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1. continue to check vital signs every 2 hours 2. draw stat blood cultures x2 3. CT of abdomen 4. start broad-spectrum IV antibiotic 4 hours after blood cultures are drawn 5. draw CBC, CRP, ESR, and UA with culture and sensitivity if indicated 6. ensure patent IV access for fluid bolus. The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the last 24 hours, but the client now has a temperature of 38.4°C (101.1°F), a heart rate of 116, and a respiratory rate of 26 breaths/min. The client has an IV infusion running at a keep open rate. The nurse contacts the physician and receives the prescriptions on the accompanying chart. Which of the following prescriptions should the nurse implement first? a) Obtain CT of abdomen. b) Chart vital signs. c) Increase the rate of the intravenous infusion. d) Obtain blood cultures.
Obtain blood cultures. Explanation: The nurse should first obtain the blood culture because subsequent treatment will be dependent on the results. The client has an intravenous infusion; the physician did not write a prescription to increase the infusion rate. Unless indicated otherwise, the nurse can take the client's vital signs after completing scheduling the CT scan and other laboratory work
Pancrelipase, an enzyme replacement, has been prescribed for a client with chronic pancreatitis. Which of the following points should the nurse include in the client's teaching plan about the drug? a) If taking the capsule, the client should chew it thoroughly. b) The enzyme mixture should be taken after each meal. c) The enzyme mixture should be stored in the refrigerator to keep it fresh. d) The client should be careful not to inhale the powder when mixing it with food.
The client should be careful not to inhale the powder when mixing it with food. Explanation: When mixing the enzyme (lipase, protease, amylase) powder into food, the client should be careful not to inhale it as the powder may trigger an asthma attack. The enzymes are taken before or with each meal, not after. The drug does not need to be stored in the refrigerator. The client should not chew the capsules.
A graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first? a) The sleeping client who received pain medication 1 hour ago b) The client receiving continuous tube feedings who needs the tube-feeding residual checked c) The client who underwent surgery 3 days ago and who now requires a dressing change d) The newly admitted client with acute abdominal pain
The newly admitted client with acute abdominal pain Explanation: The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings. These tasks are of equal importance. They should assess the sleeping client who received pain medication 1 hour ago last because he just received relief from his pain and is able to sleep.
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply. a) Hypothyroidism. b) Excessive alcohol use. c) Abdominal trauma. d) Gallstones. e) Hypertension. f) Hyperlipidemia with excessive triglycerides.
b• Excessive alcohol use. d• Gallstones. c• Abdominal trauma. f• Hyperlipidemia with excessive triglycerides. Explanation: Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.
Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he needs to follow at home? a) "I should avoid alcohol and caffeine." b) "I should eat a bland, soft diet." c) "I should drink several glasses of milk a day." d) "It is important to eat six small meals a day."
"I should avoid alcohol and caffeine." Explanation: Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acid.
A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholycystectomy later in the day, the client asks the nurse why the procedure is needed. Which of the following is the appropriate response by the nurse? a) "This is a common procedure performed using a scope and will relieve your symptoms." b) "The surgeon feels this is the best option for you at this time based on your symptoms." c) "You have stones in your gallbladder and the treatment is to remove the gallbladder." d) "I will ask the surgeon to come speak to you about the procedure."
"I will ask the surgeon to come speak to you about the procedure." Explanation: It is the surgeon's responsibility to explain the procedure to the client and to answer questions so the client can provide an informed consent. The nurse can reinforce the information after the consent is obtained and clarify the information, but the surgeon must explain the procedure initially
The nurse has an order to administer sulfasalazine 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? ___ tablets
4 Explanation: To administer 2 g sulfasalazine, the nurse will need to administer 4 tablets. The following formula is used to calculate the correct dosage: The first step is to convert grams into milligrams: 1 g/1,000 mg = 2 g/X mg X = 2,000 mg. Then, 2,000 mg/X tablets = 500 mg/1 tablet X = 4 tablets
A client tells the nurse about occasional use of over-the-counter of cimetidine. The nurse should instruct the client to tell the health care provider about prolonged: a) Ataxia. b) Heartburn. c) Diarrhea. d) Nausea.
Ataxia. Explanation: The use of histamine2 (H2) blockers such as cimetidine can cause paradoxic central nervous system (CNS) stimulation, resulting in ataxia in the elderly. Impaired vision, gait, and thinking may also occur. Nausea, heartburn, and diarrhea are not related to CNS effects of H2 blockers.
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? a) Decreased mental status. b) Decreased urine output. c) Elevated blood pressure. d) Labored respirations.
Decreased mental status. Explanation: The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.
When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Encouraging frequent visits from family and friends b) Administering an analgesic once per shift, as ordered, to prevent drug addiction c) Positioning the client on the side with the knees flexed d) Administering frequent oral feedings
Positioning the client on the side with the knees flexed Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest
A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task? a) Teaching the client coughing and deep breathing exercises b) Initiating I.V. therapy, as ordered c) Teaching the client how to collect a urine specimen d) Weighing the client
Initiating I.V. therapy, as ordered Explanation: The RN must confirm that the LPN has specialized I.V. training before asking her to begin I.V. therapy for this client. Initiating I.V. therapy is beyond the usual scope of practice for an LPN. Weighing the client, teaching coughing and deep breathing exercises, and teaching the client how to collect a urine specimen are within the scope of LPN practice and don't require additional training.
After teaching the mother of an infant with pyloric stenosis about the disease, which of the following, if stated by the mother as a cause, indicates effective teaching? a) "A result of giving the baby more formula than is necessary." b) "A result of my baby taking the formula too quickly." c) "An enlarged muscle below the stomach sphincter." d) "A telescoping of the large bowel into the smaller bowel."
"An enlarged muscle below the stomach sphincter." Explanation: Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis.
An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching? a) "I can remove the bag momentarily to allow gas to escape." b) "I can unclamp the bag momentarily to allow gas to escape." c) "I can place an odor-relieving tablet in the bag when changing the appliance to reduce odors." d) "I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently."
"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently." Explanation: The nurse requires additional teaching if she states that she can make a hole in the drainage bag to let gas out. Any hole in the drainage bag, no matter how small, will destroy the odor-proof seal. Removing or unclamping the bag is the only appropriate method for releasing the gas accumulated in the bag. Odor-relieving tablets, usually made of charcoal, can be placed in the bag to help with the odor.
A client who has had a laparoscopic cholecystectomy receives discharge instructions from the nurse. Which statement indicates that the client has understood the instructions? a) "I can remove the dressing from my incision tomorrow and take a shower." b) "I can return to work in 4 to 6 weeks." c) "I need to maintain a low-fat diet for the next 6 months." d) "I can anticipate some nausea for several days after surgery."
"I can remove the dressing from my incision tomorrow and take a shower." Explanation: Postoperative care after a laparoscopic cholecystectomy includes removal of the dressing from the incisional site the day after surgery and allowing the client to bathe or shower. The client can resume a normal diet but may wish to follow a low-fat diet for a few weeks after surgery. Nausea is not expected to last for several days after surgery. The client usually can return to work within 1 week.
Which of the following statements indicates the client understands the lifestyle modifications he needs to make because of his ulcerative colitis? a) "I am allowed to have alcohol as long as I only drink wine." b) "I can eat popcorn for an evening snack." c) "I will have to stop smoking." d) "I may have coffee with my meals."
"I will have to stop smoking." Explanation: Tobacco is a gastrointestinal stimulant and should be avoided by clients with ulcerative colitis. Caffeine are alcohol are gastrointestinal stimulants and should be avoided by clients with ulcerative colitis. High-fiber foods such as popcorn and nuts are not allowed.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? a) "It is best for me to take my antacid 1 to 3 hours after meals." b) "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." c) "I should take my antacid before I take my other medications." d) "My antacid will be most effective if I take it whenever I experience stomach pains."
"It is best for me to take my antacid 1 to 3 hours after meals." Explanation: Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain
A client who is recovering from gastric surgery is receiving I.V. fluids to be infused at 100 mL/hour. The I.V. tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? ____ gtt/minute
25 Explanation: To administer I.V. fluids at 100 mL/hour using tubing that has a drip factor of 15 gtt/mL, the nurse should use the following formula: 100 mL/60 minutes × 15 gtts/1 mL = 25 gtt/minute.
A nurse is caring for a client after a hemorrhoidectomy. Which of the following orders would the nurse question on the medical record? a) Fluid encouragement b) Warm sitz baths as needed c) Low-fiber diet d) Stool softener daily
Low-fiber diet Explanation: The nurse would question a low-fiber diet. Increased fluids and fiber would be encouraged to prevent constipation. Warm sitz baths would decrease rectal muscle spasms. A stool softener would be indicated to prevent straining.
After completing assessment rounds, which of the following should the nurse discuss with the physician first? a) A client with stable vital signs following a cholecystectomy who has been receiving IV ciprofloxacin for 1 day and has developed a rash on the chest and arms. b) A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular. c) A client with pancreatitis whose family requests to speak with the physician regarding the treatment plan. d) A depressed client with cirrhosis who has refused to eat for the past 2 days.
A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular. Explanation: A change in a client's baseline vital signs should be brought to the physician's attention immediately. In this case, the client's heart rate has increased and the rhythm appears to have changed; the physician may order an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the physician information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the physician's attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the physician but only after all immediate physical and psychological needs of all clients have been met.
The nurse should assess the client with severe diarrhea for which acid-base imbalance? a) Metabolic alkalosis. b) Respiratory alkalosis. c) Metabolic acidosis. d) Respiratory acidosis.
Metabolic acidosis. Explanation: A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.
A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which of the following problems is associated with cirrhosis of the liver? a) Mental alertness and increased perception b) Dilute urine in large amounts related to kidney excretion of bile byproducts c) Ascites related to portal hypertension d) Small bowel ulcerations related to jaundice
Ascites related to portal hypertension Explanation: The jaundice is a result of inability of the liver to break down the end products from red blood cells, resulting in elevated bilirubin levels. Small bowel ulcerations do not occur as a result of elevated bilirubin levels and are not problems commonly associated with cirrhosis. The remaining choices are all associated with advanced cirrhosis. Ascites presents because of portal hypertension; clear dilute urine is incorrect as it would be dark due to the inability to eliminate some of the bile byproducts. Confusion and disorientation would occur when the brain is inundated by high levels of circulating toxins because of a failing liver not mental alertness and increased perception.
A client is scheduled for oral cholecystography. Prior to the test, the nurse should? a) Administer an intravenous contrast agent as the evening before the test. b) Ask the client about possible allergies to iodine or shellfish. c) Give tap-water enemas until clear. d) Have the client drink 1,000 ml of water.
Ask the client about possible allergies to iodine or shellfish. Explanation: Iodine compounds used as radiographic contrast agents, such as iopanoic acid, should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur. Drinking large amounts of water is indicated for certain kidney or urinary bladder studies, not gallbladder studies. The contrast agent is administered orally 10 to 12 hours before the test. The client is NPO after administration of the contrast agent. Enemas are not required for cholecystography.
The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 ml less than was ordered for the day. The nurse should: a) Maintain the flow rate at the current rate and document any discrepancy in the chart. b) Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved. c) Increase the flow rate to infuse an additional 300 ml over the next hour. d) Assess the infusion system, note the client's condition, and notify the physician.
Assess the infusion system, note the client's condition, and notify the physician. Explanation: The nurse's most appropriate action is to assess the infusion system to determine the cause of the inaccurate flow rate and to note the client's response to the decreased infusion, especially signs of hypoglycemia. The physician should be notified of the infusion discrepancy. The flow should never be increased without a physician's order, nor should large volumes of TPN ever be infused over a short period of time. Too rapid administration of TPN can cause hyperglycemia, electrolyte imbalances, and dangerous fluid shifts. This action delays a definitive intervention and does not meet the client's needs. There is no clinical reason to remove the TPN and TPN should never be discontinued abruptly. If there is a need to temporarily discontinue the TPN, such as the client going to surgery or the next bag is unavailable, a 10% dextrose solution should be infused. This prevents a rebound hypoglycemia.
A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for: a) Alternating periods of constipation and diarrhea. b) Bloody, diarrheal stools. c) Steatorrhea. d) Constipation.
Bloody, diarrheal stools. Explanation: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome
A client with cholecystitis is taking propantheline bromide. The expected outcome of this drug is: a) Absence of infection. b) Relief from nausea. c) Increased bile production. d) Decreased biliary spasm.
Decreased biliary spasm. Explanation: Propantheline bromide is an anticholinergic used to decrease biliary spasm. Decreasing biliary spasm helps to reduce pain in cholecystitis. Propantheline does not increase bile production or have an antiemetic effect, and it is not effective in treating infection.
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? a) Sigmoid colon b) Liver c) Appendix d) Spleen
Liver Explanation: The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.
A nurse notes that a client is an Orthodox Jew. Because of religious beliefs, the client refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next: a) Explain alternatives to food such as intravenous fluids that can provide nutrition during hospitalization. b) Encourage the client's family to bring food for the client because of the special circumstances. c) Teach the client that it is important to eat the food served. d) Discuss the situation and possible courses of action with the dietitian and the client.
Discuss the situation and possible courses of action with the dietitian and the client. Explanation: The best course of action when a client refuses to eat food that is contrary to religious beliefs is to discuss the situation with the client and the dietitian. Health team members may need to confer about this client's needs. Telling the client that it is important to eat what is served is unlikely to help; the client has already refused the food and this approach does not address the client's concerns. Encouraging her family to bring suitable food to the hospital may be acceptable. However, the family should not bear sole responsibility for meeting the client's nutritional needs. Health care team members need to seek ways the hospital can address the client's concerns. Suggesting intravenous fluids may be perceived as a threat and is not a realistic solution
A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? a) Notify the physician. b) Administer a tap water enema. c) Encourage the client to ambulate at least three times per day. d) Apply moist heat to the client's abdomen.
Encourage the client to ambulate at least three times per day. Explanation: The nurse should encourage the client to ambulate at least three times per day. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a physician order. A tap water enema is typically administered as a last resort after other methods fail. A physician's order is needed with a tap water enema as well. Notifying the physician isn't necessary at this point because the client is exhibiting bowel function by passing flatus.
output record 12PM - 50mL 4PM - 60 mL 8PM - 60 mL 12AM - 70 mL 4AM - 70 mL 8 AM - 10 mL At 8 am, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should: a) Irrigate the t-tube. b) Evaluate the tube for patency. c) Report the 24-hour drainage amount at 12 noon. d) Clamp the t-tube.
Evaluate the tube for patency. Explanation: The t-tube should drain approximately 300 to 500 mL in the first 24 hours, and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 am, the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without a prescription
Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: a) Demonstrate appropriate use of analgesics to control pain. b) Explain the rationale for eliminating alcohol from the diet. c) Eliminate contact sports from his or her lifestyle. d) Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
Explain the rationale for eliminating alcohol from the diet. Explanation: Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.
A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values? a) Increased calcium level. b) Increased serum amylase and lipase levels. c) Decreased urine amylase level. d) Decreased glucose level.
Increased serum amylase and lipase levels. Explanation: Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.
A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone P.O. 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently? a) It has a slow onset of action. b) It's highly metabolized. c) It has a prolonged half-life. d) It has a short duration of action.
It has a short duration of action. Explanation: Because of the short duration of action, frequent doses of antacids are needed. Antacids usually provide a rapid to immediate onset of action, don't have prolonged half-lives, and aren't highly metabolized
Prochlorperazine is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following? a) Nausea. b) Dizziness. c) Abdominal distention. d) Abdominal spasms.
Nausea. Explanation: Prochlorperazine is administered postoperatively to control nausea and vomiting. Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not used to treat dizziness, abdominal spasms, or abdominal distention.
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Iron-rich diet b) Ice chips only c) Nothing by mouth d) Increased dairy products
Nothing by mouth Explanation: Bleeding must be controlled before oral intake, so the client should receive nothing by mouth. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Dairy shouldn't be given because it increases gastric acid production, which could prolong bleeding. A clear liquid diet is the first diet offered after bleeding is controlled.
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, boardlike abdomen. The nurse should do which of the following first? a) Notify the physician. b) Prepare to insert a nasogastric tube. c) Administer pain medication as ordered. d) Raise the head of the bed.
Notify the physician. Explanation: The client is experiencing a perforation of the ulcer and the nurse should notify the physician immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain. Elevating the head of the bed will not minimize the perforation. A nasogastric tube may be used following surgery.
When administering intermittent enteral feeding to an unconscious client, the nurse should: a) Obtain a sterile gavage bag and tubing. b) Weigh the client before administering the feeding. c) Place the client in a semi-Fowler's position. d) Heat the formula in a microwave.
Place the client in a semi-Fowler's position. Explanation: The client should be placed in a semi-Fowler's position to reduce the risk of aspiration. The formula should be at room temperature, not heated. Administering enteral tube feedings is a clean procedure, not a sterile one; therefore, sterile supplies are not required. Clients receiving enteral feedings should be weighed regularly, but not necessarily before each feeding.
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution: a) Provides essential fatty acids. b) Maintains a normal body weight. c) Provides extra carbohydrates. d) Promotes effective metabolism of glucose.
Provides essential fatty acids. Explanation: The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body's energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a) Ascites and orthopnea b) Purpura and petechiae c) Gynecomastia and testicular atrophy d) Dyspnea and fatigue
Purpura and petechiae Explanation: A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 98.96 (37.2° C); heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse? a) Obtain an order for blood cultures. b) Prepare for a paracentesis. c) Assess heart sounds. d) Raise the head of the bed.
Raise the head of the bed. Explanation: Elevating the head of the bed will allow for increased lung expansion by decreasing the ascites pressing on the diaphragm. The client requires reassessment. A paracentesis is reserved for symptomatic clients with ascites with impaired respiration or abdominal pain not responding to other measures such as sodium restriction and diuretics. There is no indication for blood cultures. Heart sounds are assessed with the routine physical assessment.
A nurse is giving instructions to a client with a new colostomy. The client states, "I am so tired today; I just cannot think." The nurse should: a) Give the client a written instruction sheet instead of verbal teaching. b) Reschedule the appointment at a time when the client is rested. c) Give the teaching session to the spouse instead of the client. d) Ask the client to concentrate because the instructions are important.
Reschedule the appointment at a time when the client is rested. Explanation: The client's readiness to learn is compromised by fatigue and lack of concentration. The teaching session should be rescheduled to a better time for improved learning readiness. Written instructions or involving the spouse can supplement verbal instructions but cannot replace teaching the client directly. The client has indicated that he is too tired to focus on learning. The nurse should reschedule the appointment, rather than asking the client to concentrate
Which position would be best for the client in the early postoperative period after a hemorrhoidectomy? a) Supine. b) Trendelenburg's. c) High Fowler's. d) Side-lying.
Side-lying. Explanation: Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective. A high Fowler's or supine position will place pressure on the operative site and is not recommended. There is no need for Trendelenburg's position.
The client is to take nothing by mouth after 4 a.m. (0400). The nurse recognizes that the client has deficient knowledge when he states that he: a) Brushed his teeth at 4:00 a.m. (0400) but did not swallow. b) Ate a gelatin dessert at 3:30 a.m. (0330). c) Held a cold washcloth against his lips. d) Smoked a cigarette at 6:00 a.m. (0600).
Smoked a cigarette at 6:00 a.m. (0600). Explanation: The client has deficient knowledge if he smoked a cigarette after 4 a.m. (0400) because, even though he did not have anything to eat or drink, smoking has increased the production of gastric hydrochloric acid, which can increase the risk of aspiration in an anesthetized client. A gelatin dessert is a clear liquid and is acceptable. Comfort measures, such as brushing the teeth without swallowing or holding a cold washcloth against the lips, are acceptable for a client who is to have nothing by mouth.
The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 ml of the irrigating solution. The nurse should first: a) Massage the abdomen gently. b) Stop the flow of solution. c) Remove the irrigation tube. d) Reposition the client on to the right side.
Stop the flow of solution. Explanation: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.
A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the nursing assistant to look for and report which of the following symptoms? a) Hypotension. b) Bright red blood in the stools. c) Jaundice. d) Tarry stools.
Tarry stools. Explanation: A client with a suspected slow gastrointestinal bleed should be observed for tarry (black) stools, which indicate slow bleeding from an upper gastrointestinal site. The longer the blood remains in the system, the darker it becomes from the degradation of hemoglobin and release of iron. Hypotension does not occur with a slow gastrointestinal bleed. Bright red blood indicates bleeding from the lower gastrointestinal tract or profuse, massive gastrointestinal bleeding. Jaundice is not an indicator of gastrointestinal bleeding, but it is an indicator of liver or biliary tract dysfunction.
The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should be the nurse's first response? a) Rub the client's abdomen gently until the cramps subside. b) Raise the height of the enema container. c) Temporarily stop the infusion and have the client take deep breaths. d) Clamp the tubing and carefully withdraw the tube.
Temporarily stop the infusion and have the client take deep breaths. Explanation: If the client begins to experience abdominal cramping during administration of the enema fluid, the nurse's first action is to temporarily stop the infusion and have the client take a few deep breaths. After the cramping subsides, the nurse can continue with the enema solution. If the cramping does not subside, the nurse should clamp the tubing and remove it. Raising the height of the container will increase the flow of fluid and cause the cramping to increase. Rubbing the abdomen while infusing the enema fluid will not stop the cramping.
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care? a) Prepare the client for a gastrostomy tube placement. b) Administer topical ointment to the rectal area to decrease bleeding. c) Test all stools for occult blood. d) Administer morphine routinely, as ordered.
Test all stools for occult blood. Explanation: Blood in the stools is one of the warning signs of colorectal cancer. The nurse should plan on checking all stools for both frank and occult blood. The blood in the stool is coming from the colon or rectum; administering an ointment wouldn't help decrease the bleeding. Preparing a client for a gastrostomy tube isn't appropriate when diagnosing colorectal cancer. Colorectal cancer is usually painless; administering opioid pain medication isn't needed
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician? a) The stoma is slightly edematous. b) The stoma is dark red to purple. c) The stoma oozes a small amount of blood. d) The stoma does not expel stool.
The stoma is dark red to purple. Explanation: A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.
While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist? a) Timely administration of breathing treatments. b) Reinforce teaching of coughing and deep breathing. c) Instruct on how to best induce a sputum specimen. d) Instruct on reporting abnormal color and consistency of sputum produced.
Timely administration of breathing treatments. Explanation: The nurse should collaborate with the respiratory therapist to make sure breathing treatments are administered and the client's respiratory status is watched closely before and after surgery, because of the increased risk of infection and post operative pneumonia. An induced sputum specimen is not necessary at this time. The nurse alone can teach the client coughing and deep breathing exercises and monitor the color and consistency of sputum specimens.
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease? a) To promote client compliance b) To increase pepsin activity c) To maintain a regular bowel pattern d) To keep gastric pH at 3.0 to 3.5
To keep gastric pH at 3.0 to 3.5 Explanation: To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance rather than promote it. Antacids don't regulate bowel patterns, and they decrease pepsin activity.
Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis? The client: a) Verbalizes the importance of small, frequent feedings. b) Uses a heating pad to decrease abdominal cramping. c) Maintains a daily record of intake and output. d) Accepts that a colostomy is inevitable at some time in his life.
Verbalizes the importance of small, frequent feedings. Explanation: Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation. The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs. A heating pad should not be applied to the intestine as it is inflamed. It is not inevitable that the client will require surgery to treat the ulcerative colitis as about 85% respond favorably to conservative therapy. If the severity of the disease mandates surgery, the colon will be removed, resulting in an ileostomy
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy. Which of the following vitamins would be affected by this? a) Vitamin A b) Vitamin E c) Vitamin D d) Vitamin K
Vitamin K Explanation: Intestinal bacteria synthesize such nutritional substances as vitamin K, thiamine, riboflavin, vitamin B12, folic acid, biotin, and nicotinic acid. Antibiotic therapy may interfere with synthesis of these substances, including vitamin K. Intestinal bacteria do not synthesize vitamins A, D, or E
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) appendicitis. b) cirrhosis. c) peptic ulcer disease. d) cholelithiasis.
cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.
A 58-year-old client with osteoarthritis is admitted to the hospital with peptic ulcer disease. Which findings are commonly associated with peptic ulcer disease? Select all that apply. a) Localized, colicky periumbilical pain b) Nausea and weight loss c) Low-grade fever d) Tachycardia e) Epigastric pain that is relieved by antacids f) History of nonsteroidal anti-inflammatory drug (NSAID) use
• History of nonsteroidal anti-inflammatory drug (NSAID) use • Epigastric pain that is relieved by antacids • Nausea and weight loss Explanation: Peptic ulcer disease is characterized by nausea, hematemesis, melena, weight loss, and left-sided epigastric pain, occurring 1 to 2 hours after eating and that is relieved with antacids. Use of NSAIDs is also associated with peptic ulcer disease. Appendicitis begins with generalized or localized colicky periumbilical or epigastric pain, followed by anorexia, nausea, a few episodes of vomiting, low-grade fever, and tachycardia. (