MS HESI
auscultation of bowel sounds to detect paralytic ileum. amount of food eaten each meal. effectiveness of pain control. urine output.
The nurse caring for a patient with acute pancreatitis will include in the daily assessments:
lethargy
The nurse caring for a patient with metabolic acidosis would expect the patient to exhibit which symptom?
liquid stool from the ileum contains digestive enzymes that are especially harmful to skin.
The nurse caring for the patient with an ileostomy will make special interventions to prevent skin breakdown and irritation at the stomal site because the:
hemarthrosis
The nurse caring for the patient with hemophilia should plan care that includes measures to manage which condition?
gallstones
The nurse cautions that a common side effect of bariatric surgery is that the patient will develop:
sewing synthetic mesh over the abdominal wall defect to reduce hernia.
The nurse explains that a hernioplasty involves:
changes in bowel wall allow herniation
The nurse explains that diverticula occur in the older adult because:
restrictive
The nurse explains that the circumgastric banding surgery is considered to be:
50
The nurse explains that the diagnosis of morbidly obese is reserved for people who are ____% above their recommended weight.
portal hypertension. decrease in metabolic processes of the liver. decrease in clotting factors. increase in ascites. increase in aldosterone.
The nurse explains that, when the damage caused by cirrhosis blocks the blood flow through the liver, the result is: (Select all that apply.)
liver biopsy
The nurse is aware that a definitive diagnosis of cirrhosis is made based on the results of a(n):
bowel rupture and shock
The nurse is aware that an unresolved bowel obstruction can lead to:
esophageal reflux
The nurse is aware that the major cause of Barrett's esophagus is:
cancer of the colon
The nurse is aware that the person with ulcerative colitis is at risk for:
an inflammatory process
The nurse is caring for a female patient whose sedimentation rate is 25 mm/hr. What condition does the nurse suspect this patient to be experiencing?
urinary retention
The nurse is caring for a patient receiving epidural analgesia. The patient should be monitored for which side effect?
positive homan's sign
The nurse is caring for an immobile patient. Which assessment finding should alert the nurse to a potential problem?
They should only be taken with a prescriber's approval.
The nurse is instructing a pregnant patient about how to manage reflux. Which point about histamine H2 blockers does the nurse include in the teaching plan?
persistent hoarseness
The nurse is performing an admission assessment on a patient who is scheduled for several diagnostic respiratory procedures. Which symptom(s) reported by the patient would make the nurse suspect the patient may have laryngeal cancer?
confusion
The nurse is preparing an older adult patient who has been prescribed famotidine (Pepcid) for discharge. Which common side effect should the nurse instruct the patient's family to watch for?
5-10 mins
The nurse is preparing to administer an injection to a patient with a blood dyscrasia. To prevent bruising, how long should the nurse apply pressure to the injection site after administering the injection?
Prevent an adult client from getting up at night when there is insufficient staffing on the unit
The nurse is providing education about the use of restraints to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what?
"I left my pills in the bedroom and I forgot to take them with breakfast.
The nurse notes that a client is not adhering to prescribed antibiotic therapy. Which reason should the nurse document?
excessive exercise. body image disturbance. amenorrhea. refusal to maintain recommended weight. development of complicated food rituals.
The nurse outlines behavior seen in a person with anorexia nervosa, which includes:
preforate and cause peritonitis
The nurse urges the patient with diverticulitis to seek treatment because the inflamed bowel wall may:
a tumor obstructs the lumen of the bowel
The nurse uses a visual aid to demonstrate the process of a mechanical bowel obstruction that occurs when:
avoiding garlic
The nurse will encourage the patient who has gastroesophageal reflux disease (GERD) to modify her diet by:
taking digoxin
The nurse would question an order for esomeprazole (Nexium) for the patient who is:
cholecystitis
The patient presents in the emergency department with the complaint of severe vomiting and nausea and a temperature elevation to 101° F. The patient complains of stomach pain that radiates to his right scapula. These assessments suggest:
intestinal obstruction
The patient who has had an incarcerated hernia for many years begins to experience abdominal pain and vomit dark material with a fecal odor. The nurse recognizes these signs as indications of:
notify charge nurse immediately of possible obstruction.
The patient with a 4-day-old ileostomy complains of cramping. The nurse notes a drop in the effluent for the ileostomy. The bowel sounds are rapid with a "tinkling" sound. The nurse should:
Hypocalcemia
electrocardiographic changes (heart block, dysrhythmias, and cardiac arrest), tetany, confusion, and hallucinations
Hyperkalemia s/s
electrocardiographic changes, muscle weakness, twitching, paresthesia, paralysis, muscle cramps, nausea, vomiting, lethargy, and syncope
37-47%
female hematocrit
42-52%
male hematocrit
lymphocytes
natural killer cells
5000/mm3 to 10,000/mm3
normal number of WBCs ranges from:
weakness, lethargy, headache, and confusion
symptoms of metabolic acidosis include:
dark brown stool
In a patient who had a cholecystectomy 3 days ago, the nurse assesses that the bile is no longer obstructed from entering the bowel by the appearance of:
fewer than normal T cells
In terms of the immune system, a patient over the age of 70 is likely to have which of these findings?
Rotavirus
_________ vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself.
Active immunity
___________ develops as the body defends itself from the presence of an active infection.
Proximate cause
____________ is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury
The pt thinks she might be pregnant
A patient is to have a measles vaccine. Which factor, if present in the patient's history, should be reported because it may be a contraindication to giving the immunization?
hold the drug and notify the prescriber
A patient prescribed metoclopramide (Reglan) reports having difficulty sleeping, difficulty concentrating, tiredness, and feeling hopeless. What is the nurse's best action?
Instruct the patient that this is an expected effect of the drug.
A patient prescribed metoclopramide (Reglan) tells the nurse that his abdomen is making gurgling sounds. What is the nurse's best action?
report the finding
A patient receives an analgesic. Several hours later, the patient develops hives and itching. Which action is essential for the LPN/LVN to take immediately?
Place the pt in the fowler position
A patient who is near death has the following nursing diagnosis—Impaired gas exchange related to fluid in the lungs. Which intervention is most appropriate?
Teach the patient that antidiarrheal drugs should not be taken for more than 2 days unless instructed to by their prescriber.
A patient reports taking attapulgite (Kaopectate) for diarrhea over the past 4 days. What is the nurse's best action?
the pt uses humor about her hair loss
A patient undergoes chemotherapy and loses her hair. Which of these findings is most indicative that the patient has satisfactorily adjusted to her alopecia?
Oral temp increase of 2*
A patient who is prescribed prochlorperazine (Compazine) for postoperative nausea and vomiting has all of the following changes. For which change does the nurse immediately contact the prescriber?
oral temp increase of 2*
A patient who is prescribed prochlorperazine (Compazine) for postoperative nausea and vomiting has all of the following changes. For which change does the nurse immediately contact the prescriber?
"Sucralfate forms a thick coating to cover the ulcer, protect from further damage, and allow healing."
A patient who is prescribed sucralfate asks the nurse how this drug will help treat his gastric ulcer. What is the nurse's best response?
Alternating periods of activity with periods of rest
A patient with AIDS becomes short of breath and fatigued while completing activities of daily living. Which measure should be included in the patient's care to promote independence?
notify the prescriber immediately
A patient with a history of GI ulcers reports feeling new onset burning, gnawing stomach pain. What is the nurse's best action?
pneumonia
A patient who experienced high fever and chills, a productive cough, chest pain, general malaise, and aching muscles during the past week is admitted to the hospital. The nurse realizes these symptoms correspond most closely with which disease?
Notify the prescriber immediately
A patient who has been prescribed rabeprazole (Aciphex) develops black, tarry stools. What is the nurse's best first action?
Darkened urine and white stool
A patient who has been taking cimetidine (Tagamet) for a year has all of the following symptoms. Which symptom does the nurse report immediately to the prescriber?
Tetanus, hepatitis B, influenza, and pneumococcal vaccines
A nurse is caring for a 26-year-old client recently diagnosed with human immunodeficiency virus (HIV). The client's immunizations need to be updated, and she asks which ones are needed. Which vaccines are required to comply with the recommended immunization schedule for a client with HIV?
Applying sterile, moist nonadherent dressings to the sac
A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?
muscle weakness
A patient has ingested a large amount of a cathartic containing magnesium. The nurse should observe for which symptom of hypermagnesemia?
chickenpox can be fatal to pts with leukemia
A child with leukemia is to continue taking prednisone (Meticorten) at home. The nurse discovers that the child's sibling is home from school with chickenpox. What is the nurse's priority concern?
Sexual abstinence should be practiced during the last 6 weeks of pregnancy.
A client at 16 weeks gestation calls the nurse at the prenatal clinic and states that her partner just told her that he has genital herpes. What should the nurse include when advising the client regarding sexual activity?
schilling test
A patient has possible pernicious anemia. Because it is most likely to be used as a diagnostic tool, which of these diagnostic tests should be explained to the patient?
"This antibiotic helps keep babies from contracting eye infections."
A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse?
It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately.
A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and states that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin. What should the nurse consider regarding isotretinoin?
Measles, mumps, and rubella virus vaccine (MMR)
A 4-year-old child develops thrombocytopenia after vaccination. Which vaccination may be responsible?
isolation room
A child with a diagnosis of tuberculosis is admitted to the pediatric unit. Which location should the nurse select as the best placement for the child?
Verify the pain medication prescription in the clinical record
A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours PRN for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain at a level of 8 on a pain scale of 1 to 10. What is the first thing the covering nurse should do?
Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.
A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when collecting this specimen from an indwelling urinary catheter?
"The restraint will keep your baby's arms straight and prevent touching or pulling at the sutures."
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond?
evaluating daily I&O
An older male patient with nausea is prescribed scopolamine (L-hyoscine). Which nursing assessment does the nurse perform to determine whether he is experiencing a serious side effect?
relax the sphincter, allowing reflux
For the patient with a hiatal hernia, the nurse recommends avoidance of fats because fats:
12-16 g/dL
Hemoglobin Female
14-18 g/dL
Hemoglobin Male
purplish red stoma
The nurse assessing the stoma of a patient 1 day after a transverse colostomy will immediately report the finding of a(n):
diabetic, obese, malnourished, or dehydrated; have a malignancy; experienced multiple traumas to the abdomen; infected wounds.
Patients who are most at risk for dehiscence and evisceration are those who are:
hyperglycemia
The nurse caring for a patient on total parenteral nutrition (TPN) will monitor for the presence of:
indication of retroperitoneal hemmorage
The nurse caring for a patient with acute pancreatitis assesses a bluish tinge around the patient's umbilicus. The nurse reports this finding as an:
an injection of hepatitis B immune globulin (HBIG).
The 20-year-old college student who has not been immunized against hepatitis B virus (HBV) comes to the clinic and reports he has had an exposure to hepatitis B. The nurse recommends that he get immediate protection by acquiring:
3000/mm3 to 7000/mm3
The normal number of neutrophils ranges from 60% to 70%, or:
5000 mm 3 to 10,000 mm 3
The normal white blood cell count ranges from:
hyperinflation of the lungs
The nurse assesses a patient with emphysema and notes a barrel chest. What is the reason for this patient's chest anomaly?
confusion rt rising ammonia levels
The nurse assesses that the patient with cirrhosis is deteriorating when there is evidence of:
"The disease is characterized by decreased lung expansion."
The student nurse is caring for a patient with a restrictive respiratory disease. Which description demonstrates the student's knowledge of the disease?
"Acquired immunity can be achieved when the person is born with certain immunities."
The student nurse is discussing the topic of acquired immunity with the instructor. Which statement by the student indicates the need for further instruction?
"It would be best to speak with your husband by phone and stay home today."
The wife of an inpatient who is prescribed dexamethasone (Decadron) tells the nurse over the phone that she has developed a cold with a low-grade fever. What is the nurse's best advice at this time?
syncope
What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?
Immature neutrophils in the blood
What does a shift to the left indicate in the white blood cell count differential?
muscle aches
When a patient has a systemic reaction to an inflammation, which sign or symptom is the patient likely to exhibit?
T cells
When studying the various types of cells, the student nurse correctly identifies which cells as providing cellular immunity?
20,000/mm3
When the platelet count is less than __________, spontaneous bleeding can occur. Platelet transfusions may be necessary.
Fexofenadine
Which antihistamine drug is considered nonsedating?
potassium
Which laboratory value must the nurse monitor after a patient takes bisacodyl (Dulcolax) for constipation?
"Wear a hat and sunscreen outdoors to prevent sunburn." =
Which precaution is most important for the nurse to teach a patient who is prescribed raberprazole (Aciphex)?
avoid driving until you know how this drug affects you
Which precaution is most important for the nurse to teach an older patient who is starting histamine H2 blockers for gastroesophageal reflux disease (GERD)?
The stomach secretes a thick gel-like mucus to coat itself.
Which protective mechanism by the stomach protects it from stomach acids and the formation of gastric ulcers?
"Clean up the spill using paper towels and disposable gloves."
Which statement should the nurse make when providing information to the parent of a toddler-age client who calls the pediatric clinic after dropping a mercury thermometer at home?
Inhibited calcium absorption makes bones more fragile.
Why are older patients who are prescribed proton pump inhibitors more at risk for drug-induced hip fracture?
It contains aspirin that can cause Reye's syndrome.
Why should parents be taught not to give bismuth subsalicylate (Pepto-Bismol) to a child?
