Med- Surg Final Exam Practice Questions
The nurse administer mannitol (osmitrol) to the client with increased ICP. Which parameter requires close monitoring? a. Muscle relaxation b. Intake and output c. Widening of the pulse pressure d. Pupil dilation
b. Intake and output
When assessing a patient with a brain injury using the GCS, the nurse gathers information regarding which of the following parameters? a. Reflex activity b. Level of consciousness c. Cognitive ability d. Sensory involvement
b. Level of consciousness
A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? 1. "Your behavior is caused by temporary confusion brought on by your illness." 2. "Your behavior is caused by the excess thyroid hormone in your system." 3. "Your behavior is caused by your worrying about the seriousness of your illness." 4. " Your behavior is caused by the stress of trying to manage a career and cope with your illness"
2. "Your behavior is caused by the excess thyroid hormone in your system."
When providing care for a client with acute pancreatitis, the nurse would anticipate which of the following orders? a. Increase oral intake to 3,000 mL every 24 hours b. Insert a nasogastric tube and connect it to low suction c. Place the client in the reverse Trendelenburg position d. Place the client on enteric precautions
b. Insert a nasogastric tube and connect it to low suction
The family of a hospitalized client demonstrates understanding of the teaching about Advanced Directives when they make which of the following statements? Select all that apply. a) "Advanced Directive documents give instructions about future medical care and treatment" b) "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken" c) "Ethics experts agree that the family is the sole deciding factor when the client is competent." d) "Medical power-of attorney gives primarily financial access to the designee." e) "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself." f) "Advanced Directives documents give details about the client's past medical history."
a) "Advanced Directive documents give instructions about future medical care and treatment" b) "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken" e) "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable to make an informed decision for himself or herself."
A 58-year-old man is going to have chemotherapy for lung cancer. He asks the nurse how the chemotherapeutic drugs will work. The most accurate explanation the nurse can give is which of the following? a) "Chemotherapy affects all rapidly dividing cells." b) "The molecular structure of the DNA is altered." c) "Cancer cells are susceptible to drug toxins." d) "Chemotherapy encourages cancer cells to divide."
a) "Chemotherapy affects all rapidly dividing cells."
A nurse assessing a patient for symptoms of neurogenic shock following a spinal cord injury should monitor the patient for symptoms of: a) Bradycardia b) Hypertension c) Cool, moist skin d) Absence of reflex
a) Bradycardia
A client informs the nurse that she is using an herbal therapy while receiving chemotherapy. Which of the following actions should the nurse take? a) Determine what substances the client is using and make sure that the physician is aware of all therapies the client is using b) Guide the client in the decision-making process to select either Western or alternative medicine c) Encourage the client to seek alternative modalities that do not require the ingestion of substances d) Recommend that the client stop using the alternative medicines immediately
a) Determine what substances the client is using and make sure that the physician is aware of all therapies the client is using
The heart of a patient who has suffered a myocardial infarction is pumping an inadequate supply of oxygen to the tissue. For what should the nurse assess? a) Dysrhythmias b) Increase in blood pressure c) Decrease in heart rate d) Decrease in oxygen demands
a) Dysrhythmias
During the first 12 to 18 hours postburn, hypovolemia may be characterized by all of the following except: a) Hypoventilation b) Fall in blood pressure c) Decreased urinary output d) Low central venous pressure
a) Hypoventilation
Which of the following components of a thorough cancer pain assessment is most significant? a) Intensity b) Cause c) Aggravating factors d) Location
a) Intensity
The nurse should recognize that fluid shift in a client with a burn injury results from an increase in the: a) Permeability of capillary walls b) Total volume of intravascular plasma c) Total volume of circulating whole blood d) Permeability of the kidney tubules
a) Permeability of capillary walls
A nurse who is teaching smoking cessation programs to healthy adult smokers is participating in what type of prevention activity? a) Primary b) Secondary c) Tertiary d) Nonspecific
a) Primary
A client with colon cancer had a left hemicolectomy 3 weeks previously. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. Which of the following nutritional support methods would the nurse anticipate for the client? a) Total parenteral nutrition through a central catheter b) Intravenous infusion of dextrose c) Nasogastric feeding tube with protein supplement d) Jejunostomy for high caloric feedings
a) Total parenteral nutrition through a central catheter
When caring for a client with central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply. a) Verify patency of the line by the presence of a blood return at regular intervals b) Inspect the insertion site for swelling, erythema, or drainage c) Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present d) If unable to aspirate blood, reposition the client and encourage the client to cough e) Contact the health care provider about verifying placement if the status is questionable
a) Verify patency of the line by the presence of a blood return at regular intervals b) Inspect the insertion site for swelling, erythema, or drainage d) If unable to aspirate blood, reposition the client and encourage the client to cough e) Contact the health care provider about verifying placement if the status is questionable
Which of the following statements by the client would indicate that she is at high risk for recurrence of cystitis? a. " I can usually go 8 to 10 hours without needing to empty my bladder" b. "I take a tub bath every evening." c. "I wipe from front to back after voiding." d. "I drink a lot of water during the day."
a. " I can usually go 8 to 10 hours without needing to empty my bladder"
The nurse demonstrates understanding of natural immunity when he makes which of the following statement? a. "Breastfeeding is the best way to enhance the infant's immunity" b. "Timely vaccination could easily provide protection from hepatitis." c. "The skin provides the first line of defense in warding off disease" d. "Administration of human immune globulins boosts the immunity."
a. "Breastfeeding is the best way to enhance the infant's immunity"
The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure and weight gain of 2 pounds in 1 day. Based on these data, which of the following nursing diagnoses is appropriate? a. Excess fluid volume related to the kidney's inability to maintain fluid balance b. Increased cardiac output related to fluid overload c. Ineffective tissue perfusion related to interrupted arterial blood flow d. Ineffective therapeutic regimen management related to lack of knowledge about therapy
a. Excess fluid volume related to the kidney's inability to maintain fluid balance
"Why should I use condoms? They don't work," reports D. a young gay client being treated for his third sexually transmitted disease. The nurse's most appropriate response would be: a. "Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual intercourse, they reduce your risk of getting infected with HIV or other STD's b. "You are correct: condoms don't always work. so your best protection is to limit your number of partners. c. "Condoms do not provide 100% protection so you should always discuss with your sexual partners their HIV status of ask if they have any STD's" d. "Condoms do not provide 100% protection, but when used with a spermicide, you can be assured of complete protection against HIV and other STD's"
a. "Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual intercourse, they reduce your risk of getting infected with HIV or other STD's
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? a. "Some people have a warning that the seizure is about to start" b. "Auras occur when you are physically and psychologically exhausted" c. "You're concerned that you do not have auras before your seizures." d. " Auras usually cause you to be sleepy after you have a seizure"
a. "Some people have a warning that the seizure is about to start"
The client with acute renal failure asks thee nurse for a snack. Because the client's potassium level is elevated, which of the following snacks would be most appropriate? a. A gelatin dessert b. Yogurt c. An orange d. Peanuts
a. A gelatin dessert
What assessment finding will the nurse expect to observe in a tetraplegic patient in spinal shock? a. Absence of reflexes along with flaccid extremities b. Positive Babinski's reflex along with spastic extremities c. Hyperreflexia along with spastic extremities d. Spasticity of all four extremities
a. Absence of reflexes along with flaccid extremities
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention would the nurse implement first to prevent ARF? a. Administer normal saline IV b. Take vital signs c. Place the client on telemetry d. Assess abdominal dressing
a. Administer normal saline IV
The initial diagnosis of pancreatitis is confirmed if the client's blood work shows a significant elevation in which of the following serum values? a. Amylase b. Glucose c. Potassium d. Trypsin
a. Amylase
The client is diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? a. BUN and creatnine b. WBC and hemoglobin c. Potassium and sodium d. Bilirubin and ammonia level
a. BUN and creatnine
The client diagnosed with AIDS is angry and yells at everyone entering the room and none of the staff members want to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation? a. Call a team meeting and discuss options with the staff b. Assign a different nurse every shift to the client c. Ask the HCP to tell the client not to yell at the staff d. Force one staff member to care for the client a week at a time
a. Call a team meeting and discuss options with the staff
The client with acute renal failure is recovering and asks the nurse, "will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: a. Continue to improve over a period of weeks b. Result in need for permanent hemodialysis c. Improve only if the client receives a renal transplant d. Result in end-stage renal failure
a. Continue to improve over a period of weeks
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing? a. Decreased mental status b. Elevated blood pressure c. Decreased urinary output d. Labored respirations
a. Decreased mental status
The nurse initiates the client's first hemodialysis treatment. the client develops a headache, confusion, and nausea. These symptoms indicate which of the following potential complications? a. Disequilibrium syndrome b. Myocardial infarction c. Air embolism d. Peritonitis
a. Disequilibrium syndrome
The nurse teaches a patient tetraplegia or paraplegia which of the following guidelines related to bladder management? a. Empty the bladder frequently b. Consume 500 mL of fluid daily c. Wear synthetic underwear d. Concentrated urine should be reported to the physician immediately
a. Empty the bladder frequently
Ms. H is a 47- year old mother of 3 who had a cranial surgery to remove a pituitary tumor 3 days ago, leaving her with partial left hemiparesis and DI. Which of the following nursing diagnoses is of the greatest priority postoperatively? a. Fluid volume deficit, risk for, related to excessive loss via the urinary system b. Hopelessness related to the development of chronic illness (hemiparesis and DI) c. Oral mucous membrane alteration, risk for, related to dehydration d. Coping ineffective family: compromised risk for, related to chronic illness
a. Fluid volume deficit, risk for, related to excessive loss via the urinary system
Upon awakening from his first tonic-clonic seizure, a 20 year old client asks the nurse, "What caused me to have a seizure? I've never had one before." Which of the following would the nurse include in the response as a primary cause of tonic- clonic seizures in adults older than 2 years old? a. Head trauma b. Electrolyte imbalance c. Congenital defect d. Epilepsy
a. Head trauma
Which of the following assessments would indicate the client was experiencing a thyroid storm? a. Heart rate 140 bpm, temperature 39 C, agitation b. Heart rate 75 bpm, temperature below 36.2 C, angry c. Heart rate 132 bpm, temperature 37.5 C, confused d. Heart rate 160 bpm, temperature 36 C, Lethargy
a. Heart rate 140 bpm, temperature 39 C, agitation
The critical care nurse is caring for a client with acute renal failure in the oliguric phase. The nurse will closely monitor the client for which commonly experienced electrolyte imbalance? a. Hyperkalemia b. Hypercalcemia c. Hyperlipidemia d. Hyperbilirubinemia
a. Hyperkalemia
What is a priority nursing intervention when suctioning an unconscious client to maintain cerebral perfusion? a. Hyperoxygenate before and after suctioning b. Administer analgesics c. Provide oral hygiene d. Administer diuretics
a. Hyperoxygenate before and after suctioning
A client with rheumatoid arthritis is receiving cyclophosphamide (cytoxan) for treatment of his disease. When administering an immunosupressant, the nurse must be alert to which of the following side effects of this medication? a. Infection b. Nystagmus c. Muscle rigidity d. Hyperthermia
a. Infection
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? (Select all that apply ) a. Keep a record of seizure activity b. Take tub baths only; do not take showers c. Avoid over the counter medications d. Have anticonvulsant medication serum levels checked regularly e. Do not drive alone; have someone in the chair
a. Keep a record of seizure activity c. Avoid over the counter medications d. Have anticonvulsant medication serum levels checked regularly
The nurse in the neurointensive care unit is caring for a client with a new C-6 SCI who is breathing independently. Which nursing interventions should be implemented? (Select all that apply) a. Monitor the pulse ox reading b. Provide pureed foods six times a day c. Encourage coughing and deep breathing d. Assess for pupils for reaction e. Administer intravenously corticosteroids
a. Monitor the pulse ox reading c. Encourage coughing and deep breathing e. Administer intravenously corticosteroids
A patient hospitalized following a T4 injury complains of a severe pounding headache and is profusely diaphoretic. The nurse's best intervention is to: a. Place the patient immediately in a sitting position b. Catheterize the patient c. Manually disimpact the patient d. Administer an analgesic
a. Place the patient immediately in a sitting position
A client with intractable asthma develops Cushing syndrome. Development of this complication can most likely be attributed to long- term of excessive use of: a. Prednisone b. Theophylinne c. Metaproterenol (alupent) d. Cromolyn (intal)
a. Prednisone
In teaching the client with SLE about the disorder, the nurse uses the knowledge that pathophysiology of SLE include: a. Production of autoantibodies, directed against constituents of cellular DNA b. An autoimmune reaction resulting in degeneration, necrosis, and fibrosis of muscle fibers c. Deposition in tissue of immune complexes formed from IgG autoantibodies reacting with IgG d. Chronic inflammation and cytokine activity, which results in synovial proliferation and cartilage and bone damage
a. Production of autoantibodies, directed against constituents of cellular DNA
A client who has been scheduled to have a choledocholithotomy express anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? a. Providing the client with information about what to expect postoperatively b. Telling the client it is normal to be afraid c. reassuring the client by telling her that surgery is a common procedure d. stressing the importance of following the physician's instructions after surgery
a. Providing the client with information about what to expect postoperatively
In the oliguric phase of acute renal failure, the nurse should anticipate the development off which of the following complications? a. Pulmonary edema b. Metabolic alkalosis c. Hypotension d. Hypokalemia
a. Pulmonary edema
Ms. H is admitted to the hospital with a diagnosis of immunodeficiency disease. For ms. H the primary nursing goals would be to: a. Reduce the risk of Ms. H developing an infection b. Encourage Ms. H to provide self care c. Plan nutritious meals to provide adequate intake d. Encourage Ms. H to interact with other patients
a. Reduce the risk of Ms. H developing an infection
The initial treatment plan for a client with pancreatitis most likely would focus on which of the following as a priority? a. Resting the gastrointestinal tract b. Ensuring adequate nutrition c. Maintaining client's body weight d. Preventing the development of an infection
a. Resting the gastrointestinal tract
The nurse admits an elderly man with acute alcoholism. On initial assessment, the nurse notes that the client is slightly confused, irritable, emaciated, has poor dentition, and is homeless. A likely nursing diagnosis would be? a. Risk for infection b. Ineffective coping c. Disturbed body image d. Deficient knowledge
a. Risk for infection
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? a. The client may be developing hypocalcemia b. The client is experiencing a reaction to meperidine (Demerol) c. The client has nutritional imbalance d. The client needs a muscle relaxant to help him rest
a. The client may be developing hypocalcemia
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first? a. The client who has flushed warm skin with tented turgor b. The client who states that the staff ignores the call light c. The client whose vital signs are Temp 99.9 F, Pulse 101, RR 26, BP 110/68 d. The client who is unable to provide a sputum specimen
a. The client who has flushed warm skin with tented turgor
The client has a sustained ICP of 20mmHg. Which client position would be most appropriate? a. The head of the bed elevated 30 -45 degrees b. Trendelenburg's position c. Left Simm's position d. The head elevated on 2 pillows
a. The head of the bed elevated 30 -45 degrees
To prevent infection of family members caring for a client with HIV at home, family members should be encouraged to: a. Use caution when shaving the client b. Use separate dishes for the client and family members c. Use separate bed linens for the the client d. Disinfect the client's pajamas
a. Use caution when shaving the client
The client in acute renal failure has an external cannula inserted in the forearm for hemodialysis. Which of the following nursing measures is appropriate for the care of the client? a. Use the unaffected arm for blood pressure measurement b. Draw blood from the cannula for routine laboratory work c. Percuss the cannula for bruits each shift d. Inject heparin into the cannula each shift
a. Use the unaffected arm for blood pressure measurement
The client has returned from the PACU to the step down unit after a unilateral nephrectomy related to cancer. The nurse is developing a care plan for this client. What is the priority nursing diagnosis for thee client following a nephrectomy? a. ineffective breathing pattern related to the surgical incision b. acute pain related to abdominal distention and the surgical incision c. urine retention related to anesthesia d. Anxiety related to fear of kidney failure
a. ineffective breathing pattern related to the surgical incision
The son of a 78-year-old client with metastatic prostate cancer is asking the nurse about the purpose of hospice care. Which of the following statements by the nurse best describes hospice care? a) "Hospice care uses a team approach to direct hospice activity." b) "Clients and their families are the focus of care." c) "The client's physician coordinates all the care." d) "All hospice clients will die at home."
b) "Clients and their families are the focus of care."
The client asks the nurse what the word eschar means. Which of the following descriptions by the nurse best defines eschar? a) "Eschar is scar tissue in a developmental stage." b) "Eschar is crust formation without a blood supply." c) "Eschar is burned issue that has become infected." d) "Eschar is visible living tissue with a rich blood supply."
b) "Eschar is crust formation without a blood supply."
A 40-year-old woman is losing most of her hair as a result of chemotherapy. Which of the following statements best explains chemotherapy-induced alopecia? a) "The new growth of hair will be gray." b) "The hair loss is temporary." c) "New hair growth will always be same texture and color as it was before chemotherapy" d) "The client should avoid use of wigs when possible"
b) "The hair loss is temporary."
The nurse would plan to begin rehabilitation efforts for the burn client: a) Immediately after the burn has occurred b) After the client's circulatory status has been stabilized c) After grafting of the burn wounds has occurred d) The day of discharge
b) After the client's circulatory status has been stabilized
A patient who is being transferred from the medical-surgical unit to the intensive care unit is in the progressive stage of shock. The nurse caring for the patient is aware that shock affects many organ systems and that nursing management will focus on: a) Reviewing the cause of shock and trying to limit the progression b) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care c) Giving the prescribed treatment but shifting focus to providing family time, as the patient is unlikely to survive d) Giving progressive care to the patient and family using critical pathways for shock therapy
b) Assessing and understanding shock and the significant changes in assessment data to guide the plan of care
A trauma patient arrives to the emergency room and is hemorrhaging. The nurse is aware that this patient is at greatest risk for which type of shock? a) Cardiogenic b) Hypovolemic c) Neurogenic d) Septic
b) Hypovolemic
After completing the nurse assessment for a client and family entering the palliative care program, the nurse would expect to develop a teaching plan that includes an understanding of which of the following as goals or outcomes of this type of care? a) Alternation in the family's usual coping strategies b) Improvement in the client's quality of life c) Death must be accepted d) Advocation for prolonging life while curing the disease
b) Improvement in the client's quality of life
The nurse recognizes that antidiuretic hormone (ADH) plays a role during hypovolemic shock. What assessment finding will the nurse likely observe related to the role of ADH during hypovolemic shock? a) Increased hunger b) Increased thirst c) Increased urinary output d) Increased capillary perfusion
b) Increased thirst
The development of a culturally sensitive health education program for the socioeconomically disadvantaged requires the nurse to: a) Locate the program at an existing government facility b) Integrate folk beliefs and traditions into the content c) Prepare materials in the primary language of the program sponsor d) Exclude community leaders from initial planning efforts
b) Integrate folk beliefs and traditions into the content
The nurse teaches the client with chronic cancer pain about optimal pain control. Which of the following recommendations is most effective for pain control? a) Get used to some pain and use a little less medication than needed to keep from being addicted b) Take prescribed analgesics on an around-the clock schedule to prevent recurrent pain c) Take analgesics only when pain returns d) Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain
b) Take prescribed analgesics on an around-the clock schedule to prevent recurrent pain
A patient is receiving dopamine, a vasoactive drug, to increase stroke volume for shock. The nurse should be aware of which of the following when monitoring a vasoactive drug? a) The drug should be discontinued immediately after blood pressure increases b) The drug dose should be weaned prior to discontinuation c) The drug may cause respiratory alkalosis d) The drug reduces oxygen demands of the heart
b) The drug dose should be weaned prior to discontinuation
Nursing plays an important role in the care of patients at risk for septic shock. What can the nurse do to decrease a patient's risk of septic shock? a) Provide prophylactic antibiotic coverage b) Use thorough hand washing techniques c) Cover all incisions d) Increase fluids
b) Use thorough hand washing techniques
The physician gives instructions to a client with a transplant regarding the use of immunosuppressive drugs. Which of the following client statements indicates a need for further instructions? a. "These medications put me at risk for various types of infections" b. "Organ rejection is no longer my concern" c. "Some of my body's defense would remain intact" d. "My physician would adjust the dosage of these medications, depending on my response."
b. "Organ rejection is no longer my concern"
The client with chronic renal failure complains of feeling nauseated at least part of every day. The nurse should explain that the nausea is the result of: a. Acidosis caused by the medications b. Accumulation of waste products in the blood c. Chronic anemia and fatigue d. Excess fluid load
b. Accumulation of waste products in the blood
A client with COPD presents to the emergency department with muscle weakeness, hypotension, hypoglycemia, and fatigue. The client's family reports that the client recently stopped taking all medications because the medications were too expensive. The nurse reviews the list of medications provided by the family and notes that the client has been taking prednisone daily. Based upon this information, the nurse's assessment findings are consistent with characteristics associated with: a. Cushing's syndrome b. Addisions disease c. Pheochromocytoma d. Thyrotoxicosis
b. Addisions disease
Which of the following nursing interventions is likely to provide the most relief for the pain associated with renal colic? a.Applying moist heat to the flank area b. Administering Meperidine (demerol) c. Encouraging high fluid intake d. Maintaining complete bed rest
b. Administering Meperidine (demerol)
A client receiving vent- assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? a. Count the rate to be sure that ventilations are deep enough to be sufficient b. Call the physician while another nurse checks the vital signs and ascertains the patient's GCS c. Call the physician to adjust the ventilator settings d. Check deep tendon reflexes to determine the best motor response
b. Call the physician while another nurse checks the vital signs and ascertains the patient's GCS
It is necessary for the nurse caring for a patient to understand the pathophysiology behind shock. Which of the following statements best describes the pathophysiologic rationale for shock? a. Blood is shunted from vital organs to peripheral areas of the body b. Cells lack an adequate blood supply and are deprived of oxygen and nutrients c. Circulating blood volume is decreased d. Hemorrhage occurs as a result of trauma
b. Cells lack an adequate blood supply and are deprived of oxygen and nutrients
The client's with which of the following medical histories is at the greatest risk of developing renal failure? a. Polycystic kidney disease b. DM with poorly controlled hypertension c. Vascular disorders d. Respiratory infections
b. DM with poorly controlled hypertension
The physician has ordered an anticonvulsant to prevent post-traumatic seizures in a patient who has sustained a missile injury to the head. Which of the following medications is classified as an anticonvulsant? a. Mestinon (pyridostigmine) b. Dilantin (phenytoin) c. Sinemet (Levodopa-carbidopa) d. Cogentin (benztropine
b. Dilantin (phenytoin)
After an IVP, the nurse should anticipate incorporating which of the following measures into the client's plan of care? a. Maintaining bed rest b. Encouraging adequate fluid intake c. Assessing for hematuria d. Administering a laxative
b. Encouraging adequate fluid intake
The nurse plans for the client with hepatitis A with the understanding that the causative virus will be excreted from the client's body primarily through the: a. Skin b. Feces c. Urine d. Blood
b. Feces
If a gallstone becomes lodged in the common bile duct, the nurse should anticipate that the client's stools would most likely become what color? a. Green b. Grey c. Black d. Brown
b. Grey
The client has returned form surgery following a total parathyroidectomy. The nurse should assess for which of the complications following this surgery? a. Tetany b. Hypocalcemia c. Brittle bones d. Fatigue
b. Hypocalcemia
Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication? a. Increase the amount of potassium in the diet b. Maintain a regular program of weight-bearing exercise c. Limit dietary vitamin D intake d. Perform isometric exercise
b. Maintain a regular program of weight-bearing exercise
Which of the following nursing interventions should be included in the client's care plan during dialysis therapy? a. Limit the client's visitors b. Monitor client's blood pressure c. Pad the side rails of the bed d. Keep the client NPO
b. Monitor client's blood pressure
The client is eight hours post- transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time? a. Control postoperative pain b. Monitor fluid and electrolyte balance c. Assess abdominal dressing d. Encourage early ambulation to prevent DVT
b. Monitor fluid and electrolyte balance
The most common opportunistic infection and malignant neoplasm in the client with advanced HIV disease (AIDS) are: a. Streptococcal pneumonitis, myeloma b. Pneumocytic carinii pneumonia, Kaposi's sarcoma c. S. Pneumonia, malignant melanoma d. Mycoplasma pneumonitis, Kaposi's sarcoma
b. Pneumocytic carinii pneumonia, Kaposi's sarcoma
For breakfast in the morning a client is to have an EEG, the client is served a soft- boiled egg, toast with butter and marmalade, orange juice and coffee. Which of the following would the nurse do? a. Remove all the food b. Remove the coffee c. Remove thee toast butter and marmalade only d. Substitute vegetable juice for the orange juice
b. Remove the coffee
Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy? a. Avoid showering for 48 hours after surgery b. Return to work within 1 week c. Change the dressing daily until the incision heals d. Use acetaminophen to control any fever
b. Return to work within 1 week
K. Has been advised to be tested for HIV because of multiple sexual partners and intravenous illicit drug use. The nurse should assure that K. understands the test informing him that: a. The blood is test with the highly sensitive test called the western blot, then with the ELISA b. The blood is tested with an ELISA; if positive, it is tested again with ELISA and then the western blot c. A series of HIV tests are performed to conform if K has AIDS d. If the HIV tests are negative, K can be assured that he isn't infected
b. The blood is tested with an ELISA; if positive, it is tested again with ELISA and then the western blot
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy? a. Pains in the joints of the hands and feet b. Tingling in the fingers c. Bleeding on the back of the dressing d. Tension on the suture line
b. Tingling in the fingers
The nurse is conducting a post-operative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician? a. Temperature= 99.8 F b. Urine output 20 ml/hr c. Absence of bowel sounds d. A 2'2" inch area of serous sanguineous drainage on the flank dressing
b. Urine output 20 ml/hr
A 60 year old woman is diagnosed with hypothyroidism. Signs and symptoms of hypothyroidism include? a. Tachycardia b. Weight gain c. Diarrhea d. Nausea
b. Weight gain
A 24- year old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis. Which of the following symptoms would the nurse most likely expect the client to report during the assessment? a. Fever and chills b. frequency and burning on urination c. Flank pain and nausea d. Hematuria
b. frequency and burning on urination
Vasopressin is administered to the client with diabetes insipidus because it: a. Decreases blood pressure b. increases tubular reabsorption of water c. increases release of insulin from the pancreas d. decreases glucose production within the liver
b. increases tubular reabsorption of water
A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. Using the "rule of nines," the nurse would determine that about what percentage of the client's body surface has been burned? a) 18% b) 27% c) 45% d) 64%
c) 45%
Shock is best described as a condition in which systemic blood pressure is inadequate to deliver oxygen to the tissues. The nurse knows that without prompt intervention any type of shock will eventually result in: a) Decreased blood flow to the tissue and edema b) A loss of sympathetic tone and hypervolemia c) Anaerobic metabolism and cellular death d) An overwhelming inflammatory response and infection
c) Anaerobic metabolism and cellular death
During the pre-hospital or first aid phase of burn injury, the nurse would do all of the following activities except: a) Apply cool, moist, clean or sterile dressing to the wound b) Remove belts and jewelry c) Apply soothing ointments or creams to the wound d) Allow clothing to remain over the burned area unless the clothing is ignited
c) Apply soothing ointments or creams to the wound
Which of the following symptoms is associated with anemia? a) Decreased salivation b) Bradycardia c) Cold intolerance d) Nausea
c) Cold intolerance
According to experimental and epidemiologic evidence, it is suggested that a high-fat diet increases the risk of several cancers. Which of the following cancers is linked to a high-fat diet? a) Ovarian b) Lung c) Colon d) Liver
c) Colon
An appropriate nursing intervention for clients with fatigue related to cancer treatment includes teaching the client to: a) Increase fluid intake b) Minimize naps or periods of rest during day c) Conserve energy by prioritizing activities d) Limit dietary intake of high-fiber foods
c) Conserve energy by prioritizing activities
When a 62-year-old client and his family receive the initial diagnosis of colon cancer, the nurse can act as an advocate by: a) Helping them maintain a sense of optimism and hopefulness b) Determining their understanding of the results of the diagnostic testing c) Listening carefully to their perceptions of what their needs are d) Providing them with written materials about the cancer site and its treatment
c) Listening carefully to their perceptions of what their needs are
The nurse in the intensive care unit is caring for a patient suffering from multiple organ dysfunction syndrome (MODS). The nurse's plan of care should focus on: a) Encouraging the family to stay hopeful and educating the family to the fact that, in most cases, the prognosis is good b) Encouraging the family to leave the hospital and to take time for themselves as care of the MODS patient may last for years c) Promoting communication with the patient and family along with addressing end-of-life issues d) Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea
c) Promoting communication with the patient and family along with addressing end-of-life issues
Many oncology clients are at risk for development of a hypercoagulable state and thrombosis. Laboratory tests to monitor for these complications include: a) Carcinoembryonic antigen (CEA) b) α-fetoproetin (AFP) c) Prothrombin time (PT) and partial thromboplastin time (PTT) d) Complete blood cont (CBC) with differential
c) Prothrombin time (PT) and partial thromboplastin time (PTT)
The nurse knows that patients who are in shock have special nutritional needs; these special nutritional needs are directly related to the: a) Use of albumin as a food source by the body because of the need for increased caloric intake b) Loss of fluids due to stress ulcers and decreased stomach acids due to increased parasympathetic activity c) Release of catecholamines that creates an increase in metabolic rate and caloric requirements d) Increase in gastrointestinal function during shock and the resulting diarrhea
c) Release of catecholamines that creates an increase in metabolic rate and caloric requirements
The nurse has completed a set of vital signs on a patient at risk for shock. Which assessment finding is a potential sign of shock? a) Elevated systolic blood pressure b) Elevated mean arterial pressure c) Shallow, rapid respirations d) Bradycardia
c) Shallow, rapid respirations
A patient is receiving an initial dose of penicillin IV. During the infusion, the patient becomes short of breath. What is the first thing the nurse should do? a) Increase the head of the bed b) Place the patient in a recovery position c) Stop the infusion of the medication d) Slow down the infusion of the medication
c) Stop the infusion of the medication
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a) massage the abdomen once a shift. b) elevate the lower extremities. c) use an alternating air pressure mattress. d) institute range-of-motion (ROM) exercise every 4 hours.
c) use an alternating air pressure mattress.
The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching? a. "I should eat a high-protein, high carbohydrate diet to provide energy." b. It is safer for me to take acetaminophen for pain instead of aspirin." c. "I should avoid constipation to decrease chance of bleeding." d. " If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."
c. "I should avoid constipation to decrease chance of bleeding."
The client with a spinal cord injury asks the nurse why the dietitian has recommended that she decrease her total daily intake of calcium. Which of the following responses by the nurse would provide the most accurate information? a. "Excessive intake of dairy products makes constipation more common" b. Immobility increases calcium absorption from the intestine" c. "Lack of weight bearing causes demineralization of the long bones" d. Dairy products likely will contribute to weight gain"
c. "Lack of weight bearing causes demineralization of the long bones"
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse. "Why can I not stop talking about these things? I know those days are gone forever." Which of the following response by the nurse conveys the best understanding of the client's behavior? a. "Be patient. It takes time to adjust to such a massive loss." b. "Talking about the past is a form denial. We have to help you focus on today." c. "Reviewing your losses is a way to help you work through your grief and loss" d. "It's a simple escape mechanism to go back and live again in happier time"
c. "Reviewing your losses is a way to help you work through your grief and loss"
A client with an acute exacerbation of rheumatoid arthritis has localized pain and inflammation of the fingers, wrists, and feet with swelling, redness and limited movement of the joints. In developing a plan with the client to promote the management of the disease, the nurse recognizes that a client outcome appropriate for the client at this time is to: a. Maintain a positive self-image b. Perform activities of daily living independently c. Achieve satisfactory control of pain and fatigue d. Make a successful adjustment to the disease progression
c. Achieve satisfactory control of pain and fatigue
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which sign would the nurse anticipate findings? a. Peripheral edema b. Ascites c. Anorexia d. Jaundice
c. Anorexia
Which of the following is contraindicated for a client with seizure precautions? a. Encouraging him to perform his own personal hygiene b. Allowing him to wear his own clothing c. Assessing oral temperature with a glass thermometer d. Encouraging him to be out of bed
c. Assessing oral temperature with a glass thermometer
The physician orders oral neomycin as well ass a neomycin enema for a client with cirrhosis. The nurse understands that the purpose of this therapy is to: a. Reduce abdominal pressure b. Prevent staining during deification c. Block ammonia formation d. Reduce bleeding within the intestine
c. Block ammonia formation
Which activity would the nurse encourage the client to avoid when there is a risk for increased ICP? a. Deep breathing b. Turning c. Coughing d. Passive range of motion exercises
c. Coughing
The hormones responsible for "flight or fight" are: a. Estrogen and testosterone b. FSH and LH c. Epinephrine and norepinephrine d. Calcotonin and parathormone
c. Epinephrine and norepinephrine
The nurse would instruct the client with HIV on which of the following diets? a. High calorie, High fiber, low protein b. Low calorie, low fiber, high protein c. High calorie, high protein, low residue d. Low calorie, high fiber, high protein
c. High calorie, high protein, low residue
A client with cirrhosis complains that his skin always feels itchy and that he "scratches himself raw" while he sleeps. The nurse should recognize that the itching is the result of which abnormality associated with cirrhosis? a. Folic acid deficiency b. Prolonged prothrombin time c. Increased bilirubin levels d. Hypokalemia
c. Increased bilirubin levels
The transplant nurse is assessing a client during a post-transplant follow-up appointment. Which of the following signs and symptoms may indicate organ rejection? a. Hypotension, polyuria, dramatic weight loss and tenderness over the transplanted kidney b. Polyuria, hypothermia, edema, and hypotension c. Increasing blood pressure, oliguria, fever, and weight gain d. Edema, hypothermia, oliguria, and numbness over the transplanted kidney
c. Increasing blood pressure, oliguria, fever, and weight gain
A 35 year old woman has recently been diagnosed with rheumatoid arthritis. She tells the nurse that her husband and children were supportive when they were first informed of her diagnosis but show increasing lack of patience with her when she is unable to be involved in some family activities. The most appropriate response by the nurse is to: a. Refer the patient to a marriage counselor to help her resolve the difficulty she is having with her husband consult his physician b. Suggest to the patient that she develop her own divisional activities that are compatible with her arthritis c. Inform the patient about local arthritis support group that offer education and counseling for patients and families d. Tell the patient that her needs are primary and that she should inform her family members how they can best help her
c. Inform the patient about local arthritis support group that offer education and counseling for patients and families
Which of the following nursing goals is a priority when caring for the awake and oriented head injured patient? a. Maintaining caloric intake b. Demonstrating normal sleep- wake cycles c. Keeping blood gas values within normal ranges d. Maintaining intact skin integrity
c. Keeping blood gas values within normal ranges
The nurse helps the client with chronic renal failure develop a home diet plan with the goal of helping the client maintain adequate nutritional intake. Which of the following diets would be most appropriate for a client with chronic renal failure? a. High carbohydrate, high protein b. High calcium, high potassium, high protein c. Low protein, low sodium, low potassium d. Low protein, high potassium
c. Low protein, low sodium, low potassium
What is the most potentially dangerous complication of peritoneal dialysis? a. Abdominal pain b. Gastrointestinal bleeding c. Peritonitis d. Muscle cramps
c. Peritonitis
The client diagnosed with acute renal failure is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help potassium level? a. Erythropoietin b. Calcium gluconate c. Regular insulin d. Osmotic diuretic
c. Regular insulin
The client has returned following a thyroidectomy. How should the client be positioned to promote comfort? a. Side- lying with one pillow placed under the head b. Head of the bed elevated to 30 degrees and no pillow placed under the head c. Semi- fowlers position with the head supported on two pillows d. Flat with a small roll supporting the neck
c. Semi- fowlers position with the head supported on two pillows
Dr. Q asks you to talk with Mr. C about HIV is transmitted. Which of the following routes of transmission would you discuss with Mr.C? a. Receiving blood, donating blood b. Food, water, air c. Sexual intercourse, sharing needles, mother to child transmission d. Dirty toilets, swimming pools, mosquitoes
c. Sexual intercourse, sharing needles, mother to child transmission
A client with seizure asks the nurse how penytoin sodium (dilantin) will help. Based on knowledge of the drug's action, what is the nurse's best response? a. It corrects the abnormal synthesis of norepinephrine in the body b. Transmission of abdominal impulse in the spinal cord is depressed c. The responsiveness of neurons in the brain to abnormal impulses is reduced d. It interrupts the flow of abnormal impulses from peripheral neurons in the viscera to the brain
c. The responsiveness of neurons in the brain to abnormal impulses is reduced
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed nursing assistant? a. To teach the Crede maneuver to the client needing to void b. To administer the tube feeding to the client who is quadriplegic c. To assist with bowel training by placing the client on the bedside commode d. To observe the client demonstrating self- catheterization
c. To assist with bowel training by placing the client on the bedside commode
The nurse is caring for a patient admitted with a gastrointestinal bleed who is in the compensatory stage of shock. What is an early sign that accompanies initial shock? a) Increased urine output b) Increased heart rate c) Hyperactive bowel sounds d) Cool, clammy skin
d) Cool, clammy skin
The nurse is caring for a client with a burn injury and understand that stress reactions can result in hypersecretion of gastric acids. Therefore, the nurse must assess the client for signs and symptoms of which of the following potential complications? a) Paralytic ileus b) Gastric distention c) Hiatal hernia d) Curling ulcer
d) Curling ulcer
The client with a major burn injury receives total parenteral nutrition (TPN). The primary reason for this therapy is to help: a) Correct water and electrolyte imbalance b) Allow the gastrointestinal tract to rest c) Provide supplemental vitamins and minerals d) Ensure adequate caloric and protein intake
d) Ensure adequate caloric and protein intake
A 32-year-old woman whose mother recently died from malignant melanoma asks the nurse what she can do to prevent the development of malignant melanoma in herself and her children. The best response by the nurse regarding risk factors for malignant melanoma is that: a) There is no familial tendency to develop malignant melanoma b) Moles that develop during adulthood are the most likely to become malignant c) Nothing prevents malignant melanoma, but it is curable if detected early d) Excessive exposure to the sun should be avoided, and protection should be used when exposure occurs
d) Excessive exposure to the sun should be avoided, and protection should be used when exposure occurs
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope? a) Assume decision making for the client b) Encourage strict compliance with all treatment regimens c) Inform the client of all possible adverse treatment effects d) Identify available resources
d) Identify available resources
A patient who was admitted with cardiogenic shock and is experiencing chest pain has an order for the administration of morphine for the onset of chest pain. What is the rationale for administering morphine to this patient? a) It decreases urine output b) It stimulates the patient so he or she is more alert c) It decreases gastric secretions d) It dilates the blood vessels
d) It dilates the blood vessels
In setting goals for client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a realistic desired outcome for the client? a) Normalize albumin levels b) Return to ideal body weight c) Gain 1 pound every 2 weeks d) Maintain current weight
d) Maintain current weight
A priority nursing diagnosis category for a client with burns during the acute period would be: a) Excess fluid volume b) Imbalanced nutrition: less than body requirement c) Risk for injury (falling) d) Risk for infection
d) Risk for infection
The nurse can be an important advocate for the client who is considering an alternative method of cancer treatment, which of the following statements best demonstrates the nurse as client advocate? a) The nurse will provide the information about standard therapies b) The nurse will monitor blood tests as indicated by the alternative therapy c) The nurse will document the client's desire to try an alternative therapy d) The nurse will allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions
d) The nurse will allow the client to make health care choices on her own but will assist in ensuring the client is fully informed when making those decisions
A 78 year old male client has been newly diagnosed with hypothyroidism. He lives in his own apartment in a community development designed for the elderly. He asks the nurse assigned to this complex for advice about his condition. What would be the best advice the nurse could give the client? a. "Stop taking your self- prescribed aspirin." b. "Stop attending group activities" c. "keep the temperature in your apartment cooler than usual" d. " Increase the fiber and fluids in your diet"
d. " Increase the fiber and fluids in your diet"
Which statement should the nurse make when teaching the client about taking oral glucorticoids: a. "take your medication with vitamin supplement." b. "Take your medication on an empty stomach" c. "Take your medication at bedtime to increase absorption" d. "Take your medication with meals."
d. "Take your medication with meals."
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis? a. "Don't worry. It's normal to feel that way." b. " Your friends are probably afraid of contracting hepatitis from you." c. "I am sure you're imagining that." d. "Tell me more about your feelings of isolation"
d. "Tell me more about your feelings of isolation"
A male client with a head injury regains consciousness after several days. Which of the following nursing statement is most appropriate as the client awakens? a. "I'll get your family" b. "Can you tell me your name and where you live?" c."I'll bet you're a little confused right now." d. "You are in the hospital. You were in an accident and unconscious"
d. "You are in the hospital. You were in an accident and unconscious"
It is the night before a client is to have a CT scan of the head without contrast. Which statement by the nurse would be most appropriate? a. "You must shampoo your hair tonight to remove all oil and dirt" b. "You may drink fluids until midnight; but after that drink nothing until the scan is completed" c. " You will have some hair shaved to attach the small electrode to your scalp" d. "You will need to hold your head very still during the examination"
d. "You will need to hold your head very still during the examination"
Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? a. Maintain the client on bed rest b. Administer butabarbital sodium (phenobarbital) 30 mg orally, three times per day c. Close the door to the room to minimize stimulation d. Administer cabamazepine (tegretol) 200 mg orally, twice a day
d. Administer cabamazepine (tegretol) 200 mg orally, twice a day
A client with cirrhosis vomits bright red blood and the physician suspects bleeding esophageal varices. the physician decides to insert a SB tube. the nurse should explain to the client that the tube acts by: a. Providing a large diameter for effective gastric lavage b. Applying direct pressure to gastric bleeding sites c. Blocking blood flow to the stomach and esophagus d. Applying direct pressure to the esophagus
d. Applying direct pressure to the esophagus
A client hospitalized with an acute exacerbation of SLE is withdrawn and responds very little to her family's visits. She tells the nurse that she just cannot cope with the unpredictability of her disease and that she will just become more incapacitated and dependent on her family. The best response by the nurse is to: a. Teach the client stress-reducing strategies such as mediation and yoga b. Refer the client for counseling to help her learn to live with the disease c. Inform the client that although SLE is a chronic disease, most individuals with the disorder live a normal life span d. Arrange planning session with the patient and her family to increase her sense of support and the family's sense of involvement
d. Arrange planning session with the patient and her family to increase her sense of support and the family's sense of involvement
Immune disorders that result from failure of the tolerance to "self" responding immunologically to one's own antigen are called: a. Immunodeficiency disease b. Hypersensitivity disorders c. Desensitization disorders d. Autoimmune disorders
d. Autoimmune disorders
The expanded definition for Aids is that the person will: a. Have the HIV present b. Have a dysfunction of the immune system and be HIV positive c. Be HIV positive and have an opportunistic disease d. Be HIV positive with CD4 lymphocyte count below 200
d. Be HIV positive with CD4 lymphocyte count below 200
A client has signs of increased ICP. which of the following is an early indicator of deterioration in the clients condition? a. Widening pulse pressure b. Decrease in the pulse rate c. Dilated, fixed pupils d. Decrease in level of consciousness
d. Decrease in level of consciousness
Corticosteriods therapy is prescribed for a client with an acute exacerbation of rheumatoid arthritis. When the client has a follow- up visit 1 month later, the nurse recognizes that the client's response to the treatment may be best evaluated by: a. X-rays b. Liver function tests c. Serum electrolyte levels d. ESR
d. ESR
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? a. Push aside any furniture b. Place the client on his side c. Assess the client's vital sign d. Ease the client to the floor
d. Ease the client to the floor
Which of the following would most likely be a major nursing diagnosis for a client with acute pancreatitis? a. Ineffective airway clearance b. Excessive fluid volume c. Impaired swallowing d. Imbalanced nutrition: less than body requirements
d. Imbalanced nutrition: less than body requirements
What is the intended outcome for the nursing intervention of performing passive range of motion exercises on an unconscious client? a. Preservation of muscle mass b. Prevention of bone demineralization c. Increase in muscle tone d. Maintenance of joint mobility
d. Maintenance of joint mobility
A nurse is caring for a patient who has sustained a spinal cord injury. The nurse recognizes that the most common cause of this type of injury is which of the following? a. Sports- related injuries b. Acts of violence c. Injuries due to a fall d. Motor vehicle accidents
d. Motor vehicle accidents
When the head injured patient is thrashing around in bed, the nurse's best intervention for preventing injury is to: a. Restrain the patient b. Administer a narcotic analgesic c. Arrange for friends and family members to sit with the patient d. Pad the side rails
d. Pad the side rails
The nursing care for the client in Addision's crisis should include which of the following intervention? a. Encouraging independence with activities of daily living b. Allowing ambulation as tolerated c. Offering extra blankets and raising the heat in the room to keep the client warm d. Placing the client in a private room
d. Placing the client in a private room
A client undergoes a traditional cholecystectomy and choledochotomy and returns from surgery with a T-tube. To evaluate the effectiveness of the T-tube the nurse should understand that the primary reason for the T-tube is to accomplish which of the following? a. Promote wound drainage b. Provide a way to irrigate the biliary tract c. Minimize the passage of bile into the duodenum d. Prevent bile from entering the peritoneal cavity
d. Prevent bile from entering the peritoneal cavity
A high- carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The rationale for the high- carbohydrate diet is that carbohydrate will: a. Act as a diureetic b. Reduce demands in the liver c. Helps maintains urine acidity d. Prevent the development of ketosis
d. Prevent the development of ketosis
The client is to receive 200 mL of tube feeding every 4 hours. When the nurse checks for the client's gastric residual before administering the next schedule feeding and obtains 40 mL of gastric residual, what is the appropriate intervention? a. Withhold the tube feeding and notify the physician b. Dispose of the residual and continue with the feeding c. Delay feeding the client for 1 hour and then recheck the residual d. Re-administer the residual to the client and continue with the feeding
d. Re-administer the residual to the client and continue with the feeding
The nurse is preparing a community education program about preventing hepatitis B infection. Which of the following would be appropriate to incorporate into the teaching plan? a. Hepatitis B is relatively uncommon among college students b. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B c. Good personal hygiene habits are most effective d. The use of a condom is advised for sexual intercourse
d. The use of a condom is advised for sexual intercourse
A client undergoes a traditional cholecystectomy it is recommended that the client follow a low-fat diet at home. Which of the following foods would be most appropriate to include in a low-fat diet? a. Cheese omelet b. Peanut Butter c. Ham salad sandwich d. White fish
d. White fish
The nurse caring for a client diagnosed with ESRD writes a client problem of "non-compliance of dietary restrictions. "which intervention should be included in the plan of care? a. Teach the client the proper diet to eat while undergoing dialysis b. Refer the client and significant other to the dietician c. Explain the importance of eating the proper foods d. Determine the reason for the client not adhering to the diet
d. determine the reason for the client not adhering to the diet
