MS 3rd EXAM

A client who has undergone a fundoplication wrap for hernia repair has returned from the postanesthesia care unit with a nasogastric tube draining dark brown fluid. Which is the nurse's priority action? a. Assess the placement of the tube. b. Document the finding and continue to monitor. c. Clamp the nasogastric tube for 30 minutes. d. Irrigate the nasogastric tube with normal saline.

B. After fundoplication, drainage from the nasogastric tube is initially dark brown with old blood. This finding is expected and requires only documentation. The drainage should become yellow-green within 8 hours after surgery.

A client with diabetes asks why more than one injection of insulin is required each day. Which is the nurse's best response? A.. "You need to start with multiple injections until you become more proficient at self-injection." B. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough." C. "A regimen of a single dose of insulin injected each day would require that you could eat no more than one meal each day." D. "A single dose of insulin would be too large to be absorbed predictably, so you would be in danger of unexpected insulin shock."

B. Even when a single injection of insulin contains a combined dose of different-acting insulins, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels.

A nurse is providing dietary teaching for a client who has a new diagnosis of celiac disease. which of the following statements by the client indicates an understanding of the teaching? "I can return to my regular diet when I am free of symptoms." "I will need to avoid taking vitamin supplements while on this diet." I will eat beans to ensure I get enough fiber in my diet." "I need to avoid drinking liquids with my meals while on this diet."

C Celiac disease is an autoimmune disorder that causes changes to the intestinal mucosa, resulting in an intolerance to gluten, which is found in wheat, barley, and rye. The client should continue to avoid eating foods that contain gluten. Clients who have celiac disease are at risk for malabsorption of vitamins and minerals; therefore, the client should continue taking vitamin and mineral supplements. " MY ANSWER Clients who have celiac disease must maintain a gluten-free diet which eliminates fiber-rich whole wheat products. Clients should eat beans, nuts, fruits, and vegetables to ensure an adequate intake of fiber. Clients who have dumping syndrome should avoid drinking liquids with their meals to slow the movement of food through the intestinal tract. Clients who have celiac disease do not need to refrain from drinking liquids with meals.

The nurse is caring for a client who has just undergone traditional cholecystectomy surgery and has a Jackson-Pratt (JP) drain in place. The nurse notes serosanguineous drainage present in the drain. Which is the nurse's priority action? A. Gently milk the drain tubing. B. Notify the surgeon immediately. C. Document the finding in the client's chart. D. Irrigate the drain with sterile normal saline.

C Drainage from the JP drain initially appears serosanguineous in color. The drainage will appear bile-colored within 24 hours. The nurse does not need to notify the surgeon, milk the tubing, or irrigate the drain because this is an expected finding

A client is undergoing diagnostic testing for gastroesophageal reflux disease (GERD). Which test does the nurse tell the client is best for diagnosing this condition? A. Endoscopy B. Schilling test C. 24-Hour ambulatory pH monitoring D. Stool testing for occult blood

C. Most accurate method

A client has a new insulin pump. Which is the nurse's priority instruction in teaching the client? A.. "Test your urine daily for ketones." B. "Use only buffered insulin." C. "Keep the insulin frozen until you need it." D. "Change the needle every 3 days."

D. Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

A client with untreated diabetes mellitus has polyuria, is lethargic, and has a blood glucose of 560 mg/dL. The nurse correlates the polyuria with which finding? A. Serum sodium, 163 mEq/L B. Serum creatinine, 1.6 mg/dL C. Presence of urine ketone bodies D. Serum osmolarity, 375 mOsm/kg

D. Osmosis diuresis Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Urine ketone bodies and serum creatinine are not related to the polyuria.

A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse expect? (Select all that apply) a. Oral temp 38.4C (101.1F) b. WBC 6000/mm3 c. bloody diarrhea d. nausea and vomitting e. right lower quadrant pain

a. Oral temp 38.4C (101.1F) d. nausea and vomitting e. right lower quadrant pain Oral temperature 38.4° C (101.1° F) is correct. A low-grade temperature is an expected finding in a client who has appendicitis. WBC 6,000/mm3 is incorrect. A WBC of 10,000 to 18,000/mm3 is an expected finding in a client who has appendicitis. Bloody diarrhea is incorrect. Bloody diarrhea is an expected finding in a client who has colorectal cancer. Nausea and vomiting is correct. Nausea and vomiting are expected findings in a client who has appendicitis. Right lower quadrant pain is correct. Right lower quadrant pain is an expected finding in a client who has appendicitis.

A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a. blood glucose 110 mg/dL b. Increased serum amylase c. WBC 9,000/mm3 d. Decreased bilirubin

b. Increased serum amylase d/t the pancreatic cell injury. All other findings are all expected findings.

A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following laboratory findings should the nurse report to the provider? a. Albumin 4.0 g/dL b. INR 1.5 c. Bilirubin 0.2 mg/dL d. Ammonia 180 mcg/dL

d. Ammonia 180 mcg/dL Rationale: The RN should report an increased serum ammonia level b/c it can indicate portal-systemic encephalopathy. The Ammonia range should be 10-80. The other findings are within normal ranges. Albumin: 3.5-5, Bilirubin: 0.3-1.0, INR : 0.8-1.1

A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the following findings indicates the procedure was effective? a. presence of a fluid wave b. increased heart rate c. equal pre & post procedure weights d. decreased SOB

d. decreased SOB Increased abdominal fluid can place pressure on the diaphragm which prevents them from being able to take a deep breathe. Decreased shortness of breathe is an indicator that the procedure was effective.

A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of acute gastric dilation? a. hiccups b. elevated BP c. bradycardia d. left lower quadrant pain

. hiccups RN should ensure patency of NG tube & notify MD.

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider? a. spider angiomas b. peripheral edema c. bloody stools d. jaundice

.C bloody stools at risk for hemorrhaging and indicates GI bleed

A client is admitted with cirrhosis and hepatopulmonary syndrome. Which clinical manifestation does the nurse monitor for progression or resolution of this problem? A. Right upper quadrant pain B. Crackles on auscultation C. Skin and scleral jaundice D. Nausea and vomiting

B

A client is diagnosed with hepatitis B. Which information does the nurse include in the teaching plan as a priority? A. Avoid drinking any alcohol until the doctor says you can." B. You will need aggressive control of your serum lipids." C. "Once your lab work returns to normal, you can donate blood again." D. "Wash your hands well after handling meat and shellfish."

A

A client in the emergency department has been diagnosed with ketoacidosis. Which manifestation does the nurse correlate with this condition? A.. Increased rate and depth of respiration B. Extremity tremors followed by seizure activity C. Oral temperature of 102° F (38.9° C) D. Severe orthostatic hypotension

A. --- Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation

What does the nurse teach the client with esophageal diverticula about dietary needs? A.. "Eat soft foods and smaller meals." B. "Only eat puréed foods." C. "Avoid drinking liquids with meals." D. "Avoid dairy products."

A. ---- Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany diverticula. The client does not have to avoid liquids or dairy products because these do not cause symptoms. The client does not have to eat puréed foods because he or she does not have difficulty swallowing or chewing foods.

A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? A. Control hyperglycemia. B. Prevent hypoglycemia. C. Restrict fluid intake. D. Prevent ketosis.

A. Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.

The nurse is caring for a postoperative client who reports pain in the shoulder blades following laparoscopic cholecystectomy surgery. Which direction does the nurse give to the nursing assistant to help relieve the client's pain? A. "Ambulate the client in the hallway." B. "Apply a cold compress to the client's back." C. "Encourage the client to take sips of hot tea or broth." D."Remind the client to cough and deep breathe every hour."

A. Instruct client to ambulate frequently to minimize free air pain in right clavicle, shoulder, scalpula

The nurse recognizes which client as being at greatest risk for the development of carcinoma of the liver? A. Middle-aged client with a history of diabetes mellitus B. Young adult client with a history of blunt liver trauma C. Older adult client with a history of cirrhosis D. Older adult client with malnutrition

C

A client with diabetes is prescribed insulin glargine once daily and regular insulin four times daily. One dose of regular insulin is scheduled at the same time as the glargine. How does the nurse instruct the client to administer the two doses of insulin? A.. "Draw up and inject the insulin glargine first, then draw up and inject the regular insulin." B. "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin." C. "First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together." D. "First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together."

A. Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine, then the regular insulin right afterward.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the client's weight by 6 kg

A. Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

A client is hospitalized with acute pancreatitis. The nursing assistant reports to the nurse that when a blood pressure cuff was applied, the client's hand had a spasm. Which additional finding does the nurse correlate with this condition? A. Serum calcium, 5.8 mg/dL b. Serum sodium, 166 mEq/L c. Serum creatinine, 0.9 mg/dL d. Serum potassium, 4.2 mEq/dL

A. Spasm of the hand when a blood pressure cuff is applied (Trousseau's sign) is indicative of hypocalcemia. The client's calcium level is low. The sodium level is high, but that is not related to Trousseau's sign. Creatinine and potassium levels are normal.

A client has been taught to inject insulin. Which statement made by the client indicates a need for further teaching? A. "The abdominal site is best because it is closest to the pancreas." B. "I can reach my thigh the best, so I will use different areas of the same thigh." C. "By rotating the sites in one area, my chance of having a reaction is decreased." D. "Changing injection sites from the thigh to the arm will change absorption rates."

A. The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

The nurse is caring for a client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than in the duodenum? A. Body mass index (BMI) is 16.6. B. Stool is positive for occult blood. C. Client has had four ulcers in the last 5 years. D. Hemoglobin is 13 g/dL and hematocrit is 42%.

A. Weight loss is associated with stomach ulcer. BMI of 17.6 indicates that the client is underweight (<18.5 is underweight in adults). This finding is more commonly seen with gastric ulcers than with duodenal ulcers because the pain is made worse with food ingestion. Occult blood and low hemoglobin and hematocrit levels may be seen with both gastric and duodenal ulcers. Recurrence is more commonly seen with duodenal than with gastric ulcers.

A thin, cachectic-appearing client has hepatic portal-systemic encephalopathy (PSE). The family expresses distress that the client is receiving so little protein in the diet. Which explanation by the nurse is most appropriate? A. A low-protein diet will help the liver rest and will restore liver function." B. "Less protein in the diet will help with the confusion." C. Despite looking so thin, protein will not help with weight gain." D. "Less protein is needed to prevent fluid from leaking into the abdomen."

B

The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days post-esophagogastrostomy. Which is the nurse's priority intervention? a. Irrigate the NG tube with cold saline. b. Document the drainage in the chart. c. Reposition the tube in the opposite nostril. d. Assess the client's vital signs and abdomen.

ANS: D The initial nasogastric drainage appears bloody but should turn yellow-green by the end of the first postoperative day. If the bloody color continues, this may indicate bleeding at the suture line. The nurse should assess the client further, then should notify the provider. If the tube is draining, it is not necessary to irrigate it. Repositioning the tube will not change the drainage. In addition, repositioning the tube might cause more damage to the suture line.

The nurse is caring for a critically ill client who has diabetic ketoacidosis (DKA). The nurse finds the following assessment data: blood pressure, 90/62; pulse, 120 beats/min; respirations, 28 breaths/min; urine output, 20 mL/1 hour per catheter; serum potassium, 2.6 mEq/L. The health care provider orders a 40 mEq potassium bolus and an increase in the IV flow rate. Which action by the nurse is most appropriate? A. Give the potassium after increasing the IV flow rate. B. Increase the IV rate; consult the provider about the potassium. C. Increase the IV rate; hold the potassium for now. D. Infuse the potassium first before increasing the IV flow rate.

B

Which statement indicates that the client understands the management of his or her sliding hiatal hernia? A. "I will lie flat for 30 minutes after each meal." B. "I will remain upright for several hours after each meal." C. "I will have my blood count done in 2 weeks to check for anemia." D. "I will sleep at night while lying on my left side to prevent reflux."

B

The nurse is caring for a client with chronic pancreatitis. Which instruction by the nurse is most appropriate? A. You will need to limit your protein intake." B. "We need to call the dietitian to get help in planning your diet." C. "You cannot eat concentrated sweets any longer." D. "Try to eat less red meat and more chicken and fish

B A client with chronic pancreatitis needs 4000 to 6000 calories per day for optimum nutrition and healing. The client may have additional restrictions if he or she has other health problems such as diabetes. The nurse should collaborate with the registered dietitian to help the client plan nutritional intake.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? A. Monitor intake and output. B. Provide a low-sodium diet. C. Increase oral fluid intake. D. Weigh the client daily.

B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

A client has Barrett's esophagus. Which client assessment by the nurse requires consultation with the health care provider? a. Sleeping with the head of the bed elevated b. Coughing when eating or drinking c. Wanting to eat several small meals during the day d. Chewing antacid tablets frequently during the day

B ANS: B In Barrett's esophagus (a complication of gastroesophageal reflux disease [GERD]), fibrosis and scarring that accompany the healing process can cause esophageal stricture, leading to difficulty in swallowing. This can be manifested by coughing when the client eats or drinks and requires consultation with the health care team. The other assessments are typical of clients trying to control their GERD.

A client had an open fundoplication 2 days ago. Which assessment by the nurse indicates that an important National Patient Safety Goal is being met for this client? a. The client uses the spirometer during the shift. b. The client's pain is monitored and treated. c. The client has vital signs taken routinely. d. The client verbalizes understanding of the discharge teaching.

B ANS: B Pain must be monitored and aggressively treated after an open fundoplication because the high incision makes breathing very painful. If the client does not participate in deep-breathing exercises and will not use the spirometer, the chance of respiratory complications is quite high. National Patient Safety Goals include goals selected to reduce/prevent health care-related infection. Using the spirometer will help prevent pneumonia and atelectasis, but the client must use it hourly. Taking vital signs may help the nurse notice an infection but will not prevent the infection. Understanding discharge teaching is important, but preventing respiratory complications takes priority.

A client just had a paracentesis. Which nursing intervention is a priority for this client? A. Monitor urine output. B. Maintain bedrest as per protocol. C. Position the client flat in bed. D. Secure the trocar to the abdomen with tape.

B After a paracentesis, the client should remain on bedrest with the head of the bed elevated. A client with liver dysfunction is at risk for bleeding, and bedrest decreases this risk. Clients with liver dysfunction must have intake and output monitored, but this is not the priority after this procedure. A drain may be placed for short-term therapy in some clients.

A client is admitted for suspected cholecystitis. On reviewing laboratory results, the nurse notes that the client's amylase is elevated. Which action by the nurse is best? A. Document the finding in the chart. B. Ask the client about drinking habits. C. Notify the health care provider. D. Place the client on clear liquids.

B Serum and urine amylase levels are elevated when the pancreas becomes inflamed. One cause of pancreatitis is gallbladder disease; another causative factor is alcohol intake. The nurse should tactfully explore this subject with the client before documenting the findings and notifying the provider. The client may need to be NPO or on clear liquids, but the nurse does not have enough information yet to determine this

The nurse is caring for a client with acute pancreatitis. Which nursing intervention best reduces discomfort for the client? a. Administering morphine sulfate IV every 4 to 6 hours as needed b. Maintaining NPO status for the client with IV fluids c. Providing small, frequent feedings, with no concentrated sweets d. Placing the client in semi-Fowler's position at elevation of 30 degrees

B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric (NG) tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

A client is admitted with end-stage cirrhosis and severe vomiting. Which problem should the nurse monitor the client most carefully for? A. Intrahepatic bile stasis B. Bleeding esophageal varices C. Decreased excretion of bilirubin D. Accumulation of ascites in the abdomen

B The portal hypertension that accompanies end-stage cirrhosis predisposes the client to esophageal varices. These varices can rupture from increased pressure in the esophagus caused by coughing or vomiting. Bleeding varices can be life threatening. None of the other assessments take priority over monitoring for bleeding from esophageal varices.

A nurse is providing teaching for a client who has cirrhosis and a new prescription of lactulose. The nurse should include which of the following instructions in the teaching? a. notify the provider if bloating occurs b. expect to have 2 to 3 soft stools per day c. restrict carbohydrates in the diet d. limit oral fluid intake to 1,000 mL per day of clear liquids

B The purpse of this medication is to promote excretion of ammonia in the stool. Frequent stools are expected in order to achieve the desired outcome. Bloating,flatulence and bloating are common adverse effect to lactulose. The client should follow a diet high in carbs and protein to prevent malnutrition. The client should maintain adequate fluid intake to offset dehydrating effects from the medication.

Which laboratory data does the nurse correlate with advanced disease in a client with cirrhosis? A. Elevated serum protein level B. Elevated serum ammonia level C. Decreased serum ammonia level D. Decreased lactate dehydrogenase level

B The serum ammonia level is elevated in the presence of advanced disease because conversion of ammonia to urea for excretion is decreased. The other laboratory values do not correlate with advanced disease.

The nurse determines that which arterial blood gas values are consistent with ketoacidosis in the client with diabetes? A. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg B. B. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg C. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg D. pH 7.28, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

B When the lungs can no longer offset acidosis, the pH decreases to below normal. The arterial blood gases show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels

A client has Barrett's esophagus. Which client assessment by the nurse requires consultation with the health care provider? A. Sleeping with the head of the bed elevated B. Coughing when eating or drinking C. Wanting to eat several small meals during the day D. Chewing antacid tablets frequently during the day

B.

An obese client has reflux and asks how being overweight could cause this condition. Which response by the nurse is best? A. You eat more food, more often, than nonobese people do." B. The weight adds extra pressure, which helps push stomach contents up." C. Obese people tend to eat more high-fat food, which presents a risk." D. Obesity is not related to reflux, but losing weight would be healthy."

B.

A client with diabetes asks the nurse why it is necessary to maintain blood glucose levels no lower than about 60 mg/dL. Which is the nurse's best response? A."Glucose is the only fuel used by the body to produce the energy that it needs." B. "Your brain needs a constant supply of glucose because it cannot store it." C. "Without a minimum level of glucose, your body does not make red blood cells." D. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

B. Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The other statements are not accurate

a nurse is providing discharge teching for a client who has chronic hepatitis C. which of the following statements by the client indicates an understanding of the teaching? I will avoid alcohol until I'm no longer contagious." "I will avoid medications that contain acetaminophen." "I will decrease my intake of calories." "I will need treatment for 3 months."

B. client who has hepatitis C should avoid medications that contain acetaminophen, which can cause additional liver damage.

The nurse is providing discharge teaching for a client who has just undergone laparoscopic cholecystectomy surgery. Which statement by the client indicates understanding of the instructions? A. "I will drink at least 2 liters of fluid a day." B. "I need a diet without a lot of fatty foods." C. "I should drink fluids between meals rather than with meals." D. "I will avoid concentrated sweets and simple carbohydrates

B. After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this operation. Restriction of sweets is not required

A client newly diagnosed with type 2 diabetes tells the nurse that since increasing fiber intake, he is having loose stools, flatulence, and abdominal cramping. Which is the nurse's best response? A.. "Decrease your intake of water and other fluids until your stools firm up." B. "Decrease your intake of fiber now and gradually add it back into your diet." C. "You must have allergies to high-fiber foods and will need to avoid them." D. "Taking an antacid 1 hour before or 2 hours after meals will help this problem."

B. Many people experience these side effects when first increasing dietary fiber. Gradually incorporating high-fiber foods into the diet can minimize abdominal cramping, discomfort, loose stools, and flatulence. The client needs increased water intake with fiber. The client does not have allergies, nor should he or she take antacids in the hope that they will reduce the problem.

A client who has been taking high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition, which has now resolved, asks the nurse why she needs to continue taking corticosteroids. Which is the nurse's best response? A. "It is possible for the inflammation to recur if you stop the drugs." B. "Once you start corticosteroids, you have to be weaned off them." C. "You must decrease the dose slowly so your hormones will begin to work again." D. "The drug suppresses your immune system, which needs to be built back up."

B. One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone (ACTH) and adrenal production of cortisol.

The nurse is in the room of a client who is sleeping in the bed. The client experiences an episode of reflux with regurgitation. Which action does the nurse take first? a. Have the client roll to the side. b. Raise the head of the client's bed. c. Auscultate the client's lung sounds. d. Call the Rapid Response Team.

B. The immediate danger for this client is aspiration. The nurse first should raise the head of the bed to reduce this risk. Asking the client to roll to the side will take too much time. The nurse can auscultate the client's lungs after raising the head of the bed. Calling the Rapid Response Team may or may not be necessary but would be done after the client is in a safer position

The nurse monitors for which serologic marker in the client who is a carrier of chronic hepatitis B? A. Anti-hepatitis C virus (HCV) antibodies B. Anti-hepatitis B (HBs) antibodies C. Hepatitis B surface antigen (HBsAg) antibodies D. Hepatitis A virus (HAV) antibodies

C Persistent presence of the serologic marker HBsAg after 6 months indicates a carrier state or chronic hepatitis. The other markers are not indicative of a carrier state.

A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first? a. insert a NG tube b. administer ceftazidime c. Identify the clients current level of pain d. Instruct the client to remain NPO c. Identify the clients current level of pain

C Rationale: Clients who hace acute pancreatitis often experience sever abdominal pain so this should be assessed first. All other options may be done as well but pain is the priority.

The nurse is providing discharge teaching for a client who will be receiving pancreatic enzyme replacement at home. Which statement by the client indicates that additional teaching is needed? A.. "The capsules can be opened and the powder sprinkled on applesauce if needed." B. "I will wipe my lips carefully after I drink the enzyme preparation." C. "The best time to take the enzymes is immediately after I have a meal or a snack." D. "I will not mix the enzyme powder with food or liquids that contain protein."

C The enzymes should be taken immediately before eating meals or snacks. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. Protein items will be dissolved by the enzymes if they are mixed together.

A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider? a. Intolerance of high-fiber foods b. liquid ileostomy output c. dark purple stoma d. sensation of burning during bowel elimination

C, . dark purple stoma A dark purple stoma is an indication of bowel ischemia. All other options are expected findings.

A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the nurse monitor the client most closely for? A. Shallow slow respirations and respiratory alkalosis B. Decreased urine output and hyperkalemia C. Tachycardia and orthostatic hypotension D. Peripheral edema and dependent pulmonary crackles

C.

A client is undergoing diagnostic testing for gastroesophageal reflux disease (GERD). Which test does the nurse tell the client is best for diagnosing this condition? a. Endoscopy b. Schilling test c. 24-Hour ambulatory pH monitoring d. Stool testing for occult blood

C. ANS: C The most accurate method of diagnosing gastroesophageal reflux disease is 24-hour ambulatory pH monitoring.

A client has cirrhosis and has developed ascites and edema. Which laboratory value does the nurse correlate with this condition? A. Blood glucose, 120 mg/dL B. Serum sodium, 135 mEq/L C. Serum albumin, 2.1 g/dL D. Blood urea nitrogen, 18 mg/dL

C. Ascites occurs as a result of the inability of the liver to synthesize albumin. Loss of albumin leads to edema. This client's albumin level is low, which correlates with the condition. Sodium and blood urea nitrogen (BUN) levels are normal. The glucose level is slightly high, but this is not directly related to edema.

A client has been newly diagnosed with diabetes mellitus. Which statement made by the client indicates a need for further teaching regarding nutrition therapy? A. "I should be sure to eat moderate to high amounts of fiber." B. "Saturated fats should make up no more than 7% of my total calorie intake." C. "I should try to keep my diet free from carbohydrates." D. "My intake of plain water each day is not restricted."

C. Carbohydrates are an extremely important source of energy. They should compose at least 45% to 65% of the diabetic person's total caloric intake. The client needs to eat at least 130 g of carbohydrates a day. The other statements show good understanding.

A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the nurse monitor the client most closely for? A.. Shallow slow respirations and respiratory alkalosis B. Decreased urine output and hyperkalemia C. Tachycardia and orthostatic hypotension D. Peripheral edema and dependent pulmonary crackles

C. DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the nurse that the condition is chronic rather than acute? A. Abdomen that is hyperresonant to percussion B. Hyperactive bowel sounds and diarrhea C. Clay-colored stools and dark amber urine D. Rebound tenderness in the right upper quadrant

C. Findings include clay colored stools, dark urine, jaundice, pruiritis. In chronic cholecystitis, bile duct obstruction results in the absence of urobilinogen to color the stool. Excess circulating bilirubin turns the urine dark and foamy. The other assessment findings do not correlate with chronic cholecystitis.

.The nurse is teaching a client with type 2 diabetes about acute complications. Which teaching point by the nurse is most accurate? A. Ketosis is less prevalent among obese adults owing to the protective effects of fat. B. People with type 2 diabetes have normal lipid metabolism, so ketones are not made. C. Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia. d.Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis).

C. Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy production. The client with type 1 diabetes becomes ketotic because he or she produces no insulin, and blood glucose cannot enter the cells. In type 2 diabetes, natural insulin production continues, although at a greatly reduced level. This level is not sufficient to keep blood glucose levels in the normal range but permits just enough glucose to enter cells for energy production, so that fats are not catabolized for this purpose. The other rationales are incorrect

A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? A. I will no longer need any medication for my GERD." B. "I will avoid spicy foods because they can irritate the suture line." C. "I should take anti-reflux medications when I eat a large meal." D. "I will need to continue to watch my diet and may still need medication

D.

A client is admitted to the cardiac monitoring unit for a suspected myocardial infarction. The client reports long-standing nighttime reflux, and the health care provider orders nizatidine (Axid) 150 mg twice a day. Which action by the nurse is most appropriate? A. Consult with the health care provider because the dose is too high. B. Check the client's kidney function tests before administering the drug. C. Ask the pharmacist to recommend another histamine receptor agonist. D. Give the medication as ordered and monitor for effectiveness

C. Nizatidine, a histamine receptor agonist, can cause dysrhythmias. Because the client has a heart condition that may cause rhythm problems, the nurse should consult with the pharmacist for another drug in the same class to recommend to the provider. The dose is appropriate. Kidney function does not need to be monitored while on this drug. The nurse should monitor all drugs given for effectiveness, but this drug should not be given as prescribed.

A client who has undergone an open fundoplication hernia repair is preparing for discharge. Which information is most important for the nurse to include in discharge instructions? a. "You can take laxatives for constipation." b. "Eat three normal-sized meals daily." c. "Notify your health care provider if you get a cough." d. "You can go back to work in about a week."

C. The client is instructed to report cold or flu-like symptoms because persistent coughing associated with these conditions can cause dehiscence of the incision in the early postoperative stage. Constipation can be caused by narcotic medications, but the client should be instructed to use fiber, water, and stool softeners first before using laxatives. The client must continue eating six small meals a day. After the open procedure, activity restrictions continue for up to 6 weeks.

Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a "fruity" odor. Which is the nurse's best first action? A.Document the finding in the client's chart. B. Increase the IV fluid flow rate. C. Test the serum for ketone bodies. D. Perform pulmonary hygiene.

C. The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. The other options are not needed for this problem

The nurse has been teaching a client about a new diagnosis of diabetes mellitus. Which statement by the client indicates a good understanding of self-management? A.. "After bathing each day, I will inspect my feet and rub lotion between my toes and on my heels." B. "I can store 3 months' worth of insulin at room temperature as long as the bottles are not open." C. "My medical alert bracelet is important to identify me as having diabetes if I am unconscious." D. "If I travel eastward to see my family, I should plan on using more insulin on the day I travel."

C. --- It is important to encourage clients with diabetes mellitus to wear a medical alert bracelet. This bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Lotion should not be applied between the toes. Insulin in active use can be stored at room temperature for 28 days; otherwise insulin is stored in the refrigerator. Eastbound travel xfpittwill require a reduction in insulin.

The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the client's flanks. Which is the nurse's priority action? a. Prepare the client for emergency surgery. b. Place the client in high Fowler's position. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Ensure that the client has a patent large-bore IV site.

D Grayish-blue discoloration on the flanks (Turner's sign) indicates pancreatic enzyme leakage into the peritoneal cavity. This presents a risk of shock for the client, so IV access should be maintained with at least one large-bore patent IV catheter. The client may or may not need surgery; usually a fetal position helps with pain, and having an NG tube would not take priority over IV access.

The client with end-stage cirrhosis presents with GI bleeding, combativeness, and confusion. The nurse anticipates an order to administer which medication? A. Omeprazole (Prilosec) B. Somatostatin (Octreotide) C. Propranolol (Inderal) D. Lactulose (Heptalac)

D Lactulose helps rid the body of ammonia. Excess ammonia leads to encephalopathy, which this client is manifesting. Omeprazole is a proton pump inhibitor used for reflux and ulcer disease. Somatostatin is given to treat bleeding from esophageal varices. Inderal is given to prevent bleeding from esophageal varices.

A client is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which nursing intervention is the priority? A. Keep the client sedated to prevent tube dislodgement. B. Maintain balloon pressure at between 15 and 20 mm Hg. C. Irrigate the gastric lumen with normal saline. D. Maintain the client's airway.

D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this procedure. The other interventions are not a priority over airway.

A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value does the nurse correlate with this condition? A. Potassium, 5.5 mEq/L B. Hemoglobin, 14.2 g/dL C. Sodium, 144 mEq/L D. Erythrocyte sedimentation rate (ESR), 55 mm/hr

D The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr. Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than 12 g/dL in females. The sodium level is normal.

The health care provider is prescribing medication to treat a client's severe gastroesophageal reflux disease (GERD). Which medication does the nurse anticipate teaching the client about? A. Magnesium hydroxide (Gaviscon) B. Ranitidine (Zantac) C. Nizatidine (Axid) D. Omeprazole (Prilosec)

D.

The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? A. "I will avoid drinking coffee, even if it is decaffeinated." B. "I will take a multivitamin every morning with breakfast." C. "I will go to my tai chi class to wind down after a busy day." D. "I will take my medication every day until my heartburn is gone."

D.

The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days post-esophagogastrostomy. Which is the nurse's priority intervention? A. Irrigate the NG tube with cold saline. B. Document the drainage in the chart. C. Reposition the tube in the opposite nostril. D. Assess the client's vital signs and abdomen.

D.

A client has returned to the nursing unit after esophagogastroduodenoscopy (EGD). Which action by the nurse takes priority? A.. Keep the client on strict bed rest for 8 hours. B. Delegate taking vital signs to the nursing assistant. C. Increase the IV rate to flush the kidneys. D. Assess the client's gag reflex.

D. --- The client will receive moderate sedation and a numbing agent during the procedure. The client may temporarily lose his or her gag reflex; this should be checked before the client is permitted to eat anything by mouth. The client does not require strict bedrest for 8 hours or increased fluid to flush the kidneys. The nurse can delegate the taking of vital signs to unlicensed assistive personnel (UAP) such as the nursing assistant, but this is not the priority.

A client who has undergone Nissen fundoplication for gastroesophageal reflux disease (GERD) is ready for discharge home. Which statement made by the client indicates understanding of the disease? a. "I will no longer need any medication for my GERD." b. "I will avoid spicy foods because they can irritate the suture line." c. "I should take anti-reflux medications when I eat a large meal." d. "I will need to continue to watch my diet and may still need medication."

D. A high percentage of recurrence of reflux has been noted after this type of surgery, so clients are encouraged to continue anti-reflux regimens of medication and diet control. These include taking medications, eating small meals, and avoiding spicy or acidic foods.

The health care provider is prescribing medication to treat a client's severe gastroesophageal reflux disease (GERD). Which medication does the nurse anticipate teaching the client about? a. Magnesium hydroxide (Gaviscon) b. Ranitidine (Zantac) c. Nizatidine (Axid) d. Omeprazole (Prilosec)

D. ANS: D Proton pump inhibitors such as omeprazole are the main treatment for more severe cases of GERD. Gaviscon, Axid, and Zantac can be used to treat less severe cases.

A client is learning to inject insulin. Which action is important for the nurse to teach the client? A. Do not use needles more than twice before discarding." B. "Massage the site for 1 full minute after injection." C. "Try to make the injection deep enough to enter muscle." D. "Keep the vial you are using in the pantry or the bedroom drawer."

D. Cold insulin directly from the refrigerator is the most common cause of irritation (not infection) at the insulin injection site. Insulin in active use can be stored at room temperature. However, the bathroom is not the best place to store any medication because of increased heat and humidity. Needles should be used only once. Massage will not prevent or treat irritation from cold insulin. Insulin is given by subcutaneous, not intramuscular, injection.

A young adult client newly diagnosed with type 1 diabetes mellitus has been taught about self-care. Which statement by the client indicates a good understanding of needed eye examinations? A. "At my age, I should continue seeing the ophthalmologist as I usually do." B. "I will see the eye doctor whenever I have a vision problem and yearly after age 40." C. "My vision will change quickly now. I should see the ophthalmologist twice a year." D. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

D. Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter

A nurse is caring for a client who has GERD and new prescription for Metoclopramide. The nurse should plan to monitor for what side effect? a. thrombocytopenia b. hearing loss c. hyper salivation d. ataxia

D. The RN should monitor for extrapyramidal symptoms, such as ataxia, and should report any positive findings to the provider. The other side effects are not related to metoclopramide

A client on an intensified insulin regimen consistently has a fasting blood glucose level between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. Which is the nurse's interpretation of these findings? A. Increased risk for developing ketoacidosis B. Increased risk for developing hyperglycemia C. Signs of insulin resistance D. Good control of blood glucose

D. The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance

A client has diabetic ketoacidosis and manifests Kussmaul respirations. What action by the nurse takes priority? A. Administration of oxygen by mask or nasal cannula B. Intravenous administration of 10% glucose C. Implementation of seizure precautions D. Administration of intravenous insulin

D. The rapid, deep respiratory efforts of Kussmaul respiration is the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also have a respiratory impairment does not need additional oxygen. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. Giving the client glucose would be contraindicated. The client does not require Seizure Precautions.

The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? A. "I will avoid drinking coffee, even if it is decaffeinated." B. "I will take a multivitamin every morning with breakfast." C. "I will go to my tai chi class to wind down after a busy day." D. "I will take my medication every day until my heartburn is gone."

D. Long-term medication compliance is crucial to eradicate Helicobacter pylori and prevent recurrence. The nurse stresses the importance of continuing medications for the entire time prescribed. Decaffeinated coffee is a better choice than caffeinated coffee for the client with peptic ulcer disease. Stress management should also be part of the treatment plan. Good nutrition is always important.

A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbation over the past 3yrs. Which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbation's? (select all that apply) a. use progressive relaxation techniques b. increase dietary fiber intake c. drink two 240mL (8oz) glasses of milk per day d. arrange activities to allow for daily rest periods e. restrict intake of carbonated beverages

a. use progressive relaxation techniques d. arrange activities to allow for daily rest periods e. restrict intake of carbonated beverages Use progressive relaxation techniques is correct. Progressive relaxation techniques, a form of biofeedback, are recommended to help the client minimize stress, which can precipitate an exacerbation. Increase dietary fiber intake is incorrect. The client should restrict intake of dietary fiber, which can cause diarrhea and cramping. Drink two 240 mL (8 oz) glasses of milk per day is incorrect. Dairy products, such as milk, are poorly tolerated by clients who have ulcerative colitis and should be avoided. Arrange activities to allow for daily rest periods is correct. Daily rest periods decrease stress and reduce intestinal motility. Restrict intake of carbonated beverages is correct. The client should avoid gastrointestinal stimulants, such as carbonated beverages, nuts, peppers, and smoking.

A nurse is providing teaching about dietary management to prevent dumping syndrome for a client who is postoperative following a gastrectomy. The nurse should encourage the client to include which of the following foods to his diet? a. lactose-reduced milk b. eggs c. grape juice d. honey

b. eggs Rationale: Protein containing foods decrease the risk for manifestations of dumping syndrome. The client should eat some form of protein at every meal. Avoid sweetened juices like grape juice, simple sugars like honey, and sweetened milk products these can all cause dumping syndrome.

A nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease. The nurse should identify that which of the following medications inhibits gastric acid secretion? a. calcium carbonate b. famotidine c. aluminum hydroxide d. sucralfate

b. famotidine Famotidine is an H2 receptor antagonist that is prescribed for the treatment of PUD to inhibit gastric acid secretion. Calcium carbonate and aluminum hydroxide neutralizes gastric acids and sucralfate is a mucosal barrier fortifier that forms a protective barrier over the ulcer but does not inhibit gastric acid.

A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend? a. eggs b. fish c. yogert d. broccoli

c. yogert The nurse should suggest yogert, crackers or toast that can prevent flatus and stool odor. The other options cause flatus and stool odor.