to 15 minutes C. 15 to 30 minutes D. 30 to 45 minutes

C. 15 to 30 minutes Rationale A. 5 to 10 minutes is not enough time for a glycerin suppository to be effective. The mechanism of action requires a longer time period—between 15 and 30 minutes. B. 10 to 15 minutes is not enough time for a glycerin suppository to be effective. The mechanism of action requires a longer time period—between 15 and 30 minutes. C. Glycerin suppository agents are often used in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the sacral arc and promote rectal emptying, which occurs within 15 to 30 minutes after administration. D. Action from the suppository should have occurred by 30 minutes after insertion.

The nurse finds a client vomiting coffee ground-type material. On assessment, the client has blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention will be the nurse's first priority? A. Administering an H2 antagonist B. Initiating enteral nutrition C. Administering intravenous (IV) fluids D. Administering antianxiety medication

C. Administering intravenous (IV) fluids Rationale A. Administration of an H2 antagonist will not treat the basic problem, which is upper GI bleeding. B. Enteral nutrition will not be part of the treatment plan for acute GI bleeding. C. Administration of IV fluids is necessary to treat the hypovolemia caused by acute GI bleeding. D. Administration of antianxiety medication will not treat the basic problem causing the client's change in mental status, which is hypovolemia.

The health care provider prescribes sulfasalazine (Azulfidine) for a client with ulcerative colitis. What nursing action is most important before the client begins the medication? A. Determine if the client's insurance pays for the drug. B. Ask the client if he smokes or drinks alcohol. C. Ask the client if he has any allergies to sulfa-type drugs. D. Teach the client the importance of avoiding crowds.

C. Ask the client if he has any allergies to sulfa-type drugs.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to a home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? A. Instructing the client about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the client's medicine cabinet C. Checking and reporting the client's heart rate and blood pressure—in lying, sitting, and standing positions D. Teaching the client how to clean the perineal area after each loose stool

C. Checking and reporting the client's heart rate and blood pressure—in lying, sitting, and standing positions Rationale A. Teaching is a complex skill that should be performed by licensed nurses who have the education and scope of practice needed to safely implement this action. B. Medication administration is a complex skill that should be performed by licensed nurses who have the education and scope of practice needed to safely implement this action. C. Obtaining blood pressure and heart rate is included in the education of home health aides and other unlicensed assistive personnel (UAP). D. Teaching is a complex skill that should be performed by licensed nurses who have the education and scope of practice needed to safely implement this action.

The nurse and the dietitian are planning sample diet menus for the client who is experiencing dumping syndrome. Which sample meal is best for this client? A. Chicken salad on whole wheat bread B. Liver and onions C. Chicken and rice D. Cobb salad with buttermilk ranch dressing

C. Chicken and rice Rationale A. The client with dumping syndrome will not be allowed to have any mayonnaise and can have whole wheat bread only in very limited amounts. B. The client with dumping syndrome will not be allowed to have onions. C. Chicken and rice is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. D. The client with dumping syndrome will not be allowed to have the buttermilk ranch dressing because it is made from milk products.

A nurse case manager is discussing community resources with a client who has colorectal cancer (CRC) and is scheduled for a colostomy. Which referral is of greatest value to this client initially? A. Certified Wound, Ostomy, Continence Nurse (CWOCN) B. Home health nursing agency C. Hospice D. Hospital chaplain

C. Hospice

A quadriplegic client is recovering from an accident. What psychosocial priority problem does the rehabilitation nurse establish for this client? A. Constipation related to neurologic impairment B. Impaired Physical Mobility related to neuromuscular impairment, sensory-perceptual impairment, and/or pain C. Ineffective Coping related to situational crisis and/or inadequate time to prepare for stressor D. Potential for skin breakdown related to altered sensation and/or altered nutritional state

C. Ineffective Coping related to situational crisis and/or inadequate time to prepare for stressor Rationale A. Constipation is a physical, not a psychosocial assessment, diagnosis. B. Impaired Physical Mobility is a physical, not a psychosocial assessment, diagnosis. C. Ineffective Coping is a likely psychosocial assessment diagnosis for this client. D. Risk for Impaired Skin Integrity is a physical, not a psychosocial assessment, diagnosis.

The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed esomeprazole (Nexium). The nurse plans to contact the health care provider if the client is taking which medication? A. Acetaminophen (Tylenol) B. Furosemide (Lasix) C. Iron salts D. Prednisone (Deltasone)

C. Iron salts Rationale A. Acetaminophen (Tylenol) is an analgesic and does not interact with esomeprazole (Nexium). B. Furosemide (Lasix) is a loop diuretic and does not interact with esomeprazole (Nexium). C. Iron salts may alter the effects and absorption of esomeprazole (Nexium). D. Prednisone (Deltasone) is a glucocorticoid and does not interact with esomeprazole (Nexium).

A rehabilitation client is being discharged home. Which nursing intervention provides the best assessment for home modification while helping diminish the client's anxiety about the process of discharge? A. Doing discharge teaching B. Having a home visit made by the case manager C. Making a leave of absence (LOA) visit possible D. Performing a predischarge assessment

C. Making a leave of absence (LOA) visit possible Rationale A. Discharge teaching helps with the client's adaptation to managing care at home but does not address home modification. B. After discharge to home, various health care resources (e.g., physical therapy, home care nursing, vocational counseling) are available to the client with chronic illness and disability, but this time is often too late for home modification. C. One method of assessing the client's home is through a brief home visit, also called a leave of absence (LOA) visit, before discharge. This is a very effective method of helping the client prepare for the transition home, thus reducing any anxiety that the client may have. D. Before discharge, the case manager or occupational therapist may visit the home to assess its layout and accessibility, but this does not allay the client's apprehension and anxiety.

Following a fall, a 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. Which transfer technique is indicated for this client? A. Bear hug technique B. Cane-assisted transfer C. Mechanical lift D. Sliding board

C. Mechanical lift Rationale A. In the past, nurses and therapists used a bear hug technique to lift the client from bed to chair and back again. However, because heavy lifting can result in back injury, many facilities have adopted a "no lift" policy and rely on other methods for client transfers. B. A cane will hinder transfer of the client. C. Mechanical lifts use slings to lift, transfer, move, and reposition immobile clients. Because the client is older and has a broken collarbone and is unable to use both arms to independently transfer safely, a mechanical lift is the best method for moving this client. D. Sliding boards are typically used for transferring quadriplegic clients.

Which of these assigned clients will the nurse assess first after receiving change-of-shift report? A. Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography scan in 30 minutes B. Adult with gastroesophageal reflux disease who is describing epigastric pain at a level 6 (0 to 10 pain scale) C. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright red drainage from the nasogastric (NG) tube D. Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as needed (PRN) basis

C. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright red drainage from the nasogastric (NG) tube Rationale A. This client is stable and is scheduled for a test that does not require the nurse's immediate attention. B. This client, although in pain, does not require the nurse's immediate attention. C. The presence of blood in the NG drainage is an unexpected finding 2 days after esophagogastrectomy and requires immediate investigation. D. This client is in stable condition and does not require the nurse's immediate attention.

Situation: A 28-year-old comes to the clinic with a history of recurrent episodes of diarrhea or constipation and reports of abdominal pain and bloating. The client is diagnosed with irritable bowel syndrome (IBS). What OTC medications does a nurse suspect as a possible cause of the client's problem? A. Antihistamines B. Cough syrup C. Nonsteroidal anti-inflammatory drugs (NSAIDs) D. Sleeping pills

C. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A client with a traumatic brain injury is admitted to the rehabilitation unit. Which rehabilitation team member does the nurse assign to develop the plan to improve the client's ability to bathe and dress independently? A. Activity therapist B. Cognitive therapist C. Occupational therapist D. Physical therapist

C. Occupational therapist Rationale A. The activity therapist will assist the client with other aspects of rehabilitation such as diversional activities, games, etc. B. The cognitive therapist will assist the client with other aspects of rehabilitation such as learning, remembering, etc. C. Occupational therapists work with clients to develop skills used for self-care, such as hygiene and dressing. D. The physical therapist will assist the client with other aspects of rehabilitation such as mobility, that is, walking, balancing, etc.

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client? A. LPN/LVN who has worked with many home health clients after colostomy surgeries B. LPN/LVN with 20 years of experience in the home health agency C. RN who is new to the agency with 5 years experience in the emergency department (ED) D. Social worker who is experienced with case management of older clients

C. RN who is new to the agency with 5 years experience in the emergency department (ED)

Which staff member does the manager of an inpatient rehabilitation unit assign as the case manager for a stroke client with physical and speech deficits? A. Physical therapist B. Recreational therapist C. Rehabilitation nurse D. Speech-language pathologist

C. Rehabilitation nurse Rationale A. The physical therapist will assist with specific aspects of the client's care (e.g., mobility) but is not responsible for coordination of care. B. The recreational therapist will assist with specific aspects of the client's care (e.g., recreation, diversional activities) but is not responsible for coordination of care. C. The rehabilitation RN coordinates the efforts of the team members and may be designated as the client's case manager. D. The speech-language pathologist will assist with specific aspects of the client's care (e.g., speaking, swallowing) but will not be responsible for coordination of care.

Which nursing intervention does the rehabilitation nurse delegate to a nursing assistant who is caring for a 70-year-old client who has right-sided weakness following a stroke? A. Arrange for family members to participate in planning for discharge. B. Determine whether the client's passive range-of-motion (ROM) exercises should be increased. C. Reinforce the client's placing the right arm in the sleeve first when dressing. D. Teach the client to use an extended shoe horn when putting on shoes.

C. Reinforce the client's placing the right arm in the sleeve first when dressing. Rationale A. Planning for discharge requires broader education and scope of practice and should be done by a licensed staff member such as the RN. B. Assessing passive ROM exercises requires broader education and scope of practice and should be done by a licensed staff member such as the physical therapist. C. Reinforcement of skills that have been taught by the occupational therapist or nurse is an action that should be done by all caregivers who are involved in the client's care. D. Teaching the use of a shoe horn requires broader education and scope of practice and should be done by a licensed staff member such as the occupational therapist.

A client with an exacerbation of ulcerative colitis (UC) has been prescribed a low-residue diet. Which meal does the nurse help the client select? A. Chef's salad B. Fried chicken with rice, cooked green beans C. Scrambled eggs, white toast with margarine D. Tuna salad sandwich on whole wheat bread

C. Scrambled eggs, white toast with margarine Rationale A. Chef's salad is inappropriate for the client on a low-residue diet because of the raw vegetables it contains. B. Fried chicken is inappropriate for the client on a low-residue diet. C. Scrambled eggs and white toast are considered appropriate for the client on a low-residue diet. D. Whole wheat bread is inappropriate for the client on a low-residue diet.

. A nurse is caring for a client who returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's D. Supine

C. Semi-Fowler's Rationale A. High Fowler's position would be too high for the client postoperatively. It would place strain on the abdominal incision(s), and, if the client was still drowsy from anesthesia, this position does not enhance the client's ability to rest. B. Sims' position does not promote drainage to the lower abdomen. C. The client is maintained in semi-Fowler's position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion. D. The supine position does not facilitate drainage to the abdomen or increased lung expansion. The client would be more likely to develop complications (wound drainage stasis and atelectasis) in this position.

After an automobile accident, a client is admitted to the emergency department (ED) with possible abdominal trauma. Which health care provider request does the nurse implement first? A. Inserts a nasogastric tube and connects it to intermittent suction B. Obtains a complete blood count and coagulation panel C. Starts an IV line and infuses normal saline at 200 mL/hr D. Takes the client for a computed tomography (CT) scan of the abdomen

C. Starts an IV line and infuses normal saline at 200 mL/hr NEED TO GET IV ACCESS FIRST!!

Situation: A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made, and she is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in her medication regimen? A. Stop the corticosteroid therapy. B. Stop the sulfasalazine (Azulfidine). C. Taper the corticosteroid therapy. D. Taper the sulfasalazine (Azulfidine).

C. Taper the corticosteroid therapy. Rationale A. Stopping corticosteroid therapy abruptly is unsafe. Steroids must be gradually decreased in clients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. B. Sulfasalazine (Azulfidine) therapy for the client will be given on a long-term basis. It may be increased or decreased, depending on the client's symptoms. These decisions are made over a long period of therapy. C. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period. D. Sulfasalazine (Azulfidine) therapy for the client will be given on a long-term basis. It may be increased or decreased, depending on the client's symptoms. These decisions are made over a long period of therapy. This drug would not be decreased any time soon (if ever) for the client.

A client with gastroesophageal reflux disease (GERD) is newly diagnosed by the nurse practitioner, who prescribes pantoprazole (Protonix) 40 mg. What teaching will the nurse provide for this client about this drug? A. "Be sure to take this drug every day until you feel better." B. "Do not take the drug with tomato-based foods or drinks." C. "Be aware that this drug can cause anxiety and restlessness." D. "Do not crush the drug because it has a delayed release."

D. "Do not crush the drug because it has a delayed release." Rationale A. The client should continue to take the medication even after the GERD-associated symptoms are relieved; if the medication is stopped, the symptoms will return. Reference: p. 1208, Physiological Integrity B. Although clients with GERD should limit their intake of acidic foods, no specific food-drug interactions have been documented for Protonix. Reference: p. 1208, Physiological Integrity C. Anxiety and restlessness is not a common adverse effect documented with Protonix. Reference: p. 1208, Physiological Integrity D. Protonix is a delayed-release medication; the client should be informed to not crush, break, or chew delayed-release tablets. Reference: p. 1208, Physiological Integrity

Which statement by a newly paraplegic client indicates a need for the nurse to provide further teaching about his bowel retraining? A. "I need to eat lots of high-fiber foods like beans and raw fruits." B. "I will drink at least 2 quarts of water or other liquids every day." C. "I'll take oral laxatives every morning so I can go every day." D. "I plan to exercise by lifting weights and propelling my wheelchair."

D. "I plan to exercise by lifting weights and propelling my wheelchair." Rationale A. Increasing fiber intake and an adequate water intake are important components of a bowel retraining program. Reference: p. 104, Physiological Integrity B. Increasing fiber intake and an adequate water intake are important components of a bowel retraining program. Reference: p. 104, Physiological Integrity C. Many clients with neurologic impairment receive oral or rectal laxatives to assist with bowel management. Reference: p. 104, Physiological Integrity D. Lifting weights and propelling the wheelchair are not common components of a bowel retraining regimen. Reference: p. 104, Physiological Integrity

A Certified Wound, Ostomy, Continence Nurse (CWOCN) is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects correct understanding of the necessary self-management skills? A. "I can get my spouse to change the bag for me." B. "If I have any leakage, I'll put a towel over it." C. "I need to call my home health nurse to come out if I have any problems." D. "I will make certain that I always have an extra bag available."

D. "I will make certain that I always have an extra bag available." Rationale This is the only statement illustrating that the client is taking responsibility to care for the colostomy.

Situation: An 82-year-old woman is admitted to the transitional care unit for stroke rehabilitation. She has a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her bladder and bowel training has been successful, and she is being discharged. Before going home, she asks what foods she should eat to prevent constipation. How does the nurse respond? A. "Continue on a soft diet because this will help maintain bowel elimination." B. "Decrease your fluid intake to maintain your bowel elimination." C. "Eat at least 2 slices of whole wheat bread daily to maintain bowel elimination." D. "Increase your fiber intake through fruits, vegetables, beans, and unsalted nuts to maintain your bowel elimination."

D. "Increase your fiber intake through fruits, vegetables, beans, and unsalted nuts to maintain your bowel elimination." Rationale A. The client needs fluids and fiber in her diet, not a soft diet. B. The client needs to increase, rather than decrease, fluid intake to promote renal and bowel health. C. Eating 2 slices of whole wheat bread would be helpful but is only a start in meeting the dietary needs of the client for preventing constipation. D. For clients at risk for constipation, encourage fluids and plenty of fiber in the diet, such as whole grains, celery, fruits, and nuts.

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? A. "An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." B. "It is inherited, so it could run in your family." C. "It might be caused by a virus, so you could have gotten it almost anywhere." D. "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."

D. "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond? A. "Have you asked your health care provider what he or she thinks your chances are?" B. "It is hard to know what can predispose a person to develop a certain disease." C. "No. Just because they both had CRC doesn't mean that you will have it, too." D. "The only way to know whether you have a predisposition to CRC is by genetic testing."

D. "The only way to know whether you have a predisposition to CRC is by genetic testing."

A recently injured paraplegic client is in rehabilitation. Which client comment indicates that he or she is adapting to new self-care activities? A. "I am so tired today, I want to rest." B. "I don't want to do this today." C. "My dog can do this—why can't I do it too?" D. "This isn't working; I need to try something else."

D. "This isn't working; I need to try something else." Rationale A. This comment can be indicative of depression. The client is not trying to do "more" but rather "less." B. This comment can be indicative of depression or denial. The client is not even making an effort to engage in self-care. C. This comment exhibits extreme frustration. The client sounds angry, which should be explored to be better understood. D. This comment indicates an overall willingness to try on the client's part. When one method failed, the client was motivated to try something else.

Situation: The client is a 66-year-old man with colorectal cancer. He is started on 5-fluorouracil (5-FU) and experiences fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), is added to his treatment regimen. He takes this medication for several weeks and develops peripheral neuropathies. The health care provider discontinues the oxaliplatin and starts him on cetuximab (Erbitux). The client asks how this "new" medication works. How does the nurse respond? A. "It works by destroying the cancer's cell wall, which will kill the cell." B. "It works by decreasing blood flow to rapidly dividing cancer cells." C. "This drug works by stimulating the body's immune system and stunts cancer growth." D. "This medication works by binding to a growth factor receptor and decreases cell growth."

D. "This medication works by binding to a growth factor receptor and decreases cell growth."

Situation: A 21-year-old woman has abdominal pain, cramping, and diarrhea. She reports having 10 to 12 liquid, bloody stools per day. A stool sample for ova and parasites is negative. A diagnosis of ulcerative colitis (UC) is made, and she is started on sulfasalazine (Azulfidine). What does the nurse tell her about why she is receiving this therapy? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced."

D. "Your intestinal inflammation will be reduced."

The client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea? A. Ensure that the client takes adequate amounts of fluids with meals. B. Advance the diet to solid food and encourage the client to eat as much as possible at meals. C. Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal. D. Encourage the client to take fluids between meals rather than with meals.

D. Encourage the client to take fluids between meals rather than with meals. Rationale A. For this client, fluids with meals can lead to the development of diarrhea immediately after eating. B. The client may not be physically ready to advance to a solid diet. The client should eat six to eight small meals daily. C. Magnesium hydroxide (Milk of Magnesia) is a magnesium-based antacid that can cause diarrhea. D. Diarrhea is believed to be the result of vagotomy syndrome and can be managed by taking fluids between meals rather than with meals

The nurse reviews a medication history for a client newly diagnosed with peptic ulcer disease (PUD) who has a history of using ibuprofen (Advil, Motrin, others) frequently for chronic knee pain. The nurse anticipates that the health care provider will request which medication for this client? A. Bismuth subsalicylate (Pepto-Bismol) B. Magnesium hydroxide (Maalox, Mylanta) C. Metronidazole (Flagyl) D. Misoprostol (Cytotec)

D. Misoprostol (Cytotec) Rationale A. Bismuth subsalicylate (Pepto-Bismol) is an antidiarrheal drug that contains salicylates, which can cause bleeding and should be avoided in clients who have peptic ulcer disease (PUD). B. Magnesium hydroxide (Maalox, Mylanta) is an antacid that may be used to neutralize stomach secretions but is not used specifically to help prevent NSAID-induced ulcers. C. Metronidazole (Flagyl) is an antimicrobial agent used to treat Helicobacter pylori infection. D. Misoprostol (Cytotec) is a prostaglandin analogue that protects against NSAID-induced ulcers.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? A. Administers medication for pain B. Changes the nasogastric suction level from "intermittent" to "constant" C. Positions the client in high Fowler's position D. Prepares the client for emergency surgery

D. Prepares the client for emergency surgery Rationale A. Pain medication may mask the client's symptoms but will not address the root cause. B. A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use. C. A high Fowler's position will have no effect on an intestinal perforation or peritonitis, which this client is likely experiencing. D. The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention.

A client demonstrates the manifestations of appendicitis with a suspected complication of peritonitis. What is the priority nursing intervention? A. Assessing the client for changes in vital signs B. Medicating the client for pain C. Monitoring for changes in the client's mentation D. Preparing the client for emergency surgery

D. Preparing the client for emergency surgery Rationale A. It is expected that the client will experience changes in vital signs as a result of the infectious process and accompanying pain. Although monitoring the client's vital signs is important, the client has an immediate need to go to surgery. B. Although it is important to medicate the client for pain, it is not the highest priority. C. Although it is important to determine whether the client is experiencing changes in mentation, it is not the highest priority. D. The highest priority for this client is to prepare him or her for emergency surgery so that the source of the infection can be removed.

A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client's bladder training plan, what action does the staff RN advise a new graduate nurse to take with this client? A. Administer a dose of oxybutynin chloride (Ditropan). B. Insert a straight catheter to empty the bladder. C. Reassess the client's bladder volume in 2 hours. D. Remind the client to try the Valsalva maneuver.

D. Remind the client to try the Valsalva maneuver. Rationale A. This medication is useful in mild cases of overactive bladder. B. If the Valsalva maneuver is ineffective, straight catheterization may be used to empty the bladder. C. Because the bladder already holds 700 mL, the nurse should not wait for 2 more hours before taking action to empty the bladder. D. Clients with lower motor neuron problems have a flaccid bladder, and increasing pressure on the bladder with the Valsalva maneuver may help the client void.

A client has a priority problem of skin breakdown related to immobility and incontinence. Which nursing intervention does the rehabilitation RN delegate to a nursing assistant? A. Assessing the client's skin for areas of breakdown B. Developing a schedule for turning the client C. Planning a diet high in protein and calories D. Repositioning the client every 2 hours

D. Repositioning the client every 2 hours Rationale A. Client assessment of skin for integrity requires broader education and critical thinking and should be done by RN staff members. B. Client planning of care (developing a schedule for care) requires broader education and critical thinking and should be done by an RN. C. Client planning for a therapeutic diet requires broader education and critical thinking and should be done by an RN. D. The education and scope of practice of nursing assistants include repositioning of clients.

A client has been hospitalized with a non-life-threatening C-spine neck injury. The interdisciplinary rehabilitation team has worked with the quadriplegic client for 4 months. Which outcome indicates that the team's efforts are effective? A. Constipation now occurs only 3 days a week. B. Mobility requires multiple assistive devices. C. Personal care is performed with help from the family. D. Skin is intact, with no evidence of skin impairment.

D. Skin is intact, with no evidence of skin impairment. Rationale A. A decrease in constipation is not one of the goals of the interdisciplinary rehabilitation team. B. The client with a C-spine neck injury will have no mobility. C. Personal care activities are not part of the interdisciplinary rehabilitation program. D. Healthy intact skin indicates good care by this client's interdisciplinary rehabilitation team.

A 21-year-old with a stab wound to the abdomen has come to the emergency department (ED). Once stabilized, the client is admitted to a medical-surgical unit. What does the admitting nurse do first for this client? A. Administers pain medication B. Assesses skin temperature and color C. Checks on the amount of urine output D. Takes vital signs

D. Takes vital signs

Situation: An 82-year-old woman is admitted to the transitional care unit for stroke rehabilitation. She has a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her blood pressure is currently controlled with antihypertensive medications. Her bladder and bowel patterns are altered as a result of an uninhibited bowel and bladder. Bowel training has been unsuccessful despite consistent toileting and dietary modification. Unlicensed assistive personnel (UAP) reports to the nurse that the client's systolic blood pressure changes by 20 mm Hg when getting her out of bed. Why is bisacodyl (Dulcolax) prescribed for this client? Select all that apply. A. For its action as an effective bladder antispasmodic B. To promote bladder emptying C. To enhance the action of prescribed antihypertensive medications D. To effectively re-establish defecation patterns E. To promote rectal emptying

D. To effectively re-establish defecation patterns E. To promote rectal emptying Rationale Bisacodyl (Dulcolax) and glycerin are agents commonly prescribed by health care providers as suppositories in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the reflex arc.

The client is exhibiting symptoms of gastritis. The nurse is assessing the client to determine whether the form of gastritis being experienced is acute or chronic. Which data are correlated with a diagnosis of chronic gastritis? A. Anorexia, nausea, and vomiting B. Frequent use of corticosteroids C. Hematemesis and anorexia D. Treatment with radiation therapy

D. Treatment with radiation therapy Rationale A. Anorexia, nausea, and vomiting are all symptoms of acute gastritis. B. Corticosteroid use is associated with acute gastritis. C. Hematemesis and anorexia are more likely to be symptoms of acute gastritis. D. Treatment with radiation therapy is known to be associated with the development of chronic gastritis.

A client has an anal fissure. Which nursing intervention most effectively promotes perineal comfort for the client? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using witch hazel wipes to relieve pain

D. Using witch hazel wipes to relieve pain Rationale A. Enemas should be avoided when an anal fissure is present. B. Cold packs should be applied to acute inflammation to diminish discomfort. C. Bulk-forming agents should be used to decrease pain associated with defecation. D. Witch hazel wipes may be effective in relieving the pain associated with anal fissures.

When taking a history of a client diagnosed with a duodenal ulcer, which assessment finding does the nurse expect? A. Severe weight loss B. Pain while eating C. Hematemesis after eating D. Waking at night with pain

D. Waking at night with pain Rationale A. Clients who have a duodenal ulcer are generally well nourished, so weight loss is neither common nor anticipated. Reference: p. 1228, Physiological Integrity B. Duodenal ulcer pain is often relieved by the ingestion of food. Reference: p. 1228, Physiological Integrity C. Melena is more common than hematemesis in clients with a duodenal ulcer; hematemesis is more common than melena in clients with a gastric ulcer. Reference: p. 1228, Physiological Integrity D. The pain associated with duodenal ulcers is often described as occurring 90 minutes to 3 hours after a meal and at night and often awakens the client between 1 and 2 AM. Reference: p. 1228, Physiological Integrity

. A client who had surgery for inflammatory bowel disease (IBD) is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A. A list of medical supply facilities where wound care supplies may be purchased B. Information on proper handwashing techniques to avoid cross-contamination of the client's wound C. Information on the amount of pain medication that the client is allowed to take in each dose D. Written and oral instructions regarding symptoms to report to the health care provider

D. Written and oral instructions regarding symptoms to report to the health care provider