practice test 3

Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy? a) Teach the client to use a folded blanket or pillow to splint the incision. b) Have the client lay on the left side while coughing and deep breathing. c) Withhold pain medication so the client can be alert enough to follow the nurse's instructions. d) Have the client take rapid, shallow breaths to decrease pain.

a) Teach the client to use a folded blanket or pillow to splint the incision. A folded bath blanket or pillow placed over the incision will be most effective in helping the client cough and deep breathe after a cholecystectomy. Taking rapid, shallow breaths would not be effective in decreasing pain. Lying on the left side would cause decreased lung expansion. When possible, the client should be positioned in semi-Fowler's or Fowler's position to promote maximum lung expansion. Withholding pain medication will make the client less likely to cough and deep breathe because of the discomfort.

requires immediate intervention? a) The client complains of significant pain at the surgical site when rising out of bed. b) The client is concerned he feels bloated and cannot have a bowel movement, even when he pushes. c) The client's surgical site is reddened and swollen. d) The client's right lower leg is red, swollen, and warm to touch.

d) The client's right lower leg is red, swollen, and warm to touch. A red, swollen extremity is a possible sign of a thromboembolism, a common complication after gastric surgery. The nurse should inform the physician of the finding. Pain at the surgical site upon rising is normal, but splinting should be reinforced. A reddened surgical site is concerning, but the red, swollen leg is a higher priority. Abdominal bloating occurs due to the carbon dioxide used during the laparoscopy and will lessen when it gets absorbed. Additional teaching is needed to be sure the client does not strain at the toilet.

A nurse is assessing a client who reports abdominal pain, nausea, and diarrhea. The nurse knows that palpating the abdomen first would: a) help the client's symptoms. b) make it easier to hear the bowel sounds in all four quadrants. c) be an appropriate intervention. d) alter abdominal sounds from baseline.

d) alter abdominal sounds from baseline. The correct sequence for abdominal examination is inspection, auscultation, percussion, and palpation. This sequence differs from that used for other body regions (inspection, palpation, percussion, and auscultation) because palpation and percussion increase intestinal activity, altering bowel sounds. Therefore, the nurse should not palpate or percuss the abdomen before auscultating. Assessment of any body system or region starts with inspection; therefore, auscultating or palpating the abdomen first would be incorrect.

Which position would be best for the client in the early postoperative period after a hemorrhoidectomy? a) supine b) Trendelenburg c) high Fowler's d) side-lying

d) side-lying Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective. A high Fowler's or supine position will place pressure on the operative site and is not recommended. There is no need for Trendelenburg's position.

Which finding is normal for a client during the icteric phase of hepatitis A? a) light, frothy urine b) tarry stools c) shortness of breath d) yellowed sclera

d) yellowed sclera Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy. Profound anorexia is also common. Tarry stools are indicative of gastrointestinal bleeding and would not be expected in hepatitis. Light- or clay-colored stools may occur in hepatitis owing to bile duct obstruction. Shortness of breath would be unexpected.

Which statement indicates to the nurse that the client with Crohn's disease understands the needed nutritional modifications? a) "I can enjoy peanuts for an evening snack." b) "A diet high in vitamins and protein is important." c) "I am allowed to have two to three glasses of wine weekly." d) "I may have cola with my meals."

b) "A diet high in vitamins and protein is important." A client with Crohn's disease should follow a diet that is low in residue and high in calories, protein, and vitamins. Because of the involvement of the small bowel in Crohn's disease, it may be difficult for the client to absorb needed nutrients. It is recommended that the client avoid caffeinated drinks and alcoholic beverages. Nuts are not recommended for a client on a low-residue diet.

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis? a) a demanding and stressful job b) changing to a modified vegetarian diet c) walking 2 miles (3.2 km) every day d) beginning a weight-training program

c) walking 2 miles (3.2 km) every day Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation

A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: a) a sedentary lifestyle and smoking. b) a history of hemorrhoids and smoking. c) alcohol abuse and a history of acute renal failure. d) alcohol abuse and smoking.

d) alcohol abuse and smoking. The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: a) hypercalcemia. b) thrombocytopenia. c) hypokalemia. d) hyperalbuminemia.

c) hypokalemia. Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

A nurse on a medical surgical unit is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100° F (37.8° C). The nurse suspects that these are symptoms often associated with: a) diverticulitis. b) liver failure. c) inflammatory bowel disease (IBD). d) colorectal cancer.

c) inflammatory bowel disease (IBD). IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer; the bloody stools will present first. A client with diverticulitis commonly states he/she has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client: a) increases food intake and tolerance gradually. b) experiences a rapid weight gain within 1 week. c) experiences occasional episodes of nausea and vomiting. d) drinks 2,000 mL/day of water.

a) increases food intake and tolerance gradually. Weight gain will be slow and gradual because less food can be eaten at one time due to the decreased stomach size. More food and fluid will be tolerated as edema at the suture line decreases and healing progresses. The remaining stomach may stretch over time to accommodate more food. Nausea and vomiting can interfere with nutritional intake. Water provides hydration, but not calories and nutrients. Rapid weight gain may be due to fluid retention and would not reflect adequate nutrition.

A nurse is talking to a neighbor who asks about reoccurring symptoms of gnawing epigastric pain following meals and heartburn. Recognizing these symptoms, what suggestions could the nurse make? a) Sip green tea throughout the day b) Avoid alcohol and non-steroidal anti-inflammatory medications c) Cut back to 2 large meals each day d) Lay flat on your right side after meals

b) Avoid alcohol and non-steroidal anti-inflammatory medications Peptic ulcer disease is characterized by dull, gnawing pain in the midepigastrium or the back that worsens with eating. Recommendations for improvement in symptoms includes: Avoid all coffee and other sources of caffeine as well as alcohol and tobacco. Avoid milk and milk products as well, they increase acid secretion. Eat smaller amounts of foods more frequently. Don't let your stomach go empty for long periods of time. Drink peppermint tea and chamomile teas frequently.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: a) minimize development of scar tissue. b) provide access for wound irrigation. c) promote drainage of wound exudates. d) decrease postoperative discomfort.

c) promote drainage of wound exudates. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

Which nursing interventions would be appropriate when caring for a client during the first 24 hours after an appendectomy? Select all that apply. a) Apply an abdominal binder. b) Place the client in a semi-Fowler's position. c) Maintain a clear-liquid diet for 48 hours. d) Teach the client how to care for the incision. e) Monitor temperature every 2 hours.

b) Place the client in a semi-Fowler's position. d) Teach the client how to care for the incision. Following an appendectomy, the client should be placed in a semi-Fowler's position to relieve tension on the abdomen and the surgical incision and promote comfort. Because the client will likely be discharged within 24 to 48 hours of surgery, teaching the client how to care for the wound is a priority. The client does not need to be limited to a clear liquid diet but may resume a diet as desired following surgery. Although monitoring temperature is important, unless the temperature is elevated, it does not need to be assessed every 2 hours; every 4 hours is sufficient. An abdominal binder is typically not necessary following an appendectomy.

A client is to start on enteral tube feedings. What should a nurse do to make this as comfortable as possible for the client? a) Chill the feeding. b) Start the tube feeding slowly. c) Keep the head of the bed flat. d) Use an IV pump to deliver the feeding.

b) Start the tube feeding slowly. Administering the tube feeding too fast could upset the client's stomach causing diarrhea and putting the client at risk for aspiration. Elevation of the client's head prevents the risk of aspiration. Room temperature feeding is recommended when giving an enteric feeding. Enteric tubing and pumps should be used when giving an enteric feeding.

Which task may a nurse delegate to a nursing assistant? a) Taking orthostatic blood pressure readings on a client on a new medication b) Administering an antacid to a client with symptoms of heartburn c) Assisting a client who had surgery to ambulate in the hallway d) Irrigating a nasogastric (NG) tube

c) Assisting a client who had surgery to ambulate in the hallway Because the client had surgery 3 days ago, the nurse may safely delegate the task of helping the client walk down the hallway to a nursing assistant. Irrigating an NG tube, administering medications, and taking assessment orthostatic readings for a new medication are tasks that must be performed by licensed nursing personnel

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: a) eructation and constipation. b) severe abdominal pain radiating to the shoulder. c) anorexia, nausea, and vomiting. d) abdominal ascites.

c) anorexia, nausea, and vomiting. Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety disorder (OCD). In helping the client understand her illness, the nurse should respond with which statement? a) "The perfectionism and anxiety related to your obsessions and compulsions have led to your colitis." b) "Your ulcerative colitis has made you perfectionistic, and it has caused your OCD." c) "There is no relationship at all between your colitis and your OCD. They are separate disorders." d) "It is possible that your desire to have everything be perfect has caused stress that may have worsened your colitis, but there is no proof that either disorder caused the other."

d) "It is possible that your desire to have everything be perfect has caused stress that may have worsened your colitis, but there is no proof that either disorder caused the other." Though ulcerative colitis and OCD have some features in common, and stress can make both illnesses worse, there is no definitive cause-effect relationship between ulcerative colitis and OCD. Therefore, the only appropriate nursing response would be to acknowledge the effect of stress on both illnesses and indicate there is no proof that either illness causes the other.

A graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first? a) The client receiving continuous tube feedings who needs the tube-feeding residual checked b) The client who underwent surgery 3 days ago and who now requires a dressing change c) The sleeping client who received pain medication 1 hour ago d) The newly admitted client with acute abdominal pain

d) The newly admitted client with acute abdominal pain The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings. These tasks are of equal importance. They should assess the sleeping client who received pain medication 1 hour ago last because he just received relief from his pain and is able to sleep.

The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent: a) constipation during the immediate postoperative period. b) pressure on the diaphragm with poor lung expansion during surgery. c) gas pains and distention during the immediate postoperative period. d) vomiting and possible aspiration of vomitus during surgery.

d) vomiting and possible aspiration of vomitus during surgery. Oral food and fluids are withheld before surgery when a client receives general anesthesia primarily to help prevent vomiting and possible aspiration of stomach contents. Constipation after surgery is influenced by multiple factors, such as the nature of the surgery, the postoperative diet, and use of opioid analgesics. Food and fluids are not withheld prior to surgery to relieve pressure on the diaphragm and increase lung expansion. Withholding food and fluids before surgery does not eliminate gas pains or abdominal distention in the postoperative period. General anesthesia and manipulation of abdominal contents can cause peristaltic action to cease temporarily. This leads to abdominal distention and gas pain.