GIGU Exam 2 Study
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful? a. Arrange a dietary consult. b. Increase fluid intake. c. Limit the clients foods. d. Make the client NPO.
a. Arrange a dietary consult.
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.) a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. c. Prime the IV tubing with dextrose in water. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.
a. Ask a second nurse to double-check the blood. b. Prime the IV tubing with normal saline. d. Take and record a set of vital signs. e. Teach the client about reaction manifestations.
A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasisc. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity
A 50-year-old who has the BRCA2 gene mutation
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%
a. Body mass index of 46 d. Pregnant with twins f. Glycosylated hemoglobin level of 15%
A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Canned unsweetened apricots b. Coffee cake c. Milk shake d. Potato soup e. Steamed broccoli
a. Canned unsweetened apricots d. Potato soup
A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection
a. Client with congestive heart failure
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. "Take a 20-minute walk at least 5 days each week." b. "Attend local Alcoholics Anonymous (AA) meetings weekly." c. "Choose whole grains rather than foods with simple sugars." d. "Use cooking spray when you cook rather than margarine or butter." e. "Stay away from milk and dairy products that contain lactose." f. "We can talk to your doctor about a prescription for nicotine patches."
b. "Attend local Alcoholics Anonymous (AA) meetings weekly." d. "Use cooking spray when you cook rather than margarine or butter." f. "We can talk to your doctor about a prescription for nicotine patches."
After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates a 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."
b. "I may have been exposed when we ate shrimp last weekend."
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "Drinking at least 2 liters of water each day is suggested." b. "I will decrease the amount of fatty foods in my diet." c. "Drinking fluids with my meals will increase bloating." d. "I will avoid concentrated sweets and simple carbohydrates."
b. "I will decrease the amount of fatty foods in my diet."
A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate? a. "Do you have family or friends for support?" b. "I'd like to know what you are feeling now. " c. "Well, we knew this would probably happen." d. "Would you like me to refer you to hospice?"
b. "I'd like to know what you are feeling now. "
A nurse cares for a client with hepatitis C. The clients brother states, "I do not want to contract this infection, so I will not go into his hospital room." How should the nurse respond? a. "If you wear a gown and gloves, you will not get this virus." b. "Viral hepatitis is not spread through casual contact." c. "This virus is only transmitted through a fecal specimen." d. "I can give you an update on your brothers status from here"
b. "Viral hepatitis is not spread through casual contact."
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should 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 have your new liver checked out." c. "You should take an additional dose of cyclosporine today." d. "Take acetaminophen (Tylenol) every 4 hours until you feel better."
b. "You should go to the hospital immediately to have your new liver checked out."
A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes
d. A 66-year-old who smokes cigarettes
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.
d. Assess the client for airway patency.
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2
d. International normalized ratio (INR): 4.2
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain
d. Mid-sternal chest pain
A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene
d. Performing appropriate hand hygiene
A client wants to lose 1.5 pounds a week. After reviewing a diet history, the nurse determines the client typically eats 2450 calories a day. What should the clients calorie goal be to achieve this weight loss? (Record your answer using a whole number.) __________________calories/day
1,700 calories/day
A nurse cares for a client with acute pancreatitis who is prescribed gentamicin (Garamycin) 3 mg/kg/day in 3 divided doses. The client weighs 264 lb. How many milligrams should the nurse administer for each dose? ______________mg/dose
120 mg/dose
A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) __________________mL
280 mL
A nurse cares for a client who is prescribed 4 mg of calcium gluconate to infuse over 5 hours. The pharmacy provides 2 premixed infusion bags with 2 mg of calcium gluconate in 100 mL of D5W. At what rate should the nurse administer this medication? (Record your answer using a whole number.) ________________mL/hr
40 mL/hr
A client weighs 228 pounds (103.6 kg) and is 53 (160 cm) tall. What is this clients body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.) BMI: __________
40.4
A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. "Ambulating in the hallway twice a day will help." b. "I will apply a cold compress to the painful area on your back." c. "Drinking a warm beverage can relieve this referred pain." d. "You should cough and deep breathe every hour."
a. "Ambulating in the hallway twice a day will help."
A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."
a. "Bile salts accumulate in the skin and cause the itching."
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider
a. Registered dietitian c. Clinical pharmacist e. Health care provider
A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires 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 18 to 14 breaths/min d. A decrease in the client's weight by 6 kg
a. Urine output via indwelling urinary catheter is 20 mL/hr
An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best? a. Ask the family why they feel this way. b. Assess family concerns and fears. c. Refuse to go along with the family's wishes. d. Tell the family that such secrets cannot be kept.
b. Assess family concerns and fears.
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should 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 client gain weight and muscle mass. d. Low dietary protein is needed to prevent fluid from leaking into the abdomen.
b. Less protein in the diet will help prevent confusion associated with liver failure.
A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs
b. Performing frequent oral care
A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red biohazard bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.
b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client.
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? a. Administer ibuprofen (Motrin). b. Call the Rapid Response Team. c. Start a large-bore IV with normal saline. d. Tell the client to remain lying down.
c. Start a large-bore IV with normal saline.
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation. c. The best time to take the enzymes is immediately after I have a meal or a snack. d. I will not mix the enzyme powder with food or liquids that contain protein.
c. The best time to take the enzymes is immediately after I have a meal or a snack.
A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this clients height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers.
d. Use knee-height calipers.
After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
d. Roasted chicken breast, baked potato with chives, and orange juice
A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. All weight-loss drugs can cause suicidal ideation. b. No drugs are currently available for weight loss. c. Only over-the-counter medications are available. d. There are three drugs currently approved for this.
d. There are three drugs currently approved for this.
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy
d. Willingness to adhere to drug therapy
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond? a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for 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."
a. "Diarrhea is expected; that's how your body gets rid of ammonia."
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. "Do you have a one- or two-story home?" b. "Can you check your own pulse rate?" c. "Do you have any alcohol in your home? " d. "Can you prepare your own meals?"
a. "Do you have a one- or two-story home?"
A nurse cares for a client with end-stage pancreatic cancer. The client asks, "Why is this happening to me?" How should 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."
a. "I don't know. I wish I had an answer for you, but I don't."
A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? a. "Use a pill organizer to ensure you take this medication as prescribed." b. "Transient muscle aching is a common side effect of this medication." c. "Follow up with your provider in 1 week to test your blood for toxicity. " d. "Take your radial pulse for 1 minute prior to taking this medication.'
a. "Use a pill organizer to ensure you take this medication as prescribed."
An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the client's chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.
b. Assess the client by gently palpating the abdomen for tenderness.
A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.
b. Assist the client to void before the procedure.
A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes
b. Beginning venous thromboembolism prophylaxis
A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale.
b. Check tube placement before each feeding.
A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL
b. Cholesterol: 142 mg/dL
A clients small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.
b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. e. Try to flush the tube with 30 mL of water and gentle pressure.
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. Apply lotion to the clients dry skin areas. b. Use a basin with warm water to bathe the client. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. e. Bathe with antibacterial and water-based soaps.
a. Apply lotion to the clients dry skin areas. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails.
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner
a. A 20-year-old college student who has had several sexual partners
The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia
a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection e. Pernicious anemia
A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the clients formula. c. Dilute the clients formula. d. Slow the rate of infusion.
a. Administer free-water boluses.
A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.) a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. c. Keep the drug in its original brown bag. d. Take vital signs frequently during infusion. e. Use an in-line IV filter when infusing.
a. Administer the drug through a separate IV line. b. Infuse pantoprazole using an IV pump. e. Use an in-line IV filter when infusing.
A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.
a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. e. Provide iron supplements for the client.
The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
a. Alcohol b. Caffeine c. Corticosteroids e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks.
a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. e. Serve high-calorie, high-protein snacks.
A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.
a. Ask the client if the weight loss was intentional.
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the clients oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN.
a. Assess the 24-hour fluid balance.
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says, "I didn't know it would be this hard to live like this." What response by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard.
a. Assess the client's coping and support systems.
A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the clients endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the clients nasogastric tube to low intermittent suction. d. Start lactated Ringers solution through an intravenous catheter.
a. Assess the clients endotracheal tube with 40% FiO2.
A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down. e. Administer prescribed opioids.
a. Contact the provider immediately. b. Lower the head of the bed.
The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages
a. Cultural food preferences c. Increased need for nutrition d. Need for NPO status e. Staff shortages
A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage
a. Drainage from a fistula
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer? d. Have you ever worked as a plumber? e. Were you previously incarcerated?
a. How frequently do you drink alcohol? b. Have you ever had sex with a man? e. Were you previously incarcerated?
A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. Increase the fiber and water in your diet. b. Reduce fat to less than 30% each day. c. Report dry mouth and decreased sweating. d. Lorcaserin may cause loose stools for a few days.
a. Increase the fiber and water in your diet.
A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the client's refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.
a. Instruct the client to sit in as upright a position as possible.
A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should 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
a. Oxygen therapy c. Feet elevated on pillows d. Daily weights
An infection control nurse develops a plan to decrease the number of healthcare professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner
a. Policies related to consistent use of Standard Precautions c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner
A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of 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. Elevated international normalized ratio (INR) e. Elevated serum ammonia f. Elevated prothrombin time (PT)
A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, When I wake up I am in pain. Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client.
b. Encourage the client to use the PCA pump upon awakening.
A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client's readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave side rails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client.
b. Ensure adequate staff when moving the client.
A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating quiet time so the client can rest b. Ensuring side rails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse
b. Ensuring side rails are not causing excess pressure
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 additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.
b. I need to avoid protein in my diet.
A nurse obtains a client's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.
b. I take a lot of Tylenol for my arthritis pain.
An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.
b. Increase intake of calcium and vitamin D.
A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.
b. Increase the amount of vegetables to 1.1 cups/1000 calories. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.
b. Maintain nothing by mouth (NPO) and administer intravenous fluids.
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. Do not allow the client to eat between meals. b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice. e. Do not allow high-carbohydrate food items.
b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.
b. Notify the health care provider immediately.
A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowlers position. c. Assess vital signs once every shift. d. Provide oral rehydration.
b. Place the client in semi-Fowlers position.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.
b. Provide a low-sodium diet.
A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.
b. Request an electrocardiogram (ECG).
A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best? a. Slippery elm has no benefit for this problem. b. Slippery elm is often used for this disorder. c. There is no evidence that this will work. d. You should not take any herbal remedies.
b. Slippery elm is often used for this disorder.
Several nurses have just helped a morbidly obese client get out of bed. One nurse assesses the client's record because, "I just have to know how much she weighs!" What action by the clients nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State, "That is a violation of client confidentiality." c. Tell the nurse, "Don't look; I'll tell you her weight." d. Walk away and ignore the other nurses behavior.
b. State, "That is a violation of client confidentiality."
A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (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
b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations
b. Tachycardia d. Confusion
A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply? a. "Is your stomach rumbling or do you have bowel sounds?" b. "I need to check your gag reflex before you can eat." c. "Have you passed any flatus or moved your bowels? " d. "You will not be able to eat until the pain subsides."
c. "Have you passed any flatus or moved your bowels? "
After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the client's understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. "I should drink bottled water during my travels." b. "I will not eat off another's plate or share utensils." c. "I should eat plenty of fresh fruits and vegetables." d. "I will wash my hands frequently and thoroughly."
c. "I should eat plenty of fresh fruits and vegetables."
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should 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."
c. "I will help you identify a support system."
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition
c. A 66-year-old who has a history of cirrhosis
For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)? a. Client taking antacids b. Client taking antibiotics c. Client who is pregnant d. Client over 65 years of age
c. Client who is pregnant
A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L
c. Client with a potassium level of 2.6 mEq/L
A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the clients bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care providers notes about the prognosis for the client.
c. Determine whether the client feels like talking about his or her feelings.
A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.
c. Ensure an adequate airway.
A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the client's mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.
c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.
A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again.
c. Fill out and file a variance report.
A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the clients gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half.
c. Hold the feeding until the nausea subsides.
A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate? a. Assess the client for iodine or shellfish allergies. b. Educate the client on the side effects of sedation. c. Inform the client a second scan may be needed. d. Teach the client about bowel preparation for the scan.
c. Inform the client a second scan may be needed.
A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting
c. Intolerance of fatty foods d. Pernicious anemia
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1 F (37.8 C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
c. Light-colored stools
The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor
c. Mucosal barrier fortifier
A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight
c. Psychosocial influences on weight
A nurse answers a client's call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first? a. Assist the client back to bed. b. Notify the provider immediately. c. Put on a pair of gloves. d. Take a set of vital signs.
c. Put on a pair of gloves
A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate?a. Aspirin must be avoided. b. Do not worry about black stools. c. Report diarrhea to your provider. d. Take 1 hour before meals.
c. Report diarrhea to your provider.
A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition
c. Specific lack of protein