Hepatobiliary, Pancreatic, and infection - Nurs 220 Exam 2

Which foods will the nurse expect a client who follows a lacto-ovo vegetarian diet to select as menu items for breakfast? Select all that apply. A. Milk B. Toast C. Cereal D. Sausage E. Tuna fish F. Scrambled eggs

A, B, C, F An adult who follows a lacto-ovo vegetarian diet eats a primarily plant-based diet that also includes eggs and dairy products. Meat, poultry, and fish are avoided.

Which is the most important action for the nurse to teach visitors to avoid acquiring influenza when visiting a client with the disease? A. Keeping windows open in rooms where the client spends the most time B. Remaining at least 6 feet away from the client C. Washing hands after touching the client D. Not sharing a toilet with the client

B Influenza is spread by droplets, which are heavy and do not travel far in the air. The CDC recommends prevention by remaining at least 6 feet away from the client, which is farther than the droplets travel when the client sneezes or coughs. Influenza is not spread from toilets. Keeping windows open would be helpful for airborne diseases but is of no value for preventing infections spread by droplets.

What is the nurse's priority action when a client with ascites reports increased abdominal pain and chills? A. Applying oxygen and making the client NO B. Notifying the primary health care provider immediately C. Assessing for abdominal rigidity and taking the client's temperature D. Applying a heating blanket and raising the head of the bed to a 45-degree angle

C Increasing abdominal pain and the presence of chills in a client who has ascites indicate possible spontaneous bacterial peritonitis. The nurse would perform a complete abdominal assessment and assess for a temperature elevation before notifying the primary health care provider.

What action will the nurse take when, 12 hours after a traditional cholecystectomy, a client's Jackson-Pratt (P) drain shows serosanguineous drainage stained with bile? A. Placing the client to the left lateral Sims' position B. Clamping the drain intermittently for 30 minutes every hour C. Measuring the drainage and documenting the findings D. Disconnecting the suction device and gently irrigating the drain with sterile saline

C Serosanguineous drainage stained with bile is expected and normal during the first 24 hours after traditional cholecystectomy. The drain is not to be clamped or irrigated. Placing the client in left lateral Sims' position can be done but is not related to drainage from the JP.

Which client will the nurse recognize as having the highest risk for pancreatic cancer? A. 27-year-old man who is underweight and has opioid use disorder B. 35-year-old woman who is overweight and uses oral contraceptives C. 50-year-old woman who has ductal breast cancer and receiving radiotherapy D. 60-vear old man who smokes two packs of cigarettes daily and has liver cirrhosis

D Although the exact cause of pancreatic cancer is not known, the older man who smokes and has liver cirrhosis has four risk factors.

What instruction will the nurse provide to a client to prepare him or her to undergo ultrasonography of the right upper abdominal quadrant to diagnose gallstones? A. Do not eat or drink for at least 6 hours before the test. B. Shower with an antibacterial soap the morning before the test. C. Be sure to have someone come with you who can drive you home. D. A small instrument will be rolled over your upper abdomen and there will be no pain.

D An ultrasound is performed with an electronic probe lubricated and rolled on the skin over the area to be examined. It causes no pain, does not require the client to be NO or to be sedated, and special cleansing of the area is not needed.

Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? A. Sodium B. Potassium C. Vitamin C D. Vitamin K

D Clients with advanced liver disease, such as cirrhosis with ascites, are unable to metabolize fats and absorb fat-soluble vitamins from the GI tract. As a result, vitamin K is deficient. (Vitamin C is water-soluble).

Which common factors will the nurse recognize as contributing to or worsening of hepatic encephalopathy in clients with liver cirrhosis? Select all that apply. A. Anorexia B. Infection C. Opioids D. Diarrhea E. GI bleeding F. High-protein diet G. Diabetes mellitus H. Chronic confusion

B, C, E, F Factors that may contribute to or worsen hepatic encephalopathy in patients with cirrhosis include high-protein diet, infection, hypovolemia (decreased fluid volume), hypokalemia (decreased serum potassium), constipation, GI bleeding (causes a large protein load in the intestines), and some drugs, especially hypnotics, opioids, sedatives, analgesics, diuretics, illicit drugs.

Which is the most effective action for the nurse to take to assess adequate bowel function in a client with acute pancreatitis who is at risk for the development of paralytic (adynamic) ileus? A. Observing contents of the nasogastric drainage B. Listening for bowel sounds in all four abdominal quadrants C. Asking the client if he or she has passed flatus or had a stool D. Interpreting the report of a CT scan of the abdomen with contrast medium

C The best indicator of bowel function and adequate motility is the actual passage of flatus or stool. Bowel sounds may still be present in the presence of an adynamic ileus. A CT scan is static and does not indicate motility. Gastric contents cannot indicate bowel motility.

Which change in a client's white blood cell differential does the nurse interpret as associated with a severe or prolonged bacterial infection? A. Increased immature neutrophils B. Increased lymphocytes C. Increased eosinophils D. Increased monocytes

A A bacterial infection is usually associated with an increased total white blood cell count and an increase in the mature neutrophils. When a bacterial infection is severe or prolonged, the bone marrow increases the release of immature neutrophils, a phenomenon known as a "left shift." This change indicates that the body can no longer keep pace with the infection and the client is at increased risk for sepsis. An elevated lymphocyte count is associated with viral infections. An elevated eosinophil count is associated with allergic reactions. An elevated monocyte count is associated with mononucleosis.

Which neuromuscular assessment change indicates to the nurse that a client who has late-stage liver cirrhosis now has encephalopathy? A. Asterixis B. Positive Chvostek sign C. Increased deep tendon reflex responses D. Decreased deep tendon reflex responses

A A late finding in clients who have late-stage liver cirrhosis and encephalopathy is asterixis, which is a coarse tremor that is characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

Which activity of a nutritional screening will the nurse assign to an assistive personnel (AP)? A. Obtaining an accurate height and weight B. Asking about the client's usual food intake C. Reviewing the client's laboratory results D. Performing a psychosocial assessment

A Accurately measuring height and weight are within the AP's scope of practice. Collecting information about a client's nutrition history, reviewing laboratory findings, and performing a psychosocial assessment require greater knowledge and skill and are not within an AP's scope of practice.

In which position will the nurse place a client after an open Whipple procedure for treatment of pancreatic cancer? A. Semi-Fowler position to reduce tension on the suture line B. Prone position to prevent acute respiratory distress syndrome C. Left lateral Sims' position with knees drawn up to the chest to reduce pain D. Right lateral Sims' position with knees drawn up to the chest to reduce pain

A After a radical pancreatectomy, the client is kept in a semi-Fowler position to reduce tension on the suture line and anastomosis site.

Which precaution is most important for the nurse to instruct clients with hepatitis C (HCV) who are receiving drug therapy with any second-generation protease inhibitor? A. Avoid crowds and people who are ill. B. Do not touch these drugs with your bare hands. C. Alternate periods of activity with periods of rest. D. Be sure to take vitamin K supplements with this drug.

A All of these drugs cause some degree of immunosuppression and increase the client's risk for infection.

Which health behavior does the nurse teach a client who is immunocompromised to prevent infection from normal flora? A. Wiping perineal area from front to back after toileting for females B. Wearing insect repellent or long sleeves to avoid mosquito bites C. Washing fruit and vegetables first before eating them raw D. Receiving an annual influenza vaccination

A Although all behaviors are appropriate actions for the client to take to reduce infection risk, only the action of option A helps reduce the risk of infection caused by normal flora of the intestinal tract from improperly entering the urinary tract (which should be a sterile site).

Which precaution is most important for the nurse to instruct a client with cirrhosis and his or her family about continuing care in the home? A. Avoid taking acetaminophen or drinking alcohol. B. Maintain one-floor living to prevent excessive fatigue. C. Use cool baths to reduce the sensation of itching. D. Report any change in cognition to the health care provider.

A Although all of the listed precautions are important, the most important is the avoidance of acetaminophen and alcohol. These substances are toxic to the liver and will worsen the client's liver disease.

What nutritional deficiency does the nurse suspect when a client reports recent onset of alopecia? A. Zinc B. Vitamin A C. Riboflavin D. Vitamin C

A Hair loss is one of the first indicators of a zinc deficiency.

Which action will the nurse take first when an 80-year-old client with acute pancreatitis has no breath sounds in the left lower lung lobe? A. Apply oxygen. B. Assess the breath sounds on the right. C. Notify the primary health care provider. D. Document the finding as the only action.

A Left lower lung effusions, atelectasis, and pneumonia often develop in clients with acute pancreatitis, especially in older adults, and can lead to pulmonary failure and death. The nurse would first apply oxygen and then immediately notify the primary health care provider.

Which client will the nurse recognize as having the greatest risk for nonacoholic fatty liver disease (NAFLD)? A. 45-year-old Latino man who is 30 lb (13.9 kg) overweight and has type 2 diabetes B. 50-year-old white woman who drinks one glass of wine daily and has breast cancer C. 60-year-old black woman who is hypertensive and takes a diuretic daily D. 70-year-old Asian man who has gastroesophageal reflux disease (GERD)

A Obesity and type 2 diabetes with metabolic syndrome are risk factors for NAFLD. In addition, a genetic variation in the PNPLA3 gene increases the risk. This variation is much more common among Latinos.

Which precaution to prevent harm is most important for the nurse to teach an overweight client who is prescribed to take orlistat? A. "Take a multivitamin daily because this drug prevents absorption of some vitamins." B. "Notify your primary health care provider if you have any thoughts about hurting yourself." C. "Be sure to use a reliable method of contraception because this drug can cause birth defects." D. "Watch for feelings of light-headedness and jitteriness because this drug can cause hypoglycemia."

A Orlistat inhibits lipase so that fats are only partially digested and absorbed. The nondigested fats and many fat-soluble nutrients are eliminated in the stool, potentially leading to vitamin deficiency.

What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? A. Increased pressure in the portal vein causing backflow of blood into the spleen B. The loss of cellular regulation in the liver spreading to the spleen and causing extensive scarring C. Chronic inflammation and infection increasing the spleen's maturation and release of white blood cells D. Direct destruction of spleen cells from alcohol or other toxins causing replacement with scar tissue formation

A Portal hypertension caused by stiffened liver tissue results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. This increased portal vein pressure causes backflow of blood into the spleen, resulting in splenomegaly.

Which action will the nurse take first to promote adequate intake in a client who is malnourished? A. Asking the client about his or her food preferences B. Providing the client with high-calorie, high-protein food C. Offering frequent snacks or protein shakes between meals D. Obtaining serial weights on a weekly basis to monitor progress

A Regardless of a dietary intervention for malnutrition, if the client does not eat the food provided or recommended, malnutrition will continue. Incorporating the client's food preferences into a planned dietary intervention increases the likelihood of the intervention's success.

For which client will the nurse expect extracorporeal shock wave lithotripsy (ESWL) as treatment for gallstones to be contraindicated? A. 30-year-old who is 70 inches (1.75 m) tall and weighs 325 Ib (147.2 kg) B. 35-year-old who has cholesterol-based stones C. 45-year-old who has a shellfish allergy and uses hormone replacement therapy D. 55-year-old who has bilateral total knee replacements

A Some clients who have small, cholesterol-based stones and good gallbladder function may undergo extracorporeal shock wave lithotripsy (ESWL) to break up the stones. This procedure can be used only for patients who have a normal weight.

What is the nurse's priority action when caring for a client with acute cholecystitis who now has severe abdominal pain, diaphoresis, heart rate of 118 beats / min, BP 95 / 70, respirations 32 breaths / min, and temperature 101°F (38.3°C)? A. Initiating the Rapid Response Team B. Assisting the client to a semi-Fowler position C. Administering the prescribed opioid analgesic D. Auscultating the client's abdomen in all four quadrants

A The client is exhibiting the symptoms associated with biliary colic and possible shock. This is an emergency and, if the client's primary health care provider is not immediately available, initiating the Rapid Response Team is a priority.

Which actions are most effective for nurses and other health care workers to prevent occupational transmission of viral hepatitis? Select all that apply. A. Washing hands before and after contact with all clients B. Using needleless systems for parenteral therapy C. Using Standard Precautions with all clients regardless of age or sexual orientation D. Obtaining an immunoglobulin injection after exposure to hepatitis A E. Being fully vaccinated with the hepatitis B vaccine F. Wearing gloves during direct contact with all clients

A, B, C, D, E With the exception of F, all actions are effective in preventing or reducing transmission of infectious hepatitis among health care workers as a result of occupational exposure (see the Best Practices for Patient Safety and Quality Care: Prevention of Viral Hepatitis in Health Care Workers box). Wearing gloves during direct contact with all clients may give a false sense of security and does not prevent transmission if gloves are contaminated and then come into contact with another person. Gloves are not needed for all client contact.

Which actions will the nurse take when caring for a client after bariatric surgery to prevent harm from complications? Select all that apply. A. Monitoring oxygen saturation B. Applying an abdominal binder C. Placing the client in semi-Fowler position D. Applying sequential compression stockings E. Assessing skinfolds for redness and excoriation F. Maintaining the client on bedrest for 24 to 48 hours

A, B, C, D, E With the exception of maintaining the client on bedrest for 24 to 48 hours, all of the above actions are recommended as best practices to prevent the many potential complications associated with bariatric surgeries.

Which signs and symptoms will the nurse expect to see in a client who is diagnosed with advanced pancreatic cancer? Select all that apply. A. Light-colored urine and dark-colored stools B. Anorexia and weight loss C. Splenomegaly D. Ascites E. Leg or calf pain F. Weakness and fatigue

A, B, C, D, E, F All of the signs and symptoms listed are associated with pancreatic cancer.

Which actions will the nurse take to enhance an older client's desire to eat? Select all that apply. A. Assisting the client to make menu selections and substitutions to match his or her food preferences B. Removing any items from sight that reduce appetite such as emesis basins, urinals, and bedpans C. Eliminating distractions, such as turning down the volume of the television D. Offering the client the opportunity to toilet before the meal arrives E. Opening cartons and condiment packages for the client F. Bringing the client's medications to take with the meal G. Ensuring the food served is at appropriate temperature H. Asking all of the client's visitors to leave

A, B, C, D, E, G Although it is not possible to increase a client's appetite, actions that make the client more comfortable, reduce unpleasant thoughts, and make food more appetizing can improve a client's interest or desire to eat. These include toileting before meals, removing objects that evoke unpleasant thoughts, providing food that the client likes at the right temperatures, making it easier for the client to access food items on the tray, and avoiding interruptions with medication administration. Visitors do not have to leave and may, in fact, make the dining experience more pleasant. Visitors are only asked to leave if they hamper a client's desire to eat.

With which clients will the nurse use extra precautions to prevent harm from infection development as a result of medical or surgical intervention? Select all that apply. A. 27-year-old taking antirejection drugs after receiving a kidney transplant B. 36-year-old being mechanically ventilated C. 45-year-old with an indwelling urinary catheter D. 58-year-old with type 2 diabetes mellitus E. 60-year-old who had an artificial aortic valve replacement 4 years ago F. 65-year-old taking corticosteroids daily for chronic obstructive pulmonary disease (COPD) G. 80-year-old with mild chronic heart failure taking a diuretic daily

A, B, C, E, F Drug therapies that cause any degree of immunosuppression, such as corticosteroids or antirejection drugs, increase the risk for infection. Artificial (synthetic) medical devices also increase the risk for infection as do devices that provide a direct access to the client's internal environment and bypass normal protections, such as indwelling urinary catheters and endotracheal / tracheal tubes. Although diabetes mellitus increases a client's infection risk, this is not a medical or surgical intervention. Advancing age also increases a client's infection risk but is not a medical or surgical intervention. Diuretics do not increase infection risk.

Which advantages of minimally invasive surgery (MIS) laparoscopic cholecystectomy will the nurse reinforce to a client after the surgeon has provided information for informed consent? Select all that apply. A. Bile duct injuries are rare. B. Complications are uncommon. C. Postoperative pain is less severe. D. Mortality is about equal to that of traditional cholecystectomy. E. IV antibiotics are not needed because infection does not occur. F. Depending on the nature of the job, some clients can return to work within 1 to 2 weeks.

A, B, C, F Injuries and complications are much lower than with traditional cholecystectomy and the postoperative pain is less severe. Many clients can resume their normal activities within 1 week. The mortality rate is very low, much lower than traditional cholecystectomy. Although the infection rate is low, there is still an infection risk anytime an incision is made.

Which assessment findings will the nurse expect in a client with late-stage liver cirrhosis whose total serum albumin level is low? Select all that apply. A. Ascites B. Hypotension C. Hyperkalemia D. Hyponatremia E. Dependent edema F. Decreased serum ammonia levels

A, B, D, E Serum albumin maintains plasma oncotic pressure and sodium levels in the normal range. When albumin levels are low, plasma volume decreases as fluid leaks into the abdomen and dependent areas, forming ascites and dependent edema. Sodium follows the albumin, making serum sodium levels low. The decreased plasma volume results in hypotension.

A client has postcholecystectomy syndrome (PCS) with persistent abdominal pain accompanied by vomiting for several weeks after removal of the gallbladder. Which possible causes or complications will the nurse remain alert for in this client? Select all that apply. A. Pseudocyst B. Common bile duct leak C. Dumping syndrome D. Diverticular compression E. Ductal stricture or obstruction F. Sphincter of Oddi dysfunction G. Primary sclerosis cholangitis H. Retained or new gallstones

A, B, D, E, E, G, H PCS most commonly indicates possible problems in the biliary tract, such as pseudocyst, common bile duct leak, diverticular compression, ducal stricture or obstruction, sphincter of Oddi dysfunction, primary sclerosis cholangitis, and retained or new gallstones. Dumping syndrome is not part of the problems associated with PCS. Further testing is needed to identify the cause and provide interventions to prevent even more serious complications.

Which signs and symptoms will the nurse expect to find on assessment of a client with chronic liver disease who has an elevated serum bilirubin level? Select all that apply. A. Pruritus B. Icterus C. Hypertension D. Jaundice E. Pale, clay-colored stools F. Dark, coffee-colored urine

A, B, D, E, F Bilirubin is a bile pigment. Elevated serum bilirubin levels stain the skin yellow (jaundice) and the eyes yellow (icterus). Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning it dark and coffee-colored. With liver disease and reduced function, the bilirubin does not reach the intestinal system where it is normally broken down to give stool its dark brown color. Because the bilirubin does not reach the GI tract, stools are light with a gray or clay color.

Which signs or symptoms will the nurse assess for in a client who is suspected of having cholecystitis? Select all that apply. A. Anorexia B. Jaundice C. Ascites D. Steatorrhea E. Eructation F. Rebound tenderness

A, B, D, E, F Characteristic signs and symptoms of cholecystitis include episodic or vague upper abdominal pain or discomfort that can radiate to the right shoulder, pain triggered by a high-fat or high-volume meal, anorexia, nausea and / or vomiting, dyspepsia, eructation, flatulence, feeling of abdominal fullness, rebound tenderness (Blumberg's sign), and fever. Additional symptoms include jaundice and fatty stools (steatorrhea).

Which clients will the nurse suggest to be immunized against hepatitis B (HBV)? Select all that apply. A. People who have unprotected sex with more than one partner B. Men who have sex with men C. Any client scheduled for a surgical procedure D. Firefighters E. Health care providers F. Clients prescribed immunosuppressant drugs

A, B, D, E, F HBV can be spread by both the parenteral and sexual routes. Exposures are more likely to result in infection in clients who are immunosuppressed for any reason. Individuals who are exposed to blood and other bodily fluids in the workplace are at risk for exposure.

Which new-onset assessment findings in a client with Laennec cirrhosis indicates to the nurse that the client may be starting to have delirium tremens (DIs) from alcohol withdrawal? Select all that apply. A. Anxiety B. Tachycardia C. Hypotension D. Hypertension E. Cool, clammy skin F. Psychotic behavior

A, B, D, F Alcohol withdrawal occurs sometimes as soon as 6 to 8 hours after stopping alcohol intake after heavy and prolonged use and can lead to DIs. Cognitive, behavioral, and autonomic changes that occur may include acute confusion, anxiety, and psychotic behaviors, such as delusions and hallucinations, along with autonomic changes of tachycardia, elevated blood pressure, and diaphoresis.

For which infectious diseases will the nurse recommend immunizations for older adult clients? Select all that apply. A. Influenza B. Pneumonia C. Human papilloma virus D. Herpes zoster (shingles) E. Measles, mumps, and rubella F. Tetanus, diphtheria, and pertussis

A, B, D, F The recommended immunizations for older adults include the following: • Pneumococcal 13-valent conjugate vaccine (Prevnar 13) to prevent pneumonia • Pneumococcal vaccine polyvalent vaccine (Pneumovax) to prevent pneumonia • Yearly influenza vaccine (trivalent or quadrivalent) to prevent influenza (flu) • Zoster vaccine recombinant (Shingrix) to prevent shingles (herpes zoster) • Adult Tap vaccine to prevent tetanus, diphtheria, and pertussis (whooping cough) (and Td booster every 10 years after Tdap). Immunization against the human papilloma virus or against the childhood disorders of measles, mumps, and rubella are not recommended.

Which serum laboratory values will the nurse expect to be elevated in a client who has acute pancreatitis? Select all that apply. A. Amylase B. Bilirubin C. Calcium D. Lipase E. Magnesium F. Glucose

A, B, D, F With acute pancreatitis, the pancreatic enzymes amylase and lipase are elevated. Bilirubin also is usually elevated as a result of biliary dysfunction or obstruction. Blood glucose levels are often elevated because pancreatic secretion of insulin is reduced. Most often, magnesium and calcium levels are decreased.

Which client factors does the nurse identify as increasing the risk for infection? Select all that apply. A. Drinking four to five alcoholic beverages daily B. Smoking two packs of cigarettes daily C. Using hormone-based contraceptives D. Eating a balanced vegetarian diet E. Serving a 5-year prison term F. Walking 2 miles daily

A, B, E Client factors that increase infection risk include cigarette smoking and drinking substantial amounts of alcohol daily. Living in crowded conditions, especially in institutions, also increases the risk for infection transmission. Hormone-based contraceptives, eating a balanced vegetarian diet, and regular participation in low-impact exercise do not increase a client's susceptibility to infection.

Which actions and precautions will the nurse educate a client with chronic pancreatitis about when starting pancreatic enzyme replacement therapy (PERT)? Select all that apply. A. Do not crush or chew the capsules. B. Take these drugs with all meals and snacks. C. Sit in an upright position for at least 30 minutes after taking the drug. D. Wear sunscreen and protective clothing outdoors to prevent severe sunburn. E. Check your stools for amount and presence of fat to assess whether the drugs are working. F. If you are too nauseated to eat or to take the drug, go to an emergency department for an injectable form of the drug.

A, B, E PERT is used to assist in the digestion of foods. Thus, it must be taken orally only whenever the client eats a meal or snack. Capsules are not to be opened, crushed, or chewed for maximum benefit. The amount of fat in the stools, as well as the amount and consistency of stools are used to evaluate PERT effectiveness. It is not necessary to remain upright, and the drug does not cause or increase photosensitivity.

Which signs/ symptoms in an older client admitted for a medical problem indicate to the nurse the possibility of "failure to thrive?" Select all that apply. A. Weakness B. Exhaustion C. Poor skin turgor D. Reduced hearing E. Stress incontinence F. Slow walking speed G. Low physical activity H. Unintentional weight loss

A, B, F, G, H "Failure to thrive" in older clients is a combination of any three of these five symptoms: weakness, slow walking speed, low physical activity, unintentional weight loss, and exhaustion.

Which actions are appropriate for the nurse to perform to prevent harm in a client with cirrhosis and ascites who has just undergone an esophagogastroduodenoscopy (EGD)? Select all that apply. A. Measuring oxygen saturation B. Checking for leakage from the site C. Assessing for return of the gag reflex D. Monitoring heart rate and blood pressure E. Auscultating bowel sounds in all four quadrants F. Comparing weight with that obtained before the procedure

A, C, D A client with cirrhosis and ascites is at risk for bleeding and hemorrhage as a result of reduced blood clotting factor synthesis. The endoscope placement for an ED can irritate or rupture any varices in the esophagus, stomach, or duodenum and lead to hemorrhage. The client must be closely monitored for indications of bleeding and hemorrhage by examining for changes in oxygen saturation, heart rate, and blood pressure. In addition, the procedure is performed under local anesthesia or light sedation and the client's gag reflex is affected.

Which signs and symptoms will the nurse expect to find on assessment of a client who is admitted with obstructive jaundice? Select all that apply. A. Pruritus B. Hypertension C. Pale, clay-colored stools D. Dark, coffee-colored urine E. Pink discoloration of sclera F. Bright red bleeding from the gums

A, C, D Jaundice is a yellow discoloration of the skin and mucous membranes from excessive bilirubin in these structures and blood. Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning it dark and coffee-colored. The obstruction prevents bilirubin from reaching the intestinal system where it is broken down and gives stool its dark brown color. Because the bilirubin does not reach the GI tract, stools are light with a gray or clay color.

Which actions will the nurse take to prevent harm when caring for a client receiving continuous enteral tube feeding? Select all that apply. A. Checking the residual volume at least every 6 hours B. Changing the feeding bag and tubing every 12 hours C. Keeping the head of the bed elevated at least 30 degrees D. Using clean technique when changing the feeding system E. Discarding unused open enteral products after 24 hours F. Warming the enteral products before infusion

A, C, D, E Residual volume must be assessed at least every 6 hours to prevent reflux and aspiration, as well as other complications. Keeping the head of the bed elevated to at least 30 degrees also helps prevent reflux and aspiration. Clean technique is required to prevent GI infection, as is discarding any unused enteral products that have been open for 24 hours. The feeding bag and tubing are changed every 24 to 48 hours as needed and in accordance with agency policy. Warming of the enteral product is not required or recommended.

Which clients will the nurse expect to be prescribed total enteral nutrition (TEN) to help attain or maintain an adequate nutrition status? Select all that apply. A. 28-year-old who remains comatose 10 days after a head injury B. 38-year-old with esophageal strictures and an intestinal blockage C. 48-year-old who eats all meals but remains 22 lb (10 kg) underweight D. 58-year-old who has lung cancer and cachexia E. 68-year-old with no teeth or dentures F. 78-year-old who cannot swallow after a stroke

A, C, D, F As long as the stomach and lower GI system are functioning, clients can receive TEN to provide all or part of their nutritional needs regardless of their level of consciousness, if they are unable to meet these needs by eating (clients in options C and F). The client with an intestinal blockage should be NO and may require parenteral nutrition. The client who has no teeth or dentures can use liquids, semisolids, soft foods, and chopped or minced foods that require no chewing. The client with lung cancer and cachexia can receive TEN if he or she chooses to do so.

Which situations are examples of an animate reservoir? Select all that Apply. A. Coronavirus (COVID-19) influenza was first transmitted to humans from infected bats and snakes. B. Escherichia coliform (E. Coli) bacteremia has been contracted from eating contaminated romaine lettuce. C. An immunocompromised client with HIV-III develops toxoplasmosis from changing a cat litter box daily. D. A 48-year-old man living in the tropics develops malaria after being extensively bitten by a swarm of mosquitoes. E. Health care personnel can transmit skin infections from one client to another by not cleaning stethoscope surfaces between clients. F. A 38-year-old client who is immunosuppressed from receiving chemotherapy develops aspergillus pneumonia while his 100-year-old house is renovated.

A, D Animate reservoirs include people, animals, and insects. COVID-19 influenza and mosquito-borne malaria are the examples in this list that meet the criteria. Romaine lettuce, kitty litter, stethoscopes, and aspergillus mold are inanimate reservoirs. Aspergillus is a newly designated inanimate reservoir of mold spores that becomes environmental particulate matter when released into the atmosphere such as during extensive renovation of older buildings.

Which symptoms in a client with cirrhosis and encephalopathy indicate to the nurse that the prescribed lactulose therapy is effective? Select all that apply. A. Decreased confusion B. Increased urine output C. Musty odor to the breath D. Two to three soft stools daily E. Lower serum bilirubin levels F. Lower serum ammonia levels

A, D, F Lactulose helps reduce encephalopathy by increasing stools, which causes the loss of some nitrogen-producing bacteria in the intestinal tract. This loss reduces ammonia levels and helps decrease confusion. Lactulose does not affect serum bilirubin levels or increase urine output. A musty odor of the breath (fetor hepaticus) is an indication of worsening encephalopathy.

Which actions will the nurse take to help relieve the severe pain in a client with acute pancreatitis? Select all that apply. A. Maintaining the client on NPO status B. Administering oral NSAIDs around the clock C. Inserting a nasogastric (NG) tube to low suction D. Providing opioids by patient-controlled analgesia E. Administering pancreatic enzyme replacement therapy F. Assisting the client to a side-lying position with knees drawn up to the chest

A, D, F Pain can be reduced by preventing pancreatic stimulation by keeping the client NO. Opioids are needed for severe pain and are best provided by PCA. Clients may obtain some pain relief from a side-lying position with the knees drawn closely to the chest. NSAIDs are not used and pancreatic enzyme replacement therapy would only make the pancreatitis worse at this time. NG tube placement is reserved for only those clients who have continuous vomiting or biliary obstruction.

For clients with which types of hepatitis will the nurse teach about prevention of infection spread through the oral-fecal contamination route? Select all that apply. A. Hepatitis A (HAV) B. Hepatitis B (HBV) C. Hepatitis C (HCV) D. Hepatitis D (HDV) E. Hepatitis E (HEV) F. Toxic hepatitis

A, E HAV and HEV are spread by the oral-fecal route from contaminated food and water sources. HBV, HCV, and HDV are spread primarily by the parenteral route although sexual contact can also result in infection spread. Toxic hepatitis is not infectious and is caused by exposure to hepatotoxic chemicals.

Indications of which vitamin deficiency will the nurse be sure to assess for in a client who follows a strict vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D3

B A strict vegan diet is plant-based only. All animal sources of protein, such as meat, poultry, fish, seafood, eggs, and dairy products are avoided as are any complex foods that contain these products. Vitamin By is highest in red meats.

Which complication in a client with acute necrotizing pancreatitis who develops a temperature spike to 104°F (40°C) will the nurse suspect? A. Pancreatic pseudocyst B. Pancreatic abscess C. Chronic pancreatitis D. Pancreatic cancer

B A sudden temperature elevation in a client with acute necrotizing pancreatitis is a strong indicator of pancreatic abscess that develops as a secondary bacterial infection with suppuration and pus formation of the necrotic pancreatic tissue. This condition can lead to sepsis and multiple organ dysfunction syndrome (MODS).

Which assessment is the priority for the nurse to make in the immediate postoperative period for a client after bariatric surgery? A. Asking the client to rate his or her pain B. Checking oxygen saturation and respiratory effort C. Examining the wound for indications of infection or dehiscence D. Monitoring skinfold areas for cleanliness and indications of breakdown

B Although all the listed assessments are important, airway management is the priority in the immediate postoperative period after bariatric surgery. Obese clients often have short, thick necks and compromised airways. These clients are more likely to need mechanical ventilation or other types of respiratory support to ensure adequate gas exchange.

Which action will the nurse take first to prevent harm when an assistive personnel (AP) reports that an 88-year-old client has a temperature of 100.2°F (37.9°C)? A. Administer prescribed acetaminophen. B. Assess the client for other indications of infection. C. Instruct the AP to recheck the temperature in 4 hours. D. Report the temperature elevation to the primary health care provider.

B Although the client's temperature is not greatly above normal, older adults usually do not have high fevers even when infection is present. The most appropriate action is for the nurse to assess the client for other indications of infection before notifying the primary health care provider. Because this low-grade fever could represent a serious infection in an older client, administering acetaminophen is not performed before assessment to prevent masking the infection. Rechecking the temperature in 4 hours is not the first or priority action. The nurse will report the temperature elevation to the primary health care provider after gathering other pertinent assessment data.

Which serum electrolyte value in a client with early-stage ascites from chronic liver disease who is taking spironolactone will the nurse report immediately to the primary health care provider? A. Sodium 133 mEq / L (mmol /L) B. Potassium 6.4 mEq / L (mmol /L) C. Chloride 101 mEq / L (mmol /L) D. Calcium 8.9 mg / dL (2.2 mmol /L)

B Although the sodium and calcium levels are slightly low, they do not pose a significant risk at this time. The serum potassium level is well above normal, which may be related to the spironolactone therapy because it causes sodium excretion and potassium retention, and must be reported to the primary health care provider immediately. The serum chloride level is normal.

With which client will the nurse avoid relying on body mass index (BMI) as an indicator of nutrition status? A. 25-year-old female with anorexia B. 35-year-old male weight-lifter who works out daily C. 55-year-old female runner who is post-menopausal D. 65-year-old male who plays golf twice a week and walks 5 miles daily

B BMI is an unreliable indicator of overnutrition or undernutrition in adults who are very athletic and muscular. When muscle mass is significantly greater than average, the client will weigh more even though the percentage of body fat is low.

Which fluid and electrolyte balance assessment action will the nurse perform most often for a client with pancreatic cancer after surgery with a traditional Whipple procedure? A. Using a reflex hammer to check deep tendon reflexes B. Pinching up skin over the sternum and checking for tenting C. Applying a blood pressure cuff and assessing for a Trousseau sign D. Asking the client whether he or she has noticed tingling or numbness around the mouth

B Clients are at extreme risk for dehydration during and after a traditional Whipple surgical procedure for pancreatic cancer because of variety of factors. These factors include exposure of the bowel during surgery, extensive NO status, the presence of drainage tubes, and protein malnutrition resulting in poor osmotic/oncotic pressure.

How will the nurse interpret a client's laboratory finding of the presence of immunoglobulin G antibodies directed against hepatitis A (HAV)? A. Active, infectious HAV is present. B. Permanent immunity to HAV is present. C. This is the client's first infection to HAV. D. The risk for infection if exposed to HAV is high.

B Immunoglobulin G (IgG) directed against HAV are antibodies that indicate the client was previously exposed to HAV and developed immunity against it.

In addition to Standard Precautions, which type of transmission-based precautions will the nurse use to prevent infection transmission when caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)? A. Airborne Precautions B. Contact Precautions C. Cutaneous Precautions D. Droplet Precautions

B MRSA is an organism that is spread by direct and indirect transmission, not by the airborne or droplet route. The most appropriate type of precautions in addition to Standard Precautions are Contact Precautions. Cutaneous Precautions are not a designated category for protection.

When will the nurse draw blood from a client who has been ordered to have a serum trough level of the prescribed antibiotic measured? A. At the halfway interval between two scheduled doses B. 30 minutes before the next ordered dose C. 60 minutes after the next ordered dose D. Immediately after giving a scheduled dose

B Peak and trough levels may be measured to determine the consistent blood levels of a prescribed antibiotic. A specimen for a trough level (lowest serum drug concentration) is drawn about 30 minutes before the next scheduled dose. Specimens for peak levels are drawn about 60 minutes after a dose is given.

Which client's previous health history will the nurse most associate with a risk for developing postnecrotic cirrhosis of the liver? A. 28-year-old woman who had gallstones 1 year ago and has recently lost 20 lb (9 kg) on a low-calorie, low-fat diet B. 45-year-old man with hepatitis C infection and chronic use of acetaminophen C. 50-year-old man who has many years of excessive alcohol consumption D. 55-year-old woman who has chronic biliary obstruction

B Postnecrotic cirrhosis of the liver is caused by viral hepatitis, especially hepatitis C, and drugs that are liver toxic, such as acetaminophen. Cirrhosis caused by chronic alcoholism is Laennec cirrhosis. Chronic biliary obstruction can result in biliary cirrhosis. Gallstones are not associated with cirrhosis unless chronic biliary obstruction is also present.

What is the priority action for the nurse to take for a client who has just been diagnosed with scabies? A. Provide meticulous mouth care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Perform precise measurement of intake and output.

B Scabies is an infectious mite infestation of the skin that can be transmitted by both direct and indirect contact. This infection is not oral and does not cause fever. In addition, it has no deleterious effect on kidney function.

Which action will the nurse take to prevent harm when a client's total parenteral nutrition (IN) bag has only 20 mL left in it and the next bag will not be delivered for at least 1 hour? A. Capping the TPN line until the next TPN solution is available B. Infusing 10% dextrose / water until the TN solution is available C. Preparing to treat the client for hypoglycemia D. Notifying the primary health care provider

B The TPN infusion line cannot be capped and must remain patent. The nurse infuses a 10% glucose infusion to keep the line open and prevent changes in blood glucose levels.

Which nursing assessment has the highest priority for the nurse to perform on a client admitted in severe pain with acute pancreatitis? A. Asking the client to rate the level of pain B. Measuring heart rate, blood pressure, and oxygen saturation C. Auscultating bowel sounds in all four abdominal quadrants D. Determining the amount of alcoholic beverages the client consumes daily

B The client with acute pancreatitis is at high risk for death from hemorrhage and shock as a result of necrotic blood vessels destroyed by enzymatic digestion. Although all the above assessments are appropriate, the priority is to determine whether any indications of internal hemorrhage and shock are present.

Which client is the nurse most likely to recommend for directly observed therapy (DOT)? A. Older client with poor dentition who requires liquid medications B. Homeless man with tuberculosis (TB) prescribed four anti-TB drugs daily C. College student prescribed oral antibiotics for a sexually transmitted infection D. Athlete with methicillin-resistant Staphylococcus aureus (MRSA) infection on the hand

B Tuberculosis is a highly contagious pulmonary infection transmitted by the airborne route that most commonly requires at least 6 months of daily drug therapy with four drugs. Failure to adhere to the drug regimen can result in disease progression, development of resistant organisms, and transmission to others. A homeless person is less likely to be adherent to the regimen for many reasons and would benefit most from directly observed therapy.

Which action performed during hand hygiene by an assistive personnel does the nurse need to correct? A. Wetting hands before applying soap B. Using hot water and a scrub brush C. Using friction under running water D. Washing for at least 15 seconds

B Using hot water and scrub brushes can injure the skin surface and may cause open areas in which microorganisms can enter. Although friction is required for good hand hygiene, abrading the skin with a brush is not.

Which assessment will the nurse use as the most reliable indicator of a client's fluid status? A. Intake and output B. Trends in weight C. Changes in skin turgor D. Presence of dependent edema

B Weight change is the most reliable indicator of fluid status. A liter of water weighs 1 kg (2.2 lb). An actual weight gain or loss can account for a daily change of only about a half Ib (~ 240 g). More than that indicates increased fluid and less than that indicates fluid loss.

Which activities are most important for the nurse to teach a client with esophageal varices to prevent harm from bleeding or hemorrhage? Select all that apply. A. Avoid alcoholic beverages. B. Eat soft foods and cool liquids. C. Do not engage in strenuous exercise or heavy lifting. D. Try to eat six smaller meals daily instead of three larger ones. E. Be sure to keep your mouth open when sneezing or coughing. F. Cross your legs only at the ankles when sitting, rather than the knees.

B, C Esophageal varices are thin-walled blood vessels that bleed easily with mechanical irritation or any increase in pressure within the portal system. Clients must avoid any activity that increases intra-abdominal pressure such as strenuous exercise and heavy lifting. Hard or rough foods can mechanically open the varices and cause bleeding. Avoiding alcohol may prevent worsening of the liver problems but does not directly prevent bleeding or hemorrhage. None of the other activities alter intra-abdominal pressure or prevent direct injury to the varices.

Which clients will the nurse recognize as having a higher risk for development of acute pancreatitis? Select all that apply. A. 26-year-old woman who is a marathon runner B. 34-year-old man with Stage II HIV disease C. 40-year-old woman who has had cholelithiasis for 3 years D. 56-year-old man who drinks alcohol heavily and is underweight E. 62-year-old woman with gastroesophageal reflux disease F. 70-year-old man who has type 2 diabetes

B, C, D Although the cause of acute pancreatitis is often unknown, risk factors include viral infection with HIV, long-term cholelithiasis that can lead to obstruction, and alcoholism. Being thin and active is not directly associated with pancreatitis. Neither gastroesophageal reflux disease nor type 2 diabetes increase the risk for acute pancreatitis.

Which changes in a 60-year-old client's assessment findings over the past 4 weeks indicate to the nurse the need for a nutrition status evaluation? Select all that apply. A. Sprained a wrist 2 weeks ago B. Initiation of a strict vegan diet C. Unintentional weight loss of 6% D. Initiation of a regular exercise program E. Reports starting counseling for depression F. Reduced cigarette smoking from two packs/ day to one pack / day

B, C, E The changes that could alter nutrition status the most for this 60-year-old client are the start of a strict vegan diet, unintentional weight loss greater than 5% in a month, and the presence of depression. Many people who decide to begin a strict vegan diet are unaware of what types of plant-based foods will be needed to maintain an adequate intake of micronutrients and protein. Many, but not all, people with depression often lose interest in maintaining an adequate nutritional intake.

Which physical factors does the nurse assess for in an older adult client that are likely to increase the risk for infection? Select all that apply. A. Increased antibody production B. Thin, delicate skin C. Decreased gag reflex D. Increased gastrointestinal motility E. Decreased mobility F. Higher incidence of chronic disease

B, C, E, F Thin, delicate skin is easily injured, reducing the barrier function and increasing the risk for infection. A decreased gag reflex increases the risk for aspiration and respiratory infection. Decreased mobility contributes to infection risk in many ways including venous stasis and loss of skin integrity. Increased age is associated with many chronic illnesses such as diabetes, chronic obstructive pulmonary disease, and neurologic impairment that also increase infection risk. Increased antibody production reflects good immunity, which is not associated with aging. Increased intestinal motility also does not increase infection risk.

Which techniques will the nurse instruct the family who will be caring for an 88-year-old female client who has severe osteoarthritis, muscle weakness, and dementia to use to improve nutrition and prevent harm? Select all that apply. A. "Be sure to keep her in bed while eating to prevent her from becoming over tired." B. "Let her feed herself as much as possible even if she uses her fingers." C. "Always include some foods that you know she likes for every meal." D. "Withhold her pain medications before meals to prevent nausea. E. "If she doesn't finish a meal in 20 minutes, take the food away." F. "During meals, be sure she has her glasses and hearing aid on."

B, C, F Clients are more likely to eat when they enjoy the experience and have some control over the process. Clients are encouraged to feed themselves whenever it is possible and to eat food that they like. Wearing prescribed glasses and hearing aids increase sensory perception, which can help hold the client's interest in eating. Having the client up in a chair for meals, rather than in bed, improves movement through the GI tract, reduces the risk for aspiration, and helps keep the client awake. Clients are more likely to eat if they are not in pain. Giving prescribed pain medication an hour to 30 minutes before meals can increase the comfort. The family is instructed to let the client eat at her own pace. Hurrying the client can result in an increased risk for aspiration, as well as make the experience less pleasant.

Which actions will the nurse take to prevent disease transmission when caring for a client who has an infection with a multidrug resistant organism? Select all that apply. A. Taking a prophylactic antibiotic daily B. Showering as soon as reaching home after work C. Remaining at least 6 feet away from infected clients D. Keeping work clothes separate from personal clothes E. Wearing scrubs and changing clothes before leaving work F. Wearing gloves while drawing blood for laboratory assessment

B, D, E To help prevent the transmission of an MDRO, nurses are expected to wear scrubs and change clothes before leaving work. Keeping work clothes separate from personal clothes, as well as taking a shower on reaching home helps rid the body of any unwanted pathogens. Taking prophylactic antibiotics can contribute to the development of MDRO and is most definitely not recommended. Remaining 6 feet away from infected clients is not possible during client care. Wearing gloves during blood draws is part of Standard Precautions and does not specifically address infection prevention for MDROs.

Which circumstances are examples of colonization? Select all that apply. A. Health care provider contacts the Centers for Disease Control and Prevention because client has symptoms of smallpox. B. A nurse has a nasal swab that cultures out methicillin-resistant Staphylococcus aureus (MRSA) and remains asymptomatic. C. An 86-year-old client who is immunocompromised because of multiple chronic health problems lives in a long-term care facility. D. An assistive personnel chooses to use an alcohol-based hand rub rather than washing with soap and water after caring for a client with Clostridium difficile. E. A 55-year old client with fever and a productive cough has a sputum culture that is positive for Streptococcus pneumonae. F. A 64-year-old woman's urine culture is positive for Escherichia coli although the urine is clear and no symptoms of cystitis are present.

B, F Colonization is the presence of microorganisms (often pathogenic) in the tissues of the host that do not cause symptomatic disease because of normal flora. Options B and F are consistent with this definition. Option A is incorrect because the client has disease symptoms although the organism remains unknown, and option E is incorrect because the client has infectious symptoms consistent with the organisms in the culture. In option C, the client is at increased risk for infection development but is not known to be harboring any pathogenic organisms. For option D, the client has an actual known infection and the assistive personnel is not using the recommended precautions to prevent spread.

Which symptom reported by a client after eating eggs indicates to the nurse a possible allergy to eggs rather than an egg intolerance? A. Diarrhea B. Excessive flatulence C. Throat itching and swelling D. Nausea when smelling eggs

C A true food allergy is an immune and inflammatory response that can occur as a systemic response, as well as in tissues that came into direct contact with the allergen in the food. A food intolerance is seen as a physiologic change in gastrointestinal responses that indicate a problem with digesting the food item. The nausea after smelling the odor of eggs is a learned behavior that is neither a food allergy nor a physiologic food intolerance.

Which assessment findings will the nurse expect in a client with chronic a vitamin D deficiency? A. Swollen, bleeding gums B. Reddened and dry conjunctiva C. Osteomalacia, bone pain, and rickets D. Enlargement of the liver and spleen

C Activated vitamin D is needed to absorb and use calcium, an element that contributes to bone density. When a client is chronically deficient in vitamin D, bones become soft (osteomalacia), bend (rickets), and bone pain increases.

What is the nurse's best first action when a client who just had a liver transplant develops oozing around two IV sites as well as has some new bruising? A. Applying pressure to the IV sites B. Checking the client's platelet levels C. Notifying the surgeon immediately D. Documenting the findings as the only action

C Bleeding around the IV sites is a strong indicator of clotting problems. Such problems are an indicator of impaired function of the transplanted liver and may be an early sign of transplant rejection. Immediate action is needed to prevent harm in the form of graft loss.

Which client will the nurse recognize as having the most risk factors for cholelithiasis? A. 25-year-old white female athlete who is 10 lb (4.5 kg) underweight and had an appendicitis 2 months ago B. 35-year-old African-American male who is 10 lb (4.5 kg) overweight and is hypertensive C. 50-year-old Mexican-American female who has three children and takes hormone replacement therapy D. 60-year-old Asian-American male who had coronary artery bypass graft surgery 4 weeks ago

C Cholelithiasis has a higher incidence among Mexican-Americans, especially women who have had multiple pregnancies, and among those who are taking estrogen / progesterone hormone replacement therapy.

For which client care situation will the nurse teach assistive personnel to perform handwashing, rather than using alcohol-based hand rubs (ABHRs)? A. After removing gloves used when emptying a Foley catheter bag B. After setting up a basin and towels for a client's morning care C. After contact with a client who has had diarrhea for 3 days D. Before having direct contact with any clients

C Handwashing is recommended instead of ABHRs when hands are visibly dirty or soiled or feel sticky and after toileting (including toileting clients). ABHRs are ineffective against spore-forming organisms such as Clostridium difficile, a common cause of health care-associated diarrhea, especially in older adults. A client with diarrhea may have spores in the fecal matter or on his or her body.

What liver problem does the nurse suspect in a client whose liver is hard with a nodular texture and the hepatic enzymes remain normal? A. Prenecrotic inflammation B. Postnecrotic inflammation C. Compensated cirrhosis D. Decompensated cirrhosis

C In compensated cirrhosis, the liver is scarred with physical changes and cellular regulation is impaired, but the organ can still perform essential functions, including maintaining normal liver enzyme levels without causing major symptoms. In decompensated cirrhosis, liver function is impaired with obvious signs and symptoms of liver failure, including elevated liver enzymes.

Which action does the nurse take to prevent indirect contact transmission of microorganisms to a susceptible client? A. Wearing a high-efficiency particulate air filter mask when providing direct care to a client with a respiratory infection B. Placing the client on Airborne Precautions until a negative tuberculosis test is verified C. Cleaning the glucometer with disinfectant between testing clients D. Wearing gloves when obtaining blood for glucose testing

C Indirect contact transmission occurs when microorganisms are transmitted from a source to a host by passive transfer from a contaminated object. A commonly used object that can be contaminated is a glucose testing device such as a glucometer. Even if blood is not seen on the device, it should be disinfected appropriately between clients to prevent indirect contact transmission of infection. The use of Airborne Precautions, wearing of filter masks, and wearing gloves are examples of preventing direct transmission, not indirect transmission of infection.

Which client will the nurse identify as most at risk for the marasmic-kwashiorkor form of protein-energy malnutrition (PEM)? A. 48-year-old with rheumatoid arthritis who has worn dentures for 6 years B. 58-year-old who suffered a traumatic amputation of the left arm 15 years ago C. 68-year-old vegan who is 10 lb (4.5 kg) underweight and has bacterial pneumonia with a high fever D. 78-year-old who has type 2 diabetes mellitus and lives with his 50-year-old daughter

C Marasmus is an energy (caloric) malnutrition with some degree of starvation in which body fat and muscle proteins are wasted although serum proteins may be normal. The client appears thin. Kwashiorkor malnutrition occurs with a severe protein deficiency although overall caloric intake may be adequate to maintain a normal weight, but serum proteins are low. Marasmic-kwashiorkor is a more severe malnutrition in which both protein and caloric intake are inadequate and the client is seriously underweight. It is most common when a client already is malnourished and develops a health problem that greatly increases the metabolic need for nutrients.

What is the nurse's best response to a client who fears he may have been exposed to hepatitis A while attending a banquet last week after which three restaurant workers were diagnosed with hepatitis A? A. "Which types of food did you eat at the banquet?" B. "If you have no symptoms at this time, you are probably safe." C. "You can receive an immunoglobulin injection to prevent the infection." D. "Contact your primary health care provider about receiving the hepatitis A vaccine."

C Receiving immunoglobulin with a high concentration of antihepatitis A antibodies within 2 weeks of exposure can prevent an exposed person from developing the infection. Receiving the vaccination at this time takes too long to develop sufficient immunity to prevent an infection from this exposure.

Which precaution is most important for the nurse to teach a client prescribed to take oral delafloxacin to treat a skin lesion infected with methicillin-resistant Staphylococcus aureus (MRSA)? A. Report any burning on urination to your primary health care provider immediately. B. Remain in an upright position for at least 1 hour after taking this drug. C. Take this drug 2 hours before or 6 hours after taking an antacid. D. Drink at least 3 L of fluid daily while taking this drug.

C The drug can combine with any metal or divalent cation such as magnesium, reducing its effectiveness. Because many antacids contain magnesium, clients are taught not to take an antacid with or close to when delafloxacin is taken. There are no fluid requirements or position restrictions associated with the drug. Delafloxacin does not increase the risk for urinary tract infection.

Which change in electrolyte values will the nurse expect in a client with acute pancreatitis who reports numbness around the mouth and leg muscle twitching? A. Hyponatremia B. Hypokalemia C. Hypocalcemia D. Hypochloremia

C The free or unbound serum calcium level is usually low in clients who have acute pancreatitis as a result of fat necrosis and the inability of the body to use protein-bound calcium.

Which electrolyte imbalance will the nurse assess for most frequently in a client who is receiving total parenteral nutrition with a solution that contains both glucose and insulin? A. Hypochloremia B. Hyperchloremia C. Hypokalemia D. Hyperkalemia

C The presence of insulin in the TPN solution activates the sodium-potassium ATPase pump on cell membranes and moves potassium from the extracellular fluid across the membranes into the cells, resulting in hypokalemia. Because the potassium is not present in the blood in high concentrations, any movement out of the blood can result in hypokalemia and serious physiologic changes.

Which health problem will the nurse assess for in an obese client who has a 40-inch waist circumference and a waist-to-hip ratio of 0.90? A. Rheumatoid arthritis B. Chronic kidney disease C. Cardiovascular disease D. Type 1 diabetes mellitus

C Waist circumference (WC) is a strong predictor of coronary artery disease (CAD), and WC greater than 35 inches (89 cm) in women and greater than 40 inches (102 cm) in men indicates central obesity. A waist-to-hip ratio (WHR) of 0.95 or greater in men (0.8 or greater in women) indicates android obesity with excess fat at the waist and abdomen, which is also a strong predictor of CAD. Rheumatoid arthritis symptoms are made worse by obesity but are not caused by it. Type 2 diabetes is associated with obesity but type 1 is not. Chronic kidney disease is not directly related to obesity.

For which clients does the nurse ensure placement in a private room? Select all that apply. A. 28-year-old client with influenza B. 36-year-old after a cholecystectomy who is HIV positive C. 48-year-old severely immunosuppressed client receiving cancer chemotherapy D. 59-year-old with active tuberculosis E. 63-year-old client with hepatitis C F. 84-year-old with methicillin-resistant Staphylococcus aureus (MRSA)

C, D Although all types of infections that can be transmitted by the direct contact, droplet, or the airborne routes are recommended to be cared for in private rooms, those that require private rooms are those clients who have airborne transmitted infections and those who are severely immunosuppressed and need a protected environment. HIV infection and hepatitis C are bloodborne infections and do not require separate private rooms to prevent transmission. Those clients who have infections spread by droplets, such as influenza, and those who have infections spread by contact (MRSA) can be cohorted with another client who has the same infection.

Which actions will the nurse take when a client is placed on Droplet Precautions? Select all that apply. A. Using chlorhexidine for handwashing B. Wearing a disposable gown whenever entering the client's room C. Using a mask when within 6 feet of the client D. Putting a mask on the client whenever transport is necessary E. Double gloving before entering the client's room F. Prohibiting all visitors

C, D Infections spread by droplet transmission are heavy and released when the client sneezes or coughs. These droplets travel short distances, usually only 3 feet or less, and do not remain in the air. Wearing a mask within 6 feet of the client and having the client wear a mask whenever he or she is out of the room is all that is needed. Visitors are permitted but must remain at least 3 feet away from the client or wear a mask. Soap and water for handwashing is sufficient and gowns are not needed.

Which personal protective equipment (PPE) does the nurse assemble for use when giving oral and parenteral drugs to a client who has diarrhea from Clostridium difficile overgrowth? Select all that apply. A. Air-purifying respirator B. Eye goggles C. Gloves D. Gown E. Hair cover F. Surgical mask

C, D When performing the action of giving either oral or parenteral drugs to any client with diarrhea, including those who have Clostridium difficile, only Contact Precautions are needed.

Which statements about eating habits and diet therapy indicate to the nurse that the client recovering from acute pancreatitis understands the recommendations made in collaboration with the registered dietitian nutritionist? Select all that apply. A. "Now I can go back to my usual three meals a day." B. "Replacing carbohydrates with protein will speed my recovery." C. "Although they do not contain fat, I will avoid chocolate and caffeine." D. "If vomiting or diarrhea occur, I will call my primary health care provider." E. "I can't wait to have some good, spicy Mexican food after all this hospital food." F. "I am planning on joining Alcoholics Anonymous and giving up drinking altogether."

C, D, F Recommendations for diet therapy during recovery from acute pancreatitis includes small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals with bland, nonspicy food; avoidance of alcohol; and avoidance of GI stimulants such as caffeine-containing food (tea, coffee, cola, and chocolate). If clients start to have nausea, vomiting, or diarrhea after eating, he or she is instructed to notify the primary health care provider.

Which actions will the nurse perform when preparing a client for paracentesis? Select all that apply. A. Obtaining informed consent B. Maintaining the client on NO status C. Asking the client to void before the procedure D. Placing the client in the flat supine position E. Weighing the client before the procedure F. Assessing the respiratory rate and blood pressure

C, E, F Vital signs, including weight, are taken before the procedure to use as a baseline for changes after the procedure. Weight is important because it can help determine the volume of fluid removed (clients are expected to weigh less after a paracentesis). Having the client void before procedure helps prevent injury to the bladder. The health care provider performing the paracentesis is responsible for obtaining informed consent, not the nurse. The client does not need to be NO before the procedure. The client is positioned with the head of the bed elevated.

Which assessment findings in an older client indicate to the nurse that this client is at increased risk for developing undernutrition? Select all that apply. A. Male B. Is of Jewish ethnicity C. Reports chronic diarrhea D. Receiving oxygen after surgery E. Does not consume pork products F. Has chronic obstructive pulmonary disease G. Presence of chronic draining pressure injury H. Presence of swollen gums and many missing teeth

C, F, G, H The risk for malnutrition is not particularly associated with ethnicity or gender. Conditions that increase nutrient loss, such as chronic wounds and chronic diarrhea contribute to undernutrition risk. Poor dentition interferes with a client's ability to consume adequate nutrients. Health problems that increase energy expenditure, such as COPD, greatly increase caloric need and promote undernutrition. Although pork is an animal protein source, its elimination from the diet does not alone contribute to undernutrition. Receiving oxygen after surgery is common and not an indicator of undernutrition risk.

Which action will the nurse use during client care to prevent infection by mechanically disrupting biofilms? A. Washing hands with chlorohexidine for 15 seconds B. Cleaning the skin with alcohol prior to venipuncture C. Using sterile technique when inserting a urinary catheter D. Helping the client to floss and to brush teeth

D A biofilm is a complex of microorganisms that group together and form a gel-like coating (glycocalyx) that supports continued growth of the microorganisms. Effective treatment or prevention starts with disruption of biofilm. Human biofilms include plaque on teeth and gums, a coating on and in the crypts of tonsils, and as a layer of exudate in wounds. They do not usually form on normal skin or mucous membrane.

Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal hypertension? A. Interpreting the serum albumin value B. Measuring the client's abdominal girth C. Testing stool for the presence of occult blood D. Weighing the client daily at the same time of the day

D Although measuring abdominal girth can show increases in girth that can be interpreted as more ascites, weighing the client provides more accurate information of water retention in the abdominal and dependent areas.

Which statement indicates to the nurse that a client who is experiencing frequent episodes of "indigestion" and flatulence may have cholecystitis? A. "My stools are sometimes very dark and tarry looking." B. "Sometimes at night I have bad-tasting fluid in my mouth." C. "Usually about a half hour after I eat, I become sweaty and nauseated." D. "My right arm and shoulder always seem to hurt after I eat fried foods."

D Cholecystitis and cholelithiasis can cause referred pain to the right shoulder area, including under the right shoulder blade. Dark, tarry stools are associated with GI bleeding. Bad-tasting fluid or vomitus in the mouth at night is related to gastroesophageal reflux disease. Becoming sweaty and nauseated after a meal is associated with dumping syndrome, not gallbladder disease.

Which problem does the nurse suspect in a client who is 4 weeks postoperative from gastric bypass surgery and reports that after a meal her heart races, she is nauseated, and has abdominal cramping with diarrhea? A. Hyperglycemia B. Intestinal obstruction C. Possible peritonitis D. Dumping syndrome

D Dumping syndrome occurs when food enters the small intestine rather than the stomach after gastric bypass surgery, which results in increased blood flow to that site with decreased blood flow elsewhere. This causes hypotension and tachycardia from reduced central circulation and increased intestinal peristalsis with abdominal cramping and diarrhea from the stimulation caused by the sudden expansion of the intestinal lumen.

Which set of energy balance factors leads to body weight loss? A. Energy intake and energy use are balanced. B. Energy use and energy intake are both zero. C. Energy intake exceeds energy use. D. Energy use exceeds energy intake.

D Energy balance is the relationship between energy use and energy intake. When energy used is greater than energy taken in or stored, weight loss occurs.

What is the nurse's best action to prevent harm for a client who is receiving enteral feedings by nasogastric (NG) tube when stomach contents cannot be aspirated and the client is coughing continuously? A. Notify the primary health care provider to request an order for a chest x-ray. B. Use a piston-style syringe and gentle pressure to instill 30 mL of water. C. Reposition the client on his or her right side and apply oxygen. D. Remove the tube.

D If the position of the NG tube is in doubt or questionable, remove the tube. The fact that the client is continuously coughing is an indication that the tube may no longer be in the esophagus. Although a chest X-ray could establish tube placement, removal is warranted to prevent respiratory distress.

Which complication does the nurse suspect when a client in a starvation state receiving enteral feedings has shallow respirations, weakness, acute confusion, and oozing from the IV site? A. Sepsis B. Aspiration C. Hypoglycemia D. Refeeding syndrome

D Refeeding syndrome is a life-threatening complication of aggressive enteral feeding in a severely malnourished client that is caused by fluid and electrolyte shifts. This condition can lead to heart failure, muscle breakdown, seizures, and hemolysis. Main electrolyte imbalances are hypokalemia and hypophosphatemia. The hypokalemia causes shallow respiration, as does heart failure. Bleeding around the IV site can be caused by the accompanying hemolysis and poor clotting.

Which response during sponging of a client with a high fever indicates to the nurse that cooling may be occurring too quickly? A. Increased temperature B. Decreased urine output C. Acute confusion D. Shivering

D Shivering during any form of external cooling usually indicates that the client is being cooled too quickly. A rising temperature indicates the cooling method is not effective. Neither acute confusion nor changing urine output indicate excessive or too rapid cooling.

What is the nurse's best first action when assessment findings on a client after gastric bypass surgery reveal increased back pain, restlessness, heart rate of 126 beats / min, and a urine output of only 15 mL for the past 2 hours? A. Increasing the IV infusion rate B. Inserting a fresh nasogastric tube C. Listening for bowel sounds in all abdominal quadrants D. Notifying the surgeon or Rapid Response Team immediately

D These assessment findings strongly suggest an anastomotic leak, which is an emergency and can lead to peritonitis, sepsis, and death.