hushpuppy

The nurse has been assigned to provide care for four clients at the beginning of the day shift. Who should the nurse assess first 1. The client awaiting hiatal hernia repair at 11 am. 2. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests. 3. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain. 4. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw

3

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: 1. Contact the surgeon to request an order for a narcotic for the pain. 2. Maintain the client in a recumbent position. 3. Place the client on nothing-by-mouth (NPO) status. 4. Apply heat to the abdomen in the area of the pain.

3

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Document the findings. 4. Notify the health care provider.

3

The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

3

The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care? 1. Allow any of the client's favorite foods as long as the amount is limited. 2. Have the client perform eructation exercises several times a day. 3. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. 4. Encourage

3

A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? 1. Conduct physical activity in the morning so that he can rest in the afternoon. 2. Have the family agree to perform the necessary yard work at home. 3. Give up jogging and substitute a less demanding hobby. 4. Incorporate periods of physical and mental rest in his daily schedule.

4

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis.

4

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? 1. Promptly assess the client for potential perforation. 2. Tell the assistant to change thermometers and retake the temperature. 3. Plan to give the client acetaminophen (Tylenol) to lower the temperature. 4. Ask the assistant to bathe the client with tepid water

1

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

2

Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: 1. Demonstrate appropriate use of analgesics to control pain. 2. Explain the rationale for eliminating alcohol from the diet. 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. Eliminate contact sports from his or her lifestyle

2

Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease? A. The clients pain is controlled with the use of NSAIDs B. The client maintains lifestyle modifications C. The client has no signs and symptoms of hemoptysis D. The client take s antacids with each meal

b

Which goal has the highest priority in the plan of care for a 26-yearold homeless patient admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify sources of hepatitis exposure

b

Which information given by a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 20 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation

b

Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori? a. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto- Bismol) b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) c. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) d. Metoclopramide (Reglan)

b

During the oliguric phase of AKI, the nurse monitors the patient for Select all that apply a. hypotension b. ECG changes c. hypernatremia d. pulmonary edema e. urine with high specific gravity

b, d

A 38-yr-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone . Which assessment data will be of most concern to the nurse? a. Skin is thin and fragile b. Blood pressure is 150/92. c. A nontender axillary lump. d. Blood glucose is 144 mg/dL. After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

c

A common combination of immunosuppressive agents used to prevent rejection of transplanted organs is: a. cyclosporine, sirolimus, and muromonab-CD3 b. everolimus, mycophenolate mefetil, an sirolimus c. tacrolimus, prednisone, and mycophenolate mofetil d. prednisone, polyclonal antibodies, and cyclosporine

c

A pt who has a positive test for HIV antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/uL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of an acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient has developed acquired immunodeficiency syndrome (AIDS)." d. "The patient will develop symptomatic chronic HIV infection in less

c

A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine

A

A patient with a history of peptic ulcer disease has presented to the emergency department with complaints of severe abdominal pain and a rigid, boardlike abdomen, prompting the health care team to suspect a perforated ulcer. Which of the following actions should the nurse anticipate? A. Providing IV fluids and inserting a nasogastric tube B. Administering oral bicarbonate and testing the patient's gastric pH level. C. Performing a fecal occult blood test and administering IV calcium gluconate. D. Starting parenteral nutrition and placing the patient in high-Fowler's position

A

A patient with newly diagnosed acquired immunodeficiency syndrome (AIDS) has a negative result on a skin test for tuberculosis (TB). Which action will you anticipate taking next? A. Obtain a chest radiograph and sputum smear. B. Tell the patient that the TB test results are negative. C. Teach the patient about the anti-TB drug isoniazid. D. Schedule TB testing again in 12 months.

A

A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Are you taking corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

b

A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

b

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. serum creatinine. c. d. serum potassium.

b

The client with a history of peptic ulcer disease is admitted into the intensive care unit with frank gastric bleeding. Which priority intervention should the nurse implement? A. Maintain a strict record of intake and output B. Insert a nasogastric tube and begin saline lavage C. Assist the client with keeping a detailed calorie count D. Provide a quiet environment to promote rest

b

The nurse is caring for a 68-yr-old man who had coronary artery bypass surgery 3 weeks ago. During the oliguric phase of acute kidney disease, which action would be appropriate to include in the plan of care? a. Provide foods high in potassium. b. Restrict fluids based on urine output. c. Monitor output from peritoneal dialysis. d. Offer high-protein snacks between meals.

b

The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's skin has a multiple spider-shaped blood vessel on the abd

b

When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first? a.Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate)

b

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

b

Which assessment data indicate to the nurse the clients gastric ulcer has perforated? A. Complaints of sudden, sharp, substernal pain B. Rigid, boardlike abdomen with rebound tenderness C. Frequent, clay-colored, liquid stool D. Complaints of vague abdominal pain in the right upper quadrant

b

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.

b

After receiving change-of-shift report, which patient should the nurse assess first? a. A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 96/54 mm Hg d. A patient with nausea who has a dose of metoclopramide (Reglan) scheduled

c

The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1, 2, 3, 5

The nurse is teaching a class on diverticulosis. Which interventions should the nurse discuss when teaching ways to prevent an acute exacerbation of diverticulosis? Select all that apply. 1. Eat a high-fiber diet. 2. Increase fluid intake. 3. Elevate the HOB after eating. 4. Walk 30 minutes a day. 5. Take an antacid every two (2) hours

1, 2, 4

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Instruct the client to avoid activities that will initiate vasovagal responses. 4. Encourage a high-fiber diet to promote bowel movements without straining. 5. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 6. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding. 7. Use suppository cream

1, 4, 5, 7

"The female nurse sticks herself with a dirty needle. Which action should the nurse implement first? 1.Notify the infection control nurse. 2.Cleanse the area with soap and water. 3.Request post-exposure prophylaxis. 4.Check the hepatitis status of the client

2

"What type of precautions should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. Airborne precautions 2. Standard precautions 3. Droplet precautions 4. Exposure precautions"

2

The RN is providing discharge information to a client with hep B. The RN instructs the client to prevent transmission via: 1. airborne pathogens 2. blood and body secretions 3. skin contact 4. fecal and oral routes

2

Gastroesophageal reflux disease (GERD) weakens the lower esophageal sphincter, predisposing older persons to risk for impaired swallowing. In managing the symptoms associated with GERD, the nurse should assign the highest priority to which of the following interventions? 1. Decrease daily intake of vegetables and water, and ambulate frequently 2. Drink coffee diluted with milk at each meal, and remain in an upright position for 30 minutes. 3. Eat small, frequent meals, and remain in an upright position for at least 30 minutes after eating 4. Avoid over-the-counter drugs that have antacids in them

3

Who should the nurse collaborate with for a patient diagnosed with esophageal cancer?

speech, dietary

Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states, a. "The cobalamin injections will prevent me from becoming anemic." b. "These injections will increase the hydrochloric acid in my stomach." c. "These injections will decrease my risk for developing stomach cancer." d. "The cobalamin injections need to be taken until my inflamed stomach heals."

A

Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

A

When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A Use smallest gauge needle possible when giving injections or drawing blood. B Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D Apply gentle pressure for the shortest possible time period after performing venipuncture. E Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.

A, B, C, E

HAART causes what effects? A. reversal of a patients antibody status B. decrease of the viral load C. increase of the viral load D. moe delectable HIV

B

A client with a positive skin test for TB isn't showing signs of active disease. To help prevent the development of active TB, the client should be treated with isoniazid, 300 mg daily, for how long? A10 to 14 days B2 to 4 weeks C3 to 6 months D9 to 12 months

D

Select ALL of the following that are complications associated with Crohn's Disease: A. Cobble-stone appearance of GI lining B. Lead-pipe sign C. Toxic megacolon D. Fistula E. Abscess F. Anal Fissure

A, D, E, F

Select all the medications a physician may order to treat a H. Pylori infection that is causing a peptic ulcer? A. Proton-Pump Inhibitors B. Antacids C. Anticholinergics D. 5-Aminosalicylates E. Antibiotics F. H2 Blockers G. Bismuth Subsalicylates

A, E, F, G

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

B

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level B.. Elevated serum bilirubin level c. Elevated blood urea nitrogen leveld. d. Decreased erythrocycle sedimentation rate

B

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which of the following nursing interventions is advised for this patient? a) The client should be monitored for any breathing related disorder or discomforts b) The client should not be given any food and fluids until the gag reflex returns, c.) The client should be monitored for cramping or abdominal distention, d) The client's fluid output should be measured for at least 24 hours after the procedure

B

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? a) The ostomy bag should be adjusted. b) Blood supply to the stoma has been interrupted. c) An intestinal obstruction has occurred. d) This is a normal finding 1 day after surgery

B

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time? a. Teach about the effects of antiretroviral agents. b. Encourage adequate nutrition, exercise, and sleep. c. Discuss likelihood of increased opportunistic infections. d. Monitor for symptoms of acquired immunodeficiency syndrome (AIDS).

B

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

B

Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? A. History of side effects experienced from all medications B. Use of non steroidal anti inflammatory drugs (NSAIDs) C. Any known allergies to drugs and environmental factors D. Medical histories of at lease 3 generations

B

In a patient with Dumping Syndrome, select ALL the correct statements on how to educate this patient about decreasing their symptoms: A. "It is best to eat 3 large meals a day rather than small frequent meals." B. "After eating a meal lie down for 30 minutes." C. "Eat a diet high in protein, fiber, and low in carbs." D. "Be sure to drink at least 16 oz. of milk with meals." E. drink liquids only between meals.

B, C, E

which immune function abnormalities are a result of HIV infection? (Select all that apply) A. lymphocytosis B. CD4+ depletion C. increased CD8+ activity D. long macrophage life span E. lymphocytopenia

B, E

A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I eat small meals during the day and have a bedtime snack." d. "I quit smoking several years ago, but I still chew a lot of gum."

C

A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time? a. Teach the patient about the medications available for treatment. b. Inform the patient how to protect sexual and needle-sharing partners. c. Remind the patient about the need to return for retesting to verify the results. d. Ask the patient to notify individuals who have had risky contact with the patient.

C

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct

C

A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of fat in the diet. b. history of recent weight gain or loss. c. any family history of gastric problems. d. use of nonsteroidal anti-inflammatory drugs (NSAIDs).

D

"The nurse is caring for a 68 year old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which of the following types of bowel sounds that is consistent with the patient's clinical picture? A. low pitched and rumbling above the area of obstruction B. High pitched and hypoactive below the area of obstruction C. low pitched and hyperactive below the area of obstruction D. high pitched and hyperactive above the area of obstruction

D

"When planning care for a patient with cirrhosis, the nurse will give highest priority to which of the following nursing diagnoses? A: Imbalanced nutrition: less than body requirements B: Impaired skin integrity related to edema, ascites, and pruritus C: Excess fluid volume related to portal hypertension and hyperaldosteronism D: Ineffective breathing pattern r/t pressure on diaphragm and reduced lung volume

D

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? -a. Liver enzyme -b. Hydrochloric acid -c. Histamine -d. Intrinsic factor

D

The nurse explains to the patient with gastroesophageal reflux disease that this disorder: A. results in acid erosion and ulceration of the esophagus caused by frequent vomiting, B. will require surgical wrapping or repair of the pyloric sphincter to control the symptoms, C. is the protrusion of a portion of the stomach into to esophagus through an opening in the diaphragm, D. often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the espophagus

D

What is the most appropriate nursing intervention to help an HIVinfected patient adhere to a treatment regimen? a. "Set up" a drug pillbox for the patient every week. b. Give the patient a video and a brochure to view and read at home. c. Tell the patient that the side effects of the drugs are bad but that they go away after a while. d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

D

When planning care for a patient with cirrhosis, the nurse will give highest priority to which of the following nursing diagnoses? A) Imbalanced nutrition: less than body requirements B) Impaired skin integrity related to edema, ascites, and pruritus C) Excess fluid volume related to portal hypertension and hyperaldosteronism D) Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D

Which assessment finding in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Complaints of incisional pain d. Temperature 102.1° F (38.9° C)

D

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

D(This was similar but the intervention was to involve skin team)

If patient is experiencing active bleeding provide

IV fluids and RBC transplant

"The nurse is caring for a pt. in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the pt. complains of pain in the right lower quadrant. The nurse will document this as which of the following signs of appendicitis? A. Rovsing sign B. Referred pain C. Chvostek's sign D. Rebound tenderness"

a

A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? a. Asterixis and lethargy b. Jaundiced sclera and skin c. Elevated total bilirubin level d. Liver 3 cm below costal margin

a

A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate a. administration of immunosuppressant medications. b. insertion of an arteriovenous graft for hemodialysis. c. placement of the patient on the transplant waiting list. d. drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching.

a

The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance

a

The nurse obtains a sputum specimen from a client with suspected TB for laboratory study. Which of the following laboratory techniques is most commonly used to identify tubercle bacilli in sputum? a. Acid-fast staining b. Sensitivity testing c. Agglutination testing d. Dark-field illumination

a

Which diagnostic test would be used first to evaluate a client with upper GI bleeding? - a. Endoscopy -b. Hemoglobin and hematocrit -c. Arteriography - d. Upper GI series

a

Which patient has the greatest risk for prerenal AKI? a. The patient who is hypovolemic because of hemorrhage. b. The patient who relates a history of chronic urinary tract obstruction. c. The patient with vascular changes related to coagulopathies. d. The patient receiving antibiotics such as gentamicin.

a

the nurse must administering a-interferon and ribovirin (Rebetol) to a patient woth chronic hepatitis C will plan to monitor for... a. leukopenia b. hypokalemia c. polycythemia d. hypoglicemia

a

Which assessment findings would alert the nurse that the patient has entered the diuretic phase of acute kidney injury (AKI)? Select all that apply a. Dehydration b. Hypokalemia c. Hypernatremia d. BUN increases e. Urine output increases

a, b, e

After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient says, a. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." b. "I need to be monitored closely because I have a greater chance of developing malignant tumors." c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." d. "The drugs are given in combination because they inhibit different aspects of transplant rejection

c

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. 40-year-old with chronic pancreatitis who has gnawing abdominal pain b. 58-year-old who has compensated cirrhosis and is complaining of anorexia c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

c

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. hyperkalemia and hyponatremia b. hyperkalemia and hypernatremia c. hypokalemia and hyponatremia d. hypokalemia and hypernatremia

c

The nurse is caring for a patient with stomatitis. Which nursing intervention is appropriate? a. Check the gastric residual before the feeding. b. Assess a typical 24 hour eating pattern. c. Offer frequent mouth care. d. Assess BMI

c

The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

c

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.

c

When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucous b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

c

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately

c

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure (BP), heart rate, and respirations. d. Place the patient in the supine position.

c

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

c

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice

c

Which of the following diagnostic tests is definitive for TB? AChest x-ray BMantoux test C Sputum culture D Tuberculin test

c

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take erythropoietin to boost my immune system and help prevent infection."

c

Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis? a. Taking lactulose c. Avoiding alcohol ingestion b. Maintaining good nutrition d. Using vitamin B supplements

c

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

d

A patient has a new prescription for cyclosporine after having a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

d

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. HIV genotype and phenotype b. Patient's social support system c. Potential medication side effects d. Patient's ability to comply with ART schedule

d

The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient's blood glucose level is 142 mg/dL. b. The patient complains of feeling "constantly tired." c. The patient is unable to state the side effects of the medications. d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)."

d

What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. urine testing reveals a low specific gravity b. causative factor is malignant hypertension c. urine testing reveals a high sodium concentration d. reversal of oliguria occurs with fluid replacement

d

Which assessment data support to the nurse the clients diagnosis of gastric ulcer? A. Presence of blood in the clients stool for the past month. B. Reports of a burning sensation moving like a wave. C. Sharp pain in the upper abdomen after eating a heavy meal. D. Complaints of epigastric pain 30-60 minutes after ingesting food.

d

Which assessment finding is of most concern for a 46- year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

d

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

d

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

d

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Activity level c. Temperature d. Albumin level

d