Chapter 61: Concepts of Care for Patients With Urinary Problems, Chapter 60: Assessment of the Renal/Urinary System, Chapter 60: Assessment of the Renal/Urinary System, ch. 52- Concepts of Care for Patients with Inflammatory Intestinal Disorders, 52...

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A client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which change requires immediate nursing intervention? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria) D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube after IV administration of a broad-spectrum antibiotic

Which actions are most effective for nurses and other health care workers to prevent occupational transmission of viral hepatitis? Select all that apply. A. Washing hands before and after contact with all clients B. Using needleless systems for parenteral therapy C. Using Standard Precautions with all clients regardless of age or sexual orientation D. Obtaining an immunoglobulin injection after exposure to hepatitis A E. Being fully vaccinated with the hepatitis B vaccine F. Wearing gloves during direct contact with all clients

A B C D E

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine

A B C D E F

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."

A C D

Which symptoms in a client with cirrhosis and encephalopathy indicate to the nurse that the prescribed lactulose therapy is effective? Select all that apply. A. Decreased confusion B. Increased urine output C. Musty odor to the breath D. Two to three soft stools daily E. Lower serum bilirubin levels F. Lower serum ammonia levels

A D F

"It produces an enzyme that alters the acidity of the stomach."

A patient asks the nurse how an infection such as Helicobacter pylori causes gastric ulcers. Which information would the nurse provide about this organism?

Metabolic alkalosis

A patient who has peptic ulcer disease has developed pyloric obstruction. The nurse would monitor the patient's laboratory values closely to assess for which complication?

"Those herbs could be helpful. However, you should talk with your provider before adding them to your treatment regimen."

A patient with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. Which response would the nurse provide?

A client had a computed tomography (CT) scan with contrast dye 8 hours ago. Which nursing intervention is the priority for this client? A. Promoting fluid intake B. Medicating for pain C. Monitoring for hematuria D. Maintaining bedrest

A. Promoting fluid intake

The nurse is caring for client who has just returned from the operating room for cystoscopy performed under conscious sedation. Which assessment finding requires immediate nursing action? A. Temperature of 100.8° F (38.2° C) B. Lethargy C. Pink-tinged urine D. Urinary frequency

A. Temperature of 100.8° F (38.2° C)

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.

15. The nurse is caring for a client who was recently diagnosed with pancreatic cancer. What factors present risks for developing this type of cancer? (Select all that apply.) a. Diabetes mellitus b. Cirrhosis c. Smoking d. Female gender e. Family history f. Older age

ANS: A, B, C, E, F All of these choices are risk factors except that pancreatic cancer occurs most frequently in men.

20. A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?"

ANS: A, B, D Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

2. A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? a. "Cap the catheter drain at night to prevent leakage and skin damage." b. "Position the drainage bag lower than the catheter insertion site." c. "Irrigate the catheter with an ounce of saline every night." d. "Pierce a hole in the top of the drainage bag to get rid of odors."

ANS: B An external temporary or permanent catheter drains bile by gravity into a bag that collects bile. Therefore, the drainage bag should be lower that the catheter insertion site. The catheter should not be capped or irrigated, and no holes should be made in the bag to prevent bile from having contact with the skin.

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? a. Culture and sensitivity b. Parasites and ova c. Occult blood test d. Total fat content

ANS: C Dark stools are typical in clients who have lower GI bleeding. Therefore, an fecal occult blood test would be the most appropriate test as a follow-up.

5. 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."

ANS: C The enzymes must be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

8. A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? a. Urinary tract infection b. Chronic kidney disease c. Heart failure d. Fluid and electrolyte imbalances

ANS: D Due to the length and complexity of this type of surgery, the client is at risk for fluid and electrolyte imbalances. The nurse would assess for signs and symptoms of these imbalances so they can be managed early to prevent potentially life-threatening complications.

6. Which drugs will the nurse expect to give a client with acute gastritis that are antisecretory agents? Select all that apply. A. Famotidine B. Omeprazole C. Sucralfate D. Pantoprazole E. Nizatidine F. Calcium carbonate

B, D

The nurse is teaching a client how to provide a clean-catch urine specimen. Which client statement indicates that teaching was effective? A. "I will have to drink 2 L of fluid before providing the sample." B. "I'll start to urinate in the toilet, stop, and then urinate into the cup." C. "It is best to provide the sample while I am bathing." D. "I must clean with the wipes and then urinate directly into the cup."

B. "I'll start to urinate in the toilet, stop, and then urinate into the cup."

Which client assessment data is essential for the nurse to report to the health care provider before a renal scan is performed? A. Pink-tinged urine B. Reports pregnancy C. Reports claustrophobia D. History of an aneurysm clip

B. Reports pregnancy

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French

Which over the counter product will the nurse further explore with a client, for potential impact on kidney function? A. Mouthwash with alcohol B. Vitamin C C. Acetaminophen D. Fiber supplement

C. Acetaminophen

A patient admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this patient? A. Applying hydrocortisone cream B. Cleaning the area with soap and hot water C. Using sitz baths three times daily D. Wearing absorbent cotton underwear

C. Using sitz baths three times daily An important comfort measure for a patient admitted with severe diarrhea experiencing skin breakdown is using sitz baths three times daily.Barrier creams, not hydrocortisone creams, may be used. The skin would be cleaned gently with soap and warm, not hot, water. Absorbent cotton underwear helps keep the skin dry but is not a comfort measure.

10. From where does the nurse suspect a client with PUD is bleeding when massive coffee-ground emesis occurs? A. Colon B. Rectum C. Small intestine D. Upper GI system

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.

Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal hypertension? A. Interpreting the serum albumin value B. Measuring the client's abdominal girth C. Testing stool for the presence of occult blood D. Weighing the client daily at the same time of the day

Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? A. Sodium B. Potassium C. Vitamin C D. Vitamin K

A patient who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The patient tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A. A list of medical supply facilities where wound care supplies may be purchased B. Proper handwashing techniques to avoid cross-contamination of the patient's wound C. The amount of pain medication that the patient is allowed to take in each dose D. Written and oral instructions regarding signs/symptoms to report to the primary health care provider

D. Written and oral instructions regarding signs/symptoms to report to the primary health care provider It is critically important to provide the patient and case manager with both written and oral instructions on reportable signs/symptoms to avoid the development of complications.It will be the home health nurse's responsibility to bring supplies to the patient's home. Although instruction on proper handwashing and the patient's medication regimen are important, they are not the highest priority.

Rapid urease testing

The nurse is assisting with an esophagogastroduodenoscopy (EGD) procedure on a patient who has symptoms of gastritis. Which diagnostic test will the health care provider request on the tissue samples to determine the presence of Helicobacter pylori infection?

It strengthens the mucosal lining of the stomach

Which response would the nurse use when a patient with gastritis asks, "Why am I taking this drug called sucralfate?"

Avoid exposure to lead

Which self-management measure would the nurse teach the patient who has gastritis?

Which factor does the nurse identify that places a client at risk for gastrointestinal (GI) problems? (Select all that apply.) a) Smoking a half-pack of cigarettes per day b) Taking nonsteroidal anti-inflammatory drugs (NSAIDs) c) Financial concerns d) Eating a high-fiber diet e) Use of herbal preparations

a) Smoking a half-pack of cigarettes per day b) Taking nonsteroidal anti-inflammatory drugs (NSAIDs) c) Financial concerns e) Use of herbal preparations

In which position will the nurse place a client with peritonitis to promote comfort and prevent harm from potential complications? a. Semi-Fowler b. Left side-lying with knees to chest c. Right side-lying with knees to chest d. Supine flat with hips and knees flexed

a. Semi-Fowler

The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency? a) Hydrochloric acid b) Intrinsic factor c) Glucagon d) Pepsinogen

b) Intrinsic factor

2. A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems? (Select all that apply.) a. A 24-year-old pregnant woman prescribed prenatal vitamins b. A 32-year-old bodybuilder taking synthetic creatine supplements c. A 56-year-old who is taking metformin for diabetes mellitus d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain e. A 75-year-old with chronic obstructive pulmonary disease (COPD) who is prescribed an albuterol nebulizer

b. A 32-year-old bodybuilder taking synthetic creatine supplements c. A 56-year-old who is taking metformin for diabetes mellitus d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain

Which laboratory assessment findings will the nurse expect in a client who is diagnosed with ulcerative colitis? Select all that apply a. Increased albumin b. Decreased hemoglobin c. Increased sodium d. Decreased potassium e. Elevated WBC count f. Elevate erythrocyte sedimentation rate

b. Decreased hemoglobin d. Decreased potassium e. Elevated WBC count f. Elevate erythrocyte sedimentation rate

A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time? a. Managing surgical pain b. Ambulating the client early c. Preventing respiratory complications d. Managing the nasogastric tube

c The client who has traditional surgery (rather than minimally invasive surgery) is at risk for respiratory complications such as atelectasis and pneumonia because he or she has an incision that may prevent the client from taking deep breaths or using an incentive spirometer. Therefore, the nurse's priority is to prevent these potentially life-threatening respiratory problems.

Which serum laboratory value is most important for the nurse to monitor when caring for an older client with gastroenteritis who has an irregular heart rate and reports "feeling weak"? a. Albumin b. Sodium c. Potassium d. Leukocyte count

c. Potassium

Which of these client assessment findings is typically associated with oral cancer? a. Dry sticky oral membranes b. Increased appetite c. Itchy rash in oral cavity d. Painless red or raised lesion

d A painless red or raised lesion often indicates a diagnosis of oral cancer. The client usually has a decreased appetite and thick secretions. Itchiness is not a common finding associated with oral cancer.

A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? a) Has the client lie in a supine position with legs straight and arms above the head. b) Assesses the following sequence: inspection, palpation, percussion, auscultation. c) Palpates any bulging mass very gently and documents findings. d) Examines the RUQ of the abdomen last following all other assessment techniques.

d) Examines the RUQ of the abdomen last following all other assessment techniques.

17. A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

Which precaution is most important for the nurse to instruct a client with cirrhosis and his or her family about continuing care in the home? A. Avoid taking acetaminophen or drinking alcohol. B. Maintain one-floor living to prevent excessive fatigue. C. Use cool baths to reduce the sensation of itching. D. Report any change in cognition to the health care provider.

The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy f. Respiratory therapy

A C D F

Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? A. An 80-year-old man who has benign prostatic hyperplasia B. A 62-year-old woman with a known allergy to contrast media C. A 48-year-old woman with established urinary incontinence D. A 45-year-old man receiving oral and intravenous fluid therapy

A. An 80-year-old man who has benign prostatic hyperplasia

20. The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy f. Respiratory therapy

ANS: A, C, D, F Care for a client who has hepatopulmonary syndrome would include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the patient in a prone position, on the patient's stomach. Although physical therapy may be helpful to a patient who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome. However, respiratory support from a specialized therapist may be needed

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity. DIF: Applying/Application REF: 1162 KEY: Gastrointestinal trauma| hemorrhage MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

ANS: B The local anesthetic used during this procedure depresses the client's gag reflex. After the procedure, the nurse would ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.

12. A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment finding(s) alert(s) the nurse to a complication from this surgery? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and acute kidney injury (urine output of 20 mL/6 hr) are common complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

Which blood pressure reading does the nurse expect will result in compromised kidney function for a client who sustained major injuries in an MVA? A. 160/80 mm Hg B. 140/100 mm Hg C. 80/60 mm Hg D. 68/40 mm Hg

D. 68/40 mm Hg

A patient has an anal fissure. Which intervention most effectively promotes perineal comfort for the patient? A. Administering a Fleet's enema when needed B. Applying heat to acute inflammation for pain relief C. Avoiding the use of bulk-forming agents D. Using hydrocortisone cream to relieve pain

D. Using hydrocortisone cream to relieve pain The intervention that most effectively promotes perineal comfort in a patient with anal fissure is using hydrocortisone skin cream to relieve perineal pain.Enemas would be avoided when an anal fissure is present. Cold packs would be applied to acute inflammation to diminish discomfort. Bulk-forming agents would be used to decrease pain associated with defecation.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the client's concerns prior to contacting the provider. DIF: Understanding/Comprehension REF: 1151 KEY: Colorectal cancer| assessment/diagnostic examination MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

1. Which finding does the nurse understand is an early pathologic manifestation when a client is diagnosed with acute gastritis? A. Thickened, reddened mucous membrane with prominent rugae B. Patchy, diffuse inflammation C. H. pylori infection D. Thin, atrophied wall and lining of the stomach

13. What is the nurse's best first action when a client with a gastric ulcer is found lying in the knee-chest (fetal) position with a rigid, tender, and painful abdomen? A. Notify the primary health care provider. B. Administer opioid pain medication. C. Reposition the client supine. D. Measure the abdominal circumference.

15. Which drug does the nurse expect to administer to a client in order to decrease hydrochloric acid secretion in the stomach? A. Famotidine B. Gaviscon C. Mylanta D. Antibiotic

16. Which priority teaching will the nurse provide to an older client with GERD who is prescribed omeprazole for symptom relief? A. "Older adults taking this drug may be at increased risk for hip fracture because it interferes with calcium absorption." B. "Because of this drug's side effect of decreasing potassium, you may be prescribed a potassium supplement." C. "This drug causes sodium retention, so you may be prescribed a dietary sodium restriction." D. "A pacemaker may be necessary because this drug changes magnesium levels which can lead to life-threatening dysrhythmias."

24. What is the most common symptom the nurse expects clients with esophageal cancer to report? A. Difficulty with swallowing B. Shortness of breath C. Reflux especially at night D. Productive cough

6. Which priority teaching will the nurse provide to prevent harm when a client with an oral problem is prescribed viscous lidocaine? A. "Lidocaine causes an anesthetic effect so you may not feel burns from hot liquids." B. "You should avoid drinking either cool or cold liquids which can damage the tongue." C. "When you take viscous lidocaine, you should swish it around your mouth then spit it out." D. "Viscous lidocaine will decrease the pain in your mouth when you use it regularly."

8. Which question will the nurse be sure to ask a client suspected of having leukoplakia? A. "Do you smoke, dip, or chew tobacco products?" B. "How much alcohol do you drink each day?" C. "Do you consume many of fast food meals?" D. "How often do you have dental checkups?"

For which client would the nurse expect to teach intermittent catheterization? A. 35-year-old woman who has multiple sclerosis and incontinence B. 48-year-old man who is admitted for pneumonia and is on complete bedrest C. 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. 74-year-old man who has lung cancer with brain metastasis and has advanced dementia

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg)

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected, that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding

What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? A. Increased pressure in the portal vein causing backflow of blood into the spleen B. The loss of cellular regulation in the liver spreading to the spleen and causing extensive scarring C. Chronic inflammation and infection increasing the spleen's maturation and release of white blood cells D. Direct destruction of spleen cells from alcohol or other toxins causing replacement with scar tissue formation

Which client will the nurse recognize as having the greatest risk for nonacoholic fatty liver disease (NAFLD)? A. 45-year-old Latino man who is 30 lb (13.9 kg) overweight and has type 2 diabetes B. 50-year-old white woman who drinks one glass of wine daily and has breast cancer C. 60-year-old black woman who is hypertensive and takes a diuretic daily D. 70-year-old Asian man who has gastroesophageal reflux disease (GERD)

Which neuromuscular assessment change indicates to the nurse that a client who has late-stage liver cirrhosis now has encephalopathy? A. Asterixis B. Positive Chvostek sign C. Increased deep tendon reflex responses D. Decreased deep tendon reflex responses

Which precaution is most important for the nurse to instruct clients with hepatitis C (HCV) who are receiving drug therapy with any second-generation protease inhibitor? A. Avoid crowds and people who are ill. B. Do not touch these drugs with your bare hands. C. Alternate periods of activity with periods of rest. D. Be sure to take vitamin K supplements with this drug.

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"

A B C D E F

Which assessment findings will the nurse expect in a client with late-stage liver cirrhosis whose total serum albumin level is low? Select all that apply. A. Ascites B. Hypotension C. Hyperkalemia D. Hyponatremia E. Dependent edema F. Decreased serum ammonia levels

A B D E

Which clients will the nurse suggest to be immunized against hepatitis B (HBV)? Select all that apply. A. People who have unprotected sex with more than one partner B. Men who have sex with men C. Any client scheduled for a surgical procedure D. Firefighters E. Health care providers F. Clients prescribed immunosuppressant drugs

A B D E F

Which signs and symptoms will the nurse expect to find on assessment of a client with chronic liver disease who has an elevated serum bilirubin level? Select all that apply. A. Pruritus B. Icterus C. Hypertension D. Jaundice E. Pale, clay-colored stools F. Dark, coffee-colored urine.

A B D E F

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia

A B D F

Which new-onset assessment findings in a client with Laennec cirrhosis indicates to the nurse that the client may be starting to have delirium tremens (DTs) from alcohol withdrawal? Select all that apply. A. Anxiety B. Tachycardia C. Hypotension D. Hypertension E. Cool, clammy skin F. Psychotic behavior

A B D F

Which actions are appropriate for the nurse to perform to prevent harm in a client with cirrhosis and ascites who has just undergone an esophagogastroduodenoscopy (EGD)? Select all that apply. A. Measuring oxygen saturation B. Checking for leakage from the site C. Assessing for return of the gag reflex D. Monitoring heart rate and blood pressure E. Auscultating bowel sounds in all four quadrants F. Comparing weight with that obtained before the procedure

A C D

For clients with which types of hepatitis will the nurse teach about prevention of infection spread through the oral-fecal contamination route? Select all that apply. A. Hepatitis A (HAV) B. Hepatitis B (HBV) C. Hepatitis C (HCV) D. Hepatitis D (HDV) E. Hepatitis E (HEV) F. Toxic hepatitis

A E

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| postoperative nursing| bowel care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Contact the health care provider to report these symptoms.

A patient experiences regular epigastric discomfort that usually goes away after eating. Which action would the nurse take?

Gastritis is the inflammation of the stomach mucosa.

A patient has been diagnosed with gastritis. Which information describes this condition?

Ability to swallow secretions

A patient has undergone an esophagogastroduodenoscopy (EGD) procedure. Which assessment would the nurse make the priority for this patient?

H. pylori infection is spread by the oral-to-oral or fecal-to-oral routes.

A patient is diagnosed with a duodenal ulcer caused by Helicobacter pylori infection. The patient asks the nurse how this infection was contracted. Which response would the nurse provide?

Starting a large-bore IV

A patient is experiencing bleeding related to peptic ulcer disease (PUD). Which action would the nurse take?

Do not take an antacid at the same time as sucralfate

A patient is prescribed sucralfate to treat symptoms of peptic ulcer disease. Which information would the nurse include when teaching the patient about this medication?

Helicobacter pylori

A patient presents to the clinic and is diagnosed with chronic gastritis. Which organism would the nurse suspect as the likely cause?

Calcium carbonate causes rebound acid secretion, which will make symptoms worse."

A patient tells the nurse that calcium carbonate has been effective in treating the discomfort associated with peptic ulcer disease. Which response would the nurse provide?

"Take the phenytoin 1 to 2 hours before or after the antacid."

A patient who currently takes phenytoin has been started on a multidrug regimen for treatment of peptic ulcer disease. Which information would the nurse provide about these medications?

Contact the health care provider to discuss giving omeprazole or lansoprazole instead.

A patient with a duodenal ulcer receives a prescription for pantoprazole tablets. The patient has a small-bore nasogastric (NG) tube and is NPO. Which action would the nurse take?

Maintain NG suction.

A patient with a gastric ulcer has a nasogastric (NG) tube in place. The patient develops severe epigastric pain, and the nurse notes a rigid, board-like abdomen. After the nurse notifies the health care provider of this condition, which action would the nurse take?

It will prevent a type of anemia

A patient with chronic gastritis who is prescribed vitamin B12 asks the nurse why this vitamin is necessary. Which information would the nurse provide?

Decompression of the stomach

A patient with peptic ulcer disease has developed a pyloric obstruction, and the health care provider orders placement of a nasogastric (NG) tube. For which purpose would the nurse place a NG tube in this patient?

17. Which actions will the nurse teach a client with GERD to use to prevent harm? Select all that apply. A. Do not consume caffeinated or carbonated beverages. B. Avoid peppermint, chocolate, and fried foods. C. Eat slowly and chew food thoroughly. D. Consume four to six small meals each day. E. Do not eat for 3 hours before going to bed. F. Sleep on your side to prevent regurgitation.

A, B, C, D, E

2. Which risk factors will the nurse assess for when taking a history of a client suspected of having gastritis? Select all that apply. A. Use of alcohol B. Excessive caffeine intake C. Smoking cigarettes D. Life stressors E. Prescribed steroids F. Ingestion of corrosive substances

A, B, C, D, E, F

16. Which priority actions will the nurse take to manage a client's active upper GI bleeding? Select all that apply. A. Administering oxygen B. Starting two large-bore IV lines C. Infusing 0.9% normal saline solution as prescribed D. Collecting a urine sample for urinalysis E. Inserting a nasogastric tube (NGT) F. Monitoring serum electrolytes

A, B, C, E

The nurse is caring for the following clients who are scheduled for a computed tomography (CT) scan with contrast. For which clients will the nurse communicate safety concerns to the health care provider (HCP)? (Select all that apply.) Select all that apply. A. Client who took metformin 4 hours ago B. Client with an allergy to shrimp C. Client who requests morphine sulfate every 3 hours D. Client with a history of asthma E. Client with a blood urea nitrogen of 62 mg/dL (22.1 mmol/L) and a creatinine of 2.0 mg/dL (177 umol/L)

A, B, D, E

24. Which actions will the nurse take to manage a client's dumping syndrome? Select all that apply. A. Providing smaller, more frequent meals B. Eliminating ingestion of fluids with meals C. Providing a high-carbohydrate diet D. Administering acarbose as prescribed E. Increasing fat and protein in the diet F. Administering subcutaneous octreotide three times a day before meals

A, B, D, E, F

4. What priority teaching points will the nurse include when instructing a client and family about how to prevent gastritis? Select all that apply. A. Eat a well-balanced diet and exercise regularly. B. Do not take large doses of aspirin, other NSAIDs (e.g., ibuprofen), and corticosteroids. C. Decrease the amount of smoking and/or use of other forms of tobacco. D. Manage stress levels using complementary and integrative therapies such as relaxation and meditation techniques. E. Use over-the-counter (OTC) proton pump inhibitors if you experience symptoms of esophageal reflux. F. Protect yourself against exposure to toxic substances in the workplace such as lead and nickel.

A, B, D, F

When obtaining a health history and physical assessment from a 68-year-old male client who has a history of an enlarged prostate, which finding does the nurse consider significant? Select all that apply. A. Distended bladder B. Absence of a bruit C. Frequency of urination D. Dribbling urine after voiding E. Chemical exposure in the workplace

A, C, D

11. Which signs and symptoms does the nurse expect to assess when a client experiences an upper GI bleed? Select all that apply. A. Decreased blood pressure B. Decreased heart rate C. Dizziness or light-headedness D. Melena (tarry or dark sticky) stools E. Weak peripheral pulses F. Increased hemoglobin and hematocrit levels

A, C, D, E

22. Which actions will the nurse teach a client to avoid to prevent harm after Nissen fundoplication surgery when gas bloat syndrome occurs? Select all that apply. A. Drinking carbonated beverages B. Passing flatus or belching C. Eating gas-producing foods D. Chewing gum E. Drinking through a straw F. Changing positions frequently

A, C, D, E

26. Which nonsurgical treatment options for cancer of the esophagus will the nurse discuss with the client? Select all that apply. A. Swallowing therapy B. Smoking cessation programs C. Nutritional therapy D. Chemoradiation E. Photodynamic therapy F. Esophageal dilation

A, C, D, E, F

1. Which clients will the nurse carefully assess for high risk of oral cavity disorders? Select all that apply. A. Clients who are homeless or live in institutions B. Clients with sexually transmitted infection C. Clients who are developmentally disabled D. Clients who consume an unhealthy diet E. Clients who work in coal mines F. Clients who regularly use tobacco or alcohol

A, C, D, F

20. Which postoperative instructions will the nurse provide for a client after laparoscopic Nissen fundoplication (LNF)? Select all that apply. A. Consume a soft diet for about a week; avoid carbonated beverages, tough foods, and raw vegetables that are difficult to swallow. B. You will no longer need to take antireflux medications after your surgery is over. C. You must not drive for a week after surgery; especially do not drive after taking an opioid pain medication. D. Walk every day but do not do any heavy lifting. E. Remove the small dressings and closure strips 2 days after surgery and then you may shower. F. Report fever above 101°F (38.3°C), nausea, vomiting, or uncontrollable bloating or pain.

A, C, D, F

13. Which actions will the nurse teach a client with severe GERD that causes pain after each meal, lasts for at least 45 minutes, and worsens when he or she lies down? Select all that apply. A. "Drink fluids right away." B. "When you lie down, try lying on your side." C. "Take an antacid as prescribed by the health care provider." D. "Eat something bland such as a slice of white bread." E. "Maintain an upright position for at least an hour after you eat." F. "Try pressing over your abdomen to mobilize the food in your stomach."

A, C, E

14. Which simple, noninvasive tests will the nurse expect to be ordered to detect H. pylori in a client with PUD? Select all that apply. A. Serologic testing for antibodies B. Abdominal ultrasound C. Urea breath test D. Computerized tomography scan E. Stool antigen test F. Magnetic resonance imaging

A, C, E

19. When providing discharge teaching, for which symptoms will the nurse teach a client with peptic ulcer disease (PUD) to seek immediate medical attention? Select all that apply. A. Bloody or black stools B. Dyspepsia or reflux C. Bloody vomit or vomit that looks like coffee grounds D. Odynophagia with nausea E. Sharp, sudden, persistent, and severe epigastric or abdominal pain F. Loss of appetite with dysphagia

A, C, E

The nurse is using a bladder scanner on a female client to estimate bladder volume. Which action will the nurse take? (Select all that apply.) Select all that apply. A. Aim the scanner toward the client's coccyx to visualize the bladder. B. Select the female icon since the client has had a hysterectomy. C. Two readings should be completed for best accuracy. D. Gently insert the scanner probe into the vagina. E. Place a gel pad over the client's pubic area.

A, C, E

30. Which drugs will the nurse expect the health care provider to prescribe for a client after esophageal trauma? Select all that apply. A. Broad-spectrum antibiotics B. Loop diuretics C. Corticosteroids D. Antacids E. Pain medications F. Viscous lidocaine

A, C, E, F

9. Which signs and symptoms will the nurse assess when a client is diagnosed with oral cancer? Select all that apply. A. Bleeding from the mouth B. Painful oral lesions that are red, raised, or eroded C. Difficulty chewing or swallowing D. Unplanned weight gain E. Thick or absent saliva F. Thickening or lump in cheek

A, C, E, F

5. Which actions will the nurse assign to the assistive personnel (AP) who will be helping to care for a client with stomatitis? Select all that apply. A. Providing oral care every 2 hours or more if stomatitis is not controlled B. Teaching the client to use a soft toothbrush or gauze, and to avoid commercial mouthwashes and lemon-glycerin swabs which can irritate mucosa C. Encouraging frequent rinsing of the mouth with warm saline, sodium bicarbonate (baking soda) solution, or a combination of these solutions D. Applying topical analgesics or anesthetics as prescribed by the primary health care provider and documenting effectiveness E. Instructing the client on how to select soft, bland, and nonacidic foods F. Removing dentures if the client has severe stomatitis or oral pain

A, C, F

A male patient with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? A. "A change in position may be what is needed for you to have intercourse with your wife." B. "Have you considered going to see a marriage counselor with your wife?" C. "What has your wife said about your pouch system?" D. "You must get clearance from your primary health care provider before you attempt to have intercourse."

A. "A change in position may be what is needed for you to have intercourse with your wife." The nurse tells the patient who had an emergency ileostomy that a simple change in positioning during intercourse may alleviate the patient's apprehension and facilitate sexual relations with his wife.Suggesting marriage counseling may address the patient's concerns, but it focuses on the wrong issue. The patient has not stated that he has relationship problems. Asking the patient what his wife has said about the pouch may address some of the patient's concerns, but it similarly focuses on the wrong issue. Telling the patient that he needs to get clearance from his primary health care provider is an evasive response that does not address the patient's primary concern.

A nurse is teaching a patient with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the patient? A. "Avoid large crowds and anyone who is sick." B. "Do not take the medication if you are allergic to foods with fatty acids." C. "Expect difficulty with wound healing while you are taking this drug." D. "Monitor your blood pressure and report any significant decrease in it."

A. "Avoid large crowds and anyone who is sick." The nurse emphasizes that the patient taking adalimumab for Crohn's disease needs to avoid being around large crowds to prevent developing an infection. Adalimumab (Humira), a biologic response modifier (BRM), also known as a monoclonal antibody drug, has been approved for use in Crohn's disease when other drugs have been ineffective. BRMs are approved for refractory (not responsive to other therapies) cases. These drugs cause immunosuppression and should be used with caution. Patients must be taught to report any signs of a beginning infection, including a cold, and to also avoid others who are sick.The patient would not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the patient would not experience difficulty with wound healing while taking adalimumab. Also, the patient would not experience a decrease in blood pressure from taking this drug.

A patient diagnosed with ulcerative colitis (UC) is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? A. "Be aware of the signs/symptoms of toxic megacolon that we discussed." B. "If diarrhea increases, you must let your primary health care provider know." C. "You must avoid pregnancy." D. "You will need to decrease your dose of sulfasalazine (Azulfidine)."

A. "Be aware of the signs/symptoms of toxic megacolon that we discussed." In teaching a UC patient discharged on loperamide, the nurse tells the patient to be aware of signs/symptoms of toxic megacolon that were discussed. Antidiarrheal drugs may precipitate colonic dilation and toxic megacolon. Toxic megacolon is characterized by an enlarged colon with fever, leukocytosis, and tachycardia.Loperamide will decrease diarrhea rather than increase it. Constipation is sometimes a problem. No contraindication for pregnancy is noted. Sulfasalazine therapy typically continues on a long-term basis.

An older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the best nursing response? A. "Have you tried using the toilet every couple of hours?" B. "How does that make you feel?" C. "We can fix that." D. "That happens when we get older."

A. "Have you tried using the toilet every couple of hours?"

A patient with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The patient asks the nurse how this is helpful for improving signs/symptoms. How does the nurse reply? A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." B. "It provides key nutrients and extra calories to promote healing." C. "It is bland and reduces the secretion of gastric acids." D. "It does not contain caffeine or other GI tract stimulants."

A. "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." Vivonex PLUS is an enteral elemental formula with components that are quickly absorbed in the small bowel that reduces bowel stimulation allowing the affected part of the GI tract to rest and heal. It helps to improve signs/symptoms of ulcerative colitis. For less severe exacerbations, a semielemental product of Vivonex PLUS may induce remission. These products are absorbed in the jejunum and therefore permit the distal small intestine and colon to rest.Nutritional supplements such as Ensure or Sustacal are added to provide nutrients and more calories. GI stimulants such as caffeinated beverages and alcohol need to be avoided, but this is not the reason for using Vivonex PLUS.

A patient with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The patient asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? A. "It is usually ready to be closed in about 1 to 2 months." B. "You need to talk to your primary health care provider about how long you will have this temporary ileostomy." C. "The period of time is indefinite—I am sorry that I cannot say." D. "You will probably have it for 6 months or longer, until things heal."

A. "It is usually ready to be closed in about 1 to 2 months." The nurse tells the patient with a temporary ileostomy that it is usually ready to be closed in about 1 to 2 months. The RPC-IPAA has become the most effective alternate method for ulcerative colitis (UC) patients who have surgery to remove diseased portions of intestines. Stage 1 creates a temporary ileostomy to be used while an internally created pouch is healing. Stage 2 closes the ileostomy, and the patient begins to use the pouch for storage of stool. The time between the surgeries is generally 1 to 2 months.Telling the patient that he or she will have to discuss it with the primary health care provider evades the question. The nurse can give generalities to the patient based on past practice and available data. The time that the patient has the ileostomy is not "indefinite." The intent of this procedure is to eliminate the need to have a permanent ileostomy. The pouch would heal in 1 to 2 months, not 6 months. This estimate is not based on the expected outcome.

The nurse is instructing a patient with recently diagnosed diverticular disease about diet. What food does the nurse suggest the patient include? A. A slice of 5-grain bread B. Chuck steak patty (6 ounces [170 grams]) C. Strawberries (1 cup [160 grams]) D. Tomato (1 medium)

A. A slice of 5-grain bread The nurse suggests to the patient with recently diagnosed diverticular disease to include a slice of 5-grain bread in the diet. Whole-grain breads are recommended to be included in the diet of patients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat would be reduced in patients with diverticular disease.If the patient wants to eat beef, it must be of a leaner cut. Foods containing seeds, such as strawberries, must be avoided. Tomatoes would also be avoided unless the seeds are removed. The seeds may block diverticula in the patient and present problems leading to diverticulitis.

A patient is scheduled for discharge after surgery for inflammatory bowel disease. The patient's spouse will be assisting home health services with the patient's care. What is most important for the home health nurse to assess in the patient and the spouse with regard to the patient's home care? A. Ability of the patient and spouse to perform incision care and dressing changes B. Effective coping mechanisms for the patient and spouse after the surgical experience C. Knowledge about the patient's requested pain medications D. Understanding of the importance of keeping scheduled follow-up appointments

A. Ability of the patient and spouse to perform incision care and dressing changes It is most important for the home health nurse to assess the patient's and spouse's ability to carry out incision care and dressing changes. This assessment is essential to avoid further development of the infectious process, as well as infection of the surgical incision itself.Assessing coping mechanisms and knowledge of the patient's pain medication are important but are not the priority. Understanding the importance of scheduled follow-up appointments is important but is also not the priority.

The nurse is teaching a patient who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the patient to report to the primary health care provider? A. Anorexia B. Depression C. Drowsiness D. Frequent Urination E. Headache F. Vomiting

A. Anorexia E. Headache F. Vomiting Anorexia, headache, and nausea/vomiting are side effects of sulfasalazine that must be reported to the primary health care provider.Depression, drowsiness, and urinary problems are not side effects of sulfasalazine.

Which priority teaching will the nurse provide to prevent harm for a client after a renal biopsy? A. Avoid lifting heavy objects for 1 - 2 weeks after the procedure B. Do not go up or down stairs for 10 days C. Avoid light housework including cooking and washing dishes D. Stay out of the sun until after your follow-up appointment

A. Avoid lifting heavy objects for 1 - 2 weeks after the procedure

The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? A. Client with polycystic kidney disease who is having a kidney ultrasound. B. Client with glomerulonephritis who is having a kidney biopsy. C. Client who is going for a cystoscopy and cystourethroscopy. D. Client who has just returned from having a kidney artery angioplasty.

A. Client with polycystic kidney disease who is having a kidney ultrasound.

Which laboratory test will the nurse assess as the best indicator of kidney function? A. Creatinine B. Blood urea nitrogen (BUN) C. Aspartate aminotransferase (AST) D. Alkaline phosphatase

A. Creatinine

A patient with a history of osteoarthritis has a 10-inch (25.5 cm) incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the patient's care does the nurse make certain to discuss with the primary health care provider before the patient's discharge? A. Having a home health consultation for wound care B. Requesting an antianxiety medication C. Requesting pain medication for the patient's osteoarthritis D. Placing the patient in a skilled nursing facility for rehabilitation

A. Having a home health consultation for wound care The nurse makes sure to discuss an order for a home health consultation for wound care with the primary health care provider. Home health services are most appropriate for this patient because wound care will be extensive and the patient's mobility may be limited.No indication suggests that the patient is experiencing anxiety regarding postoperative care. Pain medication may be needed for the patient's osteoarthritis, but this is not the highest priority. A skilled nursing facility is not necessary if the patient can remain in his or her home with sufficient support services.

When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? A. History of hysterectomy B. Abdominal girth C. Hematuria D. Presence of urinary infection

A. History of hysterectomy

Which client assessment data indicates to the nurse that the client has a potential need for fluids? A. Increased blood urea nitrogen B. Increased creatinine C. Decreased sodium D. Pale-colored urine

A. Increased blood urea nitrogen

The nurse is caring for a client with uremia. What assessment data will the nurse anticipate? A. Nausea and vomiting B. Insomnia C. Cyanosis of the skin D. Tenderness at the costovertebral angle (CVA)

A. Nausea and vomiting

A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the health care provider (HCP) visited the client the day before. What action will the nurse take? A. Notifies the department and the HCP. B. Asks the client's spouse to sign the form. C. Cancels the procedure. D. Asks the client to sign the informed consent.

A. Notifies the department and the HCP.

What is the most common symptom that prompts clients to seek medical attention for problems with the kidneys or urinary tract? A. Pain in flank or abdomen, or pain when urinating B. Change in the frequency or amount of urination C. Exposure to one or more nephrotoxic substances D. Change in color, clarity, or odor of the urine

A. Pain in flank or abdomen, or pain when urinating

Which assessment finding would require the nurse to take immediate action in a client who is 1 hour post kidney biopsy? Select all that apply. A. Pink-tinged urine B. Nausea and vomiting C. Increased bowel sounds D. Reports of flank pain E. The patient is ambulating to the bathroom

A. Pink-tinged urine

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| medications| adverse effects MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. "Have you been experiencing any constipation?" b. "Are you eating a diet high in fiber and fluids?" c. "Do you have a history of high blood pressure?" d. "What vitamins and supplements are you taking?"

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron. DIF: Applying/Application REF: 1146 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapi

After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss. DIF: Applying/Application REF: 1147 KEY: Herniation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity. DIF: Applying/Application REF: 1156 KEY: Ostomy care| support| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used. DIF: Applying/Application REF: 1154 KEY: Ostomy care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time. DIF: Applying/Application REF: 1151 KEY: Ostomy care MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.

15. The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? a. "Hepatitis C is not spread through casual contact." b. "If you wear a gown and gloves, you will not get this virus." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brother's status from here."

ANS: A Although family members may be afraid that they will contract hepatitis C, the nurse would educate them about how the virus is spread. Hepatitis C is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needlesticks, unsanitary tattoo equipment, and sharing of intranasal drug paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."

ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change

10. After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I should drink at least 3 L of fluid every day." b. "I will eliminate all dairy or sources of calcium from my diet." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor can give me antibiotics at the first sign of a stone."

ANS: A Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated, the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse would encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

10. The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History of hepatitis B b. History of kidney disease c. History of cardiac disease d. History of rectal bleeding

ANS: A Elbasvir can cause liver toxicity and therefore the nurse would assess for a history of or current hepatitis B

5. After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I will limit my total intake of fluids." b. "I must avoid drinking alcoholic beverages." c. "I must avoid drinking caffeinated beverages." d. "I shall try to lose about 10% of my body weight."

ANS: A Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence or cystitis. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

13. A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question would the nurse ask when determining this client's risk factors? a. "Do you smoke cigarettes?" b. "Do you use any alcohol?" c. "Do you use recreational drugs?" d. "Do you take any prescription drugs?"

ANS: A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to markedly increase the risk of developing bladder cancer.

14. A nurse teaches a young female client who is prescribed cephalexin for a urinary tract infection. Which statement would the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication."

ANS: A The client should use a second form of birth control because antibiotic therapy reduces the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the drug.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I'll avoid ibuprofen for several days before the test." d. "I'll buy a case of clear Gatorade before the prep."

ANS: A The client would be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show an understanding of the preparation for the procedure.

6. The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take antidiarrheal medication to prevent loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory as soon as possible."

ANS: A The purpose of administering lactulose to this patient is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The patient must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse would not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

18. A nurse assesses a client who presents with renal calculi. Which question would the nurse ask? a. "Do any of your family members have this problem?" b. "Do you drink any cranberry juice?" c. "Do you urinate after sexual intercourse?" d. "Do you experience burning with urination?"

ANS: A There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a patient with a urinary tract infection.

3. The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 22 to 16 breaths/min d. A decrease in the client's weight by 3 lb (1.4 kg

ANS: A decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. To prevent hypovolemic shock, no more than 2000 mL are usually removed from the abdomen at one time. The patient's weight typically only decreases by less than 2 kg or 4.4 lb.

10. A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? a. Drainage from a fistula b. Diminished bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage

ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

7. A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How would the nurse respond? a. "I don't know. I wish I had an answer for you, but I don't." b. "It's important to keep a positive attitude for your family right now." c. "Scientists have not determined why cancer develops in certain people." d. "I think that this is a trial so you can become a better person because of it."

ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse would validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may negatively impact the client-nurse relationship.

25. A nurse teaches a client about self-management after experiencing a urinary calculus treated by lithotripsy. Which statements would the nurse include in this client's discharge teaching? (Select all that apply.) a. "Finish the prescribed antibiotic even if you are feeling better." b. "Drink at least 3 L of fluid each day." c. "The bruising on your back may take several weeks to resolve." d. "Report any blood present in your urine." e. "It is normal to experience pain and difficulty urinating."

ANS: A, B, C The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 L of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the primary health care provider as these may signal the beginning of an infection or the formation of another stone.

19. The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine

ANS: A, B, C, D, E, F All of these assessment findings are very common for a client who has late-stage cirrhosis due to biliary obstruction and poor liver function. The client has vascular lesions and excess fluid from portal hypertension.

21. 6. The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply.) a. "How old are you?" b. "Do you work in health care? c. "Are you receiving hemodialysis?" d. "Do you use IV drugs?" e. "Did you receive blood before 1992?" f. "Have you even been in prison or jail?"

ANS: A, B, C, D, E, F The nurse would ask all of these questions because "baby boomers," people who use illicit drugs, people on hemodialysis, health workers, and prisoners are at a very high risk for hepatitis C. Additionally, individuals who received blood, blood products, or an organ transplant prior to 1992 before bloodborne disease screening of these products was mandated are at risk for hepatitis C

13. The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase c. Elevated glucose d. Decreased calcium e. Elevated bilirubin f. Elevated leukocyte count

ANS: A, B, C, D, E, F All of these choices are correct. Amylase and lipase are pancreatic enzymes that are released during pancreatic inflammation and injury. Leukocytes also increased due to his inflammatory response. Pancreatic injury affects the ability of insulin to be released causing increased glucose levels. Bilirubin is also typically increased due to hepatobiliary obstruction. Calcium and magnesium levels decrease because fatty acids bind free calcium and magnesium causing a lowered serum level; these changes occur in the presence of fat necrosis.

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis

ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.

18. The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that apply.) a. "Avoid alcohol ingestion." b. "Be sure and balance rest with activity." c. "Avoid caffeinated beverages." d. "Avoid green, leafy vegetables." e. "Eat small meals and high-calorie snacks."

ANS: A, B, C, E Clients who have chronic pancreatitis need to avoid GI stimulants, including alcohol, caffeine, and nicotine. Food and snacks need to be high-calorie to prevent additional weight loss. Green vegetables can be consumed if tolerated by the client.

21. The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria

ANS: A, B, C, F Fever and chills may occur in clients who have a UTI if the infection has expanded beyond the bladder into the kidneys. However, these symptoms are not urinary signs and symptoms.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care. DIF: Applying/Application REF: 1148 KEY: Herniation| postoperative care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing. DIF: Remembering/Knowledge REF: 1166 KEY: Bowel care MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

24. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their description? (Select all that apply.) a. Stress incontinence—urine loss with physical exertion b. Urge incontinence—loss of urine upon feeling the need to void c. Functional incontinence—urine loss results from abnormal detrusor contractions d. Overflow incontinence—constant dribbling of urine e. Reflex incontinence—leakage of urine without lower urinary tract disorder

ANS: A, B, D Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

16. The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection b. GI bleeding c. Irritable bowel syndrome d. Constipation e. Anemia f. Hypovolemia

ANS: A, B, D, F Anemia and irritable bowel syndrome are unrelated to developing or worsening encephalopathy, which is caused by increased protein which breaks down into ammonia. Infection can cause hypovolemia which would increase serum protein concentration. Constipation and GI bleeding causes a large protein load in the intestines.

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should 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 and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the client's pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.) a. Obtain vital signs every 15 to 30 minutes until alert. b. Assess the client for rectal bleeding and severe pain. c. Administer prescribed pain medications as needed. d. Monitor the client's serum and urine glucose levels. e. Confirm the client has a ride home and plans to rest.

ANS: A, B, E During the recovery phase after a colonoscopy, the nurse would obtain vital signs every 15 to 30 minutes until the client is alert, assess for rectal bleeding or severe pain, and confirm the client has arranged for another person to drive home to get rest. Pain medications are not necessary after the procedure, and neither is glucose monitoring.

18. The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) a. "Apply lotion to the client's dry skin areas." b. "Use a basin with warm water to bathe the patient." c. "For the patient's oral care, use a soft toothbrush." d. "Provide clippers so the patient can trim the fingernails." e. "Bathe with antibacterial and water-based soaps."

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush would be used to prevent gum bleeding, and the client's nails would need to be trimmed short to prevent the patient from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

23. A client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply.) a. Diuretic therapy b. Anorexia nervosa c. Stroke d. Dementia e. Arthritis f. Parkinson disease

ANS: A, C, D, E, F Drugs, such as diuretics, cause frequent voiding, often in large amounts. Diseases or disorders that limit mobility, such as stroke, arthritis, and Parkinson disease, can prevent an individual from getting to the bathroom in a timely manner. Mental/behavioral problems, such as dementia, impair cognition and the ability to recognize when he or she needs to void.

16. The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) a. Ascites b. Weight gain c. Steatorrhea d. Jaundice e. Polydipsia f. Polyuria

ANS: A, C, D, E, F The client who has chronic pancreatitis has all of these signs and symptoms except he or she loses weight. Ascites and jaundice result from biliary obstruction; ascites is associated with portal hypertension. Steatorrhea is fatty stool that occurs because lipase is not available in the duodenum; because it is released by the disease pancreas into the bloodstream. Polydipsia, polyuria, and polyphagia result from diabetes mellitus, a common problem seen in clients whose pancreas is unable to release adequate amounts of insulin.

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

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowler's position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the client's nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The client's head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the client's gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate. DIF: Applying/Application REF: 1159 KEY: Intestinal obstruction MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Endoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 5 years

ANS: A, C, E The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years

The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian nutritionist b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Primary health care provider

ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse would collaborate with the registered dietitian nutritionist, clinical pharmacist, and primary health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

22. The nurse is planning health teaching for a client starting mirabegron for urinary incontinence. What health teaching would the nurse include? (Select all that apply.) a. "Monitor blood tests carefully if you are prescribed warfarin." b. "Avoid crowds and individuals with infection." c. "Report any fever to your primary health care provider." d. "Take your blood pressure frequently at home." e. "Report palpitations or chest soreness that may occur."

ANS: A, D This drug can cause increase blood pressure and, therefore, the client's blood pressure should be monitored. Mirabegron can increase the effect of warfarin causing bleeding or bruising. The client will need additional coagulation studies to ensure that the INR is within a therapeutic range

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction. DIF: Applying/Application REF: 1159 KEY: Drain MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

26. After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.

ANS: A, E Woman can reduce their risk of contracting UTIs by voiding before and after intercourse, not douching or using scented feminine products, and wiping from front to back. If spermicides are currently used, the woman should consider another form of birth control. Loose-fitting cotton underwear is best.

17. 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."

ANS: A, E Client teaching related to self-management of enzyme replacement therapy would include taking the enzymes with meals and snacks but not mixing enzyme preparations with protein-containing foods. Clients would not crush enteric-coated preparations and should swallow tablets without chewing to minimize oral irritation and allow the drug to be released slowly. Wiping lips after taking enzymes also minimizes skin irritation.

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The client's vital signs may be checked after the nurse determines the client's last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy. DIF: Applying/Application REF: 1165 KEY: Postoperative nursing| urinary retention MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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, glass of diet cola 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

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants. DIF: Applying/Application REF: 1145 KEY: Irritable bowel| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How should the nurse respond? a. "This drug is still in the research phase and is not available for public use yet." b. "Unfortunately, lubiprostone is approved only for use in women." c. "Lubiprostone works well. I will recommend this prescription to your provider." d. "This drug should not be used with bulk-forming laxatives."

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men. DIF: Applying/Application REF: 1146 KEY: Irritable bowel| medications MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation. DIF: Applying/Application REF: 1165 KEY: Postoperative care| syncope MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding? a. "Use warm compresses on the client's abdomen continuously." b. "Avoid washing the client's abdomen too aggressively." c. "Apply ice to the client's abdomen every 4 hours." d. "Massage the client's abdomen to help reduce pain."

ANS: B A bruit heard over the abdominal aorta possible indicates stenosis or an aneurysm which should not be palpated or percussed. Therefore, the AP should wash the client's abdomen very gently.

5. The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

ANS: B A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the patient's dietary protein will cause complications of liver failure and would not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein

2. The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful

2. A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial cystitis). The laboratory report notes a "shift to the left" in the client's white blood cell count. What action would the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the primary health care provider and start an intravenous line for parenteral antibiotics. c. Ask assistive personnel (AP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

ANS: B An increase in band cells creates a "shift to the left." A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she would notify the primary health care provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells

11. A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

ANS: B Fever, right abdominal quadrant pain, and jaundice are signs of possible liver transplant rejection; the client would be admitted to the hospital as soon as possible for intervention. Antirejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse would not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

7. After delegating care to assistive personnel (AP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the AP's understanding. Which action indicates that the AP needs additional teaching? a. Toileting the client after breakfast b. Changing the client's incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the client's incontinence episodes

ANS: B Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should reeducate the AP on the technique of habit training. The AP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach

ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.

16. The nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question would the nurse ask first? a. "Are you drinking plenty of water?" b. "What medications are you taking?" c. "Have you tried laxatives or enemas?" d. "Has this type of thing ever happened before?"

ANS: B Some types of incontinence or other health problems are treated with anticholinergic medications. Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the he or she is taking an anticholinergic medication. The other questions are not as helpful to understanding the current situation.

7. After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

ANS: B The route of transmission for hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

12. A nurse assesses a client who is recovering from extracorporeal shock-wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. What action would the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

ANS: B The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the client's position will not decrease bleeding.

11. The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? a. Clamp the nasogastric tube. b. Place the patient in semi-Fowler position. c. Assess vital signs once every shift. d. Provide oral rehydration.

ANS: B Postoperative care for a patient recovering from an open Whipple procedure would include placing the client in a semi-Fowler position to reduce tension on the suture line and anastomosis sites and promote breathing, setting the nasogastric tube to low continuous suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids

4. 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

ANS: B The client who has acute pancreatitis reports severe boring abdominal pain that is often rated by clients as a 10+ on a 0-10 pain scale. Nausea, vomiting, and fever may also occur, but that is not the client's priority for care.

After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I must avoid dairy products to reduce gas and odor in the pouch."

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the client's skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the client's skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products. DIF: Applying/Application REF: 1154 KEY: Colorectal cancer| postoperative care MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

22. The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis

ANS: B, C, D The client who has hepatitis C has complications that do not relate to the liver, including polyarthritis, myalgia, heart disease and vasculitis, renal disease, and cognitive impairment

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach

ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others. DIF: Applying/Application REF: 1157 KEY: Colorectal cancer| ostomy care| coping| support MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client. DIF: Applying/Application REF: 1151 KEY: Colorectal cancer| intestinal obstruction MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come to the clinic this afternoon.

ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse would remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.

9. A client with pneumonia and dementia is admitted with an indwelling urinary catheter in place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "May we discontinue the indwelling catheter?" d. "Should we get another chest x-ray today?"

ANS: C An indwelling urinary catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse would inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

12. After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."

ANS: C Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client

14. The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

ANS: C Clients who have cirrhosis due to addiction may have alienated relatives over the years because of substance abuse. The nurse would assist the client to identify a friend, neighbor, clergy/spiritual leader, or group for support. The nurse would not minimize the patient's concerns. Attending AA may be appropriate, but this response doesn't address the client's concern. "Making peace" with the client's family may not be possible. This statement is not client-centered

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate? a. Administer naloxone. b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

ANS: C For an EGD, clients are given mild sedation but would still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's most appropriate action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam HCl. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

4. After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "I will have my partners tested for STIs." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily."

ANS: C Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think that they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. There are no dietary restrictions or needs while taking this medication.

4. The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French

ANS: C The Patatin-like phospholipase domain containing 3 gene (PNPLA3) has been identified as a risk gene for cirrhosis, which occurs most often in Latinos when compared to other populations

1. The nurse assesses a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? a. Urinary retention b. Urinary incontinence c. Painless hematuria d. Difficulty urinating

ANS: C The classic and most common finding in clients who have bladder cancer is painless and intermittent hematuria that can be with gross or microscopic. Dysuria, frequency, and urgency occur in clients who have bladder infection or obstruction.

17. A nurse teaches a client who is starting urinary bladder training. Which statement would the nurse include in this client's teaching? a. "Use the toilet when you first feel the urge, rather than at specific intervals." b. "Initially try to use the toilet at least every half hour for the first 24 hours." c. "Try to consciously hold your urine until the scheduled toileting time." d. "The toileting interval can be increased once you have been continent for a week."

ANS: C The client should try to hold urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The interval can be increased once the client becomes comfortable with the interval

19. The nurse is caring for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How would the nurse respond? a. "I understand how you feel. I would be mortified." b. "Incontinence pads will minimize leaks in public." c. "I can teach you strategies to help control your incontinence." d. "More people experience incontinence than you might think."

ANS: C The nurse would accept and acknowledge the client's concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse would not diminish the client's concerns with the use of pads or stating statistics about the occurrence of incontinence.

9. 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

ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen in clients with either chronic or acute cholecystitis.

6. 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

ANS: C The client is exhibiting signs of hypovolemia most likely due to internal bleeding or hemorrhage. Due to decreased blood volume, the blood pressure is low and the heart rate increases to compensate for hypovolemia to ensure organ perfusion. Respirations often increase to increase oxygen in the blood.

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac. DIF: Applying/Application REF: 1146 KEY: Herniation MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression. DIF: Applying/Application REF: 1157 KEY: Intestinal obstruction| pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful. DIF: Applying/Application REF: 1162 KEY: GI trauma| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer. DIF: Applying/Application REF: 1149 KEY: Colorectal cancer| health screening MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet, preemptive chemotherapy, and removal of polyps will decrease the client's risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet. DIF: Applying/Application REF: 1155 KEY: Colorectal cancer| genetics MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

8. The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment

ANS: D A postprocedure complication of a TIPS procedure is right-sided heart failure. Therefore, the nurse would perform a cardiovascular assessment before the procedure to determine if the client has signs and symptoms of heart failure.

13. The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? a. Have the client sign the informed consent form. b. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. d. Assist the client to void before the procedure.

ANS: D For safety, the patient would void just before a paracentesis to prevent bladder damage to the procedure. The primary health care provider would have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table.

15. A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? a. "You must clean around your catheter daily with soap and water." b. "You will need to be on your drug therapy for life." c. "Operations to repair your bladder are available, and you can consider these." d. "You might want to get pants with elastic waistbands."

ANS: D Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble ambulating or difficulty accessing the toilet. One desired outcome is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down and back up can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

1. The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C

ANS: D Hepatitis C is the leading cause of cirrhosis and an also cause liver cancer. Clients with nonalcoholic fatty liver disease often have metabolic syndrome and can also develop cirrhosis

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any type of palpation. c. Lightly palpate the RUQ first. d. Lightly palpate the RUQ last.

ANS: D If pain is present in a certain area of the abdomen, that area would be palpated last to keep the client from tensing which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.

8. A nurse plans care for a client with overflow incontinence. Which intervention does the nurse include in this client's plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

ANS: D In patients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

9. The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."

ANS: D Lamivudine can cause renal impairment and the nurse would remind the client of changes that may indicate kidney damage.

11. A nurse cares for a client who has kidney stones from gout ricemia. Which medication does the nurse anticipate administering? a. Phenazopyridine b. Doxycyline c. Tolterodine d. Allopurinol

ANS: D Stones caused by hyperuricmia caused by gout or other reason respond to allopurinol. Phenazopyridine is given to clients with urinary tract infections. Doxycycline is an antibiotic. Tolterodine is an anticholinergic with smooth muscle-relaxant properties.

The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have? a. Steatorrhea b. Ulcerative colitis c. Crohn disease d. Lactose intolerance

ANS: D The client is demonstrating signs and symptoms of lactose intolerance because they occur after the client eats or drinks dairy products which contain lactose

6. The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? a. What type of incontinence pads to use? b. What types of liquids to drink and when? c. Need to perform intermittent catheterizations. d. How to do Kegel exercises to strengthen muscles?

ANS: D The client who has stress incontinence needs to strengthen the muscles of the pelvic floor using Kegel exercises. Catheterizations would not help with incontinence. Incontinence pads may need to be used by this client but that is not the most important thing to teach, and it does not help the client regain more control over his or her bladder.

1. A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test? a. "You'll have to drink a contrast medium right before the test." b. "You'll need to do a bowel prep the nursing before the test." c. "You'll be able to drink liquids up until the test begins." d. "You'll have a large camera close to you during the test."

ANS: D Clients having a HIDA scan are NPO and receive an injectable nuclear medicine contrast. No bowel preparation is required. A large camera is close to the client for most of the test which can be a problem for clients who are claustrophobic.

3. 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

ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

11. Which action is the priority for the nurse to take when caring for clients with oral cancers? A. Providing pain control B. Maintaining the airway C. Promoting tissue integrity D. Enhancing nutrition

12. Which complication does the nurse suspect when a client with PUD suddenly develops sharp epigastric pain that spreads over the entire abdomen? A. Gastric erosion B. Perforation C. Hemorrhage D. Gastric cancer

15. Which drugs will the nurse expect to administer to a client with PUD, caused by an H. pylori infection, who is prescribed PPI-triple therapy? A. A proton pump inhibitor, two antibiotics, and bismuth B. A proton pump inhibitor and two antibiotics C. An opioid drug, proton pump inhibitor, and an antibiotic D. An H2 histamine blocker, an antibiotic, and a proton pump inhibitor

20. Which food will the nurse recommend a client avoid when he or she reports fear of stomach cancer? A. Foods that cause reflux B. Pickled or processed foods C. Large, heavy meals D. Spicy foods that cause gas

21. How does the nurse expect a client's nasogastric (NG) tube drainage to appear immediately after Nissen fundoplication surgery? A. Bright red mixed with brown B. Dark brown C. Yellowish to green D. Green to clear

22. For which client with gastric cancer does the nurse expect that minimal invasive surgery (MIS) plus radiation therapy or chemotherapy may be curative? A. 45-year-old with advanced disease B. 50-year-old with early disease C. 60-year-old with liver metastases D. 65-year-old with invasion of the stomach muscle

23. What complication does the nurse suspect when a client who had a gastrectomy develops tachycardia, syncope, and a desire to lie down 30 minutes after eating? A. Fluid overload B. Early dumping syndrome C. Late dumping syndrome D. Vitamin B12 deficiency

27. Which nonsurgical treatment will the nurse expect the client with esophageal cancer to receive for immediate relief of dysphagia? A. Photodynamic therapy B. Esophageal dilation C. Radiation therapy D. Swallowing therapy

3. Which condition or symptom does the nurse associate with a client who has chronic gastritis? A. Hematemesis B. Pernicious anemia C. Dyspepsia D. Epigastric burning

4. Which oral disorder does the nurse suspect when assessment findings reveal white plaquelike lesions that when wiped away show an underlying red and sore surface? A Leukoplakia B. Candidiasis C. Erythroplakia D. Kaposi's sarcoma

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? a. "The anti-rejection drugs you are taking make you susceptible to infection." b. "You should go to the hospital immediately to get checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen every 4 hours until you feel better soon."

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "Some medications have been known to cause hepatitis A." b. "I may have been exposed when we ate shrimp last weekend." c. "I was infected with hepatitis A through a recent blood transfusion." d. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

How will the nurse interpret a client's laboratory finding of the presence of immunoglobulin G antibodies directed against hepatitis A (HAV)? A. Active, infectious HAV is present. B. Permanent immunity to HAV is present. C. This is the client's first infection to HAV. D. The risk for infection if exposed to HAV is high.

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the patient daily.

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? a. "A low-protein diet will help the liver rest and will restore liver function." b. "Less protein in the diet will help prevent confusion associated with liver failure." c. "Increasing dietary protein will help the patient gain weight and muscle mass." d. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

Which client's previous health history will the nurse most associate with a risk for developing postnecrotic cirrhosis of the liver? A. 28-year-old woman who had gallstones 1 year ago and has recently lost 20 lb (9 kg) on a low-calorie, low-fat diet B. 45-year-old man with hepatitis C infection and chronic use of acetaminophen C. 50-year-old man who has many years of excessive alcohol consumption D. 55-year-old woman who has chronic biliary obstruction

Which serum electrolyte value in a client with early-stage ascites from chronic liver disease who is taking spironolactone will the nurse report immediately to the primary health care provider? A. Sodium 133 mEq/L (mmol/L) B. Potassium 6.4 mEq/L (mmol/L) C. Chloride 101 mEq/L (mmol/L) D. Calcium 8.9 mg/dL (2.2 mmol/L)

Which activities are most important for the nurse to teach a client with esophageal varices to prevent harm from bleeding or hemorrhage? Select all that apply. A. Avoid alcoholic beverages. B. Eat soft foods and cool liquids. C. Do not engage in strenuous exercise or heavy lifting. D. Try to eat six smaller meals daily instead of three larger ones. E. Be sure to keep your mouth open when sneezing or coughing. F. Cross your legs only at the ankles when sitting, rather than the knees.

B C

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis b. Polyarthritis c. Heart disease d. Myalgia e. Peptic ulcer disease f. Ulcerative colitis

B C D

Which common factors will the nurse recognize as contributing to or worsening of hepatic encephalopathy in clients with liver cirrhosis? Select all that apply. A. Anorexia B. Infection C. Opioids D. Diarrhea E. GI bleeding F. High-protein diet G. Diabetes mellitus H. Chronic confusion

B C E F

A nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

B E F

8. Which types of ulcers does the nurse teach a client about when discussing peptic ulcer disease (PUD)? Select all that apply. A. Pressure ulcers B. Gastric ulcers C. Duodenal ulcers D. Stress ulcers E. Esophageal ulcers F. Colon ulcers

B, C, D

The nurse is admitting a client undergoing a CT scan with contrast. Which finding does the nurse report as a possible immediate hypersensitivity reaction? Select all that apply. A. Nausea B. Pruritis C. Urticaria D. Laryngeal stridor E. Flushing of the skin

B, C, D, E

2. Which important information will the nurse include when teaching clients how to maintain healthy oral cavities? Select all that apply. A. Perform a monthly self-examination of the mouth looking for changes. B. Eat a well-balanced diet and stay hydrated by drinking water. C. If you wear dentures, make sure that they are in good repair and fit properly. D. Thoroughly brush and floss your teeth (or brush dentures) consistently twice daily. E. Use mouthwashes that contain alcohol to destroy organisms that live in the mouth. F. See the dentist regularly and have dental problems repaired as soon as possible.

B, C, D, F

1. Which adverse drug effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? (Select all that apply.) A. Insomnia B. Blurred vision C. Constipation D. Dry mouth E. Loss of sphincter control F. Increased sweating G. Worsening mental function

B, C, D, G

The nurse is teaching a class about kidney and urinary changes that occur with age. What teaching will the nurse include? (Select all that apply.) Select all that apply. A. Drug clearance is often increased which produces more drug reactions. B. Glomerular filtration rate decreases which increases the risk for fluid overload. C. Urinary sphincters lose tone and weaken with age. D. Blood flow to the kidneys increases promoting nocturia. E. The ability to concentrate urine decreases which creates urgency.

B, C, E

18. For which reasons will the nurse insert a large-bore nasogastric tube (NGT) in a client with active upper GI bleeding or possible obstruction? Select all that apply. A. To provide nutritional supplements B. To determine the presence or absence of blood in the stomach C. To assess the rate of bleeding D. To administer medications E. To prevent gastric dilation F. To administer gastric lavage

B, C, E, F

A client is on a 24-hour urine collection. At midpoint during the collection, the client tells the nurse that some of the urine was discarded. What action will the nurse take? Select all that apply. A. No action is required. B. Reinforce client education. C. Notify the laboratory staff. D. Restart the urine collection. E. Document the discarded urine. F. Notify the health care provider.

B, C, E, F

18. Which signs and symptoms will the nurse expect to assess when a client is diagnosed with a paraesophageal hernia? Select all that apply. A. Regurgitation B. Feeling of fullness (after eating) C. Dyspepsia D. Breathlessness (after eating) E. Dysphagia F. Chest pain that mimics angina

B, D, F

21. Which signs and symptoms does the nurse expect to assess when a client has early gastric cancer? Select all that apply. A. Nausea and vomiting B. Feeling of fullness C. Weakness and fatigue D. Epigastric, back, or retrosternal pain E. Palpable gastric mass F. Abdominal discomfort initially relieved with antacids

B, D, F

Which lab finding is indicative of renal function alterations and not dehydration? Select all that apply. A. BUN 20 mL/dL B. Creatinine 2.3 mL/dL C. Hemoglobin 14 g/dL D. Cystatin-c 105 mg/mL E. BUN/creatinine ratio 10 F. Creatinine clearance 175 mL/min

B, D, F

A Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a patient about caring for a new ileostomy. What information is most important to include? A. "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." B. "Call your primary health care provider if your stoma has a bluish or pale look." C. "Notify the primary health care provider if output from your stoma has a sweetish odor." D. "Remember that you must wear a pouch system at all times."

B. "Call your primary health care provider if your stoma has a bluish or pale look." It is most important for the Certified Wound, Ostomy, and Continence nurse to tell the patient with a new ileostomy to call the primary health care provider if the stoma has a bluish or pale look. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary health care provider must be notified immediately.It is true that output from the stoma after surgery may be a loose, greenish-colored liquid that may contain some blood, but this information is not the highest priority for instruction. It is normal for output from the stoma to have very little odor or a sweetish smell. Although it is true that the patient will be required to wear a pouch system at all times, this is not the highest priority for instruction.

A nurse is teaching a patient about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advice the patient? A. "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." C. "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." D. "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

B. "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." The nurse teaches the patient that the most effective way to manage diverticulitis is to consume a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided.Neither an exclusively low-fiber diet nor an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms.

A patient who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the patient to do in the meantime? A. "Avoid all solid foods to allow complete bowel rest." B. "Consume extra fluids to replace fluid losses." C. "Take an over-the-counter antidiarrheal medication." D. "Contact your primary health care provider for an antibiotic medication."

B. "Consume extra fluids to replace fluid losses." The nurse tells the patient to drink extra fluids to replace fluid lost through vomiting and diarrhea.It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial.

The nurse is teaching a client who needs a clean-catch urine specimen. What teaching will the nurse include? A. "Save all urine for 24 hours." B. "Do not touch the inside of the container." C. "Use the sponges to cleanse the urethra, and then initiate voiding directly into the cup." D. "You will receive an isotope injection, then I will collect your urine."

B. "Do not touch the inside of the container."

A patient is admitted with severe viral gastroenteritis caused by norovirus. The patient asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? A. "You may have contracted it from an infected infant." B. "You may have consumed contaminated food or water." C. "You may have come into contact with an infected animal." D. "You may have had contact with the blood of an infected person."

B. "You may have consumed contaminated food or water." When a patient with severe viral gastroenteritis caused by norovirus asks, "How did I get this disease?", the nurse answers, "You may have consumed contaminated food or water." Norovirus is the leading foodborne disease that causes gastroenteritis. It is transmitted via the fecal-oral route from person to person and from contaminated food and water. Vomiting causes the virus to become airborne.Campylobacter, not novovirus, can be transmitted by contact with infected infants or animals. Escherichia coli, not novovirus, may be spread via animals and contaminated food, water, or fomites. HIV, not novovirus, may be spread via the blood. Campylobacter and E. coli both cause bacterial gastroenteritis, while norovirus causes viral gastroenteritis.

The RN receives a change-of-shift report about four patients. Which patient does the nurse assess first? A. A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C) C. A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it D. A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

B. A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C) After a change-of-shift report the RN first assess a 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102°F (37.9°C). This patient with possible appendicitis may have developed a perforation and may be at risk for peritonitis. Rapid assessment and possible surgical intervention are needed.The patient with UC who had six liquid stools, the patient whose colostomy bag does not have any stool in it, and the patient who was admitted with acute gastroenteritis all need assessment and intervention by an RN, but they are not at immediate risk for life-threatening complications.

Which patient does the charge nurse assign to an experienced LPN/LVN? A. A 28-year-old who requires teaching about how to catheterize a Kock ileostomy B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy C. A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 (23 × 109/L) D. A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

B. A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy The charge nurse assigns to an experienced LPN/LVN a 30-year-old who needs to receive neomycin sulfate before a colectomy. The LPN/LVN would be familiar with the purpose, adverse effects, and patient teaching required for neomycin.Teaching about how to catheterize a Kock ileostomy, assessing the patient with UC with a high white blood cell count, and monitoring the patient with gastroenteritis receiving IV fluids present complex problems that require assessment or intervention by an RN.

A patient has vague symptoms that indicate an acute inflammatory bowel disorder. Which signs/symptoms are most indicative of Crohn's disease (CD)? A. Abdominal pain relieved by bending the knees, constipation B. Chronic diarrhea, abdominal colicky pain, and fever C. Epigastric cramping & persistent rectal bleeding D. Hypotension with vomiting and headache

B. Chronic diarrhea, abdominal colicky pain, and fever Signs/symptoms that are most indicative of Crohn's disease (CD) are: chronic diarrhea, abdominal colicky pain, and fever. These signs/symptoms are more specific to CD than any of the other acute inflammatory bowel disorders.Abdominal pain that is relieved by bending the knees is indicative of peritonitis or pancreatitis. Epigastric cramping is a sign/symptom more indicative of appendicitis. Hypotension with vomiting is not characteristic of CD.

Which action will the nurse include in postprocedural care for the client who has a renal scan? A. Administer captopril to increase renal blood flow B. Encourage oral fluids to assist with excretion of the isotope C. Insert a urinary catheter to measure urine output D. Administer prescribed laxatives to cleanse the bowel

B. Encourage oral fluids to assist with excretion of the isotope

A patient with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? A. Asks the patient whether family members could be trained in stoma care B. Has another patient with a stoma who performs self-care talk with the patient C. Requests that the primary health care provider request antidepressants and a psychiatric consult D. Suggests that the primary health care provider request a home health consultation so stoma care can be performed by a home health nurse

B. Has another patient with a stoma who performs self-care talk with the patient When a patient with a recently created ileostomy refuses to look at the stoma and wants the nurse to perform all required stoma care, the nurse has another patient with a stoma who performs self-care talk with the patient.If at all possible, the patient would perform stoma care so that he or she can be as independent as possible. Although the patient may need medication for depression, the priority is to encourage the patient to look at, touch, and begin caring for the stoma. A home health nurse can be a support but cannot provide all of the care that the patient will need.

A patient has developed gastroenteritis while traveling outside the country. What is the likely cause of the patient's symptoms? A. Bacteria on the patient's hands B. Ingestion of parasites in the water C. Insufficient vaccinations D. Overcooked foods

B. Ingestion of parasites in the water The likely cause of gastroenteritis when a patient travels outside the country is ingestion of water that is infested with parasites.Bacteria on the patient's hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis.

A patient admitted with severe gastroenteritis has been started on an IV, but the patient continues having excessive diarrhea. Which medication does the nurse expect the primary health care provider to prescribe? A. Balsalazide (Colazal) B. Loperamide (Imodium) C. Mesalamine (Asacol) D. Milk of Magnesia (MOM)

B. Loperamide (Imodium) The nurse expects the primary health care provider to prescribe loperamide for a patient with severe gastroenteritis who still has excessive diarrhea. If the primary health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily.Balsalazide is not the best choice for control of diarrhea in this scenario. Mesalamine is used for patients with ulcerative colitis for long-term therapy. MOM is a laxative.

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? A. Patients with CD experience about 20 loose, bloody stools daily. B. Patients with UC may experience hemorrhage. C. The peak incidence of UC is between 15 and 40 years of age. D. Very few complications are associated with CD.

B. Patients with UC may experience hemorrhage. A correct statement about differentiating Crohn's disease (CD) from ulcerative colitis (UC) is that patients with UC may experience hemorrhage. Patients with CD can have 5-6 soft, loose stools per day, but they are nonbloody.Five to six stools daily is common with CD, not 20 loose, bloody stools. The peak incidences of UC are between 30 and 40 years and again at 55 to 65 years of age, and not just 15 to 40 years of age. Fistulas commonly occur as a complication of CD.

14. Which most accurate diagnostic test will the nurse expect to be ordered for a client to verify the diagnosis of GERD? A. Esophagogastroduodenoscopy (EGD) B. Esophageal manometry C. Ambulatory esophageal pH monitoring D. Motility testing

17. Which priority teaching will the nurse provide to a client who is prescribed bismuth for peptic ulcer disease (PUD)? A. "Take this drug with an aspirin." B. "You may experience dyspepsia between doses." C. "Bismuth may cause your tongue and stool to appear black." D. "Be sure to take this drug before each meal and snack."

23. Which client does the nurse assess as at highest risk for development of esophageal cancer? A. 45-year-old on a high-fiber diet B. 50-year-old with a sedentary lifestyle C. 55-year-old who smokes and is 25 lb overweight D. 60-year-old who is prescribed famotidine for reflux

28. After esophagectomy for esophageal cancer, what is the nurse's priority for client care? A. Wound care B. Nutrition management C. Respiratory care D. Hydration status

3. For which reason will the nurse carefully examine the mouth of an older adult for candidiasis? A. Older clients are more likely to wear dentures which increases the risk for candidiasis. B. Older adults on fixed incomes consume fewer fresh vegetables and fruits. C. Older adults' immune systems decline with aging increasing their risk for candidiasis. D. Older clients are less likely to see a dentist and have healthy oral hygiene.

5. Which diagnostic test does the nurse expect will be ordered for a client with suspected gastritis? A. Computed tomography (CT) scan B. Upper gastrointestinal (GI) series C. Esophagogastroduodenoscopy (EGD) D. Barium swallow

7. What does the nurse suspect when assessing a client's mouth and finding an oral cavity tumor that appears as a red, velvety lesion on the tongue, palate, floor of the mouth, or mandibular mucosa? A. Kaposi's sarcoma B. Basal cell carcinoma C. Erythroplakia D. Leukoplakia

9. Which statement by a client indicates to the nurse that teaching about the action of sucralfate has been successful? A. "The main side effect of sucralfate is diarrhea." B. "I will take my sucralfate with each meal." C. "Sucralfate will work to heal my ulcer." D. "I will take my sucralfate with my antacid."

A 68-year-old male client is seeing the primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A 5 pack-year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I cannot drink any alcohol at all anymore." b. "I should not take over-the-counter medications." c. "I need to avoid protein in my diet." d. "I should eat small, frequent, balanced meals."

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? a. "You should make peace with your family." b. "This is not unusual. My family hates me too." c. "I will help you identify a support system." d. "You must attend Alcoholics Anonymous."

What is the nurse's best first action when a client who just had a liver transplant develops oozing around two IV sites as well as has some new bruising? A. Applying pressure to the IV sites B. Checking the client's platelet levels C. Notifying the surgeon immediately D. Documenting the findings as the only action

What is the nurse's best response to a client who fears he may have been exposed to hepatitis A while attending a banquet last week after which three restaurant workers were diagnosed with hepatitis A? A. "Which types of food did you eat at the banquet?" B. "If you have no symptoms at this time, you are probably safe." C. "You can receive an immunoglobulin injection to prevent the infection." D. "Contact your primary health care provider about receiving the hepatitis A vaccine."

What is the nurse's priority action when a client with ascites reports increased abdominal pain and chills? A. Applying oxygen and making the client NPO B. Notifying the primary health care provider immediately C. Assessing for abdominal rigidity and taking the client's temperature D. Applying a heating blanket and raising the head of the bed to a 45-degree angle

What liver problem does the nurse suspect in a client whose liver is hard with a nodular texture and the hepatic enzymes remain normal? A. Prenecrotic inflammation B. Postnecrotic inflammation C. Compensated cirrhosis D. Decompensated cirrhosis

Which actions will the nurse perform when preparing a client for paracentesis? Select all that apply. A. Obtaining informed consent B. Maintaining the client on NPO status C. Asking the client to void before the procedure D. Placing the client in the flat supine position E. Weighing the client before the procedure F. Assessing the respiratory rate and blood pressure

C E F

12. Which are the most common symptoms of gastroesophageal reflux disease (GERD) reported to the nurse by a client? Select all that apply. A. Eructation B. Water brash C. Dyspepsia D. Regurgitation E. Odynophagia F. Flatulence

C, D

The nurse is caring for an 80-year-old female client with recurrent cystitis. Which teaching will the nurse include in the plan of care? Select all that apply. A. Drink citrus juices daily. B. Douche regularly; a minimum of two times weekly. C. Encourage fluid intake of 2-3 L of fluid throughout the day. D. Instruct her to always wipe the perineum from front to back after each toilet use. E. Reinforce that she should complete the entire course of antibiotics as prescribed. F. Instruct her to empty her bladder immediately before and after having intercourse.

C, D, E, F

2. A 28-year-old female client states, "I don't know why I get cystitis every year. I don't drink much at work so that I can avoid using the public toilet." Which teaching by the nurse is most likely to reduce her risk for cystitis? Select all that apply. A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.

C, E, F, G

A patient has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the patient about diet and lifestyle choices? A. "Drinking carbonated beverages will help with your abdominal distress." B. "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." C. "Lactose-containing foods should be reduced or eliminated from your diet." D. "Raw vegetables and high-fiber foods may help to diminish your symptoms."

C. "Lactose-containing foods should be reduced or eliminated from your diet." The nurse teaches the newly diagnosed patient with ulcerative colitis that lactose-containing foods are often poorly tolerated and need to be reduced or eliminated from the diet.Carbonated beverages are GI stimulants that can cause discomfort and must be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms. Nurses would never advise patients that any amount of cigarette smoking is "OK." Raw vegetables and high-fiber foods can cause GI symptoms in patients with UC.

A home health patient has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the patient with self-care? A. Instructing the patient about the use of electrolyte-containing oral rehydration products B. Administering loperamide (Imodium) 4 mg from the patient's medicine cabinet C. Checking and reporting the patient's heart rate and blood pressure in lying, sitting, and standing positions D. Teaching the patient how to clean the perineal area after each loose stool

C. Checking and reporting the patient's heart rate and blood pressure in lying, sitting, and standing positions The RN delegates to the UAP a home health patient with severe diarrhea who needs checking and reporting of the patient's heart rate and blood pressure in lying, sitting, and standing positions. Obtaining the patient's blood pressure and heart rate is included in the education of home health aides and other UAPs.Patient teaching and medication administration are complex skills that would be performed by licensed nurses who have the education and scope of practice needed to safely implement these actions.

The nurse is preparing to obtain a sterile urine specimen from a client with a Foley catheter. What technique will the nurse use? A. Disconnect the Foley catheter from the drainage tube and collect urine directly from the Foley. B. Use a sterile syringe to withdraw urine from the urine collection bag. C. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine. D. Remove the existing catheter and obtain a sample during the process of inserting a new Foley.

C. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine.

A patient with ulcerative colitis (UC) is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the patient's medication regimen? A. Corticosteroid therapy will be stopped. B. Sulfasalazine (Azulfidine) will be stopped. C. Corticosteroid therapy will be tapered. D. Sulfasalazine (Azulfidine) will be tapered.

C. Corticosteroid therapy will be tapered. The nurse expects that corticosteroid therapy will be tapered as the UC improves in the patient who was taking both sulfasalazine and corticosteroids. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period.Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in patients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the patient's symptoms, but will likely never be stopped. These decisions are made over a long period of therapy.

A patient returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this patient after the patient is situated in bed? A. High Fowler's B. Lateral Sims' (side-lying) C. Semi-Fowler's D. Supine

C. Semi-Fowler's The nurse places the postoperative abdominal laparotomy patient in the semi-Fowler's position in bed. The patient is maintained in this position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion.High-Fowler's position would be too high for the patient postoperatively. It would place strain on the abdominal incision(s), and, if the patient was still drowsy from anesthesia, this position would not enhance the patient's ability to rest. Sims' position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion. The patient would be more likely to develop complications (wound drainage stasis and atelectasis) in the supine position.

An obese patient is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the patient's home health nurse requires immediate action? A. Pain when coughing B. States, "I am too tired to walk very much" C. States, "I feel like the incision is splitting open" D. Temperature of 100.8°F (38.2°C).

C. States, "I feel like the incision is splitting open" The assessment finding of a patient who had an exploratory laparotomy that requires immediate action by the home health nurse is the patient stating, "I feel like the incision is splitting open." The patient feeling like the incision is splitting open is at risk for poor wound healing and possible wound dehiscence. The nurse must immediately assess the wound and notify the primary health care provider.Reports of pain when coughing, being too tired to ambulate, and a temperature of 100.8°F (38.2°C) all require further assessment or intervention but are not as great a concern as the possibility of wound dehiscence for this patient.

10. What is the nurse's best response when a client asks which diagnostic test will determine if an oral tumor is cancerous? A. "MRI is the only test that you will need at this time." B. "No single test will make the diagnosis on its own." C. "Aqueous toluidine blue will be absorbed by malignancies." D. "Biopsy is the definitive method for diagnosing oral cancer."

19. Which diagnostic test will the nurse expect the client to undergo to best identify a hiatal hernia? A. Esophagogastroduodenoscopy (EGD) B. 24-hour ambulatory pH monitoring C. Esophageal manometry D. Barium swallow with fluoroscopy

25. What does the nurse suspect when assessment of a client after gastric resection reveals a tongue that is smooth, shiny, and appears "beefy"? A. Inadequate nutrition B. Hypovolemia C. Anemia D. Atrophic glossitis

25. What manifestation of esophageal cancer does the nurse recognize when a client describes experiencing a dull and steady substernal pain after drinking cold liquids? A. Angina B. Aspiration C. Dysphagia D. Odynophagia

29. Which cause does the nurse recognize as a potential intentional cause for a client's esophageal trauma? A. Nasogastric (NG) tube placement B. Esophageal ulcers C. Struck by a foreign object D. Chemical injury

3. A client is diagnosed with renal colic. What would the nurse do first? A. Prepare the client for lithotripsy. B. Encourage oral intake of fluids. C. Strain the urine and send for urinalysis. D. Administer opioids as prescribed.

4. For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. A 48-year-old man who has established paraplegia and is admitted for pneumonia C. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice

7. What priority teaching will the nurse provide to prevent harm when a client with gastritis reports taking ibuprofen regularly for discomfort related to arthritis? A. "Do not take ibuprofen more than twice a day." B. "Ibuprofen can interfere with the action of the drugs you take for gastritis." C. "This drug is excellent for pain relief related to arthritis." D. "Avoid taking ibuprofen because it can cause gastritis."

The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? a. Musculoskeletal assessment b. Neurologic assessment c. Mental health assessment d. Cardiovascular assessment

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? a. Metabolic syndrome b. Liver cancer c. Nonalcoholic fatty liver disease d. Hepatitis C

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." b. "Do not take amiodorone at any time while on this drug." c. "Monitor for jaundice, rash, and itchy skin while on this drug." d. "Report any changes in urinary elimination while on this drug."

A patient newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the patient about why this therapy has been prescribed? A. "It is to stop the diarrhea and bloody stools." B. "This will minimize your GI discomfort." C. "With this medication, your cramping will be relieved." D. "Your intestinal inflammation will be reduced."

D. "Your intestinal inflammation will be reduced." The nurse tells the newly diagnosed patient with UC who is started on sulfasalazine that, "Your intestinal inflammation will be reduced." Sulfasalazine (Azulfidine) is one of the primary treatments for UC. It is thought to inhibit prostaglandin synthesis and thereby reduce inflammation.Although it is hoped that reduction of inflammation will cause the diarrhea and bloody stools to stop, this is not the way that the drug works. Antidiarrheal drugs "stop" diarrhea. The drug's action as an anti-inflammatory will diminish the patient's pain as the inflammation subsides, but this is not the purpose of the drug. Sulfasalazine is an anti-inflammatory medication, not an analgesic.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which patient does the charge nurse assign to the float nurse? A. A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

D. A 36-year-old with peritonitis who just returned from surgery with multiple drains in place The charge nurse assigns to the ICU nurse who was floated to the medical-surgical unit a 36-year-old patient with peritonitis who just returned from surgery with multiple drains in place. The ICU nurse is familiar with the care of a patient with peritonitis, including monitoring for complications such as sepsis and kidney failure.The patient with CD who has a draining enterocutaneous fistula, the patient with UC who needs discharge teaching, and the patient with questions about an ileo-anal reservoir are best assigned to a medical-surgical nurse who is more familiar with the care and teaching needed for patients with their respective disorders.

Which client will the nurse encourage to consume 2 to 3 L of fluid each day? A. Client with heart failure B. Client with chronic kidney disease C. Client with complete bowel obstruction D. Client with hyperparathyroidism

D. Client with hyperparathyroidism

What procedural instruction will the nurse provide for a client scheduled for an ultrasonography? A. Empty your bladder just before the test begins B. Stop taking your routine medications 24 hours before the test C. You must have nothing to eat or drink after midnight before the test D. Drink 500 ml to 1000 ml of water 2 to 3 hours before the test

D. Drink 500 ml to 1000 ml of water 2 to 3 hours before the test

When a client with diabetes returns to the medical unit after a computed tomography (CT) scan with contrast dye, all of these interventions are prescribed. Which intervention will the nurse implement first? A. Administer captopril. B. Request a breakfast tray for the client. C. Administer lispro (Humalog) insulin, 10 units subcutaneously. D. Infuse 0.45% normal saline at 125 mL/hr.

D. Infuse 0.45% normal saline at 125 mL/hr.

The nurse assesses blood clots in a client's urinary catheter after a cystoscopy. What initial nursing intervention is appropriate? A. Administer heparin intravenously. B. Remove the urinary catheter. C. Irrigate the catheter with sterile saline. D. Notify the health care provider (HCP).

D. Notify the health care provider (HCP).

An 80-year-old patient with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which primary health care provider request does the nurse implement first? A. Administer acetaminophen (Tylenol) 650 mg rectally. B. Draw blood for a complete blood count and serum electrolytes. C. Obtain a stool specimen for culture and sensitivity. D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

D. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. The request the nurse implements first is to start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Fluid therapy is the focus of treatment for patients with gastroenteritis. Older patients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure.Acetaminophen 650 mg should be administered rectally soon, and blood draws and stool specimen collection would also be implemented soon, but prevention and treatment of dehydration are the priorities for this patient.

Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? A. The client experiences nausea and vomiting after drinking juice. B. The biopsy site is tender to light palpation. C. The abdomen is distended, and the client reports abdominal discomfort. D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

3. A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How would the nurse respond? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."

G R A D E S L A B . C O M ANS: B Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this patient is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

Infuse lactated Ringer's solution 500 mL

The admission assessment for a patient with acute gastric bleeding indicates a blood pressure of 82/40 mm Hg, pulse of 124/min beats/min, and respiratory rate of 26 breaths/min. Which admission prescription would the nurse implement first?

Melena

The laboratory report of a patient with acute gastritis states there are traces of blood in the stool. Which term would the nurse use to document this finding?

Administering IV fluids

The nurse finds a patient vomiting coffee ground-type emesis. The patient is acutely confused, has blood pressure of 100/74 mm Hg, and has a weak and thready pulse. Which intervention would the nurse expect to be prescribed?

"Water goes down the tube to clean out your stomach

The nurse has placed a nasogastric (NG) tube in a patient with upper GI bleeding to administer gastric lavage. The patient asks the nurse about the purpose of the NG tube for the procedure. Which response would the nurse provide?

Type O blood

The nurse is assessing a patient who reports episodes of abdominal pain. Which patient data suggest increased risk for duodenal ulcer?

Worsens with the ingestion of food

The nurse is assessing the nature of abdominal pain in a patient with a suspected gastric ulcer. Which feature of the patient's pain is consistent with a gastric ulcer?

Gastric

The nurse is caring for a patient who has granular, dark vomitus that resembles coffee grounds. Which type of ulcer would the nurse suspect in this patient?

Assess for a gag reflex.

The nurse is caring for a patient who has just returned from an endoscopic procedure. The patient's spouse verbalizes that the patient must be hungry. Which action would the nurse take?

The pain occurs 3 hours after meals and at night.

The nurse is caring for an older-adult man who reports stomach pain and heartburn. Which characteristic would lead the nurse to suspect the ulcer was duodenal rather than gastric in location?

Metronidazole

The nurse is reviewing the medications prescribed for a patient with peptic ulcer disease (PUD). Which drug treats Helicobacter pylori infection?

Use complementary and alternative therapies

The nurse is teaching a patient about self-management of gastritis. Which information would the nurse include?

"Take the famotidine at bedtime."

The nurse is teaching a patient about the use of famotidine and sucralfate to treat gastritis. Which information would the nurse include?

Nizatidine needs to be taken three times a day to be effective.

The nurse is teaching a patient with peptic ulcer disease about the prescribed drug regimen. Which statement made by the patient indicates a need for further teaching?

Tarry or dark sticky stools, Decreased blood pressure, Dizziness or light-headedness, Bright red or coffee-ground-colored vomitus

Which clinical finding is associated with upper GI bleeding? Select all that apply. One, some, or all responses may be correct.

Hemorrhage

Which complication of peptic ulcer disease is more common in older adults?

Pernicious anemia

Which condition is a complication of chronic gastritis?

Atrophic gastritis

Which disorder in older adults has a direct association with mucosa-associated lymphoid tissue (MALT) lymphoma?

Pernicious anemia, Nausea and vomiting, Intolerance to fatty food

Which finding is a key feature of chronic gastritis? Select all that apply. One, some, or all responses may be correct.

Radiation therapy

Which information found in a patient's history frequently correlates with a diagnosis of chronic gastritis?

"It is important to eat a well-balanced diet.", Avoid alcoholic beverages in excessive amounts., Avoid excessive intake of coffee or decaffeinated coffee.", "Protect against exposure to toxic substances in the workplace."

Which information would the nurse include when teaching patients to prevent gastritis? Select all that apply. One, some, or all responses may be correct.

The liquid form of this is preferable to chewable tablets.

Which information would the nurse provide the patient regarding aluminum hydroxide?

Ensure that food and water are safe and not contaminated, Try complementary and alternative therapies to manage stress., Avoid exposure to toxic substances, such as nickel, at the workplace.

Which instruction would the nurse give to help a patient prevent gastritis? Select all that apply. One, some, or all responses may be correct.

Antrum of the stomach

Which location is common for gastric ulcers?

Document instructions for a patient with chronic gastritis about how to use triple therapy

Which nursing action would the nurse delegate to an experienced licensed practical nurse/licensed vocation nurse (LPN/LVN)?

Reducing caffeine intake

Which nutritional recommendation would the nurse provide to the patient with peptic ulcer disease (PUD)?

2. A client is admitted with a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

a Airway always takes priority. Airway must be assessed first and any problems managed if present.

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor

a Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

The nurse is teaching a client about risk factors for esophageal cancer. Which risk factors would the nurse include? (Select all that apply.) a. Alcohol intake b. Obesity c. Smoking d. Lack of fresh fruits and vegetables e. Untreated GERD f. Use of NSAIDs

a b c d e all of these factors increase the risk of esophageal cancer except for the use of NSAIDs. Untreated GERD causes damage to esophageal tissue which may develop into Barrett esophagus, or precancerous cells.

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) a. Asthma b. Laryngitis c. Dental caries d. Cardiac disease e. Cancer

a b c d e Any of these complications may occur in clients who have uncontrolled or untreated GERD.

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) a. Dyspepsia b. Regurgitation c. Belching d. Coughing e. Chest discomfort f. Dysphagia

a b c d e f All of these signs and symptoms are commonly seen in clients who have GERD.

The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for this client? (Select all that apply.) a. Applying warm compresses b. Applying ice to salivary glands c. Offering fluids every hour d. Providing lemon-glycerin swabs e. Reminding the patient to avoid speaking

a c Warm compresses and fluids can help promote comfort for this client. Application of ice or lemon-glycerin swabs would not be used. Speaking has no effect on this condition.

A nurse knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) a. Coal miner b. Electrician c. Metal worker d. Plumber e. Textile worker

a c d e The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do not have this risk.

While working in the outpatient procedure unit, the RN is assigned to four clients. Which client will the nurse assess first? a) A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP). b) A 58 year old who has just arrived for a sigmoidoscopy. c) A 60 year old with questions about an endoscopic ultrasound examination. d) A 54 year old who is ready for discharge following a colonoscopy.

a) A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP).

The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed? a) Ask if the client has passed flatus (gas) within the previous 12 to 24 hours. b) Perform auscultation with the diaphragm of the stethoscope. c) Listen for bowel sounds in all abdominal quadrants. d) Count the number of bowel sounds in each abdominal quadrant over 1 minute.

a) Ask if the client has passed flatus (gas) within the previous 12 to 24 hours.

Which client with symptoms of chronic abdominal pain and frequent bowel movements will the nurse consider at highest risk for a diagnosis of ulcerative colitis? a. 26 yo woman of Jewish ancestry who has an identical twin sister with the disorder b. 40 yo black man who has just returned home from a business trip to SE Asia c. 50 yo Latino man with liver cirrhosis whose uncle died of colon cancer d. 65 yo obese asian woman who has chronic inflammatory cystitis

a. 26 yo woman of Jewish ancestry who has an identical twin sister with the disorder

Which lunch food selection made by a client with diverticulosis indicates to the nurse the correct understanding of the necessary dietary modifications for management of the problem? a. A turkey sandwich on whole weight bread, steamed carrots, and a raw apple b. Roasted chicken, potato salad, and a glass of milk c. Chicken salad sandwich on white bread, creamed soup, and hot tea d. Fried shrimp, lettuce and tomato salad, and a dinner roll

a. A turkey sandwich on whole weight bread, steamed carrots, and a raw apple

Which interventions will the nurse include when care of a client with peritonitis is focused on restoring fluid volume balance? Select all that apply a. Administering IV isotonic fluids and broad-spectrum antibiotics b. Assigning the AP to weight the client daily and record intake and output c. Providing NGT care and keeping the stomach decompressed d. Administering opioid pain medications as prescribed by the primary health care provider e. Maintaining the client on NPO status while the NGT is in place to low suction f. Assessing whether the client retains fluid used for irrigation by comparing and recording the amount of fluid returned with the amount of fluid instilled

a. Administering IV isotonic fluids and broad-spectrum antibiotics b. Assigning the AP to weight the client daily and record intake and output c. Providing NGT care and keeping the stomach decompressed e. Maintaining the client on NPO status while the NGT is in place to low suction f. Assessing whether the client retains fluid used for irrigation by comparing and recording the amount of fluid returned with the amount of fluid instilled

6. A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the client's dietary habits. b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. Hold the client's metformin (Glucophage). d. Contact the health care provider immediately.

a. Assess the client's dietary habits.

8. A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

a. Blood urea nitrogen (BUN) of 52 mg/dL

13. A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the client's capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.

a. Contact the provider and recommend discontinuing the metformin.

3. A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating

a. Decrease in urine output d. Blood clots present in the urine

5. A nurse plans care for an older adult client. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the unlicensed assistive personnel (UAP). e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.

a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.

5. A nurse contacts the health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

a. Intravenous fluids

4. A nurse prepares a client for a percutaneous kidney biopsy. Which actions should the nurse take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the client's urine. e. Administer antihypertensive medications.

a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. e. Administer antihypertensive medications.

Which actions will the nurse perform when caring for a client with acute appendicitis before surgical management? Select all that apply a. Maintaining the client on NPO status b. Administering IV fluids as prescribed c. Providing laxatives and enemas to clear the bowels d. Advising the client to maintain semi-Fowlers position e. Giving adequate medications to control the client's pain f. Applying hot compresses to the right lower quadrant

a. Maintaining the client on NPO status b. Administering IV fluids as prescribed d. Advising the client to maintain semi-Fowlers position e. Giving adequate medications to control the client's pain

What is the nurse's best first action when the stoma of a client who had a permanent ileostomy placed 2 days ago now has a dark bluish-purple appearance? a. Notifying the surgeon immediately b. Applying oxygen by nasal cannula c. Placing the client in a high-owlet position d. Documenting the findings as the only action

a. Notifying the surgeon immediately

Which important information will the nurse include when teaching a client about peritonitis? Select all that apply a. Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals b. Respiratory problems associated with peritonitis are related to increased abdominal pressure against the diaphragm c. White blood cell counts are often decreased when a client is diagnosed with peritonitis d. Chemical peritonitis is caused by leakage of pancreatic enzymes or gastric acids e. Fairly common causes of peritonitis include invasive tumors and continuous ambulatory peritoneal dialysis f. When the peritoneal cavity is contaminated by bacteria, the body begins an inflammatory reaction, walling off a localized area to fight the infection

a. Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals b. Respiratory problems associated with peritonitis are related to increased abdominal pressure against the diaphragm d. Chemical peritonitis is caused by leakage of pancreatic enzymes or gastric acids f. When the peritoneal cavity is contaminated by bacteria, the body begins an inflammatory reaction, walling off a localized area to fight the infection

Which care actions does the nurse expect to perform when caring for a client who had an appendectomy with an abscess? Select all that apply a. Providing care for wound drains inserted during the surgery b. Administering IV antibiotics as prescribed by the surgeon c. Providing the client with clear liquid diet d. Assessing the NGT position and drainage e. Providing non steroidal anti-inflammatory drugs for pain control f. Helping the patient out of bed on the evening of surgery

a. Providing care for wound drains inserted during the surgery b. Administering IV antibiotics as prescribed by the surgeon d. Assessing the NGT position and drainage f. Helping the patient out of bed on the evening of surgery

12. A nurse reviews the allergy list of a client who is scheduled for an intravenous urography. Which client allergy should alert the nurse to urgently contact the health care provider? a. Seafood b. Penicillin c. Bee stings d. Red food dye

a. Seafood

18. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP's performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female clients and male icon for all male clients b. Telling the client, "This test measures the amount of urine in your bladder." c. Applying ultrasound gel to the scanning head and removing it when finished d. Taking at least two readings using the aiming icon to place the scanning head

a. Selecting the female icon for all female clients and male icon for all male clients

To prevent harm after a surgical procedure for peritonitis, which action will the nurse teach a client to avoid? a. Taking additional acetaminophen to prevent liver toxicity b. Lifting for at least 6 months after an open surgical procedure c. Resuming normal activities for at least 3 to 4 days after the procedure d. Using stool softeners and laxatives to prevent diarrhea

a. Taking additional acetaminophen to prevent liver toxicity

Which actions will the nurse teach a client to take to prevent the spread of gastroenteritis? Select all that apply a. Washing hands well for at least 30 seconds b. Using easily accessible hand sanitizers c. Taking broad spectrum antibiotics prophylactically d. Testing all food preparation employees e. Sanitizing all surfaces that may be contaminated f. Properly preparing food and beverages

a. Washing hands well for at least 30 seconds b. Using easily accessible hand sanitizers e. Sanitizing all surfaces that may be contaminated

Which common signs and symptoms will the nurse expect to find on assessment of a 60 yo client who had gastroenteritis for the past 2 days? Select all that apply a. Weight loss b. Elevated temperature c. Dry mucous membranes d. Hypotension e. Oliguria f. Poor skin turgor

a. Weight loss b. Elevated temperature c. Dry mucous membranes d. Hypotension e. Oliguria f. Poor skin turgor

1. A nurse reviews a client's laboratory results. Which results from the client's urinalysis should the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive

a. pH: 6 b. Specific gravity: 1.015 d. Glucose: negative

A nurse participates in a community screening event for oral cancer. What client is the highest priority for referral to a primary health care provider? a. Client who has poor oral hygiene practices. b. Client who smokes and drinks daily. c. Client who tans for an upcoming vacation. d. Client who occasionally uses illicit drugs.

b Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol.

The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care? a. Encourage fluids to liquefy the client's secretions. b. Place the client on Aspiration Precautions. c. Remind the client to use an incentive spirometer. d. Manage the client's pain and inflammation.

b The client who has oral cancer often has difficulty swallowing and is at risk for aspiration and possibly aspiration pneumonia. Therefore, the most important nursing action is to place the client on precautions to prevent aspiration. The nurse would implement the other actions but they are not as vital to promote client safety.

The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) a. "You will need to be on a liquid diet for the first week after the procedure." b. "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." c. "Contact the primary health care provider after the procedure if you have increased pain." d. "You will need a nasogastric tube for a few days after the procedure." e. "You will have a small incision in your stomach area that will have a wound closure.

b c The client having this procedure does not have an incision and will not require a nasogastric tube (NGT). The client should avoid an NGT placement for at least a month after the procedure. A liquid diet is required for only 24 hours after the procedure and then the client should progress to include soft floods like custard and applesauce.

The nurse is caring for a client who had an open traditional esophagectomy. Which assessment findings would the nurse report immediately to the primary health care provider? (Select all that apply.) a. Nausea b. Wound dehiscence c. Fever d. Tachycardia e. Moderate pain f. Fatigue

b c d Wound dehiscence is a serious, potentially life-threatening problem that needs immediate attention of the primary health care provider, typically the surgeon. Fever and tachycardia may indicate that the client has a postoperative infection, another serious, potentially life-threatening complication. Indications of both of these problems need to be documented and reported by the nurse. Nausea, fatigue, and moderate pain are expected postoperative assessment findings.

A client is preparing to undergo a stool DNA (sDNA) test to screen for colon cancer. What preprocedure teaching does the nurse provide? a) "Do not eat or drink anything for 12 hours before the test." b) "No special preparation is needed prior to completing this test." c) "Give yourself tap water enemas until the fluid returns are clear." d) "Begin a clear liquid diet at least 24 hours before the test."

b) "No special preparation is needed prior to completing this test."

The nurse is teaching an older adult client. Which gastrointestinal problem does the nurse discuss that takes place during the normal aging process? a) Increased peristalsis b) Decreased hydrochloric acid levels c) Increased liver size d) Excess lipase production

b) Decreased hydrochloric acid levels

A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the health care provider? a) Flatulence b) Rectal bleeding c) Mild abdominal pain d) Borborygmi

b) Rectal bleeding

What is the most important assessment for the nurse to perform before administering the first dose of sulfasalazine to a client diagnosed with ulcerative colitis? a. Obtaining an accurate weight b. Asking whether they have an allergy to sulfa drugs c. Measuring heart and respiratory rate and blood pressure d. Determining the number of times the client has had a stool today

b. Asking whether they have an allergy to sulfa drugs

The nurse is caring for a patient who has just undergone a cystoscopy. Which assessment finding necessitates an immediate intervention by the nurse? a. Back pain b. Bright red urine c. Urinary frequency d. Burning on urination

b. Bright red urine

In collaboration with the registered dietitian nutritionist, which nutrients and substances will the nurse instruct a client with ulcerative colitis to avoid to reduce symptoms? Select all that apply a. Eggs b. Corn c. Caffeine d. Vitamin C e. Dried fruits f. Carbohydrates g. Dairy products h. Pepper-based spices

b. Corn c. Caffeine e. Dried fruits g. Dairy products h. Pepper-based spices

10. A nurse cares for a client who has elevated levels of antidiuretic hormone (ADH). Which disorder should the nurse identify as a trigger for the release of this hormone? a. Pneumonia b. Dehydration c. Renal failure d. Edema

b. Dehydration

9. A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take? a. Evaluate the client's intake and output for the past 24 hours. b. Document the finding in the chart and continue to monitor. c. Obtain a specimen for a urine culture and sensitivity. d. Encourage the client to drink more fluids, especially water.

b. Document the finding in the chart and continue to monitor.

Which disease features will the nurse commonly associate with a client who has Crohn disease that are rare or absent in a client with ulcerative colitis? Select all that apply a. The problem first appears in the rectum and proceeds in a continuous manner toward the cecum b. Fistulas commonly develop c. Clients have five to six soft, loose, nonbloody stools per day d. there is a greatly increased risk for colon cancer e. Many clients have one or more extra intestinal problems such as arthritis, ankylosing spondylitis, and erythema nondosum f. the appearance of the affected intestine areas resemble cobblestone

b. Fistulas commonly develop c. Clients have five to six soft, loose, nonbloody stools per day f. the appearance of the affected intestine areas resemble cobblestone

2. A nurse reviews the health history of a client with an oversecretion of renin. Which disorder should the nurse correlate with this assessment finding? a. Alzheimer's disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis

b. Hypertension

Which statement by a client with gastroenteritis due to infection with the norovirus indicates that the nurse's teaching about this illness has been successful? a. I got this infection from being around my grandchildren when they had respiratory illnesses b. It is most likely that I got this infectious illness from either contaminated food or water c. I may have gotten sick when I was traveling last month to Florida d. It's really important that I don't go to restaurants for at least a month after I am well

b. It is most likely that I got this infectious illness from either contaminated food or water

11. A nurse reviews a female client's laboratory results. Which results from the client's urinalysis should the nurse recognize as abnormal? a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color

b. Ketone bodies present

Which new onset assessment finding in a client with Crohn disease indicates to the nurse the possibility of fistula development? a. Anorexia b. Pyuria with fever c. Smooth, beefy red tongue d. Decreased serum albumin

b. Pyuria with fever

Which assessment findings on a client with peritonitis indicate to the nurse the probability that the fluid shift into the peritoneal cavity is continuing? Select all that apply a. Weight loss b. Tachycardia c. Hypertension d. Decreasing urine output e. Hyperactive bowel sounds f. Skin tenting over the forehead and sternum

b. Tachycardia d. Decreasing urine output f. Skin tenting over the forehead and sternum

When the nurse is providing discharge instructions for a client recovering from peritonitis, which essential findings will the client and family be instructed to report immediately to the primary health care provider? Select all that apply a. Completion of broad-spectrum antibiotics as prescribed b. Unusual or foul smelling drainage c. Signs of wound dehiscence or ileus d. Swelling, redness, warmth, or bleeding from the incision site e. A temperature higher than 101 F f. Abdominal pain or board-like stiffness in the abdomen

b. Unusual or foul smelling drainage c. Signs of wound dehiscence or ileus d. Swelling, redness, warmth, or bleeding from the incision site e. A temperature higher than 101 F f. Abdominal pain or board-like stiffness in the abdomen

Which action is appropriate for the nurse to take to prevent harm when caring for a client with ulcerative colitis who has undergone a total proctocolectomy with placement of a permanent ileostomy? a. Irrigating the ileostomy to maintain patency b. Using a skin barrier to prevent exorciation c. Monitoring the client for nausea due to decreased intestinal motility d. Giving small, frequent feedings to compensate for malnutrition from short-gut syndrome

b. Using a skin barrier to prevent exorciation

The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching? a. "I need to take out my dentures until my mouth heals." b. "I'll try to eat soft foods that aren't spicy and acidic." c. "I will use a more firm toothbrush to keep my mouth clean." d. "I'll be sure to rinse my mouth often with warm salt water."

c The client who has stomatitis has oral inflammation which causes discomfort. Therefore, all of these actions help to avoid irritation except for needing to use a soft toothbrush or gauze rather than a firm one.

The nurse is assessing a very thin client who has come to the emergency department with acute abdominal pain. Upon assessment, visible peristaltic movements are noted. What is the appropriate nursing action? a) Prepare to administer antibiotics as prescribed. b) Report finding to the health care provider. c) Monitor laboratory values for possible pancreatitis. d) Toilet quickly as diarrhea is imminent.

c) Monitor laboratory values for possible pancreatitis.

A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? (Select all that apply.) a) Percuss to determine size of liver and spleen. b) Auscultate beginning in the RLQ. c) Visually observe for contour and symmetry. d) Ask for a pain scale rating on a scale of 0-10. e) Deeply palpate the area of tenderness.

c) Visually observe for contour and symmetry. d) Ask for a pain scale rating on a scale of 0-10.

14. A nurse teaches a client who is recovering from a urography. Which instruction should the nurse include in this client's discharge teaching? a. "Avoid direct contact with your urine for 24 hours until the radioisotope clears." b. "You may have some dribbling of urine for several weeks after this procedure." c. "Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster." d. "Your skin may become slightly yellow from the dye used in this procedure."

c. "Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster."

4. A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to the renal insufficiency?" How should the nurse respond? a. "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." b. "Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density." c. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." d. "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood."

c. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."

What does the nurse suspect when a client comes to the ED with right lower cramping pain, nausea, vomiting, and guarding with rigidity of the abdomen? a. Gastroenteritis b. Ulcerative colitis c. Appendicitis d. Crohn disease

c. Appendicitis

15. A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10." Which action should the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the pulse rate and blood pressure. d. Examine the color of the client's urine.

c. Assess the pulse rate and blood pressure.

16. A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next? a. Clamp another section of the tube to create a fixed sample section for retrieval. b. Insert a syringe into the injection port and aspirate the quantity of urine required. c. Clean the injection port cap of the drainage tubing with povidone-iodine solution. d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

c. Clean the injection port cap of the drainage tubing with povidone-iodine solution.

Which laboratory finding will the nurse expect to see in a client who is suspected of having an acute, uncomplicated appendicitis? a. Decreased serum potassium level b. Increased international normalized ratio c. Increased WBC count d. Decreased erythrocyte sedimentation rate

c. Increased WBC count

Which complication will the nurse suspect when a client with peritonitis reports increased pain in the upper left abdominal quadrant and in the left shoulder, especially during inhalation? a. Sepsis b. Pneumonia c. Localized abscess d. Bacterial hepatitis

c. Localized abscess

Which action will the nurse instruct a client with celiac disease to perform to reduce symptoms? a. Limiting caffeine b. Drinking more liquids c. Reading labels on prepared foods d. Avoiding raw fruits and vegetables

c. Reading labels on prepared foods

The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include? a. "Use the drug before every meal to prevent aspiration." b. "Increase your intake of citrus foods to help with healing." c. "Use the drug only at bedtime because you won't be eating." d. "Be sure to check food temperatures before eating."

d Viscous lidocaine has an anesthetic effect in the oral cavity. Therefore, to promote client safety, the nurse would want to teach the client to check food temperature before eating.

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? a) A 40 year old who needs administration of IV midazolam hydrochloride during an upper endoscopy. b) A 36 year old who needs teaching about an endoscopic retrograde cholangiopancreatography. c) A 46 year old who is admitted with abdominal cramping and diarrhea of unknown causes. d) A 32 year old with constipation who has received a laxative.

d) A 32 year old with constipation who has received a laxative.

Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? a) Client admitted with nausea, abdominal pain, and abdominal distention. b) Client who needs discharge teaching after an endoscopic retrograde cholangiopancreatography (ERCP). c) Client with epigastric pain who needs conscious sedation during endoscopy. d) Client who has had laxatives administered and needs monitoring before a colonoscopy.

d) Client who has had laxatives administered and needs monitoring before a colonoscopy.

17. A nurse cares for a client who is having trouble voiding. The client states, "I cannot urinate in public places." How should the nurse respond? a. "I will turn on the faucet in the bathroom to help stimulate your urination." b. "I can recommend a prescription for a diuretic to improve your urine output." c. "I'll move you to a room with a private bathroom to increase your comfort." d. "I will close the curtain to provide you with as much privacy as possible."

d. "I will close the curtain to provide you with as much privacy as possible."

Which surgical client will the nurse recognize as having the highest risk for development of peritonitis? a. 35 yo having a laparoscopic appendectomy b. 45 yo having a vaginal hysterectomy c. 60 yo having a traditional cholecystectomy for cholelithiasis d. 72 yo having a bowel resection for colon cancer

d. 72 yo having a bowel resection for colon cancer

Which cardinal signs will the nurse expect to assess in a client diagnosed with peritonitis? a. Fever with headache and confusion b. Dizziness with nausea and vomiting c. Loss of appetite with nausea and weight loss d. Abdominal pain with distention and tenderness

d. Abdominal pain with distention and tenderness

For which client finding will the nurse withheld the scheduled monthly dose of a prescribed parenteral biologic for management of ulcerative colitis? a. 5lb weight gain b. Increased number of diarrhea stools per day c. Presence of occult blood in today's stool sample d. Cough and fever of 102 F

d. Cough and fever of 102 F

Which drug will the nurse be sure to question to prevent harm when prescribed for an older adult with gastroenteritis? a. Azythromycin b. Protective skin barrier cream c. Ciprofloxacin d. Diphenoxylate hydrochloride with atropine sulfate

d. Diphenoxylate hydrochloride with atropine sulfate

3. A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take? a. Contact the provider and recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Obtain a suction device and implement seizure precautions. d. Encourage the client to drink more fluids.

d. Encourage the client to drink more fluids.

7. A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the client's creatinine level. d. Increase the client's fluid intake.

d. Increase the client's fluid intake.

1. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client. b. Contact the provider and recommend a 24-hour urine test. c. Review the client's recent dietary selections. d. Perform a capillary artery glucose assessment.

Chapter 61: Concepts of Care for Patients With Urinary Problems, Chapter 60: Assessment of the Renal/Urinary System, Chapter 60: Assessment of the Renal/Urinary System, ch. 52- Concepts of Care for Patients with Inflammatory Intestinal Disorders, 52...

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