NUR 372- ATI Practice Problems
13.A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever
a -A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.
26.A nurse enters an adult client's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? A. Summon the code team. B. Begin chest compressions. C. Administer rescue breathing. D. Open the client's airway.
a -After determining that the client is in respiratory or cardiac arrest the nurse should first summon the code team before initiating CPR.
15.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? A. Relief of heartburn B. Cessation of diarrhea C. Passage of flatus D. Absence of constipation
a -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.
21.A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? A. Pitting edema around the stump dressing B. Looseness of the stump dressing C. The dressing forms a cone shape over the stump D. Figure-eight wrapping around the stump
a -If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump.
3.A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? A. Maintain immobilization and alignment. B. Provide optimal nutrition and hydration. C. Promote independence in activities of daily living. D. Provide relief from pain and discomfort.
a -Maintaining the prescribed immobilization and body alignment will keep the fracture fragments in close anatomical proximity, thereby promoting functional fracture healing. According to the safety and risk reduction priority setting framework, this goal should receive the highest priority.
1.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? A. Soy milk B. Cheddar cheese C. Low-fat yogurt D. Cottage cheese
a -Soy milk is the best choice for this client because soy milk is lactose-free
14.A nurse is caring for four clients for whom she has to administer oral medications in the morning. The nurse should administer which of the following medications before breakfast? A. Alendronate B. Digoxin C. Mycostatin mouthwash D. Divalproex
a -The client must take alendronate first thing in the morning on an empty stomach and wait at least 30 minutes before eating, drinking, or taking other medications.
7.A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. B. Check the client for a positive Chvostek's sign. C. Administer an IV vasopressor medication. D. Monitor the client for headache.
a -The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop in the level of arterial oxygen, and the client can require mechanical ventilation.
1.A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment. B. Explain the discharge instructions to the client and parents. C. Provide reassurance to the client and parents. D. Apply an ice pack to the casted leg.
a -The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."
23.A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions? A. Spontaneous bleeding B. Oliguria C. Hyperactive deep tendon reflexes D. Infection
a -The nurse should consider the risk of spontaneous bleeding that can occur in clients who have low platelets. Low platelet levels cause clotting time to increase.
22.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? A. Lower left quadrant B. Upper left quadrant C. Lower right quadrant D. Upper right quadrant
a -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.
25.A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? A. Decrease the client's fluid intake. B. Increase the client's saturated fat intake. C. Increase the client's sodium intake. D. Decrease the client's carbohydrate intake.
a -The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.
19.A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? A. Check the client's medical record for the provider's prescription. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Inform the charge nurse that the client refused the enema.
a -The nurse should use the client's medical record to verify the provider prescribed an enema for the client.
17.A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? A. "You will do special exercises in advance of getting your prosthesis." B. "You will be fitted for your prosthesis at the time of surgery." C. "A special pressure dressing will remain on to cushion your prosthesis." D. "The prosthesis will be adjustable depending on what shoe you are wearing."
a -The physical therapist will teach muscle strengthening exercises to prepare the client for prosthesis use.
12.A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? A. "Crushing the medication might cause you to have a stomachache or indigestion." B. "Crushing the medication is a good idea, and I can mix it in some ice cream for you." C. "Crushing the medication would release all the medication at once, rather than over time." D. "Crushing is unsafe, as it destroys the ingredients in the medication."
a -The pill is enteric-coated to prevent breakdown in the stomach and decrease the possibility of GI distress. Crushing the pill destroys that protection.
5.A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first? A. Checking capillary refill B. Discussing cast care C. Managing pain D. Performing range of motion
a -The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury. Capillary refill provides data about the client's circulation.
11.A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min. B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). C. Increased blood pressure from 112/68 to 120/72 mm Hg. D. Increased heart rate from 68 to 72/min.
a -This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances.
6.A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. B. Explain the procedure for an upper gastrointestinal series. C. Administer pain medication. D. Test the client's emesis for blood.
a -Using the nursing process, the first action the nurse should take is to assess the client by measuring the client's orthostatic blood pressure. This action determines if the client is hypovolemic and establishes a baseline for further measurements.
28.The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A. Evaluate chest expansion. B. Check pupillary response to light. C. Assess the capillary refill. D. Check client's response to questions about place and time.
a -When using the airway, breathing, circulation approach to client care, the nurse should plan on evaluating the client's respiratory effort and function. This involves listening to breath sounds, evaluating chest expansion, and assessing the client for chest trauma or abnormalities that would compromise breathing.
7. The community health nurse visits a client at home. Prednisone 10mg orally daily has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? a. "I can take aspirin or my antihistamine if I need it" b. "I need to take the medication every day at the same time" c. "I need to avoid coffee, tea, cola, and chocolate in my diet" d. "If I gain more than 5 pounds a week, I will call my health care provider"
a Aspirin and other OTC medications should not be taken unless the client consults with the health care provider
6. A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm? Select all that apply a. Fever b. Nausea c. Lethargy d. Tremors e. Confusion f. Bradycardia
a, b, d, e Thyroid storm is an acute and life-threatening condition. Symptoms include fever, nausea, tremors, and confusion
8. A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply a. Administer methimazole with food b. Place client on low-calorie, low-protein diet c. Assess client for unexplained bruising or bleeding d. Instruct client to report side effects such as sore throat, fever, or headache e. Use special radioactive precautions when handling urine for the first 24 hours following initial administration
a, c, d Common side effects include nausea, vomiting, diarrhea: reduced by taking with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high-caloric diet. Sore throat, fever, headache, or bleeding may indicate agranulocytosis (caused by antithyroid meds) and the HCP should be notified immediately.
19.A nurse is providing discharge teaching to a client following hip arthroplasty. Which of the following pieces of furniture should the nurse instruct the client to sit in at home? A. A reclining chair with an ottoman B. A straight-backed chair with an elevated seat C. A couch with plush cushions D. A rocking chair with a curved back
b -A straight-backed chair with an elevated seat allows the client to assume proper positioning when sitting. An elevated seat decreases the risk of hip dislocation.
10.A nurse is assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice? A. Palms of the hands B. Hard palate C. Conjunctiva D. Back of the neck
b -According to evidence-based practice, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African-American.
8.A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? A. "Irregular bowel movements are an indication of poor intestinal health." B. "Excessive laxative use may cause an electrolyte imbalance." C. "Chronic use of laxatives can lead to a tear in the rectal mucosa." D. "Decrease your intake of foods high in fiber."
b -Bisacodyl is a stimulant laxative that acts by stimulating intestinal motility and increasing the amount of water and electrolytes within the intestines; therefore, chronic use of laxatives can lead to fluid and electrolyte imbalance.
15.A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching? A. Buck's extension traction will reduce the fracture. B. Buck's extension traction will relieve muscle spasms. C. Buck's extension traction will maintain alignment of the pins. D. Buck's extension traction will allow supported movement of the extremity.
b -Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasm and trigger pain.
25.A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures? A. Diarrhea B. Hematuria C. Increased thirst D. Impaired taste
b -Clients who sustain a fracture to the pelvis and symphysis pubis should be monitored for manifestation of internal bleeding, such as blood in the urine and stool.
6.A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome? A. Petechiae B. Hypoxemia C. Headache D. Precordial chest pain
b -Evidenced-based practice indicates that the nurse should recognize hypoxemia as the first expected manifestation of fat embolism syndrome. Hypoxemia, increased respiratory rate, and shortness of breath are caused by a low arterial oxygen level.
4.A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? A. Change in temperature of the toes. B. Pallor of the toes. C. Edema of the toes. D. Inability to move toes.
b -If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.
22.A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take? A. Encourage the client to use full weight bearing. B. Identify the client's pain level and medicate if needed. C. Teach the client which positions to avoid during PT. D. Perform the client's morning care.
b -The client should have adequate pain medication and pain relief 20 to 30 min before the PT session so he can work effectively with the therapist.
17.A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." B. "Before the examination, your provider will give you a sedative that will make you sleepy." C. "I know you're anxious, but this procedure is recommended for people your age." D. "After you have signed the consent form, we can talk more about this."
b -This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure.
16.A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings? A. The ropes are in the center of the wheel grooves. B. The weights rest against the foot of the bed. C. The weights are equal on each side. D. The ropes are securely attached to the pins.
b -Weights that rest against the foot of the bed or on the floor do not apply the amount of traction essential for maintaining alignment and immobilizing the bone.
24.A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? A. Urticaria B. Stridor C. Vomiting D. Hypotension
b -When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.
3. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? a. Diarrhea b. Polyuria c. Polyphagia d. Weight gain
b Hypercalcemia is the hallmark of hyperparathyroidism. Elevated calcium levels produce osmotic diuresis and thus polyuria.
4. A client is admitted to an emergency department and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? a. Warm the client b. Maintain a patent airway c. Administer thyroid hormone d. Administer fluid replacement
b The initial nursing action would be to maintain a patent airway. Oxygen would be first followed by fluid replacement, keeping the client warm, monitoring vitals, and administering thyroid hormones.
1. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? a. Lower the head of the bed b. Test the drainage for glucose c. Obtain a culture of the drainage d. Continue to observe the drainage
b This could indicate a cerebrospinal fluid leak. Cerebrospinal fluid contains glucose. Regular mucous does not
9.A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? A. Remain on bedrest for the first 24 hr. B. Keep the leg in a dependent position. C. Apply ice to the affected area. D. Begin active range of motion.
c -Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling.
21.A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid? A. Rice B. Poached eggs C. Fresh apples D. White bread
c -Clients with dumping syndrome following a hemi-colectomy should avoid fresh fruits and choose canned or well-cooked fruits instead.
5.A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscultate B. Percuss C. Inspect D. Palpate
c -Evidence-based practice indicates the nurse should first inspect the abdomen for external abnormal conditions first.
20.A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching? A. You may donate blood 6 months after completing the medication regimen. B. Consume a high-protein diet. C. Rest frequently throughout the day. D. Take acetaminophen every 4 hr, as needed, for discomfort
c -Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands.
12.A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures? A. "The pain will disappear soon." B. "It's likely that you will have only a tingling sensation." C. "Your pain will gradually become less severe." D. "Phantom pain is mostly psychological."
c -Phantom leg pain usually diminishes over time, and often is intermittent in response to a trigger.
14.A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "Skeletal traction has less risk for infection than skin traction." B. "Clients with skin traction have more mobility than those with skeletal traction." C. "Skeletal traction is more appropriate than skin traction for reducing a fracture." D. "Clients with skin traction have more discomfort than those with skeletal traction."
c -Skeletal traction allows for reduction and alignment of a fracture. Skin traction decreases muscle spasms commonly associated with a fracture.
9.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? A. "I won't pass gas as often now that I am taking this medication." B. "I will take this medication each morning with my breakfast." C. "I have an increased risk of getting pneumonia while taking this medication." D. "I will need to take a daily stool softener while taking this medication."
c -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.
2.A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? A. Request a prescription for a medication to ease the client's anxiety. B. Irrigate the NG tube with 100 mL of sterile water. C. Check to see if the suction equipment is working. D. Remove and reinsert the NG tube.
c -The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.
3.A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority? A. Pain B. Nausea C. Gag reflex D. Level of consciousness
c -The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.
24.A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include? A. A family history increases your risk for acquiring hepatitis A. B. Hepatitis A infects the kidneys. C. Manifestations of the virus are similar to flu-like symptoms. D. The incubation of the virus is 5 days.
c -The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.
16.A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? A. Limit fluid intake not related to meals. B. Chew on mint leaves to relieve indigestion. C. Avoid eating within 3 hr of bedtime. D. Season foods with black pepper.
c -The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of bedtime.
2.A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? A. Medicate the client for pain. B. Instruct the client on use of crutches. C. Perform neurovascular checks of the extremities. D. Direct the client to perform exercises of the ankle and toes.
c -The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.
23.A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation? A. Avoid covering sores with bandages. B. Avoid handwashing after eating. C. Avoid foods prepared with tap water. D. Avoid eating meat
c -To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water.
27.A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? A. Assess the client's level of consciousness. B. Administer epinephrine. C. Auscultate for wheezing. D. Monitor for hypotension.
c -When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.
11.A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include? A. "To prevent dehydration, drink an additional liter of fluid during preparation time." B. "Expect bowel movements to begin 3 hr following completion of solution." C. "Abdominal bloating might occur." D. "Drink 400 mL every hour until bowel movements are clear."
c -While PEG is well-tolerated, adverse effects include nausea, bloating, and abdominal discomfort.
20.A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? A. Impacted B. Transverse C. Comminuted D. Oblique
c -With a comminuted fracture, the impact fragments the bone into several pieces
9. The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication? a. Headache b. Vulval pain c. Runny nose d. Flushed skin
c DDAVP administered intranasal can cause runny or stuffy nose. The other options are side effects if taken IV.
2. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptoms is most indicative of this disorder? a. Fatigue b. Diarrhea c. Polydipsia d. Weight gain
c Diabetes insipidus is characterized by hyposecretion of antidiuretic hormone, and the kidney tubules fail to reabsorb water. Polydipsia and polyuria are classic symptoms.
5. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for the client? a. Hypoglycemia b. Level of hoarseness c. Respiratory distress d. Edema at the surgical site
c The thyroid is located in the anterior neck. Monitor airway status for swelling which could lead to respiratory distress
10. The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication at which time? a. With food b. At lunchtime c. On an empty stomach d. At bedtime with a snack
c oral doses should be taken on an empty stomach to enhance absorption. Best time is in the morning before breakfast.
18.A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? A. Calcium B. RBC count C. Magnesium D. Amylase
d -Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.
7.A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy? A. 56-year-old who had a colonoscopy 6 years ago B. 34-year-old who reports a new onset of constipation C. 32-year-old who has a sister who died of colon cancer D. 51-year-old who is being seen for an annual physical examination
d -Colorectal cancer (CRC) is not common prior to the age of 40 years. When an adult turns 40, the provider should begin screening the client for risk factors of CRC (e.g., family history, inflammatory bowel disease, tobacco and alcohol use, high-fat and low-fiber diet, diet high in animal fats and red meat, sedentary lifestyle). The provider also may begin fecal occult blood testing depending on the client's risk. Screening colonoscopies are recommended starting at age 50 for those clients considered to be at normal risk with no family history and repeated every 10 years. It may begin earlier and performed more often for clients at high risk.
10.A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A. Serosanguineous drainage B. Mild erythema C. Warmth D. Fever
d -Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.
8.A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first? A. Administer an opioid analgesic. B. Obtain a prescription to adjust the weight amount. C. Offer a muscle relaxant to the client. D. Realign the client's position.
d -The greatest risk to this client is injury form circulatory compromise and tissue damage; therefore, the first action the nurse should take is to realign the client's position.
13.A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Monitor the client's calf for edema. D. Instruct the client to wiggle his toes.
d -The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.
18.A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in which of the following positions? A. Adduction. B. External rotation. C. Internal rotation. D. Abduction.
d -When caring for a client following a total hip arthroplasty, the nurse should abduct the affected extremity to prevent dislocation, positioning the legs away from the midline.
4.A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort B. Dyspepsia C. Epigastric discomfort D. Hematemesis
d -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.
