Testing and Remediation Advanced test

*A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak? A. Lethargy B. Neuralgia C. Bradycardia D. Oliguria*

Oliguria Oliguria is correct. When a gastric bypass is performed, the stomach, duodenum, and part of the jejunum are bypassed by surgically connecting the small intestine to a newly created stomach pouch. The leakage of gastric or intestinal fluids at this connection is an anastomotic leak and can result in peritonitis or death. Oliguria, or decreased urine production, is a finding consistent with peritonitis and can indicate the client is experiencing an anastomotic leak.

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider? A. A client who has diabetes mellitus with a fasting blood glucose of 150 mg/dL B. A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L C. A client who is prescribed oxygen therapy and albuterol (Proventil) with a PCO2 of 50 mm Hg D. A client who has urosepsis with a WBC count of 15,000 mm3

A client who is prescribed digoxin (Lanoxin) and furosemide (Lasix) with a potassium of 3.1 mEq/L

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching? A. "I should eat frequently." B. "I should avoid eating 1 to 2 hours prior to my treatment." C. "I should eat foods served cold." D. "I should eat low carbohydrate foods."

"I should eat low carbohydrate foods." "I should eat low carbohydrate foods" is correct. Clients who are experiencing nausea should eat foods high in carbohydrates, such as crackers, yogurt, toast, bananas, and sherbet. This is not an appropriate statement by the client and indicates a need for further teaching.

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning? A. Advocate B. Clinician C. Educator D. Manager

Advocate

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? A. Aspirin (Bayer) B. Acetaminophen (Tylenol) C. Guaifenesin (Robitussin) D. Diphenhydramine hydrochloride (Benadryl)

Aspirin (Bayer) Aspirin is correct. Aspirin and other NSAIDS can reduce the antihypertensive effects of captopril, which is an ACE inhibitor. The nurse should reinforce to the client that aspirin has the potential to reduce the antihypertensive effect of captopril and should be avoided.

A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.) Urinary tract Surgical wound Musculoskeletal system Respiratory tract Blood stream

Blood stream, Urinary tract , Surgical wound, Respiratory tract

nurse in a pediatric provider's office is conducting telephone triage and receives a call from a client regarding her 4-day-old newborn who was circumcised 2 days ago. Listen to the audio clip and determine which of the following responses by the nurse is appropriate. (Click on the audio button to listen to the telephone conversation.) A. "Use warm water to soak the penis." B. "Apply petrolatum to the penis." C. "Bring the infant to the office for evaluation by the provider." D. "Do not attempt to remove it."

Do not attempt to remove it."

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.) Drooling Stridor Difficulty swallowing Croupy cough High-grade fever

Drooling is correct. Drooling is a clinical finding associated with epiglottitis. Stridor is correct. Stridor is a clinical finding associated with epiglottitis. Difficulty swallowing is correct. Difficulty swallowing is a clinical finding associated with epiglottitis. High-grade fever is correct. High-grade fever is a clinical finding associated with epiglottitis.

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care? A. Include the family in the client's care. B. Identify one's own beliefs and values. C. Determine the client's cultural beliefs. D. Encourage the client to discuss the influence of illness on cultural practices.

Identify one's own beliefs and values.

A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney's point. (Selectable areas, or "Hot Spots," can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

McBurney's point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image.

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? A. Wrap the cord in a towel saturated with 0.9% sodium chloride. B. Apply oxygen via face mask. C. Place client in knee-chest position. D. Increase IV fluid rate.

Place client in knee-chest position. Place client in knee-chest position is correct. Placing the client in a knee-chest position will aid in keeping the pressure of the presenting part of the fetus off the cord. Using the ABC priority setting framework, the greatest risk is the cessation of circulation to the fetus; therefore, this is the priority action the nurse should take.

A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations? A. Hypertension and crackles B. Excessive thirst C. Shakiness and diaphoresis D. Twitching muscles

Shakiness and diaphoresis Shakiness and diaphoresis is correct. The nurse should observe the client for shakiness and diaphoresis. These are manifestations of hypoglycemia, which can occur if there is a sudden interruption in the delivery of TPN, resulting in the client receiving below the prescribed amount.

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider? A. Fine hand tremors B. Mild thirst C. Weight gain D. Slurred speech

Slurred speech

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching? A. Lentils B. Soybeans C. Broccoli D. Oatmeal

Soybeans

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider? A. Tachycardia B. Vomiting C. Hypotension D. Dilated pupils

Tachycardia Tachycardia is correct. Symptoms of acute alcohol withdrawal include tachycardia, hypertension, diaphoresis, disorientation, and hand tremors. These can progress to visual or tactile hallucinations, paranoid delusions, agitation, hyperthermia, and grand mal seizures. Acute alcohol is a medical emergency and can cause death if not treated with the appropriate interventions. Tachycardia indicates the client is in acute alcohol withdrawal and should be reported to the provider.

A nurse in a rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.) A. Temperature 37.6º C (99.8º F) B. Blood glucose level 144 mg/dL C. Dry mouth D. Headache

Temperature 37.6º C (99.8º F)

A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone (Rocephin) 50 mg/kg IM. The infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?

The nurse should administer 0.8 mL ceftriaxone IM.

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? A. "My child will need to be followed medically for at least 5 years." B. "My child can resume moderate activity after his fever subsides." C. "This illness will not recur because my child has now had it." D. "In a few weeks or months my child could experience sudden, involuntary movements."

This illness will not recur because my child has now had it."

A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder? A. Grandiose sense of self importance B. Reckless disregard for safety of others C. Unstable interpersonal relationships D. Lack of empathy

Unstable interpersonal relationships