MS2 Quiz

A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. What is the nurse's best response?

They aid absorption of fat-soluble vitamins

The formula for BMI is

kg ÷ (height in meters squared)

The nurse assesses the vaginal pH of four clients in the obstetrics unit. Which client has normal pH?

pH 4.2

A nurse is caring for a client with end-stage renal disease. For which clinical indicator should the nurse monitor the client?

Azotemia

A nurse is performing a health history and physical assessment of a client with cholelithiasis and obstructive jaundice. Which clinical finding should the nurse expect this client to exhibit?

pain in URQ

nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, which action should the nurse take?

place a support under the scrotum

A client who is obese and has a history of alcohol abuse is admitted to the hospital with the diagnosis of acute pancreatitis. Which is the initial priority expected client outcome in response to therapy at this time?

report decreased pain

A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client makes which comment?

"A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery?

"An indwelling urinary catheter is required for at least a day."

A client with an indwelling catheter is prescribed a urinalysis test. Arrange the steps involved in the collection of the urine sample in correct order.

1. Clamp drainage tubing 2. Attach sterile syringe 3.Aspirate urine 4. Remove the clamp

A healthcare provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. Place the nursing interventions in the order in which they should be implemented.

1.Verify the healthcare provider's prescription 2.Elevate the head of the bed to at least 30 degrees 3.Check the volume of residual against the parameters prescribed 4.Administer the volume of feeding as per the prescription 5.Flush the tube with 30 mL of water after the feeding

Calculating calories

4cal per gram

A client returns from the postanesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment?

Assess cap refill in nailbeds

A client has a permanent colostomy. During the first 24 hours there is no drainage from the colostomy. How should the nurse interpret this finding?

Absence of intestinal peristalsis is causing this.

A client is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101° F (38.3° C). The client reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, what symptom is the primary nursing concern for this client?

Acute pain

A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply.

Administer analgesics Teach relaxation exercises Monitor cardiac rate & rhtyhm

A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate? Select all that apply.

Assisting with splitting the cast Assessing urine output Evaluating the pain on a scale

A nurse is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. Which nursing care should be included in the client's plan of care? Select all that apply.

Auscultate for a bruit. Palpate the site to identify a thrill. Avoid drawing blood from the affected extremity.

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

Avoid heavy lifting & alcohol Eat small, frequent meals

A primary healthcare provider prescribes three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound (4.5 kg) weight loss in one month. To ensure valid test results, what instructions should the nurse give the client?

Avoid red meat before testing

A client has an adenocarcinoma of the colon. It is suspected that the cancer has metastasized, and a liver computed tomography (CT) scan with contrast medium has been prescribed. What would be appropriate for the nurse to include in the client's instructions?

Before the procedure, the client will be given an intravenous (IV) infusion, and the client must lie as still as possible for a period of time.

A client had a laparoscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? Select all that apply.

Call the healthcare provider if you have a fever of 100o F (37.8oC) or more for two days. Check the puncture sites daily for redness, tenderness, swelling, heat, or drainage.

A client had an abdominal cholecystectomy. The nurse is caring for the client 24 hours after the surgery and notes 150 mL of bile drainage from a client's T-tube. What is the next action the nurse should take?

Check the tube for kinks because the drainage is less than expected.

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position?

Helps stop bleeding should any occur

A client's leg is placed in Buck extension to immobilize a fracture until surgery can be performed. When planning caring for this client, the nurse considers that Buck extension is which type of traction?

Cutaneous traction

A peripheral nerve or dorsal column stimulator is implanted to relieve a client's intractable pain. What discharge instructions should the nurse provide?

D/c when taking a bath

When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.

Diarrhea Seizures

A client with a femoral fracture associated with osteomyelitis is immobilized for 3 weeks. The nurse assesses for the development of renal calculi. What is the rationale for the nurse's assessment?

Lack of weight-bearing activity promotes bone demineralization

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period, what is the priority nursing action?

Encouraging coughing & deep breathing

A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?

Hemorrhage

A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for which complication?

Hep B

A nurse is reviewing the laboratory hormonal profile of four clients. Which client should be evaluated for ovarian cancer

Estradiol 900pg/mL

After a prostatectomy the client reports that the urinary catheter tubing is pulling too tightly on the leg. The nurse observes that the indwelling catheter tubing is taut and is taped properly to the thigh. Which action should the nurse take?

Explain that traction helps control the bleeding

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition?

Explaining that fatty foods may not be tolerated for several weeks

A client is admitted to the hospital after falling and fracturing a hip. The primary healthcare provider applies a Buck boot with traction until surgery to replace the head of the femur with a prosthesis can be performed. What action can the nurse take to ensure that the Buck traction is being applied correctly?

Hang the weight to apply traction, but limit it to 10 lb (4.5 kg).

A nurse is caring for a client who had surgery for a biliary complication and now has a T-tube in place. The nurse explains that the T-tube was placed for what reason?

Help bile drain while the common bile duct is edematous

A client is returned to the surgical unit after an abdominal cholecystectomy. What is the main reason why the nurse should assess for clinical indicators of respiratory complications? 1

Incision is in close proximity to the client's diaphragm.

What information from a client's history should the nurse identify as risk factors for the development of colon cancer? Select all that apply.

Increased age & ulcerative colitis

Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply.

Insulin Growth hormone

A client who recently immigrated to the United States (Canada) has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency?

It is a necessary element of rhodopsin, which controls responses to light and dark environments.

Where should the nurse place a pillow or sandbag to prevent external rotation of a lower extremity?

Lateral to affected hip

A nurse is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing this client? Select all that apply.

Lethargy & muscle twitching

The nurse is obtaining a history and performing a physical assessment on a client who has received a new diagnosis of cancer of the tongue. Which clinical findings should the nurse expect to identify? Select all that apply.

Leukoplakia Alterations in taste Enlarged cervical lymph nodes

A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client?

hypovolemia

What are the systemic manifestations of acute osteomyelitis? Select all that apply.

Malaise Restlessness Night sweats

A nurse is caring for a client with a T-tube after an open cholecystectomy. What specific action should the nurse include in the plan of care?

Monitor color of stool

A client with an invasive carcinoma of the bladder is receiving radiation to the lower abdomen in an attempt to shrink the tumor before surgery. What should the nurse do considering the side effects of radiation?

Observe feces for blood

Considerations when caring for a client with a total hip replacement should include which interventions? Select all that apply.

Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well. Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side. When turning, the client should be log rolled to prevent the leg from falling forward or backward.

A client has circumgastric banding, a bariatric surgical procedure. The nurse provides discharge teaching about signs and symptoms of dumping syndrome and includes what physiologic response?

Palpitations

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

Paralytic illeus

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client?

Protect the abdominal skin from bile drainage

A primary healthcare provider schedules a bone scan for a client with osteoporosis. Which nursing actions are beneficial for the client? Select all that apply.

Placing the client in the supine position Instructing the client to empty the bladder before the scan

A client with extensive gastric carcinoma is admitted to the hospital for an esophagojejunostomy. What information should the nurse include in the teaching plan when preparing this client for surgery?

Post-op chest tube

A client has a shoulder immobilizer after surgical repair of a fractured humerus. What should be included in the nurse's instruction to the client about the appropriate use of the immobilizer

Release the wristband to exercise the forearm and hand routinely."

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction?

Relieving muscle spasm and pain

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. Which does the nurse conclude is most likely the causative factor?

Retention

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia? Select all that apply

Short-term irritability Dysrhythmias Muscle weakness

A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day

Shortening of the muscles

A client who has gastroesophageal reflux disease (GERD) is unable to tolerate a back rest elevation. The nurse should place the client in

Slightly elevated/reverse trendelburg

A client had a cerebrovascular accident (also known as a "brain attack"), and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client?

Splints

When does the nurse's teaching say that the client's new sigmoid colostomy should be irrigated?

Stools start to be formed

client is diagnosed with gastric cancer, and a subtotal gastrectomy is performed. After surgery the client begins to hemorrhage. What clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply.

Tachycardia Diaphoresis Oliguria

A client sustains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment is the priority?

Take the client's pedal pulse in the affected extremity.

The nurse is caring for an elderly client who has kyphotic posture with a widened gait. Which nursing interventions help reduce the severity of the client's condition? Select all that apply.

Teach proper body mechanics & Instructing the client to sit in supportive chairs with arms

A client with chronic kidney disease is admitted to the hospital with severe infection and anemia. The client is depressed and irritable. The client's spouse asks the nurse about the anticipated plan of care. Which is an appropriate nursing response?

The intake of meat, eggs, and cheese will be restricted so the kidneys can clear the body of waste products.

A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information should the nurse include in a response to this question?

Walled-off space of pancreatic enzymes and exudate

Discharge teaching for a client with hypercholesterolemia includes nutritional instructions for a diet low in saturated fat. Which items included by the client on a list of foods to avoid support the nurse's conclusion that teaching is effective?

Whole milk & hard cheeses

low-residue diet is recommended for a client. Which food should the nurse encourage the client to select from a menu?

creamed potatoes

To prepare a client for discharge, the nurse is providing dietary instructions to a client who had a pancreaticoduodenectomy (Whipple procedure). What should the nurse include in the instructions?

The surgery has interfered with the fat digestion mechanism; a low-fat diet is needed.

While assessing a knee injury, the nurse asks the client to flex the knee to 30 degrees, pulling the tibia forward while the femur is stabilized. Which test is the nurse performing?

lachmans test

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply.

Azotemia & HTN

A healthcare provider prescribes a gastrointestinal endoscopy with a capsule endoscopic device. What should the nurse instruct the client to do?

Avoiding stooping/bending during test