exit k 3

What client response indicates to the nurse that a vasodilator medication is effective?

Blood pressure changes from 154/90 to 126/72

The health care provider prescribes 1000 mL of total parenteral nutrition to be administered in 12 hours. Based on this prescription, how many milliliters of solution should be administered per hour?

83 mL/hr

A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet?

Add extra salt to food,

A nurse reviews the laboratory results of a client with acute pancreatitis. Which test is most significant in determining the client's response to treatment?

Amylase level

During auscultation of the heart, the nurse expects the first heart sound (S1) to be the loudest at the:

Apex of the heart

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask how this could happen in addition to many other questions. Hemophilia A is linked to a deficiency in:

Factor VIII

After a transurethral resection of the prostate, the retention catheter is pulled taut and secured to the client's leg. The client reports a feeling of pressure and asks why this is necessary. What rationale should the nurse include in a response to this question?

Prevents bleeding.

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is:

Shredded Wheat

A nurse is taking care of a client with cirrhosis of the liver. For which clinical manifestations should the nurse assess? Select all that apply.

- Ascites - Pruritus - Jaundice

The nurse notes asystole on the cardiac monitor. The nurse should immediately:

Assess the client's pulse.

While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe?

Atropine sulfate (Atropine)

A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do firs

Begin chest compressions.

A nurse is caring for a client with a diagnosis of cholecystitis. For which clinical manifestation of obstructive jaundice should the nurse assess the client?

Clay-colored stools

A client on a 2-gram-sodium diet states, "I never add salt to my food when I cook. I just need help selecting low sodium foods." After receiving dietary education, the client creates sample menus. The nurse concludes that the client needs further teaching when the client selects:

Cottage cheese, crackers, relish dish (celery, olives, sweet pickles)

A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors?

Listen to the client's fears

To provide comfort for a client who experienced a resection of the pancreas and placement of a T-tube, the nurse should place the client in what position?

Low-Fowler

How should the nurse position a client in the immediate postoperative period after a right pneumonectomy?

On the right side with the head elevated

A client follows a vegetarian diet and must compensate for the lack of vitamin B12 found in food of animal origin. Which food should the nurse encourage the client to consume each day?

One glass of soy milk

A nurse teaches a client about the foods allowed on a 2-gram sodium diet. What foods does the client identify that indicates that the teaching is understood?

Orange and apple juices

A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when:

The tablets are more than three months old.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?

Use lemon juice to season meat

QRS complex represents what?

ventricular depolarization

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply.

- Mental confusion - Flapping hand tremors

A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply

- Oatmeal - Rye bread

A nurse is caring for a client who is scheduled to have an abdominal perineal resection for colorectal cancer. A type and cross match is done because of a concern about blood loss. The client has type B-negative blood. The blood type that can be used for this client is:

B negative

A client is admitted with a diagnosis of duodenal ulcer. Which location is most commonly indicated by the client as being painful when the nurse assesses for the presence of referred pain? C

C female picture

During a colostomy irrigation, a client reports feeling abdominal cramps. What should the nurse do in response to the client's statement?

Clamp the catheter for a few minutes.

Which of the following symptoms indicates to the nurse that the client has an inadequate fluid volume? Select all that apply.

Decreased urine Hypotension Dry mucous membranes Poor skin turgor

A health care provider prescribes famotidine (Pepcid) for a client with dyspepsia. What is important to include about this medication in a teaching program for this client?

Decreases secretions in the stomach

A nurse provides dietary teaching about a low-sodium diet for a client with hypertension. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium?

Fruits

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response?

Heart rate increases from 80 to 135

A blood transfusion of packed cells has been prescribed for a client. The transfusion started five minutes ago and the client is complaining of chest pain and nausea, having difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 99.2 degrees, and the client seems less alert. The nurse suspects:

Hemolytic reaction.

The nurse assesses a client who is receiving total parenteral nutrition for the specific complication of:

Infection

A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema?

Left Sims

Which intervention helps prevent hepatic coma in a client with liver dysfunction?

Restrict dietary protein.

The nurse is performing an abdominal assessment on a client. Where on the abdomen should the nurse assess for McBurney's Point?

Right lower quadrant (RLQ)

A health care provider prescribed 10 mg of morphine immediately and then every 4 hours for a client who had a myocardial infarction. What clinical response will be reduced if the client experiences the intended therapeutic effect of morphine?

Workload of the heart

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?

10 to 12 hours

A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?

2 to 2 ½ inches

When teaching irrigation of a colostomy, how many inches above the stoma should the nurse teach the client to place the container?

30 cm (12 inches)

A client is seen in the clinic with sickle cell anemia. The hemoglobin range that is expected to be seen in this client in sickle cell crisis would be:

6--8g/100 mL,,

A nurse is reviewing a newly admitted client's medication administration record (MAR). The nurse identifies that it is incomplete when the record is lacking information regarding the client's:

Allergies

A low-dose intravenous dopamine hydrochloride (Dopamine) infusion drip is prescribed for a client in acute renal failure (ARF). What is the most appropriate way for the nurse to administer this intravenous medication to the client?

Peripherally inserted central line catheter (PICC) line

What is the normal pathway followed during the cardiac cycle?

SA node, AV node, bundle of His, bundle branches, Purkinje fibers

A nurse advises a client receiving furosemide (Lasix) to increase potassium intake. Which fruit should the nurse encourage the client to eat? Select all that apply.

- Prune - Banana

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply.

- Rye - Oats - Wheat

A client reports pain as a result of a gastric ulcer. What clinical findings is the nurse most likely to identify during an assessment of the client's pain? Select all that apply.

- Vomiting relieves pain. - Pain described as gnawing. - Pain occurs a half hour after meals

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply.

- Weight - Smoking

Part of discharge teaching for a client with a sigmoid colostomy includes how to protect clothing from colostomy leakage. What is the nurse's most appropriate response when the client asks about the use of appliances and dressings?

Many people do not need appliances once they regulate the bowels with routine irrigations.

While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest!" What is the priority nursing action?

Stop the transfusion and administer normal saline.

A nurse is planning education for a parent group related to procedures to be taken if accidental poisoning is suspected. What should the nurse include? Select all that apply.

- Identify the material ingested - Call the poison control center

A client with a long history of alcohol abuse develops acute pancreatitis. What should be done to best prevent stimulation of the pancreas?

dminister the histamine H2-receptor antagonist as prescribed

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed?

Coolness

A nurse is teaching a client about a sodium-restricted diet. What foods should the nurse encourage the client to avoid? Select all that apply.

- Cold cuts - Processed foods

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list? Select all that apply.

- Eggs - Liver - Cheese

During the first 24 hours after open-heart surgery, serosanguineous fluid drains from the client's chest tube. How much drainage should the nurse expect during this period?

400 to 500 mL

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic?

Activated partial thromboplastin time (APTT) is two times the control value

After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. To determine the cause of the tingling, the nurse should:

Compare femoral, popliteal, and pedal pulses in both legs

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care?

Encouraging expression of concerns

A nurse has provided teaching to a client with a newly prescribed proton pump inhibitor (PPI). The nurse determines that the teaching is effective when the client states that the medication is used for the treatment of:

Gastroesophageal reflux (GERD)

A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is:

Petechiae,

The nurse identifies a decrease in serum sodium when reviewing the laboratory reports of an older client with diarrhea. A decrease in which additional electrolyte is a cause for the greatest concern for this client?

Potassium

A client is en route to the emergency department after sustaining a gunshot wound to the chest. What is the nursing priority action to prepare for the arrival of the client?

Prepare equipment for chest tube insertion.

A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include?

Put the stockings on before getting out of bed in the morning.

A client with a hiatal hernia comes to the community health clinic to attend a class about nutrition. The client reports frequently waking up at night with heartburn. Which suggestion by the nurse may help to reduce symptoms of heartburn?

Raise the head of the bed on blocks

A health care provider prescribes ranitidine (Zantac) for a client with heartburn. During a teaching session, which information will the nurse share with the client about how this drug works?

Ranitidine reduces gastric acidity in the stomach.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position?

Right side-lying,

A client with achalasia is scheduled to have a bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for what complications related to esophageal perforation?

Tachycardia and abdominal pain

A nurse is caring for a client with hepatic cirrhosis. Which elements are important to include in this client's diet? Select all that apply.

- Low protein - Low sodium - High vitamins

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F. The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, the primary nursing concern for this client is:

Acute pain.

Which is the priority assessment for the client with active gastrointestinal bleeding?

Assess the client's blood pressure and pulse

An obese client with a hiatal hernia asks the nurse how to prevent esophageal reflux. What is the nurse's best response?

Eat less food at each meal.

A client has paracentesis during which 1500 mL of fluid are removed. The nurse should monitor the client carefully for:

Hypovolemic shock

Before a cholecystectomy vitamin K is prescribed. Which element, formed in the presence of vitamin K, should the nurse determine is the purpose of administering this medication?

Prothrombin

A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing?

Cleanse the wound with wet sterile gauze from the center of the wound outward.

A client is admitted to the hospital for surgery for a laparoscopic cholecystectomy. To monitor the flow of bile to the gastrointestinal tract, the nurse assesses the client's:

Color of the stool

A client asks the nurse to review a list of the foods the client has been choosing to combat constipation. Upon review, the nurse identifies that the food item that has the least amount of fiber content is:

Cream of wheat cereal

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, the nurse should be prepared to administer:

Protamine sulfate

When inserting a catheter to irrigate a client's colostomy, the nurse meets some resistance. What should the nurse do?

nstill a small amount of solution from the irrigating container into the stoma

A nurse assesses a client who had a gastric resection. During the first 24 hours after surgery, the nurse expects to identify:

Bloody nasogastric drainage.

A health care provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management?

Divide food into four to six meals a day.

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism causes:

Metabolic acidosis

A client with advanced cirrhosis of the liver is receiving intravenous serum albumin. As a result of this treatment, the nurse expects a decrease in:

Abdominal girth

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse.

A nurse teaches a client that it is not recommended to take bicarbonate of soda regularly. What effect of bicarbonate of soda is the nurse trying to prevent?

Metabolic alkalosis

A client had an acute myocardial infarction. For which life-threatening complication should the nurse monitor during the first 48 hours?

Ventricular tachycardia,

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.

- Fever - Tachypnea - Abdominal rigidity

The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply.

- Low sodium diet - Daily abdominal girth - measurements - Daily weights

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

- Oliguria - Irritability - Hypotension

After revision of the pancreas because of cancer, total parenteral nutrition is instituted via a central venous infusion route. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, what is the next action the nurse should take?

Check the serum glucose level

A client with an obstruction of the pancreatic ducts has been diagnosed with acute pancreatitis. The client's physical condition continues to deteriorate despite supportive care, and a subtotal pancreatectomy is performed. The nurse should monitor the client for what postoperative complication?

Paralytic ileus

The nurse is taking care of a client with cirrhosis of the liver. The best choice of a lunch for a client with this disorder is:

Penne pasta with tomatoes, spinach, banana, and decaffeinated iced tea.

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone (Aldactone). What should the nurse monitor the client for?

Hyperkalemia

A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor.

Immediate defibrillation,

A nurse is preparing to insert a nasogastric tube. During insertion, which response indicates that the client is experiencing difficulty?

Inability to speak

When a client exhibits severe bradycardia, which type of drug should the nurse be prepared to administer?

Anticholinergic

A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, the nurse expects:

Steatorrhea

A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply.

- Avoid heavy lifting. - Avoid drinking alcohol - Eat small, frequent meals.

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply.

- Carrots - Leafy greens

For which clinical indicators should the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice? Select all that apply.

- Dark urine - Yellow skin - Clay-colored stool

A client is diagnosed as having colitis. Which clinical findings should the nurse expect the client to report? Select all that apply.

- Diarrhea - Abdominal cramps

The nurse is creating a discharge teaching plan for a client that had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Select all that apply.

- Eat small frequent meals - Lie down for one hour after eating

A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe what skin conditions? Select all that apply.

- Ecchymoses - Telangiectasis

The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply.

- Extreme fatigue - Coughing at night - Difficulty breathing

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse should assess for which complications? Select all that apply.

- Infection - Hyperglycemia - Electrolyte imbalance

A client is to be on a 1500 calorie diet. For breakfast the client consumes 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat), ¾ cup corn flakes (15 grams of carbohydrate, 2 grams of protein), and half of an orange (5 grams of carbohydrate). The nurse calculates that the client has ingested how many calories?

258

Which client is at greatest risk for the development of a venous thrombosis?

A 68-year-old male on bed rest following a left hip fracture

A health care provider prescribes enoxaprarin (Lovenox) 30 mg subcutaneously daily. To ensure client safety, which measure would the nurse take when administering this medication?

Administer in the abdomen.

The nurse is reviewing the plan of care for a client who is scheduled for a barium swallow. The plan will include:

Administering a laxative after the procedure

A client who has just been transferred to the inpatient unit following surgery for oral carcinoma indicates to the nurse that the client's spouse is the only person that is allowed to visit. To support the client at this time, the nurse should:

Comply with the client's wishes

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes ventricular irritability on the screen. What medication should the nurse prepare to administer?

Amiodarone (Cordarone)

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas?

Ammonia level

The client receiving a blood transfusion that was just initiated complains of urticaria and difficulty breathing. The heart rate has increased, the blood pressure is falling, and the client is becoming extremely apprehensive. These are symptoms of which type of shock?

Anaphylactic shock

A client has inoperable cancer of the head of the pancreas, and the health care provider inserts a T-tube to gravity drainage. Several days after surgery, the client reports that the skin around the T-tube is raw and uncomfortable. After assessing the skin, what should the nurse do next?

Apply a skin barrier around the T-tube exit site

A client who is suspected of having leukemia has a bone marrow aspiration. Immediately after the procedure, the nurse should:

Apply brief pressure to the site.

A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client?

Apply elastic stockings before arising.

Red blood cells appear normal in size and color; however, there is a decreased amount produced." A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk factor for the development of a pulmonary embolus?

Atrial fibrillation

A client with a history of heart failure and hypertension is admitted with reports of syncope. Which prescribed medication should the nurse prepare to administer based on the ECG rhythm strip image?

Atropine

A client is admitted to the hospital after two days of painful abdominal spasms and severe diarrhea. The nurse uses an appropriate sequence to examine the client's abdomen, starting with "inspection" followed by:

Auscultation, percussion, palpation

The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. The nurse should:

Consider this an expected event.

A client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. The nurse determines that the client has Raynaud's disease and not Raynaud's phenomenon because of the:

Bilateral involvement

A client who had a gastric resection for cancer of the stomach is admitted to the postanesthesia care unit with a nasogastric (NG) tube. The nurse expects to observe:

Bright red bloody drainage in the suction container

A frantic parent calls stating their child has swallowed dish soap. What would you advise?

Call poison control.

The nurse provides medication discharge instructions to a client who received a prescription for digoxin (Lanoxin) following the client's myocardial infarction. The nurse concludes that the teaching was effective when the client says, "I should:

Check my radial pulse rate daily."

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion?

Cyanosis

What therapeutic effect should the nurse identify as the reason for administration of neomycin sulfate to a client before colon surgery?

Destroy intestinal bacteria,

A client is receiving metoprolol (Lopressor). Which side effect should the nurse teach the client to expect?

Dizziness with strenuous activity

A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for HIV?

Enzyme-linked immunosorbent assay (ELISA)

A client is admitted to the hospital with a diagnosis of peptic ulcer. The nurse should assess the client for which complications commonly associated with the diagnosis?

Hemorrhage

Ranitidine (Zantac) has been prescribed to help treat a client's gastric ulcer. The nurse expects this drug to act specifically by:

Inhibiting the histamine H2 receptors

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis the nurse should:

Instruct the client to empty the bladder.

A day after surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." Which conflict of Erikson's developmental stages is reflected by this comment?

Integrity versus despair

A client who recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts, and figures. The nurse determines that the client is using the defense mechanism known as:

Intellectualization

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, the nurse should include:

Maintaining the supine position for a minimum of four hours

A client with gastric ulcers has episodes of vomiting blood. What change in the client's blood gases should the nurse expect because of the large amount of blood lost?

Metabolic acidosis

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for:

Monthly injections of vitamin B12

A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. The nurse can help control the bleeding by:

Pinching the nostrils together

What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?

Place the client in the orthopneic position.

A physician prescribes a Schilling Test for a client. Which measure would the nurse take to ensure the prescription is carried out?

Start a 24 to 48 hour urine specimen collection.

A client who recently had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change because the "wound looks terrible." Which defense mechanism does the nurse conclude the client is using as a form of self-protection?

Projection

After a subtotal gastrectomy a client is returned to the surgical unit. Which is the best nursing action to prevent pulmonary complications?

Promoting frequent turning and deep breathing to mobilize secretions

Ventricular depolarization is shown on the rhythm strip as a:

QRS complex.

Neomycin is prescribed for a client with cirrhosis. What should the nurse explain is the reason for taking this medication?

Reduces the blood ammonia level

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?

Rise of formula in the tube

A client had surgery for a perforated appendix with localized peritonitis. In which position should the nurse place this client?

Semi-Fowler

Which information should be included in the teaching plan for the elderly client with peptic ulcer disease who is taking an antacid and sucralfate (Carafate)?

Sucralfate should be taken on an empty stomach one hour before meals

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock?

Thirst, cool skin, and orthostatic hypotension

A client receiving 0.9% normal saline (NS) intravenously at keep vein open (KVO) complains of pain at the insertion site. The nurse notes that there is erythema and edema present at the access site. Based on the phlebitis scale, how should the nurse properly document the phlebitis?

Two (2)

A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?

Ventricular fibrillation

A client will be taking cholestyramine (Questran), a bile acid sequestrant, as treatment for type II hyperlipoproteinemia. What vitamin does the nurse anticipate may become deficient because of this drug therapy?

Vitamin D

A client with a parotid tumor expresses anxiety about the surgery to remove the tumor. The client states that perhaps surgery should be performed soon, even if the preoperative radiotherapy is not completed. The best response by the nurse is:

You are concerned about the delay of surgery?"

A client has 4 ounces (120 mL) of apple juice, 6 ounces (180 mL) of tea, and 8 ounces (240 mL) of chicken broth. How many mL of fluid will the nurse document the client ingest? Record your answer using a whole number_

calculation. 4 ounces apple juice x 30 mL/ounce = 120 mL, 6 oz tea x 30 mL/ounce = 180 mL, and 8 oz chicken broth x 30 mL/ounce = 240 mL. 120 + 180 + 240 = 540 mL that the client has ingested.

A client recovering from a gastric resection for gastric cancer is started on small frequent meals. The nurse evaluates the client's response 30 minutes after nutritional intake and determines that the client is experiencing dumping syndrome if which of the following signs and symptoms are observed? Select all that apply.

- Flushing - Diarrhea - Sweating

A client is admitted with the diagnosis of acute pancreatitis. For which clinical manifestations should a nurse assess the client? Select all that apply.

- Jaundice - Acute pain - Increased amylase

A nurse provides dietary teaching for a client with an acute exacerbation of colitis, and afterward the client makes a list of foods that can be included on the diet. Which food choices indicate that the teaching was effective? Select all that apply.

- Jelly sandwich - Lean roast beef - Scrambled eggs

A client is diagnosed with sprue (adult celiac disease). What should the nurse teach the client to avoid when providing dietary teaching? Select all that apply.

- Oatmeal - Spaghetti

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.

- Rapid, thready pulse - Elevated specific gravity

A client is receiving doxorubicin (Adriamycin) as part of a chemotherapy protocol. The nurse should assess the client for which major life-threatening side effect of doxorubicin?

Cardiotoxicity

A health care provider schedules a paracentesis. What should the nurse instruct the client to do to prepare for the procedure?

Empty the bladder before the procedure.

A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.

- Stop the transfusion - Change IV administration set - Run 0.9 normal saline at a rapid rate - Notify health care provider and blood bank,

A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? Select all that apply.

-Pallor -Tachycardia

A client arrives in the emergency department with complaints of epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Based on the client's database, the primary nursing concern is:

Metabolic alkalosis

A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis?

Serum lipase

The nurse teaches the client with gastroesophageal reflux disease that after meals the client should:

Rest in a sitting position for one hour.

A client is being discharged after an acute episode of hepatitis. The nurse expects the primary health care provider to prescribe which type of diet for this client?

High calorie, high protein, high carbohydrate, moderate fat

A client experiences angina and is admitted to the telemetry unit for observation. Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain. Which instruction should the nurse include when teaching the client about the correct use of sublingual nitroglycerine?

Hold the tablet under the tongue until it is dissolved.

When caring for a client in the early postoperative period after a hemorrhoidectomy, to ensure the client's safety, the nurse would place the client in which position?

Side-lying

A client is admitted to the hospital with signs and symptoms of obstruction of the common bile duct. Laboratory test results indicate prolonged bleeding and clotting times. What can the nurse conclude these test results indicate?

Vitamin K is not being absorbed

A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth?

Graft leakage

A nurse is caring for a client after a needle biopsy of the liver. The nurse should monitor the client for which complication that is associated with this procedure?

Hemorrhage

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy?

Hemorrhage

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear

Moist, red, and raised above the skin surface.

A health care provider prescribes enalapril (Vasotec) for a client. Which is the most important nursing action?

Monitor the client's blood pressure during therapy.

The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. What breakfast items should the nurse encourage the client to select?

Oatmeal, sliced bananas, whole-wheat toast, and milk

A client with a ruptured appendix is scheduled for an appendectomy. Preoperatively, the nurse should place the client in which position?

Semi-Fowler

A client is scheduled to receive 1 L of total parenteral nutrition (TPN) every 12 hours. The primary nursing responsibility is to monitor the client's:

Serum glucose levels

A client has an abdominoperineal resection. Which position should the nurse encourage the client to assume to promote perineal wound healing?

Side-lying

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?

Sinus tachycardia

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?

Small, frequent feeding schedule

The client has been admitted for possible acute cholecystitis with biliary colic. What clinical findings should the nurse expect when performing a health history and physical assessment? Select all that apply.

- Pain triggered by a large or high-fat meal - Pain in the upper right quadrant of the abdomen - Positive Blumberg's sign

The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? Select all that apply.

- Roast beef sandwich - Chicken noodle soup - Spaghetti and meatballs

A client has a colostomy after surgery for cancer of the colon. What postoperative nursing intervention maximizes skin integrity?

Apply stoma adhesive around the stoma and then attach the appliance

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk?

Endocarditis

A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response?

Can you tell me your reasons for refusing the procedure?"

A nurse administers cephulac (Lactulose) to a client with cirrhosis of the liver. Which response leads the nurse to determine that the cephulac is effective?

Decreased ammonia

One week after being hospitalized for an acute myocardial infarction, a client reports loss of appetite and feeling nauseated. Which of the client's prescribed medications should be withheld and the health care provider notified?

Digoxin (Lanoxin)

Immediately after a subtotal gastrectomy, a client is admitted to the postanesthesia care unit (PACU). The nurse irrigates the nasogastric tube and observes small blood clots in the return. What is the next best nursing intervention?

Document this expected response.

A nurse is caring for a client who just had a gastrectomy. What should the nurse emphasize when teaching the client how to avoid dumping syndrome?

Eat small meals with low carbohydrate and moderate fat content

A client is suspected of having thrombophlebitis of the left lower extremity. For what clinical finding should the nurse assess the client?

Edema of the left leg

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering the laboratory result, the nurse should monitor the client's electrocardiogram (ECG) for:

Elevated U and flattened T waves

A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is:

Type A or O negative

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action?

Obtain the client's vital signs.

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis?

Salad, sliced chicken sandwich, gelatin dessert

Which response should the nurse expect when assessing a client who is dehydrated? Select all that apply.

- Confusion -Sunken eyeballs - Decreased blood pressure

A client in the postanesthesia care unit following a right pneumonectomy has just regained consciousness. The priority nursing intervention is:

Encourage deep breathing

A client is cautioned to avoid vitamin D toxicity while increasing protein intake. Which nutrient selected by the client indicates to the nurse that the dietary teaching is understood?

Tofu

Three days after surgery for cancer of the colon, a nurse introduces the client to colostomy care. Which should the nurse teach the client about skin care around the stoma?

Wash the area with soap and water and then apply a protective ointment

A nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos should the nurse include in the teaching plan?

Hepatitis-C

A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L, chloride 55 mEq/L, sodium 132 mEq/L, and potassium 3.8 mEq/L. The nurse determines that the results indicate:

Metabolic alkalosis

A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. What should the nurse do first?

Obtain an x-ray to verify that the tube is in the stomach.