ATI Med-Surg Adaptive Quizzes Combo

A nurse is reinforcing preoperative teaching with a client who will undergo surgery to create a temporary colostomy. The client asks the nurse about the difference between colostomies and ileostomies. Which of the following responses should the nurse offer? A. "A colostomy drains stool and an ileostomy drains urine." B. "A colostomy is temporary and an ileostomy is permanent." C. "A colostomy is from the large intestine and an ileostomy is from the small intestine." D. "An ileostomy requires dietary restrictions while a colostomy does not."

"A colostomy is from the large intestine and an ileostomy is from the small intestine." *The name of the ostomy reflects the region the surgeon brings to the surface of the abdominal wall. *colon+ostomy (large intestine) *ileum+ostomy (small intestine)

A nurse is reinforcing teaching with a group of community residents about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by eating foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

"A hepatitis B immunization is given to infants and children." *Hepatitis B immune globulin is given as part of standard childhood immunizations. It can be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age

A nurse is reinforcing postoperative teaching with a client who had a partial gastrectomy about the management of dumping syndrome. Which of the following instructions should the nurse include? A. "Consume at least 4 ounces of fluid with meals." B. "Take a short walk after each meal." C. "Use honey to flavor foods such as cereal." D. "Eat protein with each meal."

"Eat protein with each meal." *The client should eat meals that are high in protein and fat with low to moderate carbohydrate content. Proteins should be included in every meal because it delays digestion, which helps reduce the manifestations of dumping syndrome

A nurse is reinforcing discharge techniques with a client who has a newly placed ileostomy about ostomy care while at home. Which of the following instructions should the nurse include in the teaching? A. "Empty your ostomy pouch when it gets half full." B. "Place an aspirin in the ostomy pouch to eliminate odor." C. "Change the ostomy appliance every week." D. "Cleanse the site around the stoma with hydrogen peroxide and water."

"Empty your ostomy pouch when it gets half full." *The nurse should instruct the client to empty the pouch when it is 1/3-1/2 full. This prevents the ostomy from becoming too full of stool or gas and exploding

A nurse is reinforcing discharge teaching with the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include? A. "During this illness, shemay take acetaminiphen for a fever or discomfort." B. "Encourage her to eat foods that are high in carbohydrates." C. "The provider will prescribe a medication to help her heal faster." D. "Have her perform moderate exercise to get her strength back quicker."

"Encourage her to eat foods that are high in carbohydrates." *The client's diet should be high in carbs and calories with only moderate amounts of protein and fat, especially if nausea is present.

A nurse is reinforcing teaching with a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A. "I am unable to donate blood." B. "I will need to get a booster shot of immune serum globulin every year." C. "I should stop eating raw clams." D. "I can get this disease by getting a tattoo."

"I should stop eating raw clams."

A nurse is reinforcing teaching with a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of his sexually transmitted infection (STI)? A. "I will bring in my sexual partner for treatment." B. "Now that I've had my first dose of medicine, I can resume sexual activity." C. "After I have been treated, I don't have to use condoms." D. "Once treatment is complete and I am free of symptoms, I don't have to return to the clinic."

"I will bring in my sexual partner for treatment."

A nurse is reinforcing teaching with a client who tested postive for a dust allergy about reducing her exposure to this allergen. The nurse should determine that the client understands these instructions when she states which of the following? A. "I will begin vacuuming once per week." B. "Carpeting my entire house will be very expensive, but it will be worth it." C. "I will install an electrostatic filter in my furnace." D. "Installing curtains on the window will help control the dust in the house."

"I will install an electrostatic filter in my furnace."

A nurse is reinforcing discharge teaching about foot care with a client who has dibetic neuropathy. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I can use a heating pad on my feet to keep them warm." B. "I can go barefoot as long as I stay inside the house." C. "I will wash my feet daily and apply lotion, except between my toes." D. "I will trim my toenails every morning, rounding the corners."

"I will wash my feet daily and apply lotion, except between my toes."

A nurse is reinforcing discharge teaching with the partner of a client who has acquired immune deficiency syndrome (AIDS). Which of the following statements by the client's partner indicates the need for further teaching? A. "I will dispose of soiled tissues in separate plastic bags." B. "I'll clean blood spills immediately with hot water." C. "I know that handwashing is an important preventative measure." D. "I will wash soiled clothes in hot water."

"I'll clean blood spills immediately with hot water." *should be cleaned with a bleach solution and wear gloves

A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks why he has to stay in bed, how should the nurse respond to explain the most important reason for this prescription? A. "You need to conserve energy at this time." B. "Lying quietly in bed helps slow down the activity in your intestines." C. "Staying in bed helps promote the rest and comfort you need." D. "Staying in bed will help prevent injury and minimize your fall risk."

"Lying quietly in bed helps slow down the activity in your intestines." *the greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and GI bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.

A nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. "Because most of my colon is still intact and functioning, my stool will be formed." B. "My stoma will appear large at first, but it will shrink over time." C. "My colostomy will begin to function 2 to 6 days after surgery." D. "My diet will have to change to a soft diet after surgery."

"My diet will have to change to a soft diet after surgery." *The nurse should identify that this statement requires further reinforcement of teaching. After surgery, the client's diet quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease intake of food that increase gas or odor

A nurse is reinforcing teaching with a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following pieces of information should the nurse include in the teaching? A. "PCP is sexually transmitted from person to person." B. "You were most likely exposed to a contaminated surface such as a drinking glass." C. "PCP results from an impaired immune system." D. "You might have contracted PCP from a family pet."

"PCP results from an impaired immune system."

A nurse is caring for a client with colitis who states that the stress at work increases exacerbations. Which of the following responses should the nurse offer? A. "I will contact the social worker so you can discuss career alternatives." B. "Have you thought about discussing the possibility of a part-time assignment with your employer?" C. "Why don't you ask your employer to relieve you of some work until you are stronger?" D. "Perhaps we should review your coping mechanisms and talk about alternatives."

"Perhaps we should review your coping mechanisms and talk about alternatives." *Reviewing coping mechanisms and alternative coping patterns will promote coping skills that can assist the client in reducing stress.

A nurse is reinforcing teaching with a client regarding nutrition, which of the following statement should the nurse include about nutrients? A. "Carbohydrates transport nutrients throughout the body." B. "Fats prevents ketosis." C. "Protein builds and repairs body tissue." D. "Carbohydrates help regulate body temperature."

"Protein build and repairs body tissue." *Protein is responsible for building and repairing body tissues such as muscles, tendons, and collagen. The skin, hair, nails are also made up of protein structures. A diet that is low in protein can impair wound healing.

A nurse is reinforcing teaching with a client who has Barrett's esophagus and is scheduled to undergo an esophagagastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."

"This procedure can determine how well the lower part of your esophagus works."

A nurse is reeinforcing discharge teaching with a client who has aIDS. Which of the following statements should the nurse include? A. " You can share razors with your partner as long as they are disposable." B. "You should clean bathroom surfaces with a bleach and water solution." C. "You should increase your intake of raw fruits and vegetables." D. "You can continue gardening as long as you wear a mask."

"You should clean bathroom surfaces with a bleach and water solution."

A nurse is reinforcing discharge with a client who has HIV. Which of the following instructions about infection prevention should the nurse include in the teaching? (select all that apply) A. Avoid large gatherings of people B. Clean the toothbrush by running through the dishwasher C. Change pet litter boxes with disposable gloves D. Consume raw vegetables E. Avoid digging in the garden

1. Avoid large gatherings of people 2. Clean the toothbrush by running through the dishwasher 3. Avoid digging in the garden

A nurse is reinforcing teaching about hypoglycemia with a client who has diabetes mellitus. Which of the following manifestations should the nurse include? (select all that apply) A. Bradycardia B. Diaphoresis C. Deep, rapid respirations D. Palpitations E. Shakiness

1. Diaphoresis 2. Palpitations 3. Shakiness *Sympathetic nervous responses to hypoglycemia include: diaphoresis, palpitations and a bounding heart rate, and shakiness

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse instruct the client to perform (select all that apply) A. Use antimicrobial ointment on the peristomal skin B. Empty the bag when it is one-third to one-half full C. Cut the skin barrier opening a little larger than the ostomy D. Wash the peristomal skin with mild soap and water E. Apply the skin barrier while the skin is slightly moist

1. Empty the bag when it is one-third to one-half full 2. Cut the skin barrier opening a little larger than the ostomy 3. Wash the peristomal skin with mild soap and water *Allowing the bag to become too full can cause leakage. *The client should cut an opening that is about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. *The client should avoid moisturizing soaps because their lubricants can affect adhesion of the appliance

A nurse is assisting with the admission of a client who has cirrhosis. Whcih of the following prescriptions shoult the nurse anticipate? (select all that apply) A. Obtain the client's PT and INR measurements B. Administer lactulose 30 mL PO 4 times daily C. Obtain dailty weight and abdominal girth measurements D. Administer a daily multivitamin E. Place the client on a low-protein diet

1. Obtain the client's PT and INR measurements 2. Administer lactulose 30 mL PO 4 times daily 3. Obtain daily weight and abdominal girth measurements 4. Administer a daily multivitamin *Cirrhosis interferes with the ability of the liver to produce clotting factors, which places the client at risk of hemorrage. The PT & INR are usually prolonged due to decreased synthesis of prothrombin. *Additionally, a client who has cirrhosis is unable to eliminate ammonia from the body once protein is broken down. Therefore, lactulose should be administered to increase the client's production of stool, which will help eliminate ammonia from the client's body. *The nurse should anticipate a prescription to assess the client's weight daily as a measure of fluid status An increase of 1 kg (2.2 lbs) in the client's weight indicates 1 L of fluid retention. *The nurse should also expect to measure the client's abdominal girth to determine if ascites is increasing or decreasing

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. The nurse finds the client's wound has eviscerated. Which of the following actions should the nurse take? (select all that apply) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

1. Place the client in a supine position with hips and knees flexed 2. Leave the room to call the surgeon 3. Cover the wound and intestine with a sterile, moistened dressing 4. Monitor the client for manifestations of shock *The nurse should place the client in a supine position with hips and knees flexed to prevent further tearing of the incision and to avoid wound evisceration by lessening tension on the wound *The nurse should delegate another person to immediately notify the surgeon and should stay with the client to observe for further complications such as shock. *Additionally, the nurse should cover the protruding intestine with a sterile dressing that is moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep the intestine from drying out. *Finally, the nurse should monitor the client for a physiological stimulus such as bleeding from the tearing or opening of the wound or a psychological stimulus such as viewing the intestine protruding outside of the body can increase the risk for shock. *The nurse should monitor the client for increased heart and respiratory rate, changes in blood pressure or mentation, and cool, clammy skin.

A nurse in a provider's office is collecting data from a client who has gastroesophageal reflux disease (GERD). The nurse should expect the client to report which of the following manifestations? (select all that apply) A. Regurgitation B. Nausea C. Belching D. Heartburn E Weight loss

1. regurgitation 2. Nausea 3. Belching D. Heartburn *All are manifestations of GERD

A nurse is caring for a client who is 2 days postoperative following gastric surgery and has an NG tube inserted. Which of the following findings should the nurse report to the provider? A. Dryness of the mucous membranes B. Hypoactive bowel sounds in all quadrants C. 200 mL of bright red drainage from the NG tube D. Continuous low suction

200 mL of bright red drainage from the NG tube *The nurse should notify the provider immediately regarding 200 mL of bright red drainage from the NG tube 2 days following gastric surgery. Drainage should be either a yellow-green or clear. Bright red drainage indicates blood loss and can be the result of a disrupted line or other form of internal bleeding. Volume loss from blood is a medical emergency, and the provider should be immediately notified

A nurse is collecting data from a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

Anorexia *Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product.

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure B. Place the client leaning forward over the bedside table for the procedure C. Inform the client he will be sedated during the procedure D. Instruct the client to fast for 6 hours prior to the procedure

Ask the client to empty his bladder before the procedure *this will prevent injury to the bladder

A nurse is helping develop a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should suggest monitoring the client for which of the following complications? A. Aspiration B. Infection C. Anemia D. Weight loss

Aspiration *Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus. This places the client at risk of aspiration, GERD causes effortless, uncontrolled regurgitation, whether the client is an upright position or reclining. The most common results of regurgitation are heartburn and indigestion, however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which is an indication of aspiration.

A nurse is contributing to the plan of care for a client with AIDS who has developed stomatitis. Which of the following interventions should the nurse recommend for the plan of care? A. Rinse the mouth with chlorhexidine solution every 2 hours B. Limit fluid intake with meals C. Provide oral hygiene with a firm-bristled toothbrush after each meal. D. Avoid salty foods

Avoid salty foods

A nurse is updating the plan of care for a client who has celiac disease. Which of the following dietary selections should the nurse recommend for the client? A. Whole-wheat tortilla with black beans B. Baked chicken and rice C. Turkey and cheese sandwich D. Pasta with marinara sauce

Baked chicken and rice *The nurse should recommend baked chick and rice as a dietary selection for a client who has celiac disease. Clients who have celiac disease should avoid foods containing gluten.

A nurse in a provider's office is collecting data from a client who has GERD, when documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions? A. Stair climbing B. Bending over C. Sitting D. Walking

Bending over *Gastroeophageal reflux symptoms are most evident with activities that increase intraabdominal pressure such as bending over, straining, lifting, and lying down

A nurse is obtaining a guaic test from a client. The nurse should identify that the guaic test is performed to detect which of the following? A. Fecal material in vomit B. Blood in stool C. Infestation of parasites D. Microorganisms in the urine

Blood in stool *The guaic test detects the presence of blood in the stool. It is a commonly used point-of-care test for fecal occult blood.

A nurse is collecting date from a client who has cholecystitis. Which of the following findings should the nurse expect? A. Bumberg's sign B. Ascites C. Gastrointestinal bleeding D. Kehr's sign

Blumberg's sign *The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation

A nurse is collecting data from a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Decreased heart rate B. Yellowing of the skin C. Increased blood pressure D. Board-like abdomen

Board-like abdomen *The nurse should expect this client who is experiencing perforation of a peptic ulcer to exhibit a board-like abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation also causes hemorrhaging

A nurse is caring for a client who has recovered from acute diverticulitis. The nurse should instruct the client to increase his intake of which of the following foods when the inflammation subsides? A. Cucumbers and tomatoes B. Cabbage and peaches C. Strawberries and corn D. Figs and nuts

Cabbage and Peaches *When the acute inflammation has subsided, the client should increase his intake of foods that are high in fiber such as wheat bran, whole-grain bread, and fresh fruits and vegetables that do not contain seeds

A nurse is caring for a client who is 2 days posteroperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids

Clear liquids *Clear liquidss such as water or broth can be given for the first oral feedings but should be limited to 30 mL (1 oz) per feeding. Water does not contain sugarm which can cause diarrhea due to hyperosmolarity

A nurse is caring for a client who has gastrointestinal bleeding. The provider suspects a bleeding lesion in the colon. The nurse should anticipate that the most likely initial approach to treatment will involve which of the following procedures. A. Exploratory laparotomy B. Double-contrast barium enema C. Magnetic resonance imaging D. Colonoscopy

Colonoscopy *A colonoscopy involves the insertion of a flexible scope into the rectum. The provider advances the scope carefully until it enters the colon. This procedure can provide direct visualization of the inside of the colon and helps the provider identify the exact cause and location of the bleeding.

A nurse is caring for a client who has new diagnosis of acute sytemic lupus erythematosus (SLE) and is scheduled to begin medication therapy. Which of the following types of medications should the nurse expect to administer? A. Corticosteroids B. Antihistamines C. Antivirals D. Opioids

Corticosteroids *because of their rapid anti-inflammatory action

A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority? A. Dietary recommendations B. Incision care C. Coughing and deep-breathing exercises D. Pain management

Coughing and deep-breathing exercises *The greatest risk to this client is respiratory compromise. Therefore, learning how to perform coughing and deep-breathing exercises to promote lung expansion and secretion removal is the client's priority learning need.

A nurse is caring for a client who is 3 days posteroperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should theh nurse take first? A. Cover the client's wound with a sterile, moist dressing B. Flex the client's knees C. Reassure the client D. Instruct the client to avoid coughing

Cover the client's wound with a sterile, moist dressing *The greatest risk to this client is an inury from infection due to wound exposure. Therefore, the nurse should cover the wound with a sterile, moist dressing

A nurse is assisting with the plan of care for a client who has cholelithiasis. Which of the following interventions should the nurse include in the plan? A. Restrict the client's fluid intake B. Restrict the client's calcium intake C. Decrease the client's fat intake D. Decrease the client's potassium intake

Decrease the client's fat intake *this reduces the occurance of biliary colic

A nurse is reinforcing teaching with a client who has cirrhosis of the liver and a history of alcohol consumption. The nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? A. Increasing the workload of the liver by releasing stored glycogen B. Causing ulceration of liver tissue that can lead to bleeding C. Dilating the veins in the portal circulation D. Destroying liver cells that are replaced with scar tissue

Destroying liver cells that are replaced with scar tissue *The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the necrotic liver cells

A nurse is assisting with the care of a child who has had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should reply that the spleen performs which of the following functions? A. Maintains fluid balance B. Regulates calcium in the blood C. Destroys old blood cells D. produces prothrombin

Destroys old blood cells *A function of the spleen is to destroy old blood cells. The spleen also filters antigens and stores platelets. A client with the spleen removed is at an increased risk of infection and sepsis due to reduced immune function

A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse take regarding the client's diet? A. Provide foods prepared according to kosher dietary law B. Ask the kitchen to prepare grits to meet the client's dietary need for grains C. Determine the client's dietary preferences D. Prepare a diet tray that includes vegetables and barley soup

Determine the client's dietary preferences *While generalizations are often made regarding traditional eating practices of clients based on their cultural background, individual food choices can deviate from these generalizations. The nurse assess the client's dietary habits before planning for dietary needs.

A nurse is assisting with the care of a client who is receiving total parenteral nutrition (TPN) and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis

Diaphoresis *The client has the potential to develop hypoglycemia due to sudden withdrawal of the TPN solution. IN addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.

A nurse is reinforcing teaching with a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? A. Digest fats B. Produce chyme C. Stimulate gastric acid secretion D. Provide energy

Digest fats *Bile is a product of the liver and aids in the digestion of fats

A nurse is contributing to the plan of care for a client who has dumping syndrome. Which of the following instructions should the nurse include? A. Consume beverage with meals B. Eat 3 large meals per day C. Include high-fiber foods in the diet D. Eat a source of protein with each meal

Eat a source of protein with each meal *recommended because protein delays gastric emptying

A nurse is reinforcing teaching with a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? A. Eat crackers and yogurt regularly B. Chew minty gum throughout the day C. Drink orange juice every day D. Put an aspirin in the pouch

Eat crackers and yogurt regularly *Crackers, toast, and yogurt can help reduce flatus, which contributes to odor

A nurse is reinforcing teaching with a client who has constipation. Which of the following instructions should the nurse include in the teaching? A. Use bismuth subsalicylate regularly B. Consume a low-fiber diet C. Eat yogurt with live cultures D. Use bisacodyl suppositories regularly

Eat yogurt with live cultures *Yogurt that contains liver bacterial cultures provides dietary probiotics that can help maintain and promote bowel function.

A nurse is planning care for a client who is postoperative following a gastrectomy. Which of the following strategies should the nurse suggest to help prevent dumping syndrome? A. have the client drink plenty of water with meals B. Eliminate simple sugars and sugar alcohols from the client's diet C. Limit the client to 2 meals per day D. Offer the client meals that are low in protein or protein-free

Eliminate simple sugars and sugar alcohols from the client's diet *Sugar, honey, and sugar alcohols such as sorbitol and xylitol increase hypertonicity and propel food through the intestines faster than food without sweenteners

A nurse is collecting data from a client who has a bleeding duodenal ulcer. Which of the following findings should the nurse expect? A. Emesis with a coffee-ground appearance B. Increased blood pressure C. Decreased heart rate D. Bright green stools

Emesis with a coffee-ground appearance *The nurse should expect a client who has a bleeding duodenal ulcer to have emesis that resembles coffee grounds or is bright red in color. Hematemesis indicates upper GI bleeding, occurring at or above the duodenojejunal junction.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the drainage bag on the client's abdomen when transferring from the bed to a cart B. Empty the drainage bag when it is half full of urine C. Rest the drainage bad on the floor when closing the drainage spigot during emptying D. Disconnect the drainage bag when obtaining a urine specimen

Empty the drainage bag when it is half full of urine *a drainage bag that is too full can lace tension on the catheter tubing, resulting in trauma to the urethra and urinary meatus

A nurse is caring for a client who has an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take? A. Ensure bowel rest B. Offer sparkling water frequently C. Administer a stool softener D. Offer plain, warm tea frequently

Ensure bowel rest *Clients who have an exacerbation of Crohn's disease usually require NPO status to ensure bowel rest and promote healing and recovery

A nurse is reinforcing teaching with a client who has diverticulitis about preventing acute attacks. Which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories

Foods high in fiber *The results of long-term, low fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the GI tract.

A nurse is assisting with the care of a client who has a history of cirrhosis and was recently admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)

Gamma-glutamyl transferase (GGT *The GGT lab test is specific to the heptaobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring for drug toxicity and excessive alcohol use

A nurse is reinforcing teaching about dietary modifications for a client with newly diagnosed cirrhosis. Which of the following foods should the nurse recommend? A. Grilled chicken B. Potato soup C. Fish sticks D. Baked ham

Grilled chicken *A client who as cirrhosis requires protein to compensate for the weight loss as a result of the disease. Increasing protein intake from animal or plant sources will also provide more energy. They should avoid foods that are high in sodium

A nurse is reinforcing teaching with an assistive personnel (AP who is caring for a client with active pulmonary tuberculosis. The client has been placed on airborne precautions and is scheduled for a chest x-ray. Which of the following instructions should the nurse include in the teaching? A. Have the client wear a surgical mask B. Wear a gown for protection from the client's infection C. Ask the radiology staff to perform a portable chest x-ray in the client's room D. PLace an N-95 respirator on the client

Have the client wear a surgical mask

A nurse is collecting data from a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? A. Absence of bowel sounds in all four abdominal quadrants B. Passage of blood-tinged liquid stool C. Presence of flatus D. Hyperactive bowel sounds above the obstruction

Hyperactive bowel sounds above the obstruction *The nurse should expect the client to have hyperactive bowel sounds above the obstruction because the intestinal peristalsis above the obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction

A nurse is collecting data from a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate an elevation in which of the following laboratory values? A. IgM (immunoglobulin M) B. IgA (immunoglobulin A) C. IgG (immunoglobulin G) D. IgE (immunoglobulin E)

IgE (immunoglobulin E)

A nurse is assisting with preparing a teaching plan about secondary prevention actions for colorectal cancer for a community health fair for adults. Which of the following topics should the nurse recommend including? A. Smoking cessation B. Benefits of a diet that is high in cruciferous vegetables C. New types of ostomy appliances D. Importance of colonoscopy screening starting at 50 years of age

Importance of colonoscopy screening starting at 50 years of age *Screening examinations for colorectal cancer are secondary prevention

A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? Decreased lactate dehydrogenase B. Increased serum albumin C. Decreased serum ammonia D. Increased prothrombin time

Increased prothrombin time *Clients with end-stage liver failure have an inadequate supply of clotting factors and, therefore, have a prolonged time

A nurse is caring for a client who has abdominal pain and possibly pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis? A. Decreased white blood cell count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level

Increased serum lipase level *Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level

A nurse is assisting with data collection from a client who is 12 hours postoperative following an open cholecystectomy. Which of the following findings should the nurse report to the charge nurse? A. Hypoactive bowel sounds B. Indwelling urinary catheter output of 25 mL/hr C. Heart rate of 96/min D. Serous drainage at the surgical incision site

Indwelling urinary catheter output of 25 mL/hr *The nurse should report a urinary output of less than 30 mL/hr to the charge nurse, as this can indicate hypovolemia or renal complication

A nurse is assisting with the admission of a client who has manifestations of tuberculosis. Which of the following actions is the nurse's priority? A. Initiate airborne precautions B. Adminster antimicrobial therapy C. Tell the client that his infection will be communicable for 2 to 3 weeks after the start of medication therapy D. Reinforce teaching about the manifestations of tuberculosis

Initiate airborne precautions

A nurse is assisting with the planning of an in-service training session regarding nutrition. Which of the following minerals should the nurse include as a factor in oxygen transportation? A. Zinc B. Iron C. Phosphorous D. Magnesium

Iron *Iron transports hemoglobin and myoglobin. It is also a component of enzyme systems

A nurse is assisting with the admission of a client who has fulminant failure. Which of the following procedures should the nurse expect for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

Liver transplant *Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients

A nurse is reinforcing teaching about dietary therapy with a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following pieces of information should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals

Maintain a supine position after meals *The nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. A client who has dumping syndrome should decrease the amount of food eaten at a time, eat small meals more frequently, and eliminate fluids at mealtime. Fluid shifts occur in the upper GI tract when food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine. This makes blood volume decrease, causing the client to experience nausea , sweating, syncope, palpitations, increased heart rate, and hypotension.

A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet? A. Oranges and tomatoes B. Carrots and bananas C. Potatoes and squash D. Whole grains and beans

Oranges and tomatoes *Symptoms of GERD worsen following oral intake of substances that decrease lower esophageal structure (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint

A nurse is assisting with the planning of an in-service session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes has a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin

Pepsin *Pepsin is an enzyme by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down polypeptides in to amino acids, which can be used by the body.

A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is the nurse's priority? A. Performing hand hygiene before and after contact with the client B. Reducing the client's anxiety due to isolation procedures C. Assisting the client with making nutritional choices D. Monitoring the client's intake and output

Performing hand hygiene before and after contact with the client

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water B. Place the client in a semi-Fowler's position C. Cleanse the skin around the tube site D. Aspirate the tube prior to each feeding

Place the client in a semi-Fowler's position *A client who is receiving PEG tube feeding should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration.

A nurse is reinforcing teaching with a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? A. Use an alcohol-based soap to cean lesions B. Wear a condom during sexual activity when lesions are present C. Take a sitz bath once per day D. Pour running water over the lesions when urinating.

Pour running water over the lesions when urinating. *this will relieve discomfort

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? A. Preventing excessive pressure on suture lines B. Allowing gastric lavage after surgery C. Allowing early postoperative feeding D. Obtaining a gastric specimen for testing

Preventing excessive pressure on suture lines *The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the G tract. In doing so, it also prevents vomiting and GI distention

A nurse is reinforcing teaching with a client who has Raynaud's disease. Which of the following pieces of information should the nurse include in the teaching? A. Protect against the cold by wearing layers of clothing B. Begin an exercise program of 2-mile walks once per week C. Increase vitamin A in the diet D. Elevate the hands above the heart when resting

Protect against the cold by wearing layers of clothing

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

Prothrombin time *A major complication following a liver biopsy is hemorrage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), activated partial thromboplastin time (aPTT) and platetlet count should be monitored. Liver dysfunction reduces the production of blood clotting factors, which leads to increased incidence of bruising, nosebleeds, bleeding from wounds, and GI bleeding. This is due to a deficient absorption of Vitamin K from the GI tract caused by the inability of liver cells to use vitamin K to make prothrombin

A nurse is caring for a client who is postoperative following a laparotomy. The client has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings indicates that the client is developing a postoperative complication? A. Pain scale score of 5 out of 10 B. Urine output of 65 mL/hr C. 10 mL of bright red drainage from the drain D. Pulse oximetry of 85%

Pulse oximetry of 85% *Clients who have had abdominal surgery should have an oxygen saturation about 95%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention

A nurse is caring for a client who is 4 hours postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 C (101.1F) D. Oxygen saturation 92%

Right shoulder pain *The client can experience pain the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. MIld analgesics and a recumbent position can help relieve the client's pain

A nurse is checking a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Increased frequency and pitch of bowel sounds C. Rigid abdomen D. Emesis of undigested food

Rigid abdomen *Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume. A lowered blood pressure (hypotension) results.

A nurse is reinforcing dietary teaching with a client who has ulcerative colitis. Which of the following food selections by the client indicates an understanding of the teaching? A. Raw vegetable salad with low-fat dressing B. Roasted chicken and white rice C. Fresh fruit salad and milk D. Peanut butter on whole wheat bread

Roasted chicken and white rice *Clients with ulcerative colitis are restricted to a low-fiber diet, which omits whole grains and raw fruits and vegetables. Roasted chicken and white rice is the best choice

A nurse is collecting data from a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive salivation B. Skin tightening C. Periorbital edema D. Alopecia

Skin tightening

A nurse is assisting with the care of a client who has human immunodeficiency virus (HIV). Which of the following types of isolation should the nurse implement to prevent the transmission of HIV? A. Protective isolation B. Droplet precautions C. Standard Precautions D. Airborne precautions

Standard precautions

A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client says she does not understand how she will be alright without her gallbladder. The nurse should explain that which of the following is the main function of the gallbladder? A. Producing bile B. Adding digestive enzymes to bile C. Storing bile D. Eliminating bile

Storing bile *The primary function of the gallbladder is to store bile. Because this organ is only for storage, the client's liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum and perform various functions.

A nurse is collecting data on a client who has liver cirrhosis with abdominal distention. Which of the following actions is the most effective way for the nurse to note a change in the client's abdominal distention? A. Percuss the abdomen for tympanic sounds B. Inspect the contour of the abdominal wall C. Ask the client to report increased abdominal discomfort D. Take serial measurements of the abdomen with a tape measure

Take serial measurements of the abdomen with a tape measure *Measuring the abdomen is the most effective way to monitor for a change in abdominal distention. This provides concrete, objective data that can be compared at various points in time in order to monitor changes

A nurse is evaulating theh injection site for a client who had a mantoux skin test 48 hours ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make? A. The client has active tuberculosis B. The client has been exposed to tuberculosis C. The nurse must re-evaluate the result in 24 hours D. The test is negative for tuberculosis

The client has been exposed to tuberculosis

A nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 mL/hr. When the nurse checks the client 0800, which of the following findings requires intervention by the nurse? A. A full pitcher of water is sitting on the client's bedside table within the client's reach. B. The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube D. The head of the bed is elevated to 20°

The head of the bed is elevated to 20° *The head of the bed should be elevated to at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the heeding progress through the digestive system and reduces the possibility of regurgitation

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that the purpose of this procedure is which of the following? A. To visualize colon polyps B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary duct D. To determine the presence of free air in the abdomen

To detect an ulceration in the stomach *An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect tumors, ulceration, or obstructions

A nurse is preparing to administer a mantoux skin test to a client. What is the purpose of a Mantoux skin test using purified protein derivative (PPD)? A. To identify whether a client lacks immunity to tuberculosis B. To find out if a client has active tuberculosis C. To decrease the hypersensitivity of the client's reaction to PPD D. To identify whether a client has been infected with Mycobacterium tuberculosis

To identify whether a client has been infected with Mycobacterium tuberculosis

A nurse is collecting data from a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect to see? A. Confluent honey-colored, crusted lesions B. Large tender nodule located on a hair follicle C. Unilateral, localized nodular skin lesions D. Fluid-filled vesicular rash in the genital region

Unilateral, localized nodular skin lesions

A nurse is assisting with the admission of a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

Vasopressin *Vasopressin constricts the splanchnic bed and decreased portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system; thus, it is used to treat bleeding varices.

A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet? A. White bread and plain yogurt B. Shredded wheat cereal and blueberries C. Broccoli and kidney beans D. Oatmeal and pears

White bread and plain yogurt *During the acute inflammation of diverticulitis, the client should maintain a diet that is low in fiber (e.g, white bread, low-fat milk, yogurt with active cultures, poached eggs, and canned, soft fruit.)

A nurse is collecting date from a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. alcohol use

alcohol use *Alcohol consumptionis a major cause of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions, resulting in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor inprotein content and either very high or very low in fat

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk of developing hepatitis A? A. Children and young adults B. Older adults C. Women who are pregnant D. Middle-aged men

children and young adults *The hepatitis A virus can be contracted from the feces, bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, through hand-to-mouth contact, or by another form of close contact.

A nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber diet. Which of the following food items should the nurse remove from the client's meal tray? A. Canned fruit B. White bread C. Broiled hamburger D. Coleslaw

coleslaw *Coleslaw contains cabbage, which is high in fiber. Clients who are following a low-fiber diet should avoid most raw vegetables

A nurse is reinforcing teaching with the parents of a child who has celiac disease. Which of the following foods should the nurse instruct the parents to omit from the child's diet? A. Cornflakes B. Reduced fat milk C. Canned fruits D. Wheat bread

wheat bread *clients should eliminate as much gluten as possible from their diets. Wheat, rye, and barley

A nurse is assisting with the planning of an in-service session about nutrition. How many of the amino acids must be obtained from dietary intake? A. 6 B. 9 C. 11 D. 15

9 *9 amino acids are considered essential for the human body and must be obtained from the diet

A nurse in a clinic is collecting data from a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately? A. Headache and fatigue B. Swollen lymph nodes in the neck C. Abdominal pain in the left upper quadrant D. Fever and sore throat

Abdominal pain in the left upper quadrant *can indicate a enlarged spleen. if it ruptures it could lead to hemorrhaging.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hours after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

Amylase *Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3-6 hours following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hours and returns to the expected reference range within 2 to 3 days

A home health nurse is contributing to the pllan of care for a client who is receiving chemotherapy and has nutropenia. Which of the following foods should the nurse include in the client's plan of care? A. soft-boiled eggs B. Brie cheese made with unpasteurized milk C. Cold sandwiches made with deli meat D. Baked chicken

Baked chicken

A nurse is caring for a client who is NPO and has an NG tube to suction. The client reports nausea. Which of the following actions should the nurse take? A. irrigate the tube with a normal saline solution B. Provide oral hygiene C. Clamp the tube for 30 minutes D. Increase the amount of suction

Irrigate the tube with a normal saline solution *When caring for a client with an NG tube who develops nausea, the nurse should first attempt to irrigate the tube to determine patency. If the tube is not patent, gastric pressure cannot decrease, and the stead or increasing pressure can cause nausea.

A nurse is reinforcing teaching with a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A. Wash genitalia using an antimicrobial soap B. Rinse dishes with cold water C. Clean toothbrush once per month D. Incorporate raw fruits and vegetable into the diet

Wash genitalia using an antimicrobial soap

A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca Pudding C. Hard-boiled egg D. Mashed Potatoes

wheat toast *Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed the client's tray.