Exam 2

A 52-year-old client is scheduled for diagnostic testing to address prolonged signs and symptoms of genitourinary dysfunction. What signs and symptoms are particularly suggestive of urinary tract disease? Select all that apply.

Pain Gastrointestinal symptoms Changes in voiding

A client is newly diagnosed with a peptic ulcer. For which medications will the nurse prepare teaching for this client? Select all that apply.

Metronidazole Bismuth subsalicylate Omeprazole

A creatinine level has been ordered. The nurse prepares to:

Obtain a blood specimen.

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

-Remove gas and fluids from the stomach -Diagnose gastrointestinal motility disorders -Flush ingested toxins from the stomach -Administer nutritional substances

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?

30 minutes

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.

6

The nurse is caring for several older clients. For which client would the nurse be especially alert for signs and symptoms of pyelonephritis?

A client with urinary obstruction

A nurse is teaching a client and the client's family about chronic pancreatitis. Which are the majorcauses of chronic pancreatitis?

Alcohol consumption and smoking

The patient has been diagnosed with urge incontinence. What classification of medication does the nurse expect the patient will be placed on to help alleviate the symptoms?

Anticholinergic agents

The nurse is caring for a client with an ileostomy because of inflammatory bowel disease. Which assessment findings indicate to the nurse that the ileostomy is functioning as expected? Select all that apply.

Continuous liquid flows from the stoma Stoma is pink and shiny

A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply.

Tachycardia Hypotension A rigid, board-like abdomen

A major goal when caring for a catheterized patient is to prevent infection. Select all the nursing actions that apply.

-Suspend the drainage bag off the floor. -Wash the perineal area with soap and water at least twice daily -Empty the collection bag at least every 8 hours to reduce bacterial growth.

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications?

Bleeding and perforation

The nurse is to check residual urine amounts for a client experiencing urinary retention. Which of the following would be most important?

Catheterize the client immediately after the client voids.

The nurse is caring for a client who requires enteral nutrition. For which reasons will the nurse anticipate the client having a gastrostomy tube inserted? Select all that apply.

Client is comatose Enteral support needed for over 6 weeks

A client postoperatively reports to the nurse the need to urinate, but is unable to void. What should the nurse expect the healthcare provider to order? Select all that apply.

Perform a bladder scan Complete a straight catheterization

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem?

Severe pancreatitis with possible peritonitis

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube.

Sit the client in an upright position Apply gloves to the nurse's hands Measure the length of the tube that will be inserted Apply water-soluble lubricant to the tip of the tube Tilt the client's nose upward Instruct the client to lower the head and swallow

A client who has been experiencing changes in bowel function is scheduled for a barium enema. Which instruction will the nurse provide for postprocedural recovery? Select all that apply.

Stool may be light colored for 3 days Increase fluid intake to evacuate the barium

A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response?

Surgery is delayed until the acute symptoms subside.

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer?

The client has a rigid, "board-like" abdomen that is tender.

A client is learning how to perform Kegel exercises. Which statement by the client indicates a need for additional teaching?

"I need to hold the position for at least 15 seconds."

A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate?

"Make sure to eat enough fiber to prevent constipation."

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer?

"My pain resolves when I have something to eat."

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply):

-Compares exposed tube length with original measurement -Visually assesses the color of the aspirate -Checks the pH of the gastric contents

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.

-Encourage the client to eat frequent, small, well-balanced meals. -Inform the client to remain upright for at least 2 hours after meals. -Instruct the client to avoid alcohol or tobacco products. -Instruct the client to eat slowly and chew the food thoroughly.

The nurse is caring for a client with chronic gastritis. Which interventions will the nurse add to this client's plan of care? Select all that apply.

-Remind to avoid alcohol intake. -Review actions to reduce stress. -Provide omeprazole as prescribed. -Instruct to avoid foods that aggravate the condition.

The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply.

-The client must fast for 8 hours before the examination. -The throat will be sprayed with a local anesthetic. -After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours).

A client with a nasogastric tube set to low intermittent suction is receiving D51/2NS at 100 mL/hr. The nurse has identified a nursing diagnosis of deficient fluid volume. Which of the following are data that support this diagnosis? Select all that apply.

-Urine output that decreased from 60 to 40 mL/hr -Heart rate that increased from 82 to 98 beats/min within 2 hours -Fluid output of 2150 mL and total fluid intake of 2000 mL for the past 24 hours

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply.

-Weigh the client every day. -Check blood glucose level every 6 hours. -Document intake and output.

A nurse catheterized an elderly client and confirmed the presence of residual urine. What residual urine volume would be considered abnormal for an elderly client?

150 mL

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complication(s)? Select all that apply.

Atelectasis Pneumonia Metabolic imbalances

The nurse is caring for a client who is scheduled for a urea breath test to detect for Helicobacter pylori as a reason for gastric distress. Which instruction(s) will the nurse provide to the client to prepare for this test? Select all that apply.

Avoid bismuth subsalicylate before the test. Do not take proton pump inhibitors before the test.

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. Which health education related to this medication will the nurse provide? Select all that apply.

Avoid drinking alcohol while taking the drug. May produce a metallic taste.

A young adult client is prescribed misoprostol to prevent gastric ulcers caused by frequent use of nonsteroidal anti-inflammatory agents for an autoimmune disorder. For which reason will the nurse question giving the client a dose of this medication?

Awaiting the results of a pregnancy test

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan?

Bed rest lowers the metabolic rate and reduces enzyme production.

A client presents to the emergency room with a possible diagnosis of appendicitis. The health care provider asks the nurse to assess for tenderness at McBurney's point. The nurse knows to palpate which area?

Between the umbilicus and the anterior superior iliac spine

The nurse advises the patient with chronic pyelonephritis that he should

Increase fluids to 3 to 4 L/24 hours to dilute the urine.

An older adult client reports experiencing hemorrhoids of increasing severity in recent months. Which education will the nurse provide to reduce the severity of occurrence? Select all that apply.

Increased fiber intake Increased fluid intake

The nurse and urologist have both been unsuccessful in catheterizing a client with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the health care provider will use to drain the client's bladder?

Insertion of a suprapubic catheter

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options.

Inspection Auscultation Percussion Palpation

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?

Limit the use of indwelling urinary catheters.

Diagnostic imaging and physical assessment have revealed that a client diagnosed with peptic ulcer disease has experienced a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication?

Peritonitis

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?

Potassium-rich foods

The client asks the nurse about the functions of the kidney. Which should the nurse include when responding to the client? Select all that apply.

Regulation of blood pressure Vitamin D synthesis Secretion of prostaglandins

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?

Rovsing sign

The nurse is assessing the client's ileal conduit stoma in the clinic. Which assessment finding would be of greatest concern to the nurse?

The stoma is dusky red.

The nurse is caring for a client with symptoms of gallbladder disease. Which diagnostic test will the nurse anticipate preparing the client for to confirm the diagnosis?

Ultrasound

A nurse is caring for a client admitted with acute pancreatitis. Which nursing action is most appropriate for a client with this diagnosis?

Withholding all oral intake, as ordered, to decrease pancreatic secretions

The nurse is caring for a client who is scheduled to have an upper endoscopy. Which type of medication(s) might be provided during the procedure? Select all that apply.

anticholinergic agent sedative analgesic agent