Nur Exam 416 3

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.) a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. d. Provide the client with a high-fiber diet. e. Evaluate stools for occult blood

a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. e. Evaluate stools for occult blood

The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the priority action for the client's care? a. Maintain airway, breathing, and circulation. b. Monitor vital signs, including orthostatic blood pressures. c. Draw blood for hemoglobin and hematocrit immediately. d. Insert a nasogastric (NG) tube and connect to intermittent suction.

a. Maintain airway, breathing, and circulation.

a nurse is providing care for a client who has acute gastritis. which of the following nursing interventions should the nurse include in the plan of care? a. evaluate intake and output b. monitor lab reports of electrolytes c. provide three large meals a day d. administer ibuprofen for pain e. observe stool characteristics

a. evaluate intake and output b. monitor lab reports of electrolytes e. observe stool characteristics

The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan c. Amitiptyline d. Amlodipine

b. Alvimopan

a nurse is assessing a client in an extended care facility. the nurse should recognize which of the following findings is a manifestation of an obstruction of the large intestine due to fecal impaction? a. the client reports one bowel movement yesterday b. the client is having small, frequent liquid stools c. the client is flatulent d. the client indicates vomiting once this morning

b. the client is having small, frequent liquid stools

a nurse is completing an admission assessment for a client who has a small bowel obstruction. which of the following findings should the nurse report to the provider a. emesis prior to insertion of the NG tube b. urine specific gravity 1.040 c. Hct 60% d. blood K+ 3.0mEq/L e. WBC 10,000/uL

b. urine specific gravity 1.040 c. Hct 60% d. blood K+ 3.0mEq/L

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 g of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."

c. "I will take a laxative nightly at bedtime to avoid becoming constipated."

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy sign c. Clay-colored stools d. Upper abdominal pain after eating

c. Clay-colored stools

The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? a. Decreased potassium level b. Increased sodium level c. Elevated leukocyte count d. Decreased thrombocyte count

c. Elevated leukocyte count

After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

d. Baked fish with steamed carrots and a glass of apple juice

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? a. Consuming too much fruit b. Consuming fried or pickled foods c. Consuming dairy products d. Consuming raw seafood

d. Consuming raw seafood

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

d. Roasted chicken breast, baked potato with chives, and orange juice

The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed? a. Prone b. Supine c. Recumbent d. Semi-Fowler

d. Semi-Fowler

what health teaching will the nurse include to promote gastric health for an adult client? a. "stop smoking or using tobacco of any form" b. "do not drink excessive amounts of alcohol" c. "consume high-fat foods and decrease carbohydrates" d. "avoid excessive amounts of pickled or smoked food" e. "avoid taking large amounts of NSAIDS"

a. "stop smoking or using tobacco of any form" b. "do not drink excessive amounts of alcohol" d. "avoid excessive amounts of pickled or smoked food" e. "avoid taking large amounts of NSAIDS"

The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs

a. Alcohol b. Caffeine c. Corticosteroids e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth f. Decreased function

a. Edema d. Redness e. Warmth f. Decreased function

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect for the client to make an accurate diagnosis? a. Esophagogastroduodenoscopy (EGD) b. Abdominal arteriogram c. Nuclear medicine scan d. Magnetic resonance imaging (MRI)

a. Esophagogastroduodenoscopy (EGD)

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever

a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain e. Decreased urinary output f. Fevere.

A nurse is having difficulty arousing a client following an EGD. which of the following is a priority action by the nurse a. assess the clients airway b. allow the client to sleep c. prepare to administer an antidote to the sedative d. evaluate pre-procedure lab findings

a. assess the clients airway

A client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

b. Purulent drainage

the nurse is caring for a client with peritonitis from a perforated appendix. which abdominal assessment finding will the nurse most likely expect? a. soft abdomen b. board-like abdomen c. slightly distended abdomen d. absent bowel sounds

b. board-like abdomen

A client has a new diagnosis of irritable bowel syndrome with diarrhea. What health teaching by the nurse is appropriate for this client? a. "take a stool softener every day to ease defecation" b. "avoid high-fiber food in your diet" c. "avoid dairy products and caffeinated beverages" d. "ask your primary health care provider for an anti-depressant"

c. "avoid dairy products and caffeinated beverages"

a nurse is completing discharge teaching for a client who has an infection due to H.pylori. Which of the following statements by the client indicates understanding of the teaching? a. "I will continue my prescription for corticosteroids" b. "i will schedule a CT scan to monitor improvement" c. "i will take a combination of medications for treatment" d. "i will have my throat swabbed to recheck for this bacteria"

c. "i will take a combination of medications for treatment"

The nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing maximum protection against infection d. Regulating the process of self-tolerance

c. Providing maximum protection against infection

After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.) a. "I will take the enzymes between meals." b. "The enteric-coated preparations cannot be crushed." c. "Swallowing the tables without chewing is best." d. "I will wipe my lips after taking the enzymes." e. "Enzymes should be taken with high-protein foods."

a. "I will take the enzymes between meals." e. "Enzymes should be taken with high-protein foods."

A nurse is preparing to administer pantoprazole intravenously to prevent stress ulcers during surgery. What action(s) by the nurse is (are) most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown container. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing

a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. e. Use an in-line IV filter when infusing

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request the primary health care provider order blood cultures

a. Assess the client for more specific signs.

The nurse is caring for client with a complete large bowel obstruction. What assessment findings would the nurse expect? a. obstipation b. dehydration c. metabolic alkalosis d. abdominal distention e. abdominal pain f. profuse vomiting

a. obstipation d. abdominal distention e. abdominal pain

The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? a. "This drug will make you very dry because it will decrease your diarrhea." b. "Be sure to take this drug with food and water to help manage constipation." c. "Avoid people who have infection as this drug will suppress your immune system." d. "Include high-fiber foods in your diet to help produce more solid stools."

b. "Be sure to take this drug with food and water to help manage constipation."

A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) a. Weight gain b. Anorexia c. Constipation d. Anal fistula e. Abdominal pain

b. Anorexia c. Constipation e. Abdominal pain

The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? a. Abdominal distention b. Nausea c. Electrolyte imbalance d. Obstipation

c. Electrolyte imbalance

The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? a. Electrolyte imbalance b. Pleural effusion c. Internal bleeding d. Pancreatic pseudocyst

c. Internal bleeding

The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s) that the client has chronic gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting

c. Intolerance of fatty foods d. Pernicious anemia

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

c. Natural active

The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching? a. "I need to cut down on drinking martinis every might." b. "I should decrease my intake of caffeinated drinks, especially coffee." c. "I will only take ibuprofen once in a while when I really need it." d. "I can continue smoking cigarettes which is better than chewing tobacco.

d. "I can continue smoking cigarettes which is better than chewing tobacco.

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? a. "I won't let anyone use my dishes or glasses." b. "I'll wash my hands with antibacterial soap." c. "I'll keep my bathroom extra clean." d. "I'll cook all the meals for my family."

d. "I'll cook all the meals for my family."

Which statement by the client who is prescribed to take PERT indicates a need for further teaching by the nurse a. "I need to take the enzymes at every meal and with snacks" b. "after taking the enzymes, i should drink a glass of water" c. "i should wipe my mouth in case any of the enzyme got on my lips" d. "i should chew each capsule carefully so that it works in my stomach"

d. "i should chew each capsule carefully so that it works in my stomach"

The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor

d. Proton pump inhibitor

he nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 L of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

a. "Drink plenty of fluids to prevent dehydration."

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain or discomfort and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black?" e. "Do you often experience nausea and vomiting"

a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain or discomfort and what does it feel like?"

A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?

a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? e. How many bathrooms are in your home?

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon—transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer e. Fistula—dilation and colonic ileus caused by paralysis of the colon

a. Lower gastrointestinal bleeding—erosion of the bowel wall b. Abscess formation—localized pockets of infection develop in the ulcerated bowel lining d. Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer

A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L (2.6 mmol/L) b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 (8.2 × 109/L) d. Client's weight decreased by 3 lb (1.4 kg)

a. Serum potassium of 2.6 mEq/L (2.6 mmol/L)

A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L (2.8 mmol/L) b. Loss of 15 lb (6.8 kg) without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L (121 mmol/L)

a. Serum potassium of 2.8 mEq/L (2.8 mmol/L) c. Abdominal pain in upper quadrants e. Serum sodium of 121 mEq/L (121 mmol/L)

The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion ANS

a. Severe, steady right lower quadrant pain

a nurse is caring for a client who has a SBO for adhesions. which of the following finding are consistent with this diagnosis. a. emesis greater than 500mL with fecal odor b. report of spasmodic abdominal pain c. high pitched bowel sounds d. abdomen flat with rebound tenderness to palpation e. laboratory findings indicating metabolic acidosis

a. emesis greater than 500mL with fecal odor b. report of spasmodic abdominal pain c. high pitched bowel sounds

a nurse is completing discharge teaching with a client who has irritable bowel syndrome. which of the following instructions should the nurse include? a. keep a food diary to identify triggers to exacerbation b. consume 15 to 20g of fiber daily c. plan three moderate to large meals per day d. limit fluid intake to 1 l/ day

a. keep a food diary to identify triggers to exacerbation

the nurse is planning care for a client who has a new prescription for TPN. Which of the following interventions should be included in the plan of care a. obtain blood glucose four times a day b. administer prescribed medications through a secondary port on the TPN IV tubing c. monitor vital signs three times during the 12 hr shift d. change the TPN IV tubing every 24 hours e. ensure a daily aPTT in obtained

a. obtain blood glucose four times a day c. monitor vital signs three times during the 12 hr shift d. change the TPN IV tubing every 24 hours

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? a. take the medication 1 hr before a meal b. limit NSAIDS when taking this medication c. expect skin flushing when taking this medication d. increase fiber intake when taking this medication e. chew the medication thoroughly before swallowing

a. take the medication 1 hr before a meal b. limit NSAIDS when taking this medication

After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I will avoid large crowds and people who are sick." b. "I will take this medication with my breakfast each morning." c. "Nausea and vomiting are common side effects of this drug." d. "I should wash my hands after I play with my dog."

b. "I will take this medication with my breakfast each morning."

A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the nurse include prior to the test? a. "This test will determine whether you have colorectal cancer." b. "You need to avoid red meat and NSAIDs for 48 hours before the test." c. "You don't need to have this test because you can have a virtual colonoscopy." d. "This test can determine your genetic risk for developing colorectal cancer."

b. "You need to avoid red meat and NSAIDs for 48 hours before the test."

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, carbonated beverage b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice

A nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis

b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis

A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs

b. Performing frequent oral care

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature

b. Severe boring abdominal pain

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

b. Skin protection

A nurse is teaching about pernicious anemia with a client who has chronic gastritis. which of the following information should the nurse include in the teaching a. p anemia is caused when the cells producing gastric acid are damaged b. expect a monthly injection of vitamin b12 c. plan to take vitamin K supplements d. p anemia is caused by an increased production of intrinsic factor

b. expect a monthly injection of vitamin b12

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? 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 best time to take the enzymes is immediately after I have a meal or a snack."

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

c. Heart rate and rhythm

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? a. Positive Murphy sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

c. High-pitched, rushing bowel sounds in the right lower quadrant

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? a. client reports pain relieved by eating b. client states that pain often occurs at night c. client reports sensation of bloating d. client states that pain occurs 30 min to 1 hr after a meal e. client experiences pain upon palpitation of the epigastric region

c. client reports sensation of bloating d. client states that pain occurs 30 min to 1 hr after a meal e. client experiences pain upon palpitation of the epigastric region

a nurse is providing teaching to a client who has a new prescription for aluminum hydroxide. which of the following info should the nurse include in the teaching? a. take the medication with food b. monitor for diarrhea c. wait 1 hr before taking other oral medications d. maintain a low fiber diet

c. wait 1 hr before taking other oral medications