nclex challenge 6

A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?

"Eat four small meals each day." The client should avoid eating large meals because of the pressure it places on the stomach. Instead, he should eat four to six small meals per day.

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

"Eating yogurt can help decrease the amount of gas that I have." The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.

A nurse is teaching a client who has a new prescription for ranitidine to treat peptic ulcer disease. Which of the following statements by the client indicate an understanding of the teaching? (Select all that apply.)

"I can take this medication with or without food." "I will eat five small meals each day"

A nurse is teaching a client who has a new prescription for esomeprazole to manage his GERD. Which of the following statements by the client indicates an understanding of the teaching?

"I have an increased risk of getting pneumonia while taking this medication." The client taking esomeprazole is at a greater risk for developing pneumonia due to an elevation of gastric pH, especially during the first few days of treatment. The nurse should instruct the client about manifestations of a respiratory infection and to report these findings to the provider if they occur.

A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching?

"I will store the medication at room temperature." Nystatin oral suspension should be stored at room temperature.

A nurse is teaching a client who is preoperative how to do deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching?

"I'll splint my incision with a pillow to cough." The client should use a pillow to splint the incision to reduce the pain and discomfort of coughing.

A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?

3% weight loss A weight loss greater than 10% is a manifestation of severe dehydration in an infant.

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take?

Apply moistened sterile gauze to the site. The nurse should apply moistened sterile gauze to the site to reduce the risk for further injury and infection.

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

Both are inflammatory The nurse should inform the client that both disease processes are an inflammatory process of the gastrointestinal tract.

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

Both of these items are low in fiber which is advised during the inflammation of diverticulitis. In the presence of diverticulosis, a high-fiber diet is indicated.

A nurse is teaching a client who has stomatitis. Which of the following instructions should the nurse include?

Brush teeth with a soft toothbrush. The client should use a soft toothbrush and gently brush after each meal to reduce mouth irritation and prevent superinfections.

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

Chronic blood loss A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occurs over time, although the colitis may result in erosion of the intestine and hemorrhage. These clients often report bloody stools and are therefore at increased risk for developing anemia.

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)

Discontinue suction when assessing for peristalsis Irrigate the NG tube with 0.9% sodium chloride irrigation solution Place sequential compression devices on the bilateral lower extremities Reposition the client from side to side every 2 hr

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet?

Dried apricots A nurse should instruct a client who has ulcerative colitis to consume a diet low in fiber and should eliminate dried apricots from his diet. Dried apricots are high in fiber and may cause an exacerbation of the client's disease process.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Fatty stools Chronic cholecystitis occurs following several bouts of acute cholecystitis. The repeated episodes of inflammation result in a fibrotic and contracted gallbladder. Because of inflammation in the gallbladder, bile needed to absorb fat and fat-soluble vitamins is unable to enter the bowel, resulting in steatorrhea (fatty stools).

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

Hematemesis When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?

History of NSAID use The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer disease. NSAIDs break down the mucosal barrier and cause production of prostaglandins to decrease, which results in local gastric mucosal injury.

A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

I will consume less caffeine and fewer spicy foods I will sleep with the head of my bed elevated I will try not to gain weight

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

Increase ambulation. Decreased bowel motility is an adverse effect of anesthesia. The nurse should encourage the client to ambulate and increase fiber intake as prescribed to promote a return of bowel function and reduce the risk for paralytic ileus.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

Lower left quadrant The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents from the rectum causes pouch formation.

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container. If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Obtain vital signs for both clients. Using the nursing process as an organizing framework, the nurse should obtain vital signs on the two clients to determine if there are any emergent problems.

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

Offer the client a back rub. Remind the client to use incisional splinting is. Identify the client's pain level. Change the client's position.

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?

Oxygen saturation The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assess the client's oxygen saturation. The nurse should check the client's airway, listen to the client's breath sounds, and check the client's pulse oximetry to assess for respiratory depression.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

Paralytic ileus A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use.

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

Pinch the tube prior to attaching the medication syringe. After detaching the NG tube from the suction tubing, the nurse should pinch or kink the tube to prevent distention from air entering the tube.

A nurse is preparing to insert an NG tube. Place the following steps in the appropriate order. (Move the steps of NG tube placement into the box on the right, placing them in the selected order of performance. Use all the steps.)

Prepare equipment at bedside. Measure the NG tube. Instruct the client to extend the neck backwards. Instruct the client to flex his head forward. Obtain an Xray Secure the tube

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?

Pulse oximetry changed from 98% to 96% SpO2 of 96% is well above the critical level of 91% and does not warrant notifying the provider. It likely represents shallow respirations and should be continually monitored.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Purplish-colored stoma A stoma that is purplish in color indicates ischemia. The nurse should notify the provider immediately.

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

Relief of heartburn Histamine2 receptor antagonists are used to treat duodenal ulcers and prevent their return. In over-the-counter strengths, these medications, such as cimetidine and ranitidine, are used to relieve or prevent heartburn, acid indigestion, and sour stomach.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the client's electrolyte values. The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea.

A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child?

Rice Because rice is naturally gluten-free, it is an acceptable food choice for a child who has celiac disease.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Rigid abdomen A rigid, boardlike abdomen is a manifestation of peritonitis.

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

Skim milk Full liquids include milk and milk products, so the client may now ask for skim milk.

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

Soy milk Soy milk is the best choice for this client because soy milk is lactose-free.

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

Sudden abdominal pain Classic indications of gastrointestinal perforation include sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock.

A nurse is assessing a client who has a colostomy. Which of the following findings should the nurse report to the provider?

The stoma is pale in color. The stoma should be pinkish to cherry red in color, which indicates an adequate blood supply. If the stoma becomes pale, bluish, or dark, the nurse should report this finding to the provider immediately.

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

They improve your circulation to keep blood from pooling in your legs." Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis, also known as clot formation, and peripheral edema.

A nurse is caring for a client who has Crohn's disease. Which of the following food choices would follow the recommended diet for clients who have Crohn's disease?

Toast with jelly Toast with jelly is an appropriate food choice by the client. It does not contain large amounts of lactose, fat, or fiber.

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values?

WBC 17,000/mm3 The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection.

A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results?

WBC count 20,000/mm3 This result exceeds the expected reference range for WBC of 5,000 to 10,000/mm3. The client's elevated WBC count indicates infection. The nurse should notify the surgeon.

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Wipe perianal area with warm water and apply a barrier cream The nurse should instruct the client to wipe the perianal area and apply a barrier cream to decrease skin breakdown when in contact with fecal material.

A nurse is performing gastric lavage on a client using a large-bore NG tube. Which of the following actions should the nurse take?

Withdraw fluid until it is clear. The nurse should continue to instill and withdraw the lavage fluid until it is clear.

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision Thick yellow-green drainage is indicative of an infection and should be reported immediately.