Lisette's NCLEX MED SURG Study #3

A client's serum albumin value is 2.8 g/dL. The nurse evaluates that teaching is successful when the client says, "For lunch I am going to have: 1. fruit salad." 2. sliced turkey." 3. spinach salad." 4. clear beef broth."

. 2 This serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL; white meat turkey (two slices 4 × 2 × ¼ inch) contains approximately 28 grams of protein. 1 A 6-ounce serving of mixed fruit contains approximately 0.5 gram of protein. 3 A 3-ounce serving of spinach salad contains approximately 9 grams of protein. 4 A 4-ounce serving of beef broth contains approximately 2.4 grams of protein.

A 52-year-old woman 3 hours into a car trip is injured in an automobile collision and is admitted for observation. Damage to her bladder is evident. The history that indicates an increased risk of bladder rupture is: 1. Multiple bouts of cystitis 2. Familial history of bladder cancer 3. Failure to have voided before starting the trip 4. Drinking two cups of coffee before the accident

. 3 The walls of a full bladder are stretched thinner and are more susceptible to rupture when traumatized. 1 A history of cystitis predisposes the client to developing future bladder infections, not to rupturing the bladder. 2 A family member with bladder cancer might increase the risk of cancer; however, it will not predispose the client to bladder rupture. 4 This will not result in the production of enough urine to expand the bladder if the client voided before starting the trip.

A client who has a hiatal hernia is 5 feet 3 inches tall and weighs 140 pounds, asks the nurse how to prevent esophageal reflux. The nurse's best response is: 1. "Increase your intake of fat with each meal." 2. "Lie down after eating to help your digestion." 3. "Reduce your caloric intake to foster weight reduction." 4. "Drink several glasses of fluid during each of your meals."

. 3 Weight reduction decreases intra-abdominal pressure, thereby decreasing the tendency to reflux into the esophagus. 1 Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. 2 This increases the pressure against the diaphragmatic hernia, increasing symptoms. 4 This will increase pressure; fluid should be discouraged with meals.

After a successful kidney transplant for a client with end-stage kidney disease, the nurse anticipates that laboratory studies will demonstrate: 1. Increased specific gravity 2. Correction of hypotension 3. Elevated serum potassium 4. Decreasing serum creatinine

. 4 As the transplanted organ functions, nitrogenous wastes are eliminated, lowering the serum creatinine. 1 As more urine is produced by the transplanted kidney, the specific gravity and concentration of the urine will decrease. 2 With end-stage kidney disease, fluid retention causes hypertension. There should be a correction of hypertension, not hypotension. 3 After the transplant, the serum potassium should correct to within expected limits for an adult

A nurse is assessing a client who reports frequency and burning when urinating. The nurse performs percussion to determine if there is tenderness that indicates the presence of an ascending urinary tract infection. Which area should be percussed? 1. Tail of Spence 2. Suprapubic area 3. McBurney's point 4. Costovertebral angle

. 4 The costovertebral angle (angle formed by the lateral and downward curve of the lowest rib and the vertebral column of the spine itself) is percussed to determine if there is tenderness in the area over the kidney; this can be a sign of glomerulonephritis or severe upper urinary tract infection. 1 The tail of Spence extends from the upper outer quadrant of the breast to the axillary area; this is the most common site for tumors associated with cancer of the breast. 2 The suprapubic area is above the symphysis pubis; it is palpated and percussed to assess for bladder distention. 3 McBurney's point is 1 to 2 inches above the anterosuperior spine of the ileum on a line between the ileum and umbilicus; external pressure produces tenderness with acute appendicitis, not a kidney infection.

After a cholecystectomy a client asks whether there are any dietary restrictions that must be followed. The nurse evaluates that the dietary teaching is understood when the client tells a family member: 1. "I should avoid fatty foods for the rest of my life." 2. "I should not eat those foods that upset me before I had surgery." 3. "I need to eat a high-protein diet for several months after surgery." 4. "I probably will be able to tolerate a regular diet after this type of surgery."

. 4 The response is individual, but ultimately most people can eat anything they want. 1 Fats may have to be gradually reintroduced, but most people tolerate them after this surgery. 2 Foods that caused gastric distress before surgery usually are tolerated after surgery. 3 Increased protein is needed only until healing has occurred.

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: 1. Monitor the client's vital signs 2. Increase the client's fluid intake 3. Improve the client's nutritional status 4. Determine the client's reasons for drinking

1 A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. 2 Increasing intake is contraindicated initially because it may cause cerebral edema. 3 Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. 4 Determining the client's reasons for drinking is not a priority until after the detoxification process.

Three hours after a subtotal gastrectomy, a client who has a nasogastric tube to continuous low suction and IV fluids complains of nausea and abdominal pain. The client's abdomen appears distended and there are no bowel sounds. The nurse should first: 1. Instill air into the tube 2. Give the prn pain medication 3. Check bowel movements for blood 4. Notify the surgeon of absent bowel sounds

1 Abdominal distention, nausea, and abdominal pain can be signs of nasogastric tube blockage. Instilling 30 mL of air may reestablish patency. 2 Although opioids usually are ordered postoperatively, they tend to decrease peristalsis and may increase abdominal distention and nausea. 3 There will be no stools for several days. 4 Bowel sounds are not expected for several days after stomach or intestinal surgery.

To determine when a client who had a subtotal gastrectomy can begin oral feedings after surgery, the nurse must assess for the: 1. Presence of flatulence 2. Extent of incisional pain 3. Stabilization of hematocrit levels 4. Occurrence of dumping syndrome

1 Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the GI tract. 2 Incisional pain is unrelated to intestinal peristalsis. 3 Hematocrit levels indicate blood loss; they are unaffected by GI functioning. 4 Dumping syndrome occurs after, not before, the ingestion of food and does not indicate readiness to ingest food.

When teaching a community health class the nurse informs the group that the person at highest risk of developing prostate cancer is a: 1. 55-year-old black male 2. 45-year-old white male 3. 55-year-old Asian male 4. 45-year-old Hispanic male

1 Cancer of the prostate is rare before age 50 but increases with each decade; black men develop cancer of the prostate twice as often and at an earlier age than white men. 2 White men develop prostatic cancer half as often as black men, but more commonly than Asian or Hispanic men. 3 This group of men has a lower incidence of prostatic cancer and lower mortality rate than white and black men. 4 This group of men has a lower incidence of prostatic cancer and lower mortality rate than white and black men.

A nurse is performing a physical assessment of a client with ulcerative colitis. The finding most often associated with a serious complication of this disorder is: 1. Decreased bowel sounds 2. Loose, blood-tinged stools 3. Distention of the abdomen 4. Intense abdominal discomfort

1 Decreased intestinal motility is associated with serious problems, such as perforation or toxic megacolon. 2 This is an uncomfortable but less serious manifestation. 3 This is an expected response that is not of primary concern at this time. 4 Intense pain is a symptom of ulcerative colitis, not a complication.

A client is scheduled for a transurethral prostatectomy. He is concerned about the operation's effect on his sexual ability. The nurse should reply that he may: 1. Experience retrograde ejaculations 2. Have prolonged erections afterward 3. Be permanently impotent after the operation 4. Develop a diminishing sex drive after the surgery

1 Ejection of semen into the bladder instead of the urethra is common after a transurethral prostatectomy. 2 This surgery will not cause prolonged erections. 3 Impotence is not usual with this approach; it may occur with the retroperitoneal approach. 4 This surgery should not interfere with the libido.

A client has surgery to repair a bladder laceration. The routine nursing intervention that takes priority in the postoperative care of this client is: 1. Repositioning frequently 2. Giving lower back care 3 times daily 3. Implementing range-of-motion exercises 4. Placing 3 side rails in the elevated position

1 Frequent position changes are important to ensure efficient urinary drainage; gravity promotes flow, which prevents obstruction. 2 Back care is necessary but is not a priority. 3 ROM is of minimal importance because the client will be able to move without limitation. 4 Raising three side rails is routine care, particularly if the client is sedated; positioning to promote urinary drainage takes priority. Clinical Area: Medical-Surgical Nursing; Client Needs: Reduction of Risk Potential; Cognitive Level: Application; Nursing Process: Planning

A client is diagnosed as having hepatitis A. The information from the admitting data that most likely is linked to hepatitis A is the client's history of working: 1. For a local plumber 2. In a hemodialysis unit of a hospital 3. As a dishwasher at a local restaurant 4. With occupational arsenic compounds

1 Hepatitis A is primarily spread via a fecal-oral route; sewage-polluted water may harbor the virus. 2 Hepatitis types B, C, and D are more often spread via the bloodborne route; using disposable equipment and proper handling of syringes decreases the risk of spreading the virus. 3 This does not increase the risk of developing the disease, but will increase the risk of an infected individual spreading the disease to others. 4 Exposure to arsenic or carbon tetrachloride can cause toxic hepatitis, which is not communicable.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for: 1. Monthly injections of vitamin B12 2. Regular daily use of a stool softener 3. Weekly injections of iron dextran (Imferon) 4. Daily replacement therapy of pancreatic enzymes

1 Intrinsic factor is lost with removal of the stomach, and vitamin B12 is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. 2 Adequate diet, fluid intake, and exercise should prevent constipation. 3 This is not a routine expectation. 4 This surgery does not affect pancreatic enzymes.

A client with end-stage kidney disease is to begin continuous ambulatory peritoneal dialysis (CAPD). When assessing the client before the institution of CAPD, the nurse should be alert for the presence of: 1. Client motivation 2. Cardiac problems 3. Emotional lability 4. Pulmonary problems

1 Lack of motivation is the most serious impediment to successful CAPD. 2 This is not a contraindication to CAPD. 3 This is not a contraindication to CAPD. 4 This is not a contraindication to CAPD.

The nurse teaches a client to irrigate a new sigmoid colostomy when the: 1. Stool starts to become formed 2. Client can lie on the side comfortably 3. Abdominal incision is closed and contamination is no longer a danger 4. Perineal wound heals and the client can sit comfortably on the commode

1 Once stool is formed, peristalsis needs to be stimulated to promote the passage of stool. 2 The sitting, not side-lying, position is the position of choice for a colostomy irrigation because it facilitates evacuation of the bowel via gravity. 3 Contamination is avoided because fecal elimination flows through the sleeve of the colostomy appliance directly into the commode. 4 The perineal wound may take weeks to heal, and irrigations must be started when the stool is formed.

When a client returns from the postanesthesia care unit after a kidney transplant, the nurse should plan to measure the client's urinary output every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 15 minutes

1 Output is critical when assessing kidney function. The urinary output should be monitored every 30 to 60 minutes; decreasing urinary output is a sign of rejection. 2 This is too infrequent to monitor output immediately after a transplant. It is essential to monitor output more frequently to evaluate whether the new kidney is working or whether it is being rejected. 3 This is too infrequent to monitor output immediately after a transplant. It is essential to monitor output more frequently to evaluate whether the new kidney is working or whether it is being rejected. 4 It is not necessary to monitor urinary output this frequently.

A client with a tentative diagnosis of cholecystitis is discharged from the emergency department with instructions to make an appointment for a definitive diagnostic workup. The recommendation that will produce the most valuable diagnostic information is: 1. "Keep a journal related to your pain." 2. "Save all stool and urine for inspection." 3. "Follow the physician's orders exactly without question." 4. "Keep a record of the amount and type of fluid you are drinking daily."

1 Pain is a cardinal symptom; it is helpful to have as much specific information about it as possible, particularly its description and its relationship to foods ingested. 2 It is not necessary to save all urine and stool, although changes in color should be reported. 3 The client should be free to question orders that are not understood or agreed with. 4 Although the quality of fluid (e.g., high fat) may be significant, the amount of fluid will not add any valuable information.

A practitioner orders three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound weight loss in 1 month. To ensure valid test results, the nurse should instruct the client to: 1. Avoid eating red meat before testing 2. Test the specimen while it is still warm 3. Discard the day's first stool and use the next three stools 4. Take three specimens from different sections of the fecal sample

1 Red meat can react with reagents used in the test to cause false-positive results. 2 This may apply for testing for ova and parasites, not for occult blood. 3 If the correct procedure is followed, discarding the first specimen is unnecessary. 4 Random stool testing can be done but must be on three different bowel movements during the screening period.

A client with gastric cancer asks whether this cancer will spread. The nurse identifies that the client is looking for reassurance. When preparing a response to the client's question, the nurse recalls that gastric cancers are most likely to metastasize to the: 1. Liver and lung 2. Bone and brain 3. Pancreas and brain 4. Lymph nodes and blood

1 Statistics demonstrate that these are the most likely sites for metastasis of this tumor. 2 It is less likely that the tumor will spread to these areas. 3 It is less likely that the tumor will spread to these areas. 4 These are routes of metastasis.

A client with extensive gastric carcinoma is admitted to the hospital for an esophagojejunostomy. What information should the nurse include in the teaching plan when preparing this client for surgery? 1. Chest tube will be in place immediately after surgery 2. Liquids by mouth may be permitted the evening after surgery 3. Complete bed rest may be necessary for two days after surgery 4. Trendelenburg's position will be used on the first day after surgery

1 The thoracic cavity usually is entered for a complete resection, necessitating a chest tube. 2 Fluids are contraindicated until the suture line has healed and nasogastric suction is no longer being used. 3 The client should ambulate early to minimize the hazards of immobility. 4 There is no physiological necessity for this position.

The characteristics that alert the nurse that a client is at increased risk of developing gallbladder disease is a female: 1. Older than the age of 40, obese 2. Younger than the age of 40, history of high fat intake 3. Older than the age of 40, low serum cholesterol level 4. Younger than the age of 40, family history of gallstones

1 These characteristics are well-established risk factors for gallbladder disease (3 Fs - female, fat, and forty). 2 Although these clients usually are older than the age of 40, a high-fat intake does not predispose one to cholecystitis. 3 The age is correct, but these clients have an increase in serum cholesterol. 4 Although there is an increased risk with a family history of gallstones, these clients usually are older than the age of 40.

A client who has had a transurethral prostatectomy (TURP) experiences dribbling after the indwelling catheter is removed. To address this problem, the nurse should state: 1. "Increase your fluid intake and urinate at regular intervals." 2. "I know you're worried, but it will go away in a few days." 3. "Limit your fluid intake and urinate when you first feel the urge." 4. "The catheter will have to be reinserted until your bladder regains its tone."

1 This will improve bladder tone, which should alleviate dribbling. 2 This identifies feelings but does not actively help the client solve the problem. 3 These interventions do not increase bladder tone; fluids should be increased and the time between voidings should be increased gradually. 4 Continuous bladder decompression will reduce bladder tone; reduced bladder tone will persist when the indwelling catheter is removed until bladder tone improves.

Because of prolonged bile drainage from a T-tube after a cholecystectomy, the nurse must monitor the client for responses related to a lack of fat-soluble vitamins such as: 1. Easy bruising 2. Muscle twitching 3. Excessive jaundice 4. Tingling of the fingers

1 Vitamin K, a precursor for prothrombin, cannot be absorbed without bile. 2 This is commonly related to electrolyte imbalances, not fat-soluble vitamin deficiency. 3 Jaundice results from a backup of bile, not a deficiency of fat-soluble vitamins. 4 This may be related to electrolyte imbalances or deficiency of B vitamins, which are water soluble.

In the early postoperative period after a transurethral resection of the prostate, the most common complication the nurse should monitor for is: 1. Sepsis 2. Hemorrhage 3. Leakage around the catheter 4. Urinary retention with overflow

2 After transurethral surgery, hemorrhage can occur because of venous oozing and bleeding from many small arteries in the area. 1 Sepsis is unusual and occurs later in the postoperative course. 3 Leaking around the catheter is not a major complication. 4 Urinary retention is unlikely with an indwelling catheter in place.

A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1. Blood glucose 2. Serum amylase 3. Serum bilirubin level 4. White blood cell count

2 Amylase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems. 1 An elevated blood glucose level is not indicative of pancreatitis, but rather diabetes mellitus; however, hyperglycemia and glycosuria may occur in some people with acute pancreatitis if the islets of Langerhans are affected. 3 This occurs in other disease processes, such as cholecystitis. 4 This is not specific to pancreatitis; white blood cells are elevated in other disease processes.

A client comes to the infectious disease clinic because a sexual partner was recently diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. The nurse should assess the client for: 1. Melena 2. Anal itching 3. Constipation 4. Ribbon-shaped stools

2 Anal itching and irritation are related to erythema and edema of the anal crypts caused by the gonococci. 1 Frank rectal bleeding, not upper GI bleeding, occurs. 3 Diarrhea, not constipation, occurs. 4 The shape of formed stool does not change; however, diarrhea does occur.

After a suprapubic prostatectomy, a client's plan of care must include the prevention of postoperative deep vein thrombosis. This is best achieved by increasing the: 1. Coagulability of the blood 2. Velocity of the venous return 3. Effectiveness of internal respiration 4. Oxygen-carrying capacity of the blood

2 Because venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity. 1 Increasing the coagulability of the blood can lead to the development of deep vein thrombosis. 3 This will not affect the prevention of deep vein thrombosis. 4 This will not affect the prevention of deep vein thrombosis.

When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client first: 1. Passes flatus 2. Has bowel sounds 3. Tolerates clear liquids 4. Has a bowel movement

2 Bowel sounds are the result of peristaltic movements that propel intestinal contents through the alimentary tract, causing characteristic sounds. 1 Bowel sounds will be heard before flatus is passed. 3 Liquids should not be given until bowel sounds have returned. 4 Peristalsis will return before the client has a bowel movement.

A female client is admitted to the hospital with severe renal colic caused by a ureteral calculus. Later that evening the client's urinary output is much less than her intake. When it is confirmed that her bladder is not distended, the nurse should suspect the development of: 1. Oliguria 2. Hydroureter 3. Renal shutdown 4. Urethral obstruction

2 Calculi may obstruct the flow of urine to the bladder, allowing the urine to distend the ureter, causing hydroureter. 1 There is insufficient information to come to this conclusion even though output is less than intake; oliguria is present when the output is between 100 and 500 mL in a 24-hour period. 3 Calculi do not cause renal shutdown directly; they may obstruct the urinary tract and cause damage indirectly as a result of pressure from urine buildup. 4 If the urethra is obstructed, the bladder will be distended.

Routine postoperative intravenous fluids are designed to supply hydration and electrolytes and only limited energy. Because 1 L of a 5% dextrose solution contains 50 grams of sugar, 3 L/day will supply approximately: 1. 400 kilocalories 2. 600 kilocalories 3. 800 kilocalories 4. 1000 kilocalories

2 Carbohydrates provide 4 kcal/g; therefore, 3 L × 50 g/L × 4 kcal/g = 600 kcal, only about a third of the basal energy need. 1 This is less than the kilocalories provided by the ordered IV fluid. 3 This is more than the kilocalories provided by the ordered IV fluid. 4 This is more than the kilocalories provided by the ordered IV fluid.

A client with colitis inquires as to whether surgery will eventually be necessary. When teaching about the disease and its treatment, the nurse should emphasize that: 1. Medical treatment for colitis is curative; surgery is not required 2. Surgery for colitis is considered only as a last resort for most clients 3. Surgery for colitis is done early in the course of the disorder for most clients 4. Medical treatment is all that will be needed if the client can acquire some emotional stability

2 Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. 1 This is untrue; medical treatment is symptomatic, not curative. 3 It is usually performed as a last resort. 4 Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.

A 40-year-old client is admitted with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of: 1. Pruritus 2. Bleeding 3. Flatulence 4. Hypokalemia

2 Obstruction of bile flow impairs absorption of vitamin K, a fat-soluable vitamin; prothrombin is not produced and the clotting process is prolonged. 1 Although deposition of bile salts in the skin may lead to pruritus, this is not life threatening. 3 Although there may be an increase in flatulence with biliary disease, it is not life threatening. 4 Obstructive jaundice does not affect potassium levels.

Diet instruction for a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD) for chronic glomerulonephritis includes the need for: 1. Low-calorie foods 2. High-quality protein 3. Increased fluid intake 4. Foods rich in potassium

2 Proteins eaten should be high quality to replace those lost during dialysis. 1 A high-calorie diet is encouraged. 3 Usually there is a modest restriction of fluids when the client is on dialysis. 4 Usually there is a restriction of high-potassium foods when the client is on dialysis.

A 62-year-old woman who has been on hemodialysis for several weeks asks the nurse what substances are being removed by the dialysis. The nurse informs the client that one of the substances passing through the membrane is: 1. RBCs 2. Sodium 3. Glucose 4. Bacteria

2 Sodium is an electrolyte that passes through the semipermeable membrane during hemodialysis. 1 These do not pass through the semipermeable membrane during hemodialysis. 3 This does not pass through the semipermeable membrane during hemodialysis. 4 These do not pass through the semipermeable membrane during hemodialysis.

A male client with a history of chronic kidney disease is hospitalized. The nurse assesses the client for signs of related kidney insufficiency, which include: 1. Facial flushing 2. Edema and pruritus 3. Dribbling after voiding 4. Diminished force and caliber of stream

2 The accumulation of metabolic wastes in the blood (uremia) can cause pruritus; edema results from fluid overload caused by impaired urine production. 1 Pallor occurs with chronic kidney disease as a result of anemia. 3 This is a urinary pattern that is not caused by chronic kidney disease; this may occur after prostate surgery. 4 These occur with an enlarged prostate, not kidney disease.

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, the primary nursing intervention is to: 1. Coax the client into caring for the ileostomy alone 2. Evaluate the client's ability to care for the ileostomy 3. Ensure the client understands the dietary limitations that must be followed 4. Have the client change the dry sterile dressing on the incision without assistance

2 The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge. 1 People should not be pressured into performing self-care before they are physically and emotionally ready. 3 The diet is not limited; however, the client should be encouraged to eat a high-protein diet or a regular diet with supplemental protein; a high-fluid intake should be maintained. 4 Often the client no longer needs a dressing on the incision at the time of discharge; a collection pouch is used over the stoma.

When performing a peritoneal dialysis procedure, the nurse should: 1. Place the client in a side-lying position 2. Warm dialysate solution slightly before instillation 3. Infuse the dialysate solution slowly over several hours 4. Withhold the routine medications until after the procedure

2 The infusion should be warmed to body temperature to lessen abdominal discomfort and promote dilation of peritoneal vessels. 1 The side-lying position may restrict fluid inflow and prevent maximum urea clearance; the client should be placed in the semi-Fowler position. 3 The infusion of dialysate solution should take approximately 5 to 10 minutes. 4 Routine medications should not interfere with the infusion of dialysate solution.

An acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy for cancer of the kidney is: 1. Sepsis 2. Hemorrhage 3. Renal failure 4. Paralytic ileus

2 The kidney, an extremely vascular organ, receives a large percentage of the blood flow, and hemorrhage from the operative site can occur. 1 This may occur later in the postoperative period. 3 This may occur later in the postoperative period. 4 This can occur, but it is not life threatening.

An 80-year-old male client had surgery for a strangulated hernia. One hour after surgery his blood pressure drops from 134/80 to 114/76. Assessment reveals that he does not have postoperative bleeding. The nurse should: 1. Turn him onto his left side 2. Encourage him to move his legs 3. Call the practitioner immediately 4. Administer his prescribed pain medication

2 The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return. 1 This will not increase the blood pressure; this intervention is used for pregnant women to move the gravid uterus off the vena cava, which increases placental perfusion. 3 This eventually may be done after performing the initial interventions and evaluating results. 4 Opioid analgesics may decrease the blood pressure further.

A client has symptoms associated with salmonellosis. Relevant data to gather from this client include a history of: 1. Any rectal cancer in the family 2. All foods eaten in the past 24 hours 3. Any recent extreme emotional stress 4. An upper respiratory infection in the past 10 days

2 The salmonella organism thrives in warm, moist environments; washing, cooking, and refrigeration of food limits the growth of or eliminates the organism. 1 Salmonellosis is unrelated to cancer. 3 Salmonellosis is caused by the salmonella organism, not stress. 4 The salmonella organism is ingested; it is not an airborne or bloodborne infection.

When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. This area is known as the: 1. Iliac area 2. Epigastric area 3. Hypogastric area 4. Suprasternal area

2 The stomach is located within the sternal angle, known as the epigastric area. 1 This is in the area of the iliac bones. 3 This is the lowest middle abdominal area. 4 This is the area above the sternum.

The nurse evaluates that a client who had a transurethral vaporization of the prostate understands the discharge teaching when he says, "I should: 1. sit for several hours daily." 2. report if my urinary stream decreases." 3. attempt to void every 3 hours when I'm awake." 4. avoid vigorous exercise for 6 months after surgery."

2 The urethral mucosa in the prostatic area is affected during surgery, and strictures may form with healing. 1 The client should be ambulating; sitting for several hours is contraindicated because it promotes venous stasis and thrombus formation. 3 The client should void as the need arises; straining can cause pressure in the operative area, precipitating hemorrhage. 4 Although vigorous exercise should be avoided, 6 months is too long for this restriction.

A 64-year-old client diagnosed with cancer of the bladder is scheduled for a total cystectomy and the formation of an ileal conduit. When assessing the client 8 hours after surgery, the nurse identifies all of the following findings. Which finding should be promptly reported? 1. Edematous stoma 2. Dusky-colored stoma 3. Absence of bowel sounds 4. Pink-tinged urinary drainage

2 This may denote a compromised blood supply to the stoma and impending necrosis. 1 This is expected in the early postoperative period after this surgery. 3 This is expected in the early postoperative period after this surgery. 4 Pink-tinged urine may be present in the immediate postoperative period.

A client has a surgical creation of a colostomy for cancer of the rectum. When comparing the procedures of a colostomy irrigation and an enema, the nursing intervention that is unique to a colostomy irrigation is: 1. Positioning the client for evacuation of the bowel 2. Lubricating the catheter tip with a water-soluble jelly 3. Instilling the irrigating solution using a cone-shaped tip catheter 4. Clearing the tubing of air before insertion of the irrigating solution

3 A cone-shaped tip controls the depth of insertion of the catheter, which prevents perforation of the bowel and limits leakage of water from the stoma during fluid insertion. 1 In both procedures the client should be positioned for evacuation of the bowel, which allows gravity to facilitate bowel evacuation. 2 In both procedures the catheter tip should be lubricated with a water-soluble jelly, which limits trauma to the intestinal mucosa. 4 In both procedures the tubing should be clear of air to facilitate the tolerance of a larger volume of irrigating solution.

A client who had a suprapubic prostatectomy for cancer of the prostate returns to the postanesthesia care unit with a continuous bladder irrigation. The purpose of this irrigation is to: 1. Stimulate continuous formation of urine 2. Facilitate the measurement of urinary output 3. Prevent the development of clots in the bladder 4. Provide continuous pressure on the prostatic fossa

3 A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. 1 Fluid instilled into the bladder does not affect kidney function. 2 Urinary output can be measured regardless of the amount of fluid instilled. 4 The urinary retention catheter is not designed to exert pressure on the prostatic fossa.

The laboratory values of a client with cancer of the esophagus show a hemoglobin of 7 g/dL, hematocrit of 25%, and RBC count of 2.5 million/mm3. The outcome that takes priority at this time is, "The client will: 1. be free of injury." 2. remain pain free." 3. demonstrate improved nutrition." 4. maintain an effective airway clearance."

3 Based on the presented data, improving nutritional status is the priority at this time. The decreased hemoglobin and hematocrit levels and RBC count may be a result of malnutrition; also cancer of the esophagus can cause dysphagia and anorexia. 1 Although maintaining the client's safety is a goal, it is not as high a priority as another concern based on the data provided in the question. 2 Data given do not relate to the presence of pain. 4 Data given do not relate to airway obstruction.

A client who has had right upper quadrant pain for several months now experiences clay-colored stools and visits the local clinic. Based on the reported history and elevated liver enzymes, a needle biopsy of the liver is scheduled. The nurse explains that: 1. The procedure is painless because general anesthesia is used 2. Disfiguring scars are minimal because a small incision is made 3. Lying on the right side after the procedure is required because it will decrease the risk of hemorrhage 4. A light meal should be eaten 2 hours before the procedure because it stimulates gastrointestinal secretions

3 Because of the vascularity of the liver, compression of the needle insertion site limits the risk of hemorrhage; also it decreases the risk of bile leakage. 1 The procedure is performed under local anesthesia and some discomfort may be felt during instillation of the anesthetic as well as when the needle enters the liver. 2 There is no scarring because a surgical incision is not necessary for a needle biopsy. 4 The client is kept NPO for at least 6 hours before the procedure to prevent nausea and vomiting.

A client has decided to become a vegan and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse instructs this client to: 1. Add milk to grains to provide complete proteins 2. Use eggs and plant foods to provide essential amino acids 3. Plan a careful mixture of plant proteins to provide a balance of amino acids 4. Add cheese to grains and beans to increase the quality of the protein consumed

3 Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents. 1 A vegan does not consume flesh, milk, milk products, or eggs. 2 A vegan does not consume flesh, milk, milk products, or eggs. 4 A vegan does not consume flesh, milk, milk products, or eggs.

A client with carcinoma of the colon is scheduled for an abdominoperineal resection. Preparation of this client several days before surgery should include: 1. Medications to promote diuresis 2. Restriction of fluids to one L daily 3. Antibiotics to reduce intestinal bacteria 4. Abdominal exercises to facilitate recovery

3 Except in an emergency, the client receives an intestinal antibiotic for several days preoperatively to reduce the amount of intestinal bacteria. 1 Diuretics are not necessary unless prescribed for a preexisting problem. 2 Fluids usually are restricted after midnight on the day of surgery, not for days before surgery. 4 Abdominal exercises are not part of the surgical preparation.

The practitioner orders contact precautions for a client with hepatitis A. What specific interventions are required for contact precautions? 1. Private room and the door must be kept closed 2. Persons entering the room must wear a gown, a mask, and gloves 3. Gown and gloves must be worn when handling articles contaminated by urine or feces 4. Gowns and gloves must be worn only when handling the client's soiled linen, dishes, or utensils

3 Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal and/or urine contamination. 1 Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. 2 Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. 4 This is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.

A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch the client becomes diaphoretic and has palpitations. What probably has caused these responses? 1. Intolerance to fatty foods 2. Dehiscence of the surgical incision 3. Extracellular fluid shift into the bowel 4. Diminished peristalsis in the small intestine

3 Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome). 1 Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with the dumping syndrome. 2 This is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid; it is unrelated to dumping syndrome. 4 Although peristalsis may be decreased because of surgery, it does not account for the adaptations.

When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in: 1. The left side-lying position with the head of the bed elevated 2. A high Fowler's position with both arms supported on several pillows 3. The right side-lying position with pillows placed under the costal margin 4. Any comfortable recumbent position as long as the client remains immobile

3 In this position the liver capsule at the entry site is compressed against the chest wall and escape of blood and/or bile is impeded. 1 This is unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site. 2 This is unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site. 4 This is unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.

To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to: 1. Increase the daily intake of citrus juice 2. Douche frequently with alkaline agents 3. Urinate as soon as possible after intercourse 4. Cleanse from the vaginal orifice to the urethra

3 Intercourse may cause urethral inflammation, increasing the risk of infection; voiding clears the urinary meatus and urethra of microorganisms. 1 Most fruit juices, with the exception of cranberry juice, cause alkaline urine, which promotes bacterial growth. 2 Douching is no longer recommended because it alters the vaginal flora. 4 Perineal care should be accomplished with wipes from the urinary meatus toward the rectum to help prevent microorganisms from the vaginal or rectal areas from reaching the urinary meatus.

During a laparoscopic cholecystectomy on an obese client, the surgeon encounters difficulty because of the presence of adhesions as a result of the client's having had a previous surgery. An abdominal cholecystectomy is performed. After surgery the nurse plans to alleviate tension on the surgical wound by: 1. Limiting deep breathing 2. Maintaining T-tube patency 3. Maintaining nasogastric tube patency 4. Encouraging the right side-lying position

3 Maintaining nasogastric tube patency ensures gastric decompression, thus preventing abdominal distension, which places tension on the incision. 1 Deep breathing should be encouraged to prevent respiratory complications. 2 Maintaining T-tube patency only ensures a portal of exit for bile drainage; the tube is not irrigated and an obstruction will lead to jaundice rather than tension on the surgical wound. 4 The right-side-lying position after a cholecystectomy can increase, not decrease, tension in the operative area.

A client with a history of gastrointestinal varices develops severe hematemesis, and the practitioner inserts a Sengstaken-Blakemore tube. The nurse understands that this tube is a: 1. Single-lumen tube for gastric lavage 2. Double-lumen tube for intestinal decompression 3. Triple-lumen tube used to compress the esophagus 4. Multi-lumen tube for gastric and intestinal decompression

3 One lumen inflates the esophageal balloon, the second inflates the gastric balloon, and the third decompresses the stomach. 1 It is a triple-, not single-lumen tube. 2 It is a triple-, not double-lumen tube; the stomach, not the intestine, is decompressed. 4 The stomach, but not the intestine, is decompressed.

A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for signs that strangulation of the intestine may have occurred. What is an early sign of strangulation? 1. Increased flatus 2. Projectile vomiting 3. Sharp abdominal pain 4. Decreased bowel sounds

3 Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia. 1 Flatus is impeded by strangulation. 2 Vomiting is persistent, not projectile. 4 This is not an early sign of obstruction; decreased bowel sounds occur after gas and fluid accumulate.

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling's). Stress ulcers usually are evidenced by: 1. Unexplained shock 2. Melena for several days 3. Sudden massive hemorrhage 4. Gradual drop in the hematocrit value

3 Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. 1 Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. 2 Sudden massive bleeding occurs, not the slow oozing that causes melena. 4 A gradual drop in the hematocrit value indicates slow blood loss.

When a client develops steatorrhea, the nurse documents this stool as: 1. Dry and rock-hard 2. Clay colored and pasty 3. Bulky and foul smelling 4. Black and blood-streaked

3 These characteristics describe steatorrhea, which results from impaired fat digestion. 1 This is descriptive of stools resulting from constipation. 2 This is descriptive of acholic stools occurring with biliary obstruction resulting from an absence of urobilin. 4 This is descriptive of upper and lower gastrointestinal bleeding

A client who had a prostatectomy complains of painful bladder spasms. To limit these spasms the nurse should: 1. Administer the client's ordered opioid every 4 hours 2. Irrigate the indwelling catheter with 60 mL of isotonic solution 3. Encourage the client to avoid contracting his muscles as if he were voiding 4. Advance the urinary catheter to relieve the pressure against the prostatic fossa

3 This action causes the bladder muscle to contract, initiating painful bladder spasms. 1 Although opioids may dull the pain, they may not limit muscle spasms. 2 Instillation of fluid may be irritating and can precipitate bladder spasms. 4 Advancing or manipulating the catheter may precipitate bladder spasms.

A client who has cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery a low-residue diet is ordered. The nurse explains that this is necessary to: 1. Limit production of flatus in the intestine 2. Prevent irritation of the intestinal mucosa 3. Reduce the amount of stool in the large bowel 4. Lower the bacterial count in the gastrointestinal tract

3 This diet is low in fiber; after digestion and absorption there is only a small amount of residue to be eliminated. 1 This diet does not promote peristalsis; the products of digestion remain in the intestine longer, and flatus is increased. 2 Although a low-residue diet is less irritating, this is not the primary reason for its use before surgery. 4 Antimicrobials, such as neomycin, are given to do this.

After abdominal surgery a client is to receive a progressive postsurgical diet. This diet is characterized by progressive alterations in the: 1. Caloric content of food 2. Nutritional value of food 3. Texture and digestibility of food 4. Variety of food and fluids included

3 This diet progresses from the one that makes the least metabolic demand on the client (clear liquid) to a regular diet that requires the capability of unimpaired digestion. 1 The caloric content is not the focus in a progressive postsurgical diet. 2 Initially a progressive diet has little nutritional value; the focus is to rest the gastrointestinal tract immediately after surgery. 4 Initially a limited variety of fluids is presented to rest the gastrointestinal tract; food is not included until later.

Twenty-four hours after a penile implant the client's scrotum is edematous and painful. The nurse should: 1. Assist the client with a sitz bath 2. Apply warm soaks to the scrotum 3. Elevate the scrotum using a soft support 4. Prepare for an incision and drainage procedure

3 This increases lymphatic drainage, reducing edema and pain. 1 This increases circulation to the area, intensifying edema and pain in this client. 2 This increases circulation to the area, intensifying edema and pain in this client. 4 This is not indicated; scrotal swelling is caused by the trauma of surgery, not infection.

A 64-year-old client is suspected of having carcinoma of the liver, and a liver biopsy is scheduled. A liver biopsy may be contraindicated in certain situations. Therefore, for what should the nurse assess the client? 1. Confusion and disorientation 2. Presence of any infectious disease 3. Prothrombin time of less than 40% of normal 4. Inclusion of foods high in vitamins E and K in the client's diet

3 This indicates that the client has a deficiency in clotting, which should be corrected before the biopsy to prevent hemorrhage. 1 Confusion and disorientation are not a contraindication for a liver biopsy; if present, the client may need support and the examiner may need assistance, but the biopsy can be done. 2 A biopsy is not contraindicated in the presence of an infectious disease. 4 Vitamin K is needed for the production of prothrombin; however, this does not guarantee clotting activity; vitamin E is not involved in clotting.

A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response? 1. Intestinal edema after surgery 2. Presurgical decrease in fluid intake 3. Absence of gastrointestinal motility 4. Effective functioning of nasogastric suction

3 This is caused by intestinal manipulation and the depressive effects of anesthesia and analgesics. 1 Edema will not totally interfere with peristalsis; there should be some output. 2 A presurgical decrease in fluid intake will not influence gastric motility 24 hours later. 4 A nasogastric tube decompresses the stomach; it does not directly influence intestinal motility at this time.

To prevent future attacks of glomerulonephritis, the nurse planning discharge teaching includes instructions for the client to: 1. Take showers instead of bubble baths 2. Avoid situations that involve physical activity 3. Continue the same restrictions on fluid intake 4. Seek early treatment for respiratory infections

4 A common cause of glomerulonephritis is a streptococcal infection. This infection initiates an antibody formation that damages the glomeruli. 1 The alkalinity of bubble baths is linked to urethritis, not glomerulonephritis. 2 Moderate activity is helpful in preventing urinary stasis, which can precipitate urinary infection. 3 Any fluid restriction is moderated as the client improves; fluid is allowed to prevent urinary stasis.

A 72-year-old male complaining of dysuria, nocturia, and difficulty starting the urinary stream is scheduled for a cystoscopy and biopsy of the prostate gland. After the procedure the client complains that he is unable to void. The nurse should: 1. Limit oral fluids until he voids 2. Assure him that this is expected 3. Insert a urinary retention catheter 4. Palpate above the pubic symphysis

4 A full bladder is palpable with urinary retention and distention, which are common problems after a cystoscopy because of urethral edema. 1 Fluids dilute the urine and reduce the chance of infection after cystoscopy and should not be limited. 2 Although urinary retention can occur, it is not expected; the nurse must assess the extent of bladder distention and discomfort. 3 More conservative nursing methods such as running water or placing a warm cloth over the perineum should be attempted to precipitate voiding; catheterization carries a risk of infection.

A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that may be present. The nurse should assess the client for which primary subjective symptom? 1. Uremia 2. Nausea 3. Voiding at night 4. Flank discomfort

4 A subjective symptom must be experienced and described by the client; flank pain, pain on the side of the body between the ribs and the ileum, accompanies renal colic. 1 This is an objective sign that can be verified by observation or measurement. 2 Although nausea is a subjective symptom and it can occur with the severe pain associated with renal colic, it is not as significant as flank pain. 3 This is an objective sign that can be verified by observation or measurement.

The response after a gastroscopy that indicates a major complication is: 1. Difficulty swallowing 2. Increased GI motility 3. Nausea with vomiting 4. Abdominal distention with pain

4 Abdominal distention, which may be associated with pain, can indicate perforation, a complication that can lead to peritonitis. 1 A local inflammatory response to insertion of the fiberoptic tube may result in a sore throat and dysphagia once the anesthesia wears off; this is expected. 2 This, together with cramping, is an expected response. 3 This is not indicative of any particular problem in this situation.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. The priority nursing intervention is to: 1. Weigh the client daily 2. Restrict the client's oral fluid intake 3. Measure the client's urine specific gravity 4. Observe the client for increasing confusion

4 An increased serum ammonia level impairs the CNS, causing an altered level of consciousness. 1 Increasing ammonia levels are not related to weight. 2 An alteration in fluid intake will not affect the serum ammonia level. 3 This is not the priority; the priority is to monitor the client's neurological status.

After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses the procedure with the client. The nurse evaluates that the teaching is understood when the client states, "After the catheter is removed I probably will: 1. have dilute urine." 2. be unable to urinate." 3. produce dark red urine." 4. experience some burning on urination."

4 Because of the trauma to the mucous membranes of the urinary tract, burning on urination is an expected response that should subside gradually. 1 The urine should no longer be dilute after the continuous bladder irrigation is discontinued and removed. However, the urine may have a slight pink tinge because of the trauma from the surgery and the presence of the catheter. 2 This should not occur unless the indwelling catheter is removed too soon and there is still edema of the urethra. 3 This is a sign of hemorrhage, which should not occur.

A nurse asks a client to make a list of the foods that cause dyspepsia. If the client has cholecystitis, the foods that are most likely to be included on this list are: 1. Nuts and popcorn 2. Meatloaf and baked potato 3. Chocolate and boiled shrimp 4. Fried chicken and buttered corn

4 Cholecystitis is often accompanied by intolerance to fatty foods, including fried foods and butter. 1 Because these foods have a high fiber content, they cause flatulence and pain for clients with lower intestinal problems such as diverticulosis. 2 These foods contain less fat than do fried foods or butter. 3 Neither chocolate nor boiled seafood contains as much fat as fried chicken or butter.

The nurse instructs a client diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported to the practitioner is: 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools

4 Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. 1 It is unnecessary to call the practitioner because this symptom is characteristic of hepatitis from the onset of clinical manifestations. 2 It is unnecessary to call the practitioner because this symptom is characteristic of hepatitis from the onset of clinical manifestations. 3 This is the expected color of urine.

A client is diagnosed as having a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report any stools that appear: 1. Frothy 2. Ribbon shaped 3. Pale or clay colored 4. Dark brown or black

4 Dark brown or black stools (melena) indicate gastrointestinal bleeding. 1 Frothy stools are indicative of inadequate fat absorption and are associated with sprue. 2 Ribbon-shaped stools indicate a bowel mass or obstruction. 3 Clay-colored stools usually are related to problems that cause a decrease in bile.

When admitting a client with benign prostatic hyperplasia, the most relevant assessment made by the nurse is: 1. Perineal edema 2. Urethral discharge 3. Flank pain radiating to the groin 4. Distention of the lower abdomen

4 Distention of the suprapubic area indicates that the bladder is distended with urine and therefore palpable. 1 Perineal edema is not related to urinary retention and benign prostatic hyperplasia. 2 Urethral discharge may be related to sexually transmitted infections. 3 Radiating flank pain may indicate renal calculi.

A client who had a gastric resection for cancer of the stomach is admitted to the postanesthesia care unit with a nasogastric tube. The nurse expects to observe: 1. Periodic vomiting 2. Intermittent bouts of diarrhea 3. Gastric distention after 6 hours 4. Bloody drainage for the first 12 hours

4 Drainage is bright red initially and gradually becomes darker red during the first 24 hours. 1 If the nasogastric tube is functioning correctly, secretions will be removed and vomiting will not occur. 2 Because the bowel was emptied before surgery and the client is now NPO, intestinal activity is not expected. 3 If the nasogastric tube is functioning correctly, gastric distention will not occur.

A client develops a gallstone that becomes lodged in the common bile duct. The practitioner schedules an endoscopic sphincterotomy. Preoperative teaching includes information that for the procedure the client will: 1. Have a spinal anesthetic 2. Receive an epidural block 3. Have a general anesthetic 4. Receive an intravenous sedative

4 During the procedure a sedative is administered intravenously as needed to help the client stay calm. 1 This is not used during this procedure. 2 This is not used during this procedure. 3 This is not used during this procedure.

To motivate an obese client to eventually include aerobic exercises in a weight-reduction program, the nurse discusses exercise and its relationship to weight loss. The nurse evaluates that this teaching is effective when the client states, "I know that exercise will: 1. decrease my appetite." 2. lower my metabolic rate." 3. raise my resting heart rate." 4. increase my lean body mass."

4 Exercise builds skeletal muscle mass and reduces excess fatty tissue. 1 Appetite may increase with exercise. 2 The metabolic rate will increase with exercise. 3 During aerobic exercise the heart rate will increase, but between periods of exercise the heart rate will decrease because of the development of collateral circulation.

The nurse teaches the client with gastroesophageal reflux disease that after meals the client should: 1. Drink 8 ounces of water 2. Take a walk for 30 minutes 3. Lie down for at least 20 minutes 4. Rest in a sitting position for 1 hour

4 Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus. 1 Water should not be taken with or immediately after meals because it overdistends the stomach. 2 Exercise immediately after eating may prolong the digestive process. 3 Lying down immediately after eating facilitates reflux of the stomach contents into the esophagus.

An obese client with calculi in the calyces of the right kidney is admitted for their removal. The nurse prepares the client for the procedure by explaining that: 1. The right ureter will be removed 2. A suprapubic catheter will be in place 3. The surgery will be performed transurethrally 4. A small incision will be present in the right flank area

4 If the calculi are in the renal pelvis, a percutaneous pyelolithotomy is performed; the calculi are removed via a small flank incision. 1 This is not necessary. 2 This usually is unnecessary. 3 This route is used for calculi in the ureters and renal pelvis.

A 75-year-old male with a history of cancer of the prostate is admitted for a prostatectomy. The client's prostate specific antigen (PSA) levels have been increasing. This finding should prompt the nurse to plan to: 1. Measure intake and output 2. Institute seizure precautions 3. Monitor his plasma pH for acidosis 4. Handle him gently when turning him

4 Increasingly elevated PSA levels may indicate a worsening of the client's condition with possible metastasis to the bone, increasing the risk of pathological fractures; therefore, handling must be gentle. 1 Although measuring intake and output is necessary for any client with prostatic cancer because of the risk of bladder obstruction, it is not the priority for this client. 2 Seizure precautions are not necessary; a PSA elevation indicates bone, not brain, involvement. 3 Elevated PSA levels do not significantly affect the plasma pH.

A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must: 1. Avoid fats and proteins 2. Drink a large amount of fluids 3. Omit dinner and limit beverages 4. Take a laxative before going to bed

4 Laxatives remove feces and flatus, providing better visualization. 1 An IVP does not require restrictions of fat and proteins. 2 Large amounts of fluids may dilute the dye, impairing visualization. 3 A light dinner and beverage are permitted.

A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client states, "I will: 1. increase my food intake." 2. take an aspirin with milk." 3. eliminate fluids with meals." 4. take an antacid preparation."

4 Over-the-counter antacid preparations neutralize gastric acid and relieve pain. 1 Although eating food initially prevents gastric acid from irritating the gastric walls, it can precipitate acid production. 2 Aspirin is contraindicated because it irritates gastric mucosa and promotes bleeding by preventing platelet aggregation. 3 Reduction of fluids with meals does not affect pain; it helps prevent dumping syndrome.

A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it is most appropriate for the nurse to: 1. Wait about 24 hours to begin clear liquids 2. Monitor the abdominal incision for bleeding 3. Offer clear carbonated beverages to the client 4. Instruct the client to resume moderate activity in 2 to 3 days

4 Recovery will be rapid because there is no large abdominal incision. 1 Clear liquids may be started as soon as the client is awake and a gag reflex has returned. 2 With a laparoscopic cholecystectomy there will be one or more puncture wounds, not an incision, on the abdomen. 3 Carbonated beverages will create gas, which will distend the intestines and increase pain.

A nurse assesses for the development of pernicious anemia when a client has a history of: 1. Hemorrhage 2. Diabetes mellitus 3. Unhealthy dietary habits 4. Having had a gastrectomy

4 Removal of the fundus of the stomach destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum). 1 Hemorrhaging may cause anemia; however, pernicious anemia occurs when the intrinsic factor is not produced. 2 The beta cells of the pancreas are not involved in secretion of intrinsic factor. 3 Dietary intake does not affect the production of intrinsic factor.

A client has a colostomy after surgery for cancer of the colon. What is the nurse's most therapeutic intervention during the postoperative period? 1. Empty the colostomy bag when it is three fourths full 2. Allow one half inch between the stoma and the appliance 3. Help the client to remove the appliance on the first postoperative day 4. Apply stoma adhesive around the stoma and then attach the appliance

4 Stoma adhesive protects the skin and helps to keep the appliance attached to the skin. 1 The appliance should be emptied when it is one third to one half full. 2 This is too much space between the stoma and the appliance; the enzymes in feces can erode the skin. 3 Initially the nurse should change the appliance; self-care usually is instituted more gradually depending on the client's physical and emotional response to the surgery.

A client who had a kidney transplant develops leukopenia 3 weeks after surgery. The nurse concludes that the leukopenia probably is caused by: 1. Bacterial infection 2. High creatinine levels 3. Rejection of the kidney 4. Antirejection medications

4 The WBC count can drop precipitously. If leukocytes are less than 3000/mm3, the drug may have to be stopped to prevent irreversible bone marrow depression. 1 Leukocytosis, not leukopenia, occurs with an infection. 2 High creatinine levels are related to kidney failure, but do not cause leukopenia. 3 The WBC count is increased, not decreased, with kidney rejection.

After 2 months of self-management for symptoms of gastritis is unsuccessful, a client goes to the practitioner, and extensive carcinoma of the stomach is diagnosed. The client asks the nurse how the disease got so advanced. The nurse's explanation is based on the knowledge that carcinoma of the stomach is: 1. Painful in the early stages of the disease process 2. Difficult to accurately diagnose until late in the disease process 3. Usually diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4. Rarely diagnosed early because the symptoms usually are nonspecific until late in the disease

4 This cancer is usually asymptomatic in the early stages; the stomach accommodates the mass. 1 Gastric cancer is painless in its early stages. 2 It can be accurately diagnosed by gastric washings or biopsy. 3 This is typical of Hodgkin's disease, not gastric carcinoma.

The nurse teaches a client receiving peritoneal dialysis that the reason the dialysis solution is warmed to body temperature before it is instilled into the peritoneal cavity is to: 1. Force potassium back into the cells, thereby decreasing serum levels 2. Add extra warmth to the body because metabolic processes are disturbed 3. Help prevent cardiac dysrhythmias by speeding up removal of excess potassium 4. Encourage removal of serum urea by preventing constriction of peritoneal blood vessels

4 This promotes vasodilation so that urea, a large-molecular substance, is shifted from the body into the dialyzing solution. 1 Heat does not affect the shift of potassium into the cells. 2 The removal of metabolic wastes is affected in kidney failure, not the metabolic processes. 3 Excess serum potassium is removed by dialyzing with a potassium-free solution, not by heat.

A nurse's postoperative plan of care for a client who had a nephrectomy should include: 1. Clamping the client's nephrostomy tube when out of bed 2. Giving the client a regular diet on the first postoperative day 3. Replacing the client's original dressing after the first 48 hours 4. Turning the client from the back to the operated side every 2 to 3 hours

4 Turning the client prevents respiratory complications. 1 There is no need for a nephrostomy tube because the kidney has been removed. 2 Because clients are prone to develop paralytic ileus, food and fluid intake are delayed until bowel sounds are auscultated. 3 The first dressing change is performed by the practitioner.

A client with acute renal failure moves into the diuretic phase after 1 week of therapy. For which signs during this phase should the nurse assess the client? Select all that apply. 1. _____ Dehydration 2. _____ Hypovolemia 3. _____ Hyperkalemia 4. _____ Metabolic acidosis

Answer: 1, 2 1 In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; dehydration will occur unless fluids are replaced. 2 In the diuretic phase, fluid retained during the oliguric phase is excreted and may reach 3 to 5 L daily; hypovolemia may occur, and fluids should be replaced. 3 Hyperkalemia develops in the oliguric phase when glomerular filtration is inadequate. 4 Metabolic acidosis occurs in the oliguric, not diuretic, phase.

A client has just undergone a subtotal gastrectomy. Part of discharge teaching includes information about dumping syndrome. What instructions by the nurse will best minimize dumping syndrome? Select all that apply. 1. _____ Drink fluids with meals 2. _____ Eat small frequent meals 3. _____ Lie down for 1 hour after eating 4. _____ Chew food five times before swallowing 5. _____ Increase the carbohydrate component of the diet

Answer: 2, 3 1 Fluids should be taken between meals to decrease the volume within the stomach at one time. 2 Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. 3 Lying down delays emptying of the stomach contents, which will limit dumping syndrome. 4 Chewing a set number of times before swallowing is not pertinent to solving this problem. 5 A low-carbohydrate, high-protein, high-fat diet and avoidance of fluids with meals help delay stomach emptying, minimizing this problem.

A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? Select all that apply. 1. _____ Avoid fluid intake after 6 pm 2. _____ Drink 8 to 10 glasses of water each day 3. _____ Urinate immediately after sexual intercourse 4. _____ Increase the daily intake of carbonated beverages 5. _____ Clean the perineal area with an astringent soap twice a day

Answer: 2, 3 1 Limiting fluid intake contributes to stasis of urine. 2 Drinking 8 to 10 glasses of water spaced throughout the day flushes the urinary tract and minimizes urinary stasis. 3 Urination flushes the urethra and urinary meatus limiting the presence of microorganisms. 4 Carbonated and caffeinated beverages irritate the bladder and should be avoided. 5 Cleaning the perineum with harsh soaps is irritating to the skin and mucous membranes, and can contribute to the development of UTIs in susceptible women.

A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply. 1. _____ Lettuce 2. _____ Oranges 3. _____ Broccoli 4. _____ Apricots 5. _____ Strawberries

Answer: 2, 3, 5 1 An entire head of lettuce contains 13 mg of vitamin C. 2 One cup of fresh orange sections contains 96 mg of vitamin C. 3 Vitamin C (ascorbic acid), an antioxidant, is found in vegetables such as broccoli, tomatoes, and potatoes; 1 cup of broccoli contains 140 mg of vitamin C. 4 Apricots contain 11 mg of vitamin C; they are a source of beta-carotene. 5 A cup of strawberries contains 106 mg of vitamin C.

A client with the diagnosis of cancer of the transverse colon is transferred from the postanesthesia care unit to a room on a surgical unit after a colon resection with an anastomosis. The nurse on the unit receives the client from the transporting nurse and observes that an IV is in progress and the client has a nasogastric tube and an indwelling urinary catheter. Place the nursing actions in order of priority when receiving this client on the unit. 1. Assess the airway 2. Take the vital signs 3. Check the abdominal dressing 4. Receive the report from the nurse Answer: _______________

Answer: 4, 1, 3, 2 The first step is for the nurse to receive report from the transporting nurse. The receiving nurse should be informed about the type of surgery performed, important events that occurred during surgery, and the client's response and current status. Once the report is completed, the next step is for the receiving nurse to ensure that the client has a patent airway. Vital signs are then taken to assess the client's current cardiopulmonary status and to assess for signs of hemorrhage or other postoperative complications. This assessment follows the ABCs (airway, breathing, circulation) of assessment. After the client's vital signs are determined to be stable, the nurse should assess and monitor the dressing, IV, and the indwelling urinary catheter.

When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as: 1. Gnawing epigastric pain or boring pain in the back 2. Located in the right shoulder and preceded by nausea 3. Sudden, sharp abdominal pain, increasing in intensity 4. Heartburn and substernal discomfort when lying down

. 1 Classic symptoms of peptic ulcer include gnawing, boring, or dull pain located in the midepigastrium or back; pain is caused by irritability and erosion of the mucosal lining. 2 This type of pain is more characteristic of cholecystitis. 3 This type of pain is more characteristic of the complication of a perforated ulcer. 4 This type of pain is more characteristic of a hiatal hernia.

A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to: 1. Decrease the urinary pH 2. Exert a bactericidal effect 3. Improve glomerular filtration 4. Relieve the symptoms of dysuria

. 1 Cranberry juice is excreted as hippuric acid, which helps acidify the urine (decrease the pH) and inhibit bacterial growth. 2 Although bacterial growth may be inhibited, bacteria are not destroyed. 3 Glomerular filtration is unaffected by cranberry juice. 4 Cranberry juice acidifies the urine and may increase the burning sensation associated with urination when an infection is present.

While the nurse is at the bedside of a client in acute renal failure, the client states, "My doctor said that I will be getting some insulin. Do I also have diabetes?" The response that best demonstrates an understanding of the use of insulin in acute renal failure is: 1. "No, the insulin will help your body handle the increased potassium level." 2. "Why don't you ask that question when the doctor comes to see you today." 3. "You probably had an elevated blood glucose level, so your doctor is being cautious." 4. "No, but insulin will reduce the toxins in your blood by lowering your metabolic rate."

. 1 Insulin promotes the transfer of potassium into cells, which reduces the circulating blood level of potassium. 2 This response halts communication and is not supportive. 3 Blood glucose levels usually are not elevated in acute renal failure. 4 Insulin will not lower the metabolic rate.

After a transurethral vaporization of the prostate, the client returns to the unit with a urinary retention catheter and a continuous bladder irrigation. What should the nurse do first when the client indicates the need to urinate? 1. Assess that the tubing attached to the collection bag is patent 2. Obtain the client's vital signs before notifying the practitioner 3. Explain that the balloon inflated in the bladder causes this feeling 4. Review the client's intake and output that was documented in the previous shift

. 1 The drainage tubing may be obstructed. Retained fluid raises intravesicular pressure, causing discomfort similar to the urge to void. 2 The client's vital signs are not related to the complaint; the practitioner should be called only if a blocked drainage tube is not corrected. 3 Although this is true, the patency of the gravity system should be ascertained before determining the cause of the complaint. 4 Although this might be done, it is not the priority. Whether urine is draining from the tubing at this point in time is significant.

After surgical implantation of radon seeds for oral cancer, the nurse observes the client for the side effects of the radiation including: 1. Nausea and/or vomiting 2. Hematuria and/or occult blood 3. Hypotension and/or bradycardia 4. Abdominal cramping and/or diarrhea

. 1 The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting. 2 These are not side effects of radiation therapy to the oral cavity. 3 These are not side effects of radiation therapy to the oral cavity. 4 These are not expected responses because of the distance between the radon seeds and the intestines.

On the third postoperative day after a subtotal gastrectomy, a client complains of severe abdominal pain. The nurse palpates the client's abdomen and identifies rigidity. The nurse should first: 1. Assist the client to ambulate 2. Obtain the client's vital signs 3. Administer the prescribed analgesic 4. Encourage the use of the spirometer

. 2 Rigidity and pain are hallmarks of bleeding from the suture line and/or of peritonitis; vital signs provide supporting data. 1 Ambulation is indicated if the pain is the result of flatulence; however, rigidity is clearly associated with bleeding or peritonitis and more data are needed. 3 An analgesic may mask the symptoms, delaying diagnosis. 4 This is unrelated to the adaptations presented.

A client receiving a 1500-calorie diet eats these foods for breakfast: 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat); ¾ cup corn flakes (15 grams of carbohydrate, 2 grams of protein); and half of an orange (5 grams of carbohydrate). How many calories has this client ingested? 1. 208 2. 258 3. 416 4. 456

. 2 The client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram. The total carbohydrate calories are 32 × 4 = 128. The total protein calories are 10 × 4 = 40. The total fat calories are 10 × 9 = 90; 128 + 40 + 90 = 258 calories. 1 This is an incorrect calculation. 3 This is an incorrect calculation. 4 This is an incorrect calculation.

An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record and completes a physical assessment. Which clinical finding is a priority to be communicated to the practitioner? 1. Sodium level 2. Potassium level 3. Creatinine results 4. Elevated blood pressure CLIENT CHART Laboratory Results Sodium 135 mEq/L Potassium 6 mEq/L Hemoglobin 8.5 g/dL Creatinine clearance 20 mL/min Client Interview The client complains of lethargy and fatigue Graphic Sheet Temperature 99° F Pulse 84 Respirations 24 Blood pressure 150/100

. 2 The potassium is increased outside the expected range for an adult, which places the client at risk for a cardiac dysrhythmia; the increased potassium level must be treated immediately because elevated levels can be lethal. 1 A serum sodium of 135 mEq/L is expected because of the electrolyte imbalance and the anemia related to the decreased production of erythropoietin by the kidney in the presence of chronic kidney failure. 3 A creatinine clearance of <20 mL/min is expected with chronic kidney disease; a creatinine clearance level of less than 10 mL/min is reflective of severe kidney impairment. 4 Although these vital signs are increased, they are not as serious a concern as another assessment; fluid overload and hypervolemia associated with chronic kidney disease are reflected in hypertension, tachycardia, and tachypnea and are expected

When planning care for a client with ureteral colic, the goal of preventing future calculi is based on the knowledge that most factors contributing to the development of renal stones can be overcome by: 1. Decreasing serum creatinine 2. Excluding milk products from the diet 3. Drinking 8 to 10 glasses of water daily 4. Excreting 2000 mL of urine per 24 hours

. 3 Increasing fluid intake dilutes the urine, and crystals are less likely to coalesce and form calculi. 1 An elevated serum creatinine has no relationship to the formation of renal calculi. 2 Calcium restriction is necessary only if calculi have a calcium phosphate or calcium oxalate basis. 4 Producing only 2000 mL of urine per 24 hours is inadequate; urine output should be maintained at 3000 to 4000 mL to limit calculus formation.

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the nursing action that is the priority for this client is: 1. Irrigating the T-tube frequently 2. Changing the dressing at least twice a day 3. Encouraging coughing and deep breathing 4. Promoting an adequate fluid and food intake

. 3 Self-splinting results in shallow breathing, which does not aerate the lungs adequately, particularly the lower right lobe. 1 The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the tube is then removed by the physician. 2 The dressing is not changed by the nurse in the immediate postoperative period; the client's respiratory status takes priority. 4 The client will be NPO immediately after surgery.

If a client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution, the nurse should: 1. Increase the rate of infusion 2. Auscultate the lungs for breath sounds 3. Place the client in a low Fowler's position 4. Drain the fluid from the peritoneal cavity

. 4 Pressure from the fluid may cause upward displacement of the diaphragm; draining the solution reduces intra-abdominal pressure, which allows the thoracic cavity to expand on inspiration. 1 Additional fluid will aggravate the problem. 2 Auscultation is important, but it does not alleviate the problem. 3 The client should be placed in the semi-Fowler's position for peritoneal dialysis; this allows inflow of fluid while not impinging on the thoracic cavity.

What should the nurse do when a client is scheduled for a barium swallow? 1. Give clear fluids on the day of the test 2. Ask the client about allergies to iodine 3. Administer cleansing enemas before the test 4. Ensure a laxative is ordered after the procedure

4 Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium. 1 The client must be kept NPO. 2 Iodine is not used with barium. 3 This is not part of the preparation; feces in the lower GI tract will not interfere with visualization of the upper GI tract.

During a health symposium a nurse teaches the group how to prevent food poisoning. The nurse evaluates that the teaching is understood when one of the participants states: 1. "Meats and cream-based foods need to be refrigerated." 2. "Once most food is cooked it does not need to be refrigerated." 3. "Poultry should be stuffed and then refrigerated before cooking." 4. "Cooked food should be cooled before being put into the refrigerator."

1 A cold environment limits growth of microorganisms. 2 All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. 3 This promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator's cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. 4 This promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Preoperative preparation for this client should include an explanation about the postoperative: 1. Gastric suction 2. Oxygen therapy 3. Fluid restriction 4. Urinary catheter

1 After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions. 2 Oxygen is not required unless the client experiences a complication necessitating its administration. 3 The average client is given about 3500 mL of fluid by IV to meet fluid needs and replace gastric losses. 4 This may or may not be necessary.

Because of chronic crampy pain, diarrhea, and cachexia, a young adult is to receive total parenteral nutrition (TPN) via a central line. Before preparing a client for the insertion of the catheter, the nurse is aware that a: 1. Parenteral solution may be administered intermittently 2. Fluoroscopy must be done before the catheter is inserted 3. Jugular vein is the most commonly used catheter insertion site 4. Client will experience a moderate amount of pain during the procedure

1 Although the central venous catheter remains in situ, total parenteral nutrition does not have to infuse continuously. Continuous versus intermittent administration depends on the practitioner's order. 2 Placement of the tube after the procedure is verified by x-ray, not fluoroscopy. 3 The subclavian veins are used most often; the jugular vein is too close to hair-growing areas, which increases the possibility of sepsis, and neck movements may interfere with maintaining placement of the catheter. 4 Although a feeling of pressure may be experienced, it is not a painful procedure.

A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for esophageal perforation, which is indicated by: 1. Tachycardia and abdominal pain 2. Faintness and feelings of fullness 3. Diaphoresis and cardiac palpitations 4. Increased blood pressure and urinary output

1 An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux. 2 These are signs of dumping syndrome. 3 These are signs of dumping syndrome. 4 An increased blood pressure may occur, but an increased urinary output has no relationship to esophageal perforation.

A client is transferred to the postanesthesia care unit after undergoing a pyelolithotomy. The client's urinary output is 50 mL/hr. The nurse should: 1. Record the findings 2. Notify the practitioner 3. Milk the client's nephrostomy tube 4. Encourage the client to drink oral fluids

1 An output of 50 mL/hr is adequate; when urine output drops below 30 mL/hr, it may indicate renal failure and the practitioner should be notified. 2 This is unnecessary because the output is adequate. 3 This is unnecessary because the output is adequate. 4 This is contraindicated; the client probably will still be under the influence of anesthesia and the gag reflex may be depressed.

A male client is diagnosed as having phosphatic calculi. The nurse teaches the client that his diet may include: 1. Apples 2. Chocolate 3. Rye bread 4. Cheddar cheese

1 Apples are low in phosphate. 2 Chocolate contains more phosphate than apples. 3 Rye bread contains more phosphate than apples. 4 Cheese is made with milk, which contains phosphate and should be avoided.

A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment is conducted to determine whether the client: 1. Is deficient in vitamins A, D, and K 2. Eats adequate amounts of dietary fiber 3. Consumes excessive amounts of protein 4. Has excessive levels of potassium and folic acid

1 Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluable vitamins. 2 Dietary fiber is not relevant to the situation. 3 Although adequate dietary protein is desirable for wound healing, it is unrelated to cholelithiasis. 4 Elevated potassium and folic acid are not related to cholelithiasis.

A home health care nurse visits a 40-year-old housewife who is receiving hemodialysis. When reviewing the diet with the client, the nurse encourages her to include: 1. Rice 2. Potatoes 3. Canned salmon 4. Barbecued beef

1 Foods high in carbohydrates and low in protein, sodium, and potassium are encouraged for these clients. 2 This is high in potassium, which is restricted. 3 This is high in protein and sodium, which usually are restricted. 4 This is high in protein, sodium, and potassium, which usually are restricted.

A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. The nurse who is providing home care instructions should include: 1. Drinking at least 3 L of fluid daily for 4 weeks 2. Removing organ meats from the diet for 6 weeks 3. Increasing the intake of dairy products for 5 days 4. Restricting movement for 3 days before resuming usual activities

1 Increasing fluid intake aids in the passage of fragments of the calculus that remain after the lithotripsy. 2 Organ meats are high in purine, an amino acid, which is a causative factor in the formation of uric acid crystals; they should be avoided by people with gout. 3 Calcium is the major component of the most common type of calculus; the intake of dairy products, which are high in calcium, should be limited. 4 Early ambulation is encouraged to aid in the passage of fragments of the calculus that remain after a lithotripsy.

When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is: 1. Scrambled eggs and applesauce 2. Barbecued chicken and French fries 3. Fresh fruit salad with cheddar cheese 4. Chunky peanut butter on whole wheat bread

1 Low-residue foods produce less fecal waste, decreasing bowel contents and irritation; protein promotes healing and calories provide energy. 2 Barbecued foods are spicy; foods high in fat can increase peristalsis. 3 Fruit and aged, sharp cheese can be irritating to the bowel. 4 Chunky peanut butter and whole wheat bread are high-residue foods.

A client with Laënnec's cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority? 1. Apply a safety jacket 2. Give the prn sedative as ordered 3. Notify the practitioner immediately 4. Provide oxygen via a nasal catheter

1 Measures must be taken immediately to ensure client safety. 2 Sedatives are contraindicated because they mask the progressive signs of hepatic encephalopathy. 3 Although the practitioner should be notified, the nurse should first take measures to ensure client safety. 4 Hepatic encephalopathy is caused by high serum ammonia levels, not hypoxia.

A 50-year-old man is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F. He reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, the primary nursing concern for this client is: 1. Acute pain 2. Inadequate nutrition 3. Electrolyte imbalance 4. Disturbed self-concept

1 Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the autodigestive process in the pancreas and peritoneal irritation. 2 Although clients with this medical diagnosis are often malnourished, addressing the client's pain takes priority. 3 There are not enough data for this conclusion; additional data such as skin turgor, serum electrolytes, and I&O are needed to identify whether the client has a fluid and electrolyte imbalance. 4 There are no data to support the presence of a disturbed selfconcept.

A client with cholelithiasis is scheduled for a lithotripsy. Preoperative teaching should include the information that: 1. Opioids will be available for postoperative pain 2. Fever is a common response to this intervention 3. Heart palpitations often occur after the procedure 4. Anesthetics are not necessary during the procedure

1 Painful biliary colic may occur in the postoperative period as a result of the passage of pulverized fragments of the calculi; this may occur 3 or more days after the lithotripsy. 2 Fever may indicate pancreatitis, which is a rare occurrence. 3 The delivery of shock waves during the procedure is synchronized with the heartbeat to avoid initiation of dysrhythmias. 4 Light sedation may be used to keep the client comfortable and as still as possible.

A practitioner tells a client that an increase in vitamin E and beta-carotene is important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are: 1. Spinach and mangoes 2. Fish and peanut butter 3. Oranges and grapefruits 4. Carrots and sweet potatoes

1 The antioxidants vitamin E and beta-carotene, which help inhibit oxidation and therefore tissue breakdown, are found in these foods. 2 These are excellent sources of vitamin E, not beta-carotene. 3 These are excellent sources of vitamin C, not vitamin E and beta-carotene. 4 These are excellent sources of beta-carotene, not vitamin E.

A client with a long history of alcohol abuse is admitted to the hospital with ascites, jaundice, and confusion. A diagnosis of hepatic cirrhosis is made. A nursing priority is to: 1. Institute safety measures 2. Monitor respiratory status 3. Measure abdominal girth daily 4. Test stool specimens for blood

1 The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority. 2 Although the client may have dyspnea as a result of ascites, it is not life threatening; safety is the priority. 3 Although this is done to monitor ascites, it is not the priority for a confused client; safety is the priority. 4 This is not the priority; providing for client safety is the priority.

The most effective method for the nurse to evaluate a client's response to ongoing serum albumin therapy for biliary cirrhosis is to monitor the client's: 1. Weight daily 2. Vital signs frequently 3. Urine output every half hour 4. Urine albumin level every shift

1 The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss. 2 The vital signs will not change drastically; "frequently" is a nonspecific time frame. 3 The urinary output is measured hourly; half-hour outputs are insignificant in this instance. 4 A serum, not urine, albumin level is significant; albumin in the urine indicates kidney dysfunction, not liver dysfunction.

A client has a body mass index (BMI) of 35 and verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by: 1. Decreasing portion size and fat intake 2. Increasing protein and vegetable intake 3. Decreasing carbohydrate and fat intake 4. Increasing fruits and limiting fluid intake

1 The most effective and safest method for achieving weight loss is to decrease caloric intake. This is best accomplished by maintaining a balance of nutrients while decreasing portion size and fat intake. A gram of fat is 9 calories, whereas a gram of protein and a gram of carbohydrate are each 4 calories. 2 Increasing protein intake can increase fat intake because animal protein also contains fat. 3 Although decreasing carbohydrate and fat intake will promote weight loss, the diet may result in an imbalance of nutrients, which may jeopardize the client's health. 4 Fruits are important in any diet, and if a balance of nutrients is to be maintained, fruit intake may need to be increased or decreased depending on the client's eating habits; water intake should not be limited in a weight loss diet; 6 to 8 glasses a day is recommended to enhance weight loss.

A client with cirrhosis of the liver and malnutrition begins to develop slurred speech, confusion, drowsiness, and tremors. With these signs and symptoms, the diet should be limited to: 1. 20 grams of protein, 2000 calories 2. 80 grams of protein, 1000 calories 3. 100 grams of protein, 2500 calories 4. 150 grams of protein, 1200 calories

1 The signs and symptoms indicate hepatic coma; protein is reduced according to tolerance, and calories are increased to prevent tissue catabolism. 2 This represents a high-protein diet, which is contraindicated in impending hepatic coma. 3 This represents a high-protein diet, which is contraindicated in impending hepatic coma. 4 This represents a high-protein diet, which is contraindicated in impending hepatic coma.

The most essential nursing care for a client with a nephrostomy tube is: 1. Ensuring free drainage of urine 2. Milking the tube every 2 hours 3. Instilling 2 mL of normal saline every 8 hours 4. Keeping an accurate record of intake and output

1 The tube must be kept patent to prevent urine backup, hydronephrosis, and kidney damage. 2 This is unnecessary unless the tube is not functioning. 3 This is a dependent function and requires a practitioner's order. 4 Although this is important, it will not ensure free drainage of urine, which is the priority

A male client who has had recurring renal calculi has a ureterolithotomy. Before discharge the nurse discusses the need to avoid urinary tract infections (UTIs). The nurse evaluates that the signs and symptoms of infection are understood when the client says he will report: 1. Urgency or frequency of urination 2. The inability to maintain an erection 3. Pain radiating to the external genitalia 4. An increase in alkalinity or acidity of urine

1 These occur with a urinary tract infection because of bladder irritability; burning on urination and fever are additional signs of a UTI. 2 This is not related to a UTI. 3 This is a symptom of a urinary calculus, not infection. 4 This is not a sign of a UTI; this may be caused by altering the diet to include foods that form acid ash or alkaline ash.

When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed: 1. In the supine position, with the right arm raised behind the head 2. On the right side, with the left arm stretched up and over the head 3. On the left side, with the right arm extended out in front across the bed 4. In the prone position, with both elbows flexed and the hands resting on the pillow

1 This position exposes the right intercostal space, making the large right lobe of the liver accessible. 2 This position will not provide accessibility to the liver; the small left lobe is not anatomically near the left chest wall. 3 In this position the liver will fall away from the chest wall and be less accessible. 4 This will not provide accessibility to the liver.

On the fourth postoperative day after a cystectomy and the formation of a continent diversion, the nurse observes mucous threads in a client's urine. The nurse should: 1. Expect this response after the diversion 2. Report this to the practitioner immediately 3. Obtain a specimen for culture and sensitivity 4. Increase the client's fluid intake for the next twelve hours

1 This response is expected because mucus continually is secreted by the intestinal mucosa. 2 This is not necessary; mucus is expected with an ileal conduit. 3 This is not necessary; at this point postsurgically the mucus is not an indication of infection; mucus in the urine after ureterostomy may indicate infection. 4 Although fluids should be encouraged to maintain urine flow, this will not eliminate mucus, which continually is discharged from the intestinal segment.

A client is cautioned to avoid vitamin D toxicity while increasing protein intake. The nurse evaluates that dietary teaching is understood when the client states, "I must increase my intake of: 1. tofu products." 2. eggnog with fruit." 3. powdered whole milk." 4. cottage cheese custard."

1 Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D. 2 Eggnog contains milk, which has vitamin D, and should be avoided. 3 This contains vitamin D and should be avoided. 4 This contains milk, which has vitamin D, and should be avoided.

A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" The nurse's best response is: 1. "Most peptic ulcers heal with medical treatment." 2. "Clients with peptic ulcers have pain while eating." 3. "Early surgery is advisable, especially after the first attack." 4. "If ulcers are untreated, cancer of the stomach can develop."

1 Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence. 2 Pain occurs 30 minutes to 1 hour after a meal. 3 Surgery may be done after multiple recurrences and for treating complications. 4 Perforation, pyloric obstruction, and hemorrhage, not cancer, are major complications.

An abdominoperineal resection with the creation of a colostomy is scheduled for a client with cancer of the rectum. The nurse anticipates that the client must sign a consent for a: 1. Permanent sigmoid colostomy 2. Permanent ascending colostomy 3. Temporary double-barrel colostomy 4. Temporary transverse loop colostomy

1 When intestinal continuity cannot be restored after removal of the anus, rectum, and adjacent colon, a permanent colostomy is formed. 2 The ascending segment of the colon lies on the right side of the abdomen and has no anatomical proximity to the rectum. 3 This temporary procedure is performed to allow a segment of colon to heal; intestinal continuity is eventually restored. 4 This procedure is commonly performed for inflammation of the colon when intestinal continuity eventually can be restored.

After abdominal surgery a client returns to the unit with a nasogastric tube to decompression. The practitioner orders an antiemetic every 6 hours prn for nausea. When the client complains of nausea, the first action by the nurse is to: 1. Check for placement of the tube 2. Administer the ordered antiemetic 3. Irrigate the tube with normal saline 4. Notify the practitioner of the problem

1 With a nasogastric tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking placement can determine whether it is in the stomach; once placement is verified, then fluid can be instilled to ensure patency. 2 The antiemetic may relieve the discomfort, but will not determine the cause. 3 If the tube is displaced it may be in the trachea or bronchi and instillation of fluid will cause respiratory impairment before placement is confirmed. 4 The nurse should always assess a situation carefully before notifying the practitioner.

When discussing future meal plans with a client who has a hiatal hernia, the nurse asks what beverages the client usually enjoys. The beverage that should be included in the diet when the client is discharged is: 1. Ginger ale 2. Apple juice 3. Orange juice 4. Cola beverages

2 Apple juice is not irritating to the gastric mucosa. 1 Carbonated beverages distend the stomach and promote regurgitation. 3 The acidity of orange juice aggravates the disorder. 4 Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

Immediately after a subtotal gastrectomy a client is brought to the postanesthesia care unit. The nurse identifies small blood clots in the gastric drainage. The nurse should: 1. Clamp the tube 2. Consider this an expected event 3. Instill the tube with iced normal saline 4. Notify the client's surgeon of this finding

2 As a result of the trauma of surgery, some bleeding can be expected for 4 to 5 hours. 1 Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. 3 Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. 4 This is not necessary; this is an expected occurrence.

Immediately after esophageal surgery the priority nursing assessment concerns the client's: 1. Incision 2. Respirations 3. Level of pain 4. Nasogastric tube

2 Because of the trauma of surgery and the proximity of the esophagus to the trachea, respiratory assessments become the priority. 1 Although this is important, an adequate airway is the priority. 3 Although this is important, an adequate airway is the priority. 4 Although this is important, an adequate airway is the priority

A client complains of urinary problems. Cholinergic medications are prescribed. Which condition is treated with cholinergic medications? 1. Kidney stones 2. Flaccid bladder 3. Spastic bladder 4. Urinary tract infections

2 Cholinergics intensify and prolong the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention. 1 Cholinergics will not prevent renal calculi. 3 Anticholinergics are prescribed for the frequency and urgency associated with a spastic bladder. 4 Preventing urinary tract infections is a secondary gain because cholinergics help prevent urinary retention that can lead to a urinary tract infection, but this is not the primary purpose for administering these drugs.

A client with jaundice associated with hepatitis expresses concern over the change in skin color. The nurse explains that this color change is a result of: 1. Stimulation of the liver to produce an excess quantity of bile pigments 2. Inability of the liver to remove normal amounts of bilirubin from the blood 3. Increased destruction of red blood cells during the acute phase of the disease 4. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding

2 Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera. 1 With hepatitis, the liver does not secrete excess bile. 3 Destruction of red blood cells does not increase in hepatitis. 4 Decreased prothrombin levels cause spontaneous bleeding, not jaundice.

A client has been receiving hemodialysis for several months. The nurse considers that bleeding into the GI tract is of particular significance to a client with chronic kidney disease because: 1. Hypovolemia can compromise kidney function 2. Blood is digested thereby increasing the kidneys' protein load 3. Clotting problems in kidney disease make diagnosis of the bleeding site difficult 4. Usual signs of blood loss will not be manifested in the client with kidney failure

2 Digested blood is protein which will increase the BUN. 1 Kidney function already is compromised; dialysis performs the function of the kidneys. 3 Although clients with chronic kidney disease have problems with bleeding, this does not interfere with identifying the site of bleeding. 4 Chronic kidney disease does not affect the signs of GI blood loss, hemorrhage, or shock

A 45-year-old client develops acute glomerulonephritis after a recent streptococcal infection. Which sign or symptom should the nurse expect the client to report? 1. Nocturia 2. Mild headache 3. Increased appetite 4. Recent weight loss

2 Headaches occur because of the retention of fluid and hypertension. 1 The client will experience oliguria, not nocturia. 3 The client will develop anorexia related to elevated toxic substances in the blood. 4 The client will have a weight gain because of the retention of fluid.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis the nurse should: 1. Shave the client's abdomen 2. Medicate the client for pain 3. Encourage the client to drink fluids 4. Instruct the client to empty the bladder

4 Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. 1 This is not necessary. 2 This is not necessary. 3 Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.

A client with chronic kidney disease is on a restricted protein diet and is taught about high-biologic-value protein foods. An understanding of the rationale for this diet is demonstrated when the client states that high-biologic-value protein foods are: 1. Needed to promote weight gain 2. Necessary to prevent muscle wasting 3. Used to increase urea blood products 4. Responsible for controlling hypertension

2 High-biologic-value (HBV) protein contains essential amino acids needed by the body for tissue building and repair; HBV proteins limit the extent of nitrogenous wastes. 1 A high-calorie diet provides for weight gain. 3 The purpose of a diet for a client with chronic kidney disease is to decrease, not increase, nitrogenous wastes. 4 This is not the purpose of HBV proteins; sodium restriction decreases blood pressure.

A client with an ileal conduit is being prepared for discharge. Before discharge the nurse instructs the client to: 1. Abstain from beer and alcohol consumption 2. Maintain fluid intake of at least two liters daily 3. Notify the practitioner if the stoma size decreases 4. Avoid getting soap and water on the peristomal skin

2 High-fluid intake flushes the ileal conduit and prevents infection and obstruction caused by mucus or uric acid crystals. 1 Alcohol is not contraindicated with an ileal conduit. 3 This is expected; as edema decreases, the stoma will become smaller. 4 Soap and water on the peristomal area help prevent irritation from waste products.

The nurse is caring for a client with acute renal failure. The most serious complication for this client is: 1. Anemia 2. Infection 3. Weight loss 4. Platelet dysfunction

2 Infection is responsible for one third of the traumatic or surgically induced deaths of clients with acute renal failure, as well as for medically induced acute renal failure. Resistance is reduced in clients with kidneys that fail because of decreased phagocytosis, which makes them susceptible to microorganisms. 1 Anemia occurs often with acute renal failure, but it is not the most serious complication and should be treated in relation to the client's adaptations; erythropoietin and iron supplements usually are prescribed. 3 Weight loss is not life threatening. 4 Platelet dysfunction occurs because of decreased cell surface adhesiveness, but it is not as serious as an infection.

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric tube. The nurse should: 1. Clamp the tube and call the surgeon immediately 2. Report the characteristics of drainage to the surgeon 3. Instill 30 mL of iced normal saline into the nasogastric tube 4. Continue to monitor the drainage and record the observations

2 Large amounts of blood or excessive bloody drainage 12 hours postoperatively must be reported immediately because the client is hemorrhaging. 1 Clamping the tube is contraindicated; accumulation of secretions causes pressure on the suture line, preventing further observation of drainage. 3 This must be ordered by the practitioner; 50 to 100 mL of normal saline at room temperature instilled every 30 to 50 minutes is the usual therapy to prevent lowering the core body temperature. 4 This is an unsafe intervention at this time; the surgeon should be notified

A client is suspected of having a gastric peptic ulcer. When obtaining a history from this client, the nurse expects the reported pain to: 1. Intensify when the client vomits 2. Occur one to three hours after meals 3. Increase when the client eats fatty foods 4. Begin in the epigastrium, radiating across the abdomen

2 Pain occurs after the stomach empties with a gastric peptic ulcer; ingesting food stimulates gastric secretions, which later act on the gastric mucosa of the empty stomach, causing the gnawing pain. 1 Vomiting temporarily alleviates pain because acid secretions are eliminated from the body. 3 There is no intolerance of fats; eating generally alleviates gastric peptic pain. 4 Gastric pain is sharply localized in the epigastrium; it can radiate across the abdomen if a gastric peptic ulcer perforates.

The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum purine. The nurse concludes that the stone is probably composed of: 1. Cystine 2. Uric acid 3. Calcium oxalate 4. Magnesium ammonium phosphate

2 Purines are precursors of uric acid, which crystallizes. 1 Cystine stones are caused by a rare hereditary defect resulting in inadequate renal tubular reabsorption of cystine (inborn error of cystine metabolism). 3 Serum purine will not be elevated if the stone is composed of calcium oxalate. 4 A struvite stone is sometimes called a magnesium ammonium phosphate stone and is precipitated by recurrent urinary tract infections with coliform bacteria.

After revision of the pancreas because of cancer, total parenteral nutrition is instituted via a central venous infusion route. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. The nurse should call the practitioner and: 1. Stop the infusion while covering the insertion site 2. Slow the infusion and check the serum glucose level 3. Prepare the client for immediate surgery for possible bowel obstruction 4. Increase fluids via a peripheral intravenous route and give analgesics for the headache

2 Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration; slowing the infusion decreases the possibility of glucose overload. 1 Stopping the flow will jeopardize the central line; this site is commonly covered by a transparent dressing to allow for assessment of the site. 3 Signs of bowel obstruction are not present. 4 The client's headache should disappear with oral fluid replacement; analgesics are not indicated.

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear: 1. Dry, pale pink, and flush with the skin 2. Moist, red, and raised above the skin surface 3. Dry, purple, and depressed below the skin surface 4. Moist, pink, flush with the skin, and painful when touched

2 The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. 1 The stoma should be moist, not dry; pale pink indicates a low hemoglobin level; although some stomas can be flush with the skin, a raised stoma is more common. 3 The stoma should be moist, not dry; purple indicates compromised circulation; a depressed stoma is retracted and unexpected. 4 Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common.

After an acute episode of upper GI bleeding, a client vomits undigested antacids and complains of severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the practitioner, the nurse should: 1. Start oxygen via nasal cannula 2. Keep the client NPO in preparation for surgery 3. Inquire whether any red or black stools have been noted 4. Place the client in the supine position with the legs elevated

2 These are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. 1 Although oxygen may minimize the tachycardia and tachypnea that are related to pain and possible blood loss, keeping the client NPO is the priority. 3 Keeping the client NPO in preparation for surgery is more important than asking about the presence of black, tarry stools or red stools. Although this question should be asked, knowing this information will not change the medical or nursing care of the client at this time. 4 The adaptations are indicative of perforation and the priority is to prepare the client for surgery.

The diet ordered for a client permits 190 grams of carbohydrates, 90 grams of fat, and 100 grams of protein. The nurse calculates that this diet contains approximately how many calories? 1. 920 calories 2. 1970 calories 3. 2470 calories 4. 2970 calories

2 This diet contains approximately 1970 calories. There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein. 1 This is an incorrect calculation; this is too few calories. 3 This is an incorrect calculation; this is too many calories. 4 This is an incorrect calculation; this is too many calories.

The home health care nurse is teaching about peritoneal dialysis to a client who has just started the procedure. The client is informed that if drainage of dialysate from the peritoneal cavity ceases before the required amount has drained out, the client should: 1. Drink a glass of water 2. Turn from side to side 3. Deep breathe and cough 4. Periodically rotate and reposition the catheter

2 Turning from side to side will change the position of the catheter, thereby freeing the drainage holes, which may be obstructed. 1 Taking fluids into the gastrointestinal tract does not influence drainage of dialysate from the peritoneal cavity. 3 This improves pulmonary ventilation but does not improve flow of dialysate from the catheter. 4 The position of the catheter should be changed by the practitioner.

When caring for a client who had abdominal intestinal surgery, it is important for the nurse to consider that: 1. Rectal intubation will relieve vomiting 2. Air swallowing causes gastric distention 3. Preoperative enemas prevent a postoperative ileus 4. Clear liquids a day after surgery stimulate peristalsis

2 When anxious, in pain, or performing deep-breathing exercises, it is common for air to be swallowed, which can cause gastric distention. 1 A rectal tube does not relieve nausea and vomiting; it facilitates expulsion of gas and some secretions trapped in the large intestines because of lack of peristalsis. 3 Preoperative enemas are not given to prevent paralytic ileus postoperatively; they are given to cleanse the lower gastrointestinal tract, decreasing the possibility of peritoneal contamination. 4 Liquids are not given until some peristalsis has returned as evidenced by the presence of bowel sounds.

A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: 1. Eat a low-fat, low-protein diet 2. Avoid foods high in carbohydrates 3. Avoid ingesting alcoholic beverages 4. Eat a bland diet of six small meals a day

3 Alcohol increases pancreatic secretions, which cause pancreatic cell destruction. 1 Although the diet should be low in fat, it should be high in protein; also it should be high in carbohydrates. 2 The client should be consuming 4,000 to 6,000 calories a day to maintain weight and promote tissue repair. 4 A bland diet is not necessary, but large, heavy meals should be avoided.

A client with uremic syndrome has the potential to develop many complications. Which complication should the nurse anticipate? 1. Hypotension 2. Hypokalemia 3. Flapping hand tremors 4. Elevated hematocrit values

3 An elevation in uremic waste products causes irritation of the nerves, resulting in flapping hand tremors (asterixis, "liver flap"). 1 Hypertension results from kidney failure because of sodium and water retention. 2 The diseased kidney is unable to excrete potassium ions, resulting in hyperkalemia, not hypokalemia. 4 The hematocrit value will be low because of a decreased production of erythropoietin, a hormone synthesized in the kidney; erythropoietin regulates the production of erythrocytes.

A nurse is obtaining a health history from a client with the diagnosis of renal calculi. Which factor in the client's history most likely contributed to the development of renal calculi? 1. High-cholesterol diet 2. Excessive exercise program 3. Excess ingestion of antacids 4. Frequent consumption of alcohol

3 An excessive use of antacids may result in hypercalciuria; most calculi contain calcium combined with phosphate or other substances. 1 Cholesterol is unrelated to the formation of renal calculi; cholesterol stones in the gallbladder are the result of increased cholesterol synthesis in the liver. 2 Immobility with the associated demineralization of bone, not exercise, contributes to the formation of renal calculi. 4 Alcohol intake is unrelated to renal calculi formation.

A 79-year-old client is admitted to the hospital with painful abdominal spasms and severe diarrhea of 2 days' duration. The order of physical skills the nurse should follow when performing an admitting examination of this client should be "inspection" followed by: 1. Percussion, palpation, auscultation 2. Percussion, palpation, auscultation 3. Auscultation, palpation, percussion 4. Auscultation, percussion, palpation

3 Auscultation must be performed before palpation and percussion because they may influence intestinal peristalsis resulting in inaccurate results. Palpation is performed before percussion because percussion will have a greater impact on peristalsis. 1 Percussion or palpation performed before auscultation may result in an inaccurate assessment of bowel sounds. 2 Percussion or palpation performed before auscultation may result in an inaccurate assessment of bowel sounds. 4 Although auscultation is performed before percussion or palpation, palpation should precede percussion when assessing the abdomen.

After a bilateral herniorrhaphy the nurse should assess a male client for the development of: 1. Hydrocele 2. Paralytic ileus 3. Urinary retention 4. Thrombophlebitis

3 Because of pain and the proximity of the operative site to the lower urinary tract, urinary retention is common after this surgery. 1 Hydrocele is not a complication of a herniorrhaphy. 2 The abdomen was not entered; there should be no interference with peristalsis. 4 Thrombophlebitis should not occur because early ambulation is permitted.

A male client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. When obtaining this client's history, the nurse gives priority to the client's statement that: 1. His pain increases after meals 2. He experiences nausea frequently 3. His stools have a black appearance 4. He recently joined Alcoholics Anonymous

3 Black (tarry) stools indicate upper GI bleeding; digestive enzymes act on the blood resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. 1 Investigation of bleeding takes priority; later the nurse should help to identify irritating foods that are to be avoided. 2 Nausea is a common symptom of gastritis, but is not life threatening. 4 Attempts to control alcoholism should be supported but this is a long-term goal; assessment of bleeding takes priority.

The nurse evaluates that dietary teaching for a client with a colostomy is effective when the client states, "It is important that I eat: 1. food low in fiber so that there is less stool." 2. bland foods so that my intestines do not become irritated." 3. everything I ate before the operation and avoid foods that cause gas." 4. soft foods that are more easily digested and absorbed by my large intestine."

3 Clients with a colostomy can eat a regular diet; only gas-forming foods that cause distention and discomfort should be avoided. 1 The amount of stool does not have to be limited; therefore, a low-residue diet is not necessary. 2 The affected tissue has been removed and healthy mucosal tissue lines the intestine and forms the stoma; therefore, bland foods are not necessary. 4 Nutrients are absorbed by the small, not the large, intestine; a regular diet usually is easily digested and absorbed.

When teaching a community health class about the signs of colorectal cancer, the nurse stresses that the most common complaint of persons with colorectal cancer is: 1. Rectal bleeding 2. Abdominal pain 3. Change in bowel habits 4. Decrease in diameter of stools

3 Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common signs of colorectal cancer. 1 This is the second most common complaint that results from destruction of the epithelial lining of the intestine. 2 Pain is reported as a symptom in less than 25% of clients; also it is a late sign after other organs are invaded. 4 This is a later sign that becomes evident when the lumen of the intestine narrows as a result of the enlarging mass.

A client with colitis has a hemicolectomy performed. After surgery the nurse identifies that, in addition to having vomited 300 mL of dark green viscous fluid, the client has increasing abdominal distention and absent bowel sounds. Immediate care should be directed toward: 1. Replacing fluid losses 2. Decreasing the vomiting 3. Decompressing the bowel 4. Restoring electrolyte balance

3 Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing. 1 Although this is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy. 2 Vomiting will subside as the bowel is decompressed. 4 Although this is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy.

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8 o'clock the next morning. The nurse advises the client to: 1. Have dinner and then nothing by mouth after 6 pm 2. Drink full liquids tonight and clear liquids in the morning 3. Consume a light evening meal and no food or fluid after midnight 4. Eat lunch the day before surgery and then not drink or eat anything until after surgery

3 Eating a light meal and eliminating food and fluids after midnight limit complications during and after surgery, which include aspiration, nausea, dehydration, and possible ileus. 1 A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. 2 Clear liquids in the morning can cause nausea, vomiting, and aspiration. 4 Fluids should not be withheld for more than 8 hours, to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.

A client is admitted to the hospital with the diagnosis of acute salmonellosis. The nurse expects that the client will receive: 1. Opioids 2. Antacids 3. Electrolytes 4. Antidiarrheals

3 Fluids of dextrose and normal saline and electrolytes are administered to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output. 1 These are not used when there is a possibility of bacterial infection because slowed peristalsis decreases excretion of the salmonella organism. 2 Salmonellosis is an infection, not a condition caused by hyperacidity. 4 These are not used when there is a possibility of bacterial infection because slowed peristalsis decreases excretion of the salmonella organism

A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. This plan can best be implemented by: 1. Offering a firm-bristled toothbrush 2. Providing an antiseptic mouthwash 3. Using a gentle spray of normal saline 4. Swabbing the mouth with a moistened gauze square

3 Gentle sprays are effective in cleaning the mouth and teeth without disturbing the sensitive tissues or radon seeds. 1 This can dislodge the radon seeds and be traumatic to the compromised oral mucosa. 2 An antiseptic mouthwash is an astringent that is too harsh for the sensitive oral mucosa. 4 This can dislodge the radon seeds and be traumatic to the compromised oral mucosa.

A client is instructed to avoid straining on defecation postoperatively. The nurse evaluates that the related teaching is understood when the client states, "I must increase my intake of: 1. ripe bananas." 2. milk products." 3. green vegetables." 4. creamed potatoes."

3 Green vegetables contain fiber, which promotes defecation. 1 These have a constipating effect, which results in straining at stool. 2 These have a constipating effect, which results in straining at stool. 4 These have a constipating effect, which results in straining at stool.

A client is admitted to the hospital with a ureteral calculus. What clinical findings should the nurse expect when the client voids? 1. Urgency and pain 2. Foul odor and dark urine 3. Hematuria with sharp pain 4. Frequency with small amounts of urine

3 Hematuria and pain may result from damage to the ureteral lining as the calculus moves down the urinary tract; the urine may become cloudy or pink tinged. 1 Although severe pain may be present, urgency is not associated with renal calculi; urgency may be associated with an enlarged prostate, cystitis, or other genitourinary problems. 2 The odor of urine is not foul with this condition; the color of urine is not dark with this condition, although it may be cloudy, pink, or red from hematuria. 4 Frequency may occur when the calculus reaches the bladder.

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. Which sign would the client have to identify for the nurse to determine that the client understands the teaching? 1. Weight loss 2. Subnormal temperature 3. Elevated blood pressure 4. Increased urinary output

3 Hypertension is caused by hypervolemia because of the failure of the new kidney. 1 Weight gain, not loss, occurs with a rejection of the kidney because of fluid retention. 2 The client will have an elevated temperature exceeding 100° F with kidney rejection. 4 Urine output will be decreased or absent, depending on the degree of kidney rejection.

A nurse evaluates that a client with chronic kidney disease understands an adequate source of high-biologic-value protein when the food the client selects from the menu is: 1. Apple juice 2. Raw carrots 3. Cottage cheese 4. Whole wheat bread

3 One cup of cottage cheese contains approximately 225 calories, 27 grams of protein, 9 grams of fat, 30 mg of cholesterol, and 6 grams of carbohydrate; proteins of high biologic value (HBV) contain optimal levels of the amino acids essential for life. 1 Apple juice is a source of vitamins A and C, not protein. 2 Raw carrots are a carbohydrate source and contain beta-carotene. 4 Whole wheat bread is a source of carbohydrates and fiber.

A traveling salesman develops gastric bleeding and is hospitalized. An important etiologic clue for the nurse to explore while taking this client's history is: 1. Any recent foreign travel 2. The client's usual dietary pattern 3. The medications that the client is taking 4. Any change in the status of family relationships

3 Some medications, such as aspirin, NSAIDs, and prednisone, irritate the stomach lining and may cause bleeding with prolonged use. 1 Travel to foreign countries may be related to intestinal irritation, causing diarrhea and intestinal bleeding, not gastric bleeding. 2 This is not the cause of gastric bleeding; it is important to ascertain dietary habits when teaching about diet therapy. 4 Although stress may play a part, the use of some medications has a more direct relationship.

A client with acute glomerulonephritis complains of thirst. What should the nurse offer the client? 1. Ginger ale 2. Milk shake 3. Hard candy 4. Cup of broth

3 Sucking on a hard candy will relieve thirst and increase carbohydrates, but does not supply extra fluid. 1 Carbonated beverages contain sodium and provide additional fluid, which must be restricted. 2 A milkshake contains both fluid and protein, which must be restricted. 4 Broth contains sodium, which increases fluid retention.

A practitioner orders a high-calorie, high-protein diet for a client who is a heavy smoker. In light of the history of smoking, the nurse encourages the client to eat foods high in: 1. Niacin 2. Thiamine 3. Vitamin C 4. Vitamin B12

3 The RDA requirement of vitamin C for an adult male is 90 mg; smoking accelerates oxidation of tissue vitamin C, so smokers need an additional 35 mg/day. 1 Niacin is not oxidized more rapidly in the smoker. 2 Thiamine is not oxidized more rapidly in the smoker. 4 Vitamin B12 is not oxidized more rapidly in the smoker.

A client has end-stage kidney disease and is receiving hemodialysis. During dialysis the client complains of nausea and a headache and appears confused. Operating on standing protocols, the nurse should: 1. Give an analgesic 2. Administer an antiemetic 3. Decrease the rate of exchange 4. Discontinue the procedure immediately

3 These are signs and symptoms of disequilibrium syndrome, which results from rapid changes in composition of the extracellular fluid and cerebral edema; the rate of exchange should be decreased. 1 Although this may relieve the headache, it will not relieve the other adaptations or the cause of disequilibrium syndrome. 2 Although this may relieve the nausea, it will not relieve the other adaptations or the cause of disequilibrium syndrome. 4 This is unnecessary; reducing the rate of exchange should reduce the adaptations of disequilibrium syndrome.

One month after abdominal surgery a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in the: 1. Supine position 2. Right Sims position 3. Semi-Fowler's position 4. Most comfortable position

3 This position promotes localization of purulent material and inflammation and prevents an ascending infection. 1 The risk of an ascending infection may be increased in this position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. 2 The risk of an ascending infection may be increased in this position because it allows fluid in the abdominal cavity to bathe the entire peritoneum. 4 The client may choose a position that increases the risk of an ascending infection.

A nurse is notified that the latest potassium level for a client in acute renal failure is 6.2 mEq. What is most important for the nurse to do? 1. Alert the cardiac arrest team 2. Call the laboratory to repeat the test 3. Take vital signs and notify the practitioner 4. Obtain an ECG strip and have lidocaine available

3 Vital signs monitor the cardiopulmonary status; the practitioner must treat this hyperkalemia to prevent cardiac dysrhythmias. 1 The cardiac arrest team responds to a cardiac arrest; there is no sign of arrest in this client. 2 A repeat laboratory test will take time and probably reaffirm the original results; the client needs medical attention. 4 These are correct interventions if available, but the priority is medical attention and the practitioner should be notified immediately.

When teaching a client about the diet after a pancreaticoduodenectomy (Whipple procedure) performed for cancer of the pancreas, the statement the nurse should include is: 1. "There are no dietary restrictions; you may eat what you desire." 2. "Your diet should be low in calories to prevent taxing your pancreas." 3. "Meals should be restricted in protein because of your compromised liver function." 4. "Low-fat meals should be eaten because of interference with your fat digestion mechanism."

4 A pancreaticoduodenectomy leads to malabsorption because of impaired delivery of bile to the intestine; fat metabolism is interfered with, causing dyspepsia. 1 These clients are anorexic, require small frequent meals, and should eat a high-calorie, high-protein, low-fat diet. 2 High-calorie meals are needed for energy and to promote use of protein for tissue repair. 3 High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless direct extension occurs.

After surgery for cancer of the pancreas, the client's nutrition and fluid regimen will be influenced by the remaining amount of functioning pancreatic tissue. Considering both the exocrine and the endocrine functions of the pancreas, the client's postoperative regimen will primarily include managing the intake of: 1. Alcohol and caffeine 2. Fluids and electrolytes 3. Vitamins and minerals 4. Fats and carbohydrates

4 Formation of lipase necessary for digestion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism. 1 Although it is necessary to avoid alcohol, this is not related to pancreatic exocrine functions; caffeine is unrelated to pancreatic function. 2 Fluid and electrolyte problems are not related specifically to exocrine or endocrine pancreatic functioning. 3 Deficiencies of vitamins and minerals may occur because of inadequate intake, but these deficiencies are not specifically related to exocrine or endocrine pancreatic functioning.

A mother whose son has hepatitis A states that there is only one bathroom in their home and she is worried that other members of the family may get hepatitis. The nurse's best reply is: 1. "I suggest that you buy a commode exclusively for your son's use." 2. "There is no problem with your son sharing the same bathroom with everyone." 3. "Your son may use the bathroom, but you need to use disposable toilet covers." 4. "It is important that family members, including your son, wash their hands after using the bathroom."

4 Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing. 1. This is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. 2 If the son uses the same bathroom as others, provision must be made for the cleaning of equipment or disposal of contaminated wastes. 3 The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the son also is used by others. Handwashing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

A client has end-stage kidney disease and is admitted for a kidney transplant. The nurse teaches the client that the donor must: 1. Have the same blood type 2. Be a member of the same family 3. Be approximately the same body size 4. Have matching leukocyte antigen complexes

4 Human leukocyte antigen compatibility provides the most specific predictions of the body's tendency to accept or reject foreign tissue. 1 Although ABO compatibility is necessary, the exact blood type is not. 2 This is unsafe unless the family member has matching leukocyte antigen complexes. This may increase the possibility of a match, but there is no guarantee that a family member will match. 3 Differences in body size do not cause rejection.

After the surgical creation of an ileostomy, a client is transferred to a rehabilitation unit. The client asks for help in selecting breakfast. What should the nurse encourage the client to eat or drink? 1. Hot coffee and oranges 2. Shredded wheat and milk 3. Toast and a western omelet 4. Cream of wheat and bananas

4 Low-residue foods will not increase motility. 1 Warmth and the fiber in the orange juice will increase motility and should be avoided. 2 Wheat cereal contains roughage and should be avoided. 3 Toast and the vegetables in a western omelet are high in residue; also the omelet is fried, which should be avoided.

A client is to be discharged after a laser laparoscopic cholecystectomy. The nurse evaluates that the discharge instructions are understood when the client states: 1. "I can change the bandages every day." 2. "I should stay on a full liquid diet for 3 days." 3. "I should not clean the surgical sites for a week." 4. "I may have mild shoulder pain for about a week."

4 Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery. 1 The bandages are removed the second day postoperatively. 2 Clients generally tolerate food after 24 to 48 hours. 3 The client may bathe and shower as usual.

A client is suspected of having late-stage (tertiary) syphilis. When obtaining a health history, the nurse determines that the statement by the client that most supports this diagnosis is: 1. "I noticed a wart on my penis." 2. "I have sores all over my mouth." 3. "I've been losing a lot of hair lately." 4. "I'm having trouble keeping my balance."

4 Neurotoxicity, as manifested by ataxia, is evidence of tertiary syphilis, which may involve the CNS; other CNS signs include confusion, paralysis, delusions, impaired judgment, and slurred speech. 1 A sore on the penis occurs in the secondary stage. 2 Sores in the mouth occur in the secondary stage. 3 Alopecia is not a sign of late-stage syphilis.

A nurse is obtaining the health history of a client with a left ureteral calculus who is scheduled for a transurethral ureterolithotomy. Which description of pain should the nurse expect the client to report? 1. Boring pain in the left flank 2. Pain that intensifies on urination 3. Dull pain that is constant in the costovertebral angle 4. Spasmodic pain on the left side that radiates to the suprapubic area

4 Pain with ureteral stones is caused by spasm and is excruciating and intermittent; it follows the path of the ureter to the bladder. 1 Pain is spasmodic and excruciating, not boring. 2 Pain intensifies as the calculus lodges in the ureter and spasms occur in an attempt to dislodge it. 3 Spasmodic pain on the left side that radiates to the suprapubis is typical of pain caused by a stone in the renal pelvis.

A male client with liver dysfunction reports that his gums bleed spontaneously. In addition, the nurse identifies small hemorrhagic lesions on his face. The nurse concludes that the client needs additional vitamin: 1. D 2. E 3. A 4. K

4 Petechiae are evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, which is necessary to activate blood clotting factors. 1 Vitamin D is not involved in the clotting process. 2 Vitamin E is not involved in the clotting process. 3 Vitamin A is not involved in the clotting process, even though the transformation of carotene to vitamin A takes place in the liver.

A long-term complication that a client must be made aware of after a pancreaticoduodenectomy for cancer of the pancreas is hypoinsulinism. The nurse evaluates that the teaching about hypoinsulinism is understood when the client states, "I should seek medical supervision if I experience: 1. oliguria." 2. anorexia." 3. weight gain." 4. increased thirst."

4 Polydipsia is characteristic of hypoinsulinism (diabetes mellitus) because excessive urine is excreted related to glycosuria. 1 Polyuria, not oliguria, is characteristic of diabetes mellitus because the kidneys excrete excess fluid with the glucose. 2 Increased appetite is characteristic of diabetes mellitus because of impaired metabolism. 3 Weight loss characterizes diabetes mellitus because of the use of body mass as a source of energy.

Part of discharge teaching for a client with a sigmoid colostomy includes how to protect clothing from colostomy leakage. What is the nurse's most appropriate response when the client asks about the use of appliances and dressings? 1. "Appliances are used to avoid soiling your clothing." 2. "Special appliances are expensive but they provide for better bowel control." 3. "I will give you enough appliances to last until your next visit to the physician." 4. "Many people do not need appliances once they regulate their bowels with routine irrigations."

4 Regular irrigation and effective evacuation prevent unexpected bowel movements; generally a drainage pouch is needed only immediately after an irrigation. 1 Once the colostomy is regulated, an appliance is necessary only immediately after the irrigation (approximately 1 hour). 2 Appliances collect what is evacuated; they do not control the function of the colostomy; a "special" appliance is not needed. 3 This response does not address the client's concern.

A male client, age 56, is being assessed for possible cancer of the urinary bladder. Of the client's signs and symptoms, the one most significant for cancer of the urinary tract is: 1. Dysuria 2. Retention 3. Hesitancy 4. Hematuria

4 Research statistics indicate that hematuria is the most common early sign of cancer of the urinary system, probably because of the urinary system's rich vascular network. 1 Dysuria is not specific for bladder cancer; usually it is associated with an enlarged prostate in the male. 2 Retention is not specific for bladder cancer; usually it is associated with an enlarged prostate in the male. 3 Hesitancy is not specific for bladder cancer; usually it is associated with an enlarged prostate in the male.

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1. Froot Loops 2. Corn Flakes 3. Cap'n Crunch 4. Shredded Wheat

4 Shredded Wheat contains 5.5 grams of fiber per serving, which is more than the other choices. 1 Froot Loops contain 0.8 gram of fiber per serving. 2 Corn Flakes contain 0.7 gram of fiber per serving. 3 Cap'n Crunch contains 0.7 gram of fiber per serving.

After a cholecystectomy to remove a cancerous gallbladder, the client has a T-tube in place that has drained 300 mL of bile-colored fluid during the first 24 hours. The nurse should: 1. Clamp the tube intermittently to slow drainage 2. Increase the rate of intravenous fluids to compensate for this loss 3. Empty the portable drainage system and reestablish negative pressure 4. Consider this an expected response after surgery and record the results

4 The T-tube provides an outlet for bile produced by the liver and is expected to drain 300 to 500 mL in the first day. 1 Clamping the tube during the early postoperative period may cause a buildup of pressure and leakage of bile into the peritoneum. 2 The rate of fluid administration is prescribed by the practitioner. 3 Drainage from the T-tube is by gravity; negative pressure is not applied.

When planning care for a client with a continuous bladder irrigation after a transurethral vaporization of the prostate, the nurse should: 1. Measure the output hourly 2. Monitor the specific gravity of the urine 3. Irrigate the catheter with saline three times daily 4. Exclude the amount of irrigant instilled from the output

4 The amount of irrigant instilled into the bladder must be deducted from the total output to determine the amount of urine produced. 1 Unless the irrigant is subtracted from the output, the total will be inaccurate. 2 Specific gravity measures the concentration of urine; this measurement will be inaccurate because the urine is diluted with GU irrigant. 3 This is unnecessary; the urinary bladder is constantly being irrigated with GU irrigant.

The nurse should ask the client with secondary syphilis about sexual contacts during the past: 1. 21 days 2. 30 days 3. 3 months 4. 6 months

4 The client is in the secondary stage, which begins from 6 weeks to 6 months after primary contact; therefore, a 6-month history is needed to ensure that all possible contacts are located. 1 Any time less than 6 months may miss contacts that may have become infected. 2 Any time less than 6 months may miss contacts that may have become infected. 3 Any time less than 6 months may miss contacts that may have become infected.

The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. The nurse concludes that: 1. Fluid is leaking into the intestine 2. The pancreas has been lacerated 3. This is a typical, expected response 4. A biliary vessel has been penetrated

4 The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy. 1 Fluid will leak through the puncture site or into the peritoneum, not the intestine. 2 The pancreas does not contain bile; it is in the upper left, not upper right, quadrant. 3 This is a complication, not an expected outcome.

A 50-year-old executive reports a loss of 20 pounds in 3 months. The stools are black and tarry, and a colonoscopy is scheduled. The nurse prepares the client for this test by: 1. Administering an oil-retention enema just before the test 2. Instructing that a bland diet be eaten the night before the test 3. Explaining that the pretest cathartic will cause diarrhea after the test 4. Telling the client not to eat or drink anything the morning of the test

4 The initiation of the gastrocolic reflex can cause intestinal contents to reach the lower GI tract and interfere with visualization of the colon. 1 An oil-retention enema will interfere with visualization during the colonoscopy and therefore should not be administered. 2 A liquid, not bland, diet should be consumed the night before the test. 3 Diarrhea should not occur after the test.

When preparing a client to go home with total parenteral nutrition (TPN), the nurse helps the client plan: 1. The days to be used for administration 2. For daily insertion of the circulatory access 3. For professional help to administer the TPN 4. A schedule of administration around regular activity

4 The less disruptive the procedure, the greater the acceptance by the client. 1 Most often, total parenteral nutrition is set up to run daily during sleeping hours. 2 Depending on the type of circulatory access used, it may not need to be changed for weeks. 3 The client or a significant other can be taught the principles of administration.

After a subtotal gastrectomy a client experiences an episode reflective of dumping syndrome. About 1½ hours after the initial attack, the client experiences a second period of feeling "shaky." The nurse determines that this latter effect is caused by: 1. A second more extensive rise in glucose 2. An overwhelmed insulin-adjusting mechanism 3. A distention of the duodenum from an excessive amount of chyme 4. An overproduction of insulin that occurs in response to the rise in blood glucose

4 The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome. 1 The physiological adaptations related to late dumping syndrome are caused by an increase in insulin, not glucose. 2 The insulin-adjusting mechanism is not overwhelmed, but responds vigorously, causing rebound hypoglycemia. 3 Dumping syndrome is related to the high glucose content of food, not the amount of food, entering the duodenum.

For what common early clinical manifestation should the nurse monitor in clients with renal carcinoma? 1. Flank pain 2. Weight gain 3. Periorbital edema 4. Intermittent hematuria

4 This is a classic sign of renal carcinoma; it is due to capillary erosion by the cancerous growth. 1 Dull flank pain may occur but not as frequently as bleeding. 2 Weight loss, not weight gain, will occur. 3 This will not occur with renal carcinoma; it may occur with glomerulonephritis.

A middle-aged male client has an adenocarcinoma of the colon. The practitioner suspects that this has metastasized and orders a CT scan of the liver. When preparing the client for the CT scan the nurse explains that: 1. After the procedure he must rest in bed for about six hours to prevent complications 2. There will be some discomfort during the procedure but the practitioner will administer an analgesic 3. He will be in twilight sleep during the procedure and may be able to hear people talking in the same room 4. He will be given an IV infusion containing a contrast medium before the procedure and must lie as still as possible for a period of time

4 This is an accurate explanation of what the client can expect during the CT scan. 1 It is not necessary to rest in bed for 6 hours. 2 The procedure causes no physical pain, and an analgesic is not necessary. 3 The client will be awake; neither sedation nor anesthesia is used with a CT scan.

A practitioner orders total parenteral nutrition 1 L every 12 hours. The primary nursing responsibility is to monitor the client's: 1. Electrolytes 2. Urinary output 3. Blood pressure 4. Serum glucose levels

4 This is essential because the solution is hyperosmolar, and a concentrated source of glucose can result in hyperglycemia. 1 Although important, it is not the priority. 2 Although important, it is not the priority. 3 Although important, it is not the priority.

A male client comes to the emergency department because he has a discharge from his penis. The practitioner suspects gonorrhea and asks the nurse to obtain a specimen and to send it for a culture. The nurse should: 1. Instruct the client to provide a semen specimen 2. Swab the discharge when it appears on the prepuce 3. Teach the client how to obtain a clean catch specimen of urine 4. Swab the drainage directly from the urethra to obtain a specimen

4 This method obtains a specimen uncontaminated by environmental organisms. 1 This is not as accurate as obtaining the purulent discharge from the site of origin. 2 This will contaminate the specimen with organisms external to the body. 3 This will dilute and possibly contaminate the specimen.

A client with Parkinson's disease complains about a problem with elimination. The nurse should encourage the client to: 1. Eat a banana daily 2. Decrease fluid intake 3. Take cathartics regularly 4. Increase residue in the diet

4 This produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson's disease. 1 Bananas are binding and will intensify the problem of constipation. 2 This will intensify the problem; fluids need to be increased. 3 Cathartics are irritating to the intestinal mucosa, and their regular administration promotes dependence.

To facilitate micturition in a male client, the nurse should instruct him to: 1. Use a urinal for voiding 2. Drink cranberry juice daily 3. Wash his hands after voiding 4. Assume the standing position for voiding

4 This uses gravity to allow urine to exert pressure on the area of the trigone, initiating relaxation of the urinary sphincter and facilitating micturition. 1 Although this may be important when urine is collected to be strained, analyzed, or measured, it will not facilitate micturition. 2 An acid-ash diet may be used to prevent urinary infection and the formation of calcium stones; it will not facilitate micturition. 3 This is important after urination but will not help facilitate micturition.

A client who was diagnosed with cancer of the head of the pancreas 2 months ago is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the admission history and physical assessment, the nurse expects the client's stool to be: 1. Green 2. Brown 3. Red-tinged 4. Clay-colored

4 Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum. 1 Green stools may occur with prolonged diarrhea associated with gastrointestinal inflammation. 2 The feces are brown when there is unobstructed bile flow into the duodenum. 3 Inflammation or ulceration of the lower intestinal mucosa results in blood-tinged stools.

A 76-year-old obese client arrives at the clinic complaining of epigastric distress and esophageal burning. During the health history the client admits to binge drinking and frequent episodes of bronchitis. After diagnostic studies, a diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1. _____ Aging 2. _____ Obesity 3. _____ Bronchitis 4. _____ Alcoholism 5. _____ Esophagitis

Answer: 1, 2 1 Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. 2 Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. 3 Inflammation of the bronchi will not weaken the diaphragm. 4 Alcoholism may cause an enlarged liver or pancreatitis but not a hiatal hernia. 5 Esophagitis does not cause a hiatal hernia.

A client who has been receiving hemodialysis for several years is to receive a kidney transplant. The nurse plans to review the essential information that the client should know before surgery. Select all that apply. 1. _____ Precautions needed to prevent infection 2. _____ Kidney may not function immediately 3. _____Urinary catheter will be present postoper-atively 4. _____ Immunosuppressive medications to be given preoperatively 5. _____ AV fistula will be used for drawing blood specimens preoperatively

Answer: 1, 2, 3 1 Because infection is a major complication of a kidney transplant, prevention begins with the recognition of the earliest signs and symptoms. 2 The transplanted kidney does not always function immediately; the client should know that dialysis may have to be continued for several weeks. 3 Just prior to surgery a urinary catheter is inserted and an antibiotic is instilled into the bladder to decrease the risk of infection. 4 Immunosuppressive therapy is started after, not before, surgery. 5 The vascular access is never used for drawing blood, or instilling IV medications.

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. 1. _____ Fever 2 _____ Tachypnea 3. _____ Hypertension 4. _____ Abdominal rigidity 5. _____ Increased bowel sounds

Answer: 1, 2, 4 1 The metabolic rate will be increased and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. 2 Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. 3 Hypovolemia and therefore hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. 4 With increased intra-abdominal pressure, the abdominal wall will become rigid and tender. 5 Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intra-abdominal pressure.

A client with end-stage kidney disease is receiving continuous ambulatory peritoneal dialysis. The nurse is monitoring the client for manifestations of complications associated with peritoneal dialysis. Select all that apply. 1. _____ Pruritus 2. _____ Oliguria 3. _____ Tachycardia 4. _____ Cloudy outflow 5. _____ Abdominal pain

Answer: 3, 4, 5 1 Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. 2 The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis. 3 Tachycardia can be caused by peritonitis, a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. 4 Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. 5 Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms.

A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. What skin conditions should the nurse expect to observe? Select all that apply. 1. _____ Vitiligo 2. _____ Hirsutism 3. _____ Melanosis 4. _____ Ecchymoses 5. _____ Telangiectasis

Answer: 4, 5 1 This refers to patches of depigmentation resulting from destruction of melanocytes. 2 This is excessive growth of hair; with cirrhosis, endocrine disturbances result in loss of axillary and pubic hair. 3 Dark pigmentary deposits result from a disorder of pigment metabolism. 4 Ecchymoses are small areas of bleeding into the skin or mucous membrane forming a blue or purple patch. With cirrhosis there is decreased synthesis of prothombin in the liver. 5 Telangiectasis is a vascular lesion formed by dilation of a group of small blood vessels. When cirrhosis causes an increase in pressure in the portal circulation that results in a dilation of cutaneous blood vessels around the umbilicus, it is specifically called caput medusae.