Concepts Exam 1

A patient is recovering from discomfort from a peptic ulcer. The doctor has ordered to advance the patient's diet to solid foods. The patient's lunch tray arrives. Which food should the patient avoid eating? A. Orange B. Milk C. White rice D. Banana

A. Orange When an ulcer is actively causing signs and symptoms, the patient should avoid acidic foods like tomatoes or citric fruits/juices, chocolate, alcohol, fried foods and caffeine.

The nurse is performing a health history for a new client in the clinic. Which should the nurse identify as a risk factor for cellulitis in an​ adult? (Select all that​ apply.) A. Peripheral vascular disease B. Hypertension C. Obesity D. Diabetes mellitus E. Impetigo

A. Peripheral vascular disease C. Obesity D. Diabetes mellitus

T or F: cellulitis can be localized or can cover an entire limb

TRUE

The nurse is evaluating a client's pain. When documenting the pain assessment, the nurse should take into consideration what information about pain? a.Whatever the client says it is b.Described only in objective terms c.The same for everyone d.Managed only through opioid intervention

a.Whatever the client says it is

The nurse is evaluating a client's pain. The client states that the pain is at level 2. The client is indicating which aspect of pain assessment? a.Duration b.Intensity c.Quality d.Onset

b.Intensity

The nurse is caring for a toddler who is experiencing a painful medical procedure. Which nursing intervention would be most appropriate? a.Offer a pacifier to the toddler b.Offer distractions such as toys or treats to the toddler. c.Assist the toddler in guided imagery. d.Have parent swaddle the toddler.

b.Offer distractions such as toys or treats to the toddler.

A hospice nurse caring for a terminally ill client should adjust the dose of morphine administered to the client based on which assessment? a.Level of consciousness b.Pain assessment c.Request of family member d.Blood pressure

b.Pain assessment

When describing pain, the client reports having a dull, aching pain. The nurse determines the client's pain is most likely of what type? a.Neuropathic pain b.Visceral pain c.Referred pain d.Phantom pain stenosis

b.Visceral pain

A client indicates an intensity of 8 on the 0-10 pain scale. Which is the most appropriate nursing action to take? a.Check back in 30 minutes to see whether the pain has changed. b.Give pain medication. c.Further assess pain to determine the best intervention. d.Do nothing, because the pain is at a tolerable level.

c.Further assess pain to determine the best intervention.

The nurse assesses which of the following clinical manifestations in a client with osteomyelitis?Select all that apply: A. Night sweatsB . Cool extremities C. Petechiae D. Fever E. Nausea F. Restlessness

A. Night sweats D. Fever E. Nausea F. Restlessness

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate?

Naloxone

"A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nursedetermines a need for additional instruction when the patient says," a. ""I may have an occasional alcoholic drink if I include it in my meal plan."" b. ""I will need a bedtime snack because I take an evening dose of NPH insulin."" c. ""I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia."" d. ""I may eat whatever I want, as long as I use enough insulin to cover the calories.

"D. ""I may eat whatever I want, as long as I use enough insulin to cover the calories."" Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction."

Ordered: D5W 1,000 mL IV over 8 hours. Drip factor 10 gtt/mL. How many drops per minute should this infusion deliver?

21 gtt/min

Ordered Normal Saline 50 mL over 30 minutes. The drip factor is 15 gtt/mL. At what drip rate should this infusion run?

25 gtt/min

The provider has ordered Normal Saline 1,000 mL to be infused over 6 hours. The infusion set delivers 10 gtt/mL (drop factor). What should the drip rate be?

28 gtt/min

A 76 year old female is admitted due to a recent fall. The patient is confused and agitated. The family members report that this is not normal behavior for the patient. They explain that the patient is very active in the community and cares for herself. Based on the information you have gathered about the patient, which physician's order takes priority? A. "Collect a urinalysis" B. "Collect a T3 and T4 level" C. "Insert a Foley Catheter" D. "Keep patient NPO"

A. "Collect a urinalysis" Elderly patients do NOT exhibit the typical signs and symptoms of a UTI. Instead, they may become confused, experience falls, become agitated etc.

he client with osteoarthritis is prescribed the COX-2 inhibitor celecoxib (Celebrex), an nonsteroidal anti-inflammatory drug. Which statement by the client warrants intervention by the nurse? A. "I will take aspirin daily to help prevent heart disease." B. "I am allergic to penicillin and aminoglycosides." C. "I know I'm overweight and I need to lose 50 pounds." D. "I walk 30 minutes at least three times a week."

A. "I will take aspirin daily to help prevent heart disease."

Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply: A. A 53 year old female recovering from abdominal surgery. B. A 69 year old patient who recently received the pneumococcal conjugate vaccine. C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.

A. A 53 year old female recovering from abdominal surgery. C. A 42 year old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.

On your nursing care plan for a patient with a urinary tract infection, which of the following would be appropriate nursing interventions? SELECT-ALL-THAT-APPLY: A. Encourage voiding every 2-3 hours while awake. B. Restrict fluid intake to 1-2 liters per day. C. Monitor intake and output daily. D. The patient verbalizes the importance of using vaginal sprays to decrease reoccurrence of urinary tract infections prior to discharge home.

A. Encourage voiding every 2-3 hours while awake. C. Monitor intake and output daily.

A client is admitted with cellulitis. Which manifestation should the nurse​ monitor? (Select all that​ apply.) A. Fever B. Chills C. Itching D. Headache E. Malaise

A. Fever B. Chills D. Headache E. Malaise

An infant who is severely malnourished is admitted to the hospital. The medical team plans care for this child focusing on which of the following? A. Fostering adequate nutritional intake B.Administering medications C.Providing IV fluids D.Conducting diagnostic studies

A. Fostering adequate nutritional intake

The physician has ordered omeprazole 20 mg twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1 g daily for a client with peptic ulcer disease (PUD). It is most important for the nurse to instruct the client to do which measure when taking these medications? A. Stop the drugs and notify the physician if a rash, hives, or itching develops. B. Consume 8 oz of yogurt or buttermilk daily while on the medication. C. Take the drugs on an empty stomach, 1 hour before breakfast and at least 2 hours after dinner. D.Take the drugs with a full glass of water.

A. Stop the drugs and notify the physician if a rash, hives, or itching develops.

The nurse assigns vital signs to an experienced nursing assistant. The patient has been diagnosed with osteomyelitis. Which vital sign do you want the nursing assistant to report immediately? A. Temperature 99.90 F B. Blood pressure 136/80 C. Heart rate 96/minute D. Respiratory rate 24/minute

A. Temperature 99.90 F

Which of the following would be appropriate nursing interventions for a child with appendicitis? Select all that apply. A.) Administer IV Fluids B.) Monitor temperature and vital signs C.) Maintain a regular diet D.) Administer antibiotics as ordered E.) Administer analgesics as ordered

A.) Administer IV Fluids B.) Monitor temperature and vital signs D.) Administer antibiotics as ordered E.) Administer analgesics as ordered

The nurse is caring for a client with poorly controlled GERD. The nurse is providing education regarding foods that can exacerbate the condition. Which of the following would be an appropriate food for this client to eliminate? A.) Chocolate B.) Whole grain foods C.) Gluten-containing foods D.) Purine-containing foods like organ meats (liver, kidneys)

A.) Chocolate

A patient is diagnosed with Congestive Heart Failure and must follow a specific diet. Which spices are okay for the patient to use daily? A.) Ginger & Bay Leaves B.) Garlic Sodium & Nutmeg C.) Onion Salt & Garlic Powder D.) Sea Salt & Pepper

A.) Ginger & Bay Leaves Patients with CHF should avoid excessive sodium. All of the options expect one contain at least one sodium spice, therefore, Ginger & Bay Leaves are okay to use.

The nurse is caring for a client with an intestinal ulcer who takes sucralfate. The nurse knows to monitor the client for which of the following adverse reactions? Select all that apply. A.) Hematemesis B.) Nausea C.) Melena D.) Diarrhea E.) Oliguria

A.) Hematemesis-cofee-ground emesis, sign of GI bleed C.) Melena-bloody stool, sign of GI bleed

A client has been diagnosed with sickle cell anemia, and the nurse is providing education on sickle cell crisis prevention. Which of the following is the best advice for the nurse to give the client? A.) Increase fluid intake B.) Increase exercise C.)Decrease fatty food intake D.) Promote lots of rest

A.) Increase fluid intake is important to note that management of sickle cell crisis will include hemodilution in the form of IV fluids. Additionally, staying hydrated will help prevent sickling of the cells.

A nurse is providing client education to the parents of a three-year-old who has sickle cell anemia about how to prevent an acute crisis. The nurse accurately includes which of the following in the teaching? Select all that apply. A.) It's very important that your child drinks a lot of fluids B.) Exposure to extreme temperatures may trigger a crisis C.) Your child should get the flu vaccine every year D.) Your child should avoid all types of physical exertion no matter what E.) You may be prescribed an antibiotic to help prevent infections

A.) It's very important that your child drinks a lot of fluids B.) Exposure to extreme temperatures may trigger a crisis C.) Your child should get the flu vaccine every year E.) You may be prescribed an antibiotic to help prevent infections

A client has GERD. What changes should the nurse recommend to improve symptoms? Select all that apply. A.) Lose weight B.) Eat large meals C.) Quit smoking D.) Quit drinking alcohol E.) Raise the foot of the bed 4-6 inches

A.) Lose weight C.) Quit smoking D.) Quit drinking alcohol For the management of gastroesophageal reflux disease (GERD), the head of the bed should be raised 4-6 inches, the client should eat small meals, quit smoking, quit drinking, lose weight, and should not eat within four hours of bedtime. Smoking can cause irritation and worsen GERD.

A client with a peptic ulcer has been brought in to the healthcare clinic and is being assessed by the nurse for an upper GI bleed. Which of the following signs or symptoms would the nurse expect to see with this condition? Select all that apply. A.) Melena B.) Epigastric pain C.) Hematemesis D.) Abdominal fullness E.) Swelling in the lower legs

A.) Melena B.) Epigastric pain C.) Hematemesis

The nurse is reviewing a medication list for a client who reports they take a medication for gastroesophageal reflux. The client asks the nurse to confirm which medication is used for this condition. Which of the following medications is taken for reflux? Select all that apply. A.) Omeprazole B.) Furosemide C.) Fentanyl D.) Metoclopramide

A.) Omeprazole- This medication is a proton pump inhibitor used to treat GERD and ulcers. D.) Metoclopramide- accelerates gastric emptying, strengthens the esophageal sphincter

The nurse is teaching a client who has been diagnosed with peptic ulcer disease about what foods to eat. Which of the following is a food that the client is allowed to eat with this diagnosis? A.) Purine containing foods B.) Coffee C.) Tea D.) Chocolate

A.) Purine containing foods

The nurse is caring for a child with sickle cell anemia. The nurse is discussing with the biological parents of the child the chances of their future children having sickle cell anemia. Which of the following statements by the nurse is correct? A.) There is a 25% chance that your future children will have the disease B.) There is a 25% chance that your future children will be carriers of the genetic trait C.) There is a 75% chance that your future children will have the disease D.) There is a 50% chance that your future children will have the disease

A.) There is a 25% chance that your future children will have the disease Sickle cell anemia is a recessive trait which means both parents have to have the genetic trait to pass it on.

A nurse is caring for a client with chronic alcohol abuse and is concerned the client may have developed pancreatitis. Which of the following signs are indicative of this? Select all that apply. A.) Turner's Sign B.) Chadwick's Sign C.) Goodell's Sign D.) McBurney's Sign E.) Cullen's Sign

A.) Turner's Sign is bruising along the flank that is indicative of pancreatitis. E.) Cullen's Sign is bruising around the umbilicus that is indicative of pancreatitis or inflammation of the pancreas.

ou are providing discharge teaching to a patient taking Sucralfate (Carafate). Which statement by the patient demonstrates they understand how to take this medication? A. "I will take this medication at the same time I take Ranitidine." B. "I will always take this medication on an empty stomach." C. "It is best to take this medication with antacids." D. "I will take this medication once a week."

B. "I will always take this medication on an empty stomach." It should always be taken on an empty stomach without food so it can coat the site of ulceration.

You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material? A. "I'll use hand sanitizer regularly while I'm out in public." B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia." C. "I will try to avoid large crowds of people during the peak of flu season." D. "It is important I try to quit smoking."

B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia."

The nurse is creating a care plan for a client hospitalized for treatment of cellulitis. The cellulitis does not seem to be responding to the antibiotic therapy. Which risk requiring monitoring secondary to this issue should the nurse include in the care​ plan? (Select all that​ apply.) A. Seizures B. Arthritis C. Serious systemic infection D. Renal failure E. Osteomyelitis

B. Arthritis C. Serious systemic infection E. Osteomyelitis

An infant who has clinical manifestations of AOM is brought to an outpatient facility by his parent. The nurse should recognize that which of the following factors places the infant at risk for otitis media? (Select all that apply.) A. Breastfeeding without formula supplementation. B. Attends day care 4 days per week. C. Immunizations are up to date D. History of cleft palate repair. E. Parents smoke cigarettes outside.

B. Attends day care 4 days per week D. History of cleft palate repair. E. Parents smoke cigarettes outside.

Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply: A. Stridor B. Coarse crackles C. Oxygen saturation less than 90% D. Non-productive, nagging cough E. Elevated white blood cells F. Low PCO2 of less than 35 G. Tachypnea

B. Coarse crackles C. Oxygen saturation less than 90% E. Elevated white blood cells G. Tachypnea These are typical signs and symptoms of pneumonia. Stridor is not very common. A PRODUCTIVE cough that can be nagging is very typical, and there is usually a HIGH PCO2 of 45 or greater due to the lungs retaining carbon dioxide.

A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21, oxygen saturation 93% on 2L nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply: A. Keep head-of-the-bed less than 30 degrees at all times. B. Collect sputum cultures. C. Encourage 3L of fluids a day to keep secretions thin. D. Encourage incentive spirometer usage E. Provide education about receiving the Pneumovax vaccine every 5 years.

B. Collect sputum cultures. D. Encourage incentive spirometer usage E. Provide education about receiving the Pneumovax vaccine every 5 years.

A patient has developed a duodenal ulcer. As the nurse, you know that which of the following plays a role in peptic ulcer formation. Select ALL that apply: A. Spicy foods B. Helicobacter pylori C. NSAIDs D. Milk

B. Helicobacter pylori C. NSAIDs Helicobacter pylori and NSAIDS are the most common causes for peptic ulcer formation.

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? A. Apply ice to the affected area. B. Perform sterile dressing changes. C. Instruct the client on leg exercises. D. Measure the leg circumference daily.

B. Perform sterile dressing changes.

A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? (Select all that apply.) A. Decreased pain in the supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying

B. Rolling head side to side C. Loss of appetite E. Crying

When handing a pillow to a postop patient the abdominal incisions who is coughing the nurse understands the pillow is for A. Pain relief B. Splinting C. Distraction D. Anxiety reduction

B. Splinting

The nurse collects a drainage sample to be cultured from the affected area of a client with cellulitis. Which organism should the nurse suspect is the most likely cause of the​ cellulitis? A. Escherichia coli B. Staphylococcus aureus C. Bacillus subtilis D. Group A Streptococcus

B. Staphylococcus aureus

A patient with a peptic ulcer is suddenly vomiting dark coffee ground emesis. On assessment of the abdomen you find bloating and an epigastric mass in the abdomen. Which complication may this patient be experiencing? A. Obstruction of pylorus B. Upper gastrointestinal bleeding C. Perforation D. Peritonitis

B. Upper gastrointestinal bleeding Signs and symptoms of a possible GI bleeding with a peptic ulcer include: vomiting coffee ground emesis along with bloating, and abdominal mass.

The nurse is teaching a client with cellulitis about home care measures to increase comfort. Which instruction should the nurse​ provide? (Select all that​ apply.) A. ​"Apply ice packs to the affected area to reduce​ edema." B. ​"Apply sterile saline dressings to the affected area to promote​ drainage." C. ​"Keep the affected area below the level of the heart to promote​ circulation." D.​ "Wash hands thoroughly before touching the affected​ area." E. ​"Get enough​ rest."

B. ​"Apply sterile saline dressings to the affected area to promote​ drainage." D.​ "Wash hands thoroughly before touching the affected​ area." E. ​"Get enough​ rest."

A 57-year-old client with peptic ulcer disease is being seen for abdominal pain. Which of the following are assessments for hemorrhage in this client? Select all that apply. A.) Recording hourly urinary output B.) Assessing for symptoms of dizziness or nausea C.) Speaking calmly to the client to reduce anxiety D.) Monitoring the client's hemoglobin and hematocrit levels E.) Administering stool softeners

B.) Assessing for symptoms of dizziness or nausea D.) Monitoring the client's hemoglobin and hematocrit levels

A nurse is caring for a client with pancreatitis. Which of the following labs would the nurse NOT expect to see? Select all that apply. A.) Elevated WBC B.) Decreased liver enzymes C.) Hypercalcemia D.) Elevated bilirubin E.) Hypermagnesemia

B.) Decreased liver enzymes C.) Hypercalcemia E.)Hypermagnesemia In pancreatitis, clients are more likely to have INCREASED liver enzymes, not decreased.Pancreatitis creates hypocalcemia, not hypercalcemia. The nurse would expect to see hypomagnesemia, not hypermagnesemia.

A nurse is planning medication administration for a client who has all of the following oral medications due at 0900: Calcium carbonate, Codeine, Levetiracetam, Metoclopramide. What is the most appropriate action by the nurse? A.) Give Codeine 30 minutes before the others B.) Give Calcium carbonate 1 hour after the others C.) Give Metoclopramide 1 hour before the others D.) Give Levetiracetam 30 minutes after the others

B.) Give Calcium carbonate 1 hour after the others Calcium carbonate is an antacid, which should always be given 1 hour after other oral medications, otherwise it may impair absorption of those medications.

The nurse is caring for a client who was just diagnosed with acute pancreatitis. Which of the following is the priority nursing intervention? A.) Monitor for hypoglycemia B.) Maintaining NPO status C.) Pain management D.) Promoting a clear liquid diet

B.) Maintaining NPO status Pancreatic rest (NPO) is key in pancreatitis. Pain occurs due to the release of pancreatic enzymes needed to digest the food. Therefore, NPO is essential.

The nurse is caring for a client who has a kidney stone. Which of the following foods should the nurse teach the client to avoid? Select all that apply. A.) Rice B.) Milk C.) Potato chips D.) Chocolate E.) Grapes

B.) Milk C.) Potato chips D.) Chocolate The nurse should teach the client to avoid dairy products, sodium, oxalated products such as spinach, soda, teas, and chocolate as well as foods with vitamin D. Potato chips contain oxalate and therefore contribute to kidney stones. Chocolate contains oxalate which contributes to kidney stones.

A nurse working in the ER is assessing a 15-year-old client with a history of sickle cell anemia. The client is complaining of extreme pain in the left knee. The nurse knows which of the following interventions should be the top priority? A.) Drawing blood for a complete blood count B.) Placing an IV for fluid administration C.) Putting the client on 2L O2 via nasal cannula D.) Giving 300 mg of ibuprofen

B.) Placing an IV for fluid administration Hydration is the most important intervention for treating sickle cell crises and preventing or correcting the vaso-occlusive crisis.

A client reports to the nurse that she is having a sickle cell crisis. The nurse knows that the client will have which abnormal lab? A.) Platelets B.) Red blood cells C.) Neutrophils D.) Leukocytes

B.) Red blood cells Sickle cell anemia is a condition where the RBCs can become sickled and hemolyze, resulting in a low level of RBCs.

A nursing caring for an eight-year-old with appendicitis knows that the most intense area of pain may be at McBurney's point, which is located where on the abdomen? A.) Left upper quadrant B.) Right lower quadrant C.) Left lower quadrant D.) Right upper quadrant

B.) Right lower quadrant McBurney's Point is located in the right lower quadrant of the abdomen.

A nurse is caring for a client that has been diagnosed with pancreatitis. Which of the following is NOT a complication commonly associated with this disease process? A.) Hypocalcemia B.) Right lung effusion C.) Disseminated intravascular coagulopathy D.) Hypovalemia

B.) Right lung effusion In pancreatitis, effusions are usually seen in the LEFT lung, not right, because of its proximity to the pancreas.

A patient with chronic peptic ulcer disease underwent a gastric resection 1 month ago and is reporting nausea, bloating, and diarrhea 30 minutes after eating. What condition is this patient most likely experiencing? A. Gastroparesis B. Fascia dehiscence C. Dumping Syndrome D. Somogyi effect

C. Dumping Syndrome After a gastric resection the stomach is not able to regulate the movement of food due to the removal of sections of the stomach.

. A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 'F. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia? A. Aspiration pneumonia B. Ventilator acquired pneumonia C. Hospital-acquired pneumonia D. Community-acquired pneumonia

C. Hospital-acquired pneumonia If the patient presents with signs and symptoms of pneumonia 48-72 hours after admission it is classified as hospital-acquired.

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse understands that this condition is most likely to be a result of which events in the client's recent history? A. Sprained left ankle B. Decreased calcium intake C. Open trauma to the left leg D. Starting to smoke cigarettes

C. Open trauma to the left leg

A nurse is caring for a 2-year-old child who has had three ear infections in the past 5 months. The nurse should know that the child is at risk for developing which of the following as a long-term complication? A. Balace difficulties B. Prolonged hearing loss C. Speech delays D. Mastoiditis

C. Speech delays

You're educating a patient with pneumonia on how to deep breathe by using an incentive spirometer. Which of the following is the correct way to use this device? A. Encourage the patient to use it twice a day. B. The patient exhales into the device rapidly and then coughs. C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales. D. The patient rapidly inhales 10 times from the device and then exhales for 6 seconds.

C. The patient inhales slowly from the device until no longer able, and then holds breath for 6 seconds and exhales

The nurse is providing home care instruction to the client with cellulitis. Which​ statement, if made by the​ client, should concern the​ nurse? A. ​"I will keep all​ follow-up appointments with my healthcare​ provider." B. ​"I will be sure to get enough rest and stay off my affected​ leg." C. ​"I will take my antibiotics until the affected area looks less​ red." D. ​"I will keep my affected leg elevated to keep swelling​ down."

C. ​"I will take my antibiotics until the affected area looks less​ red."

A nurse is admitting a client with severe upper abdominal pain, nausea and vomiting, and elevated amylase and lipase. What is the likely diagnosis? A.) Chronic gastritis B.) Liver cirrhosis C.) Acute pancreatitis D.) Acute cholecystitis

C.) Acute pancreatitis Abdominal pain, nausea and vomiting, along with an elevated amylase and lipase usually means the client has acute pancreatitis, and must immediately be put on bowel rest with robust pain management and monitoring for changes in the client's clinical condition.

The client has a chronic peptic ulcer and wants to know the difference between an acute and chronic peptic ulcer. How does the nurse educate the client? A.) H. pylori is present with a chronic ulcer but not with an acute ulcer B.) An acute ulcer lasts only a month and a chronic ulcer lasts greater than one month C.) An acute ulcer is a superficial erosion, while a chronic ulcer extends through the muscular wall of the stomach D.) An acute ulcer is treated with H2 blockers while a chronic ulcer is treated with proton pump inhibitors

C.) An acute ulcer is a superficial erosion, while a chronic ulcer extends through the muscular wall of the stomach

The nurse is caring for a child who has sickle cell anemia. The child's family asks the nurse about a cure for the disease. The nurse explains to the family that the cure for sickle cell anemia is which of the following? A.) Repeated blood transfusions B.) Pneumococcal immunization C.) Bone marrow transplant D.) Increased folate and iron in the diet

C.) Bone marrow transplant Upon bone marrow transplantation, the bone marrow begins to produce healthy red blood cells instead of diseased ones.

A client presents to the clinic with a renal calculus. The nurse knows that which of the following components most commonly makes up a renal calculus? A.) Phosphate B.) Uric acid C.) Calcium D.) Bacteria

C.) Calcium A urinary tract stone is most commonly made up of calcium oxalate. While they are made of calcium, eating fewer oxalate-rich foods, such as chocolate, potato chips, peanuts and beets, can prevent these stones from forming. Getting plenty of calcium can actually prevent stones from forming.

A client presents to the clinic with a history of kidney stones. The client states he is having symptoms of kidney stones again. The nurse knows that which of the following symptom is consistent with this condition? A.) Bloating B.) Anuria C.) Colicky abdominal pain D.) Pus at the urethral meatus

C.) Colicky abdominal pain When a renal calculus travels down the ureter, the client will experience severe pain in the abdomen, groin, or on one side of the back. Other symptoms of renal calculi include discolored or bloody urine, fever, chills, nausea, and vomiting.

The nurse is caring for a client who is recovering from a gastric resection. The nurse provides teaching about how to prevent dumping syndrome. Which of the following statements are correct? Select all that apply. A.) Increase carbohydrate intake B.) Eat two large meals each day C.) Do not consume fluids with meals D.) Lie down after each meal E.) Avoid consuming sugar, salt and milk

C.) Do not consume fluids with meals D.) Lie down after each meal E.) Avoid consuming sugar, salt and milk

The nurse is caring for a client who has been admitted with pancreatitis. Which of the following assessment findings is consistent with this diagnosis? A.) Neutropenia B.) Non-reactive Cullen's sign C.) Flank bruising D.) Weight gain

C.) Flank bruising A client with pancreatitis may have a positive Turner's sign, which is bruising at the flank area.

The nurse is working with a client who has peptic ulcer disease. Which of the following labs is important to monitor with this condition? A.) Procalcitonin B.) Magnesium C.) H/H D.) Lactic acid

C.) H/H

The client is scheduled for a gastric emptying study. Which of the following best describes a gastric emptying study? A.) It involves drinking barium and watching the stomach empty B.) It involves a contrast medium taken orally to assess stomach emptying C.) It is a radionuclide study that scans the stomach emptying D.) It involves a small camera at the end of a flexible tube

C.) It is a radionuclide study that scans the stomach emptying The test involves timing how long the meal takes to get through the stomach.

A client has an amylase of 155. Which of the following organs is being tested with this lab value? A.) Spleen B.) Liver C.) Pancreas D.) Uterus

C.) Pancreas The pancreas produces amylase, an enzyme that breaks down carbohydrates. The normal value for amylase is between 0-130 U/L. This lab is drawn and evaluated most often to diagnose pancreatitis.

The nurse is assessing a client and observes Cullen's sign and Grey Turner's sign. The nurse knows that these are signs of which of the following conditions? A.) Cholecystitis B.) Diverticulitis C.) Pancreatitis D.) Nephritis

C.) Pancreatitis

The nurse is caring for a client who requires treatment for sickle cell disease. Which of the following are treatments for this condition? Select all that apply. A.) Steroid administration B.) Vitamin B12 C.) Steroid splenectomy D.) Folic acid supplement E.) Antibiotics

C.) Steroid splenectomy D.) Folic acid supplement E.) Antibiotics A splenectomy may be necessary if the client has recurrent episodes of splenic sesquestration.Folic acid is used to build up stores of folate, and desferrioxamine is used to chelate iron and decrease iron overload. Antibiotics are to protect the client against infection due to splenic dysfunction.

The nurse is caring for a client who has been diagnosed with appendicitis and is scheduled for surgery later today. Which of the following assessment findings is the MOST concerning? A.) Increased WBC on CBC B.) Abdominal pain at McBurney's point C.) Sudden pain relief D.) Rebound tenderness

C.) Sudden pain relief This is the most concerning because it indicates that the appendix has ruptured.

The parents of a newborn want to speak with a nurse about the chances of their child developing sickle cell disease, since they both have family histories of the condition. Which information should the nurse provide to this family about testing? A.) The child cannot be tested until 1 year of age B.) Testing is done by assessing white blood cell counts and comparing them to red blood cell counts C.) Testing is performed automatically as part of the newborn screening program D.) Most children are not tested unless they demonstrate signs of sickle cell crisis

C.) Testing is performed automatically as part of the newborn screening program

You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. Which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately? A. "I'm seeing yellow halos around the light." B. "My mouth tastes like metal." C. "My head hurts." D. "I have this constant ringing in my ears."

D. "I have this constant ringing in my ears." Vancomycin can cause ototoxicity. Roaring or ringing in the ears are a possible sign/symptom of this adverse effect.

You're providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours." D. "Use scented sanitary napkins or tampons during menstruation."

D. "Use scented sanitary napkins or tampons during menstruation."

You're providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours." D. "Use scented sanitary napkins or tampons during menstruation."

D. "Use scented sanitary napkins or tampons during menstruation." Options A, B, C are all correct statements in how to avoid a UTI. Option D is wrong because the patient should AVOID scented sanitary napkins or tampons during menstruation.

You're assessing your patients during morning rounding. Which patient below is at MOST risk for developing a urinary tract infection? A. A 25 year old patient who finished a regime of antibiotics for strep throat 10 weeks ago. B. A 55 year old female who is post-opt day 7 from hip surgery. C. A 68 year old male who is experiencing nausea and vomiting. D. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence.

D. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence. bowel incontinence increases the risk of a UTI due to the anatomy of the female (short urethra) and the close proximity between the rectum to the urethra.

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support to the family. B. Educate the family on care of the child. C. Prevent clinical complications. D. Administer analgesics.

D. Administer analgesics.

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? A."I'm not supposed to eat cold cuts." B."I can have most fresh fruits and vegetables." C."I'm going to weigh myself daily to be sure I don't gain too much fluid." D."I'm going to have a ham and cheese sandwich and potato chips for lunch."

D."I'm going to have a ham and cheese sandwich and potato chips for lunch."

The nurse is reviewing orders for a client with peptic ulcer disease (PUD). Which of the following would the nurse question? A.) 500 mg calcium carbonate PO QID B.) 20 mg famotidine PO BID C.) 40 mg pantoprazole PO daily D.) 325 mg aspirin PO daily

D.) 325 mg aspirin PO daily

A nurse is caring for a client who is complaining of abdominal pain. Upon inspection of the abdomen, what sign should the nurse be looking for to alert you to potential pancreatitis? A.) McBurney's Sign B.) Murphy's Sign C.) Battle's Sign D.) Cullen's Sign

D.) Cullen's Sign Cullen's sign is bruising located in the umbilicus area and indicates potential pancreatitis.

The nurse is caring for a client admitted for sickle cell crisis. What type of transfusion will the nurse expect to give if the client is anemic? A.) Packed red cells with D5W to maintain glucose level B.) Whole blood transfusion to maintain hemodynamic stability C.) Packed red blood cells to increase hemoglobin and iron D.) Exchange red blood cell transfusions to replace diseased cells

D.) Exchange red blood cell transfusions to replace diseased cells Exchange transfusions are PRBC transfusions that decrease the number of circulating sickle cells.

The nurse is discharging a client who is newly diagnosed with GERD. Which of the following medication prescriptions indicate the presence of this condition? A.) Oxytocin B.) Olanzapine C.) Oxycodone D.) Omeprazole

D.) Omeprazole This medication is a proton pump inhibitor used to treat GERD and ulcers.

The nurse suspects that a client has a duodenal ulcer. Which of the following signs would indicate this condition? A.) Gnawing, sharp pain 30-60 min after eating B.) Hematemesis C.) Pain immediately after eating D.) Pain 1.5-3 hours after eating, relieved by eating

D.) Pain 1.5-3 hours after eating, relieved by eating

A client has a lipase of 405 U/L. The nurse recognizes this to be an issue with which of the following organs? A.) Spleen B.) Gallbladder C.) Liver D.) Pancreas

D.) Pancreas The pancreas produces lipase which is an enzyme used to breakdown fats. The normal range is 23-300 U/L.

The provider has ordered a nephrostomy tube for a client in the nurse's care. How should the nurse explain the procedure for nephrostomy tube placement to the client? A.) The tube is placed into the renal cortex to facilitate excretion B.) The tube is placed through the ureter into the renal pelvis C.) The tube is placed in the ureter above the site of the blockage D.) The tube is placed directly into the kidney to drain urine

D.) The tube is placed directly into the kidney to drain urine