unit 3 quiz CC
A nurse caring for a client with small-bowel obstruction should plan to implement which nursing intervention first? Obtaining a blood sample for laboratory studies Administering pain medication Preparing to insert a nasogastric (NG) tube Administering I.V. fluids
Administering I.V. fluids The nurse should first administer I.V. infusions containing normal saline solution and potassium to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to help diagnose bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication commonly is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.
The nurse caring for a client with diverticulitis is preparing to administer the client's medications. The nurse anticipates administration of which category of medication because of the client's diverticulitis? Antianxiety Anti-inflammatory Antispasmodic Antiemetic
Antispasmodic The nurse anticipates administration of antispasmodic medication to decrease intestinal spasm associated with diverticulitis. The client may also be ordered an opioid analgesic to relieve the associated pain. There is no indication that the client needs antianxiety, antiemetic, or anti-inflammatory medications at this time.
A nurse applies an ostomy appliance to a client who is recovering from ileostomy surgery. Which intervention should the nurse utilize to prevent leakage from the appliance? Ask the client to remain inactive for 5 minutes. Ensure that no air is trapped in the pouch Press the adhesive faceplate from the stoma edge inward Ensure that there are no holes in the pouch
Ask the client to remain inactive for 5 minutes. After applying the ostomy appliance, the nurse should ask the client to remain inactive for 5 minutes to allow body heat to strengthen the adhesive bond. The adhesive faceplate should be pressed from the stomal edge outward to prevent the formation of wrinkles. A small amount of air should also be allowed to be trapped in the pouch; liquid feces will then drain to the bottom of the pouch, placing less tension on it.
A nurse cares for a client suspected of having iron deficient anemia. Which diagnostic test will the nurse expect the health care provider to order in order to definitively diagnose the condition? Blood smear Serum ferritin Complete blood count Bone marrow aspiration
Bone marrow aspiration The definitive method of diagnosis for iron deficiency anemia is bone marrow aspiration. The other answer choices may also be used to help with the diagnosis of the condition; however, these are not definitive diagnostic tests.
A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? Irrigate the insertion site with sterile water during each dressing change. Use clean technique and wear a mask during dressing changes. Change the dressing no more than weekly. Apply antibiotic ointment around the site with each dressing change.
Change the dressing no more than weekly. CVAD dressings are changed every 7 days unless the dressing is damp, bloody, loose, or soiled, in which case they should be changed more often. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not normally used.
A client recovering from a total gastrectomy has a low red blood cell count. Which medication will the nurse expect to be prescribed for this client? Vitamin B12 injections Transfusions of packed RBCs Oral iron tablets Erythropoietin injections
Intrinsic factor is secreted by the parietal cells in the stomach, which binds to vitamin B12 so it can be absorbed in the ileum. With the loss of some parietal cells, there is a deficiency in vitamin B12, which leads to a decreased production of red blood cells or pernicious anemia. Treatment would be vitamin B12 injections for life. Oral iron tablets would be prescribed for iron deficiency anemia. Erythropoietin injections would be prescribed for anemia caused by kidney disease. The client is not actively bleeding and would not need transfusions of packed RBCs.
Which is a true statement regarding the nursing considerations in administration of metronidazole? The drug should be given before meals. It may cause weight gain. It leaves a metallic taste in the mouth. Metronidazole decreases the effect of warfarin.
Metronidazole leaves a metallic taste in the mouth. It may cause anorexia and should be given with meals to decrease gastrointestinal upset. Metronidazole increases the blood-thinning effects of warfarin.
The nurse is caring for a client with diarrhea. For which finding will the nurse suspect the diarrhea is caused by pancreatic insufficiency? Oil droplets on the toilet water Voluminous greasy stools Nocturnal diarrhea Blood, mucus, and pus in the stool
Oil droplets on the toilet water Symptoms of diarrhea depend upon the cause and the severity of the diarrhea. Oil droplets on the toilet water may be suggestive of pancreatic insufficiency. Nocturnal diarrhea is associated with diabetic neuropathy. Voluminous greasy stools are associated with malabsorption. Blood, mucus, and pus in the stool is associated with inflammatory enteritis or colitis.
A client with sepsis is experiencing disseminated intravascular coagulation (DIC). The client is bleeding from mucous membranes, venipuncture sites, and the rectum. Blood is present in the urine. The nurse establishes the nursing diagnosis of Risk for deficient fluid volume related to bleeding. The most appropriate and measurable outcome for this client is that the client exhibits Stable level of consciousness Urine output greater than or equal to 30 mL/hour Decreased bleeding Systolic blood pressure greater than 70 mm Hg
Urine output greater than or equal to 30 mL/hour All options could be expected outcomes for a nursing diagnosis of risk for deficient fluid volume. However, the key words are most appropriate and measurable. That would be the option relating to urine output, which is the most direct measurement listed of fluid volume.
A nurse is caring for a client admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. Amylase Lipase Pepsin Ptyalin Trypsin
amylase, lipase, trypsin Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Pepsin is secreted by the stomach and ptyalin is secreted in the saliva.
The nurse caring for a client with diverticulitis is preparing to administer the client's medications. The nurse anticipates administration of which category of medication because of the client's diverticulitis? Antianxiety Antispasmodic Anti-inflammatory Antiemetic
antispasmodic The nurse anticipates administration of antispasmodic medication to decrease intestinal spasm associated with diverticulitis. The client may also be ordered an opioid analgesic to relieve the associated pain. There is no indication that the client needs antianxiety, antiemetic, or anti-inflammatory medications at this time.
Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) assessing and maintaining electrolyte balance. managing respiratory dysfunction. stimulating gastric content motility into the duodenum. utilizing supportive therapies aimed at decreasing gastrin release. withholding analgesics that could mask abdominal discomfort.
assessing and maintaining electrolyte balance. managing respiratory dysfunction. utilizing supportive therapies aimed at decreasing gastrin release. Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.
The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. Gastric vein Inferior vena cava Inferior mesenteric vein Splenic vein Saphenous vein
gastric vein, splenic vein, inferior mesenteric vein This portal venous system is composed of five large veins: the superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins, which eventually form the vena portae that enters the liver. The inferior vena cava is not part of the portal system. The saphenous vein is located in the leg.
A typical sign/symptom of appendicitis is: nausea. pain when pressure is applied to the right upper quadrant. left lower quadrant pain. high fever.
nausea Nausea, with or without vomiting, is typically associated with appendicitis. Pain is generally felt in the right lower quadrant. Rebound tenderness, or pain felt upon the release of pressure applied to the abdomen, may be present with appendicitis. Low-grade fever is associated with appendicitis.
Acute kidney injury from postrenal etiology is caused by hypovolemia or decreased cardiac output. conditions that interfere with renal perfusion. obstruction of the flow of urine. conditions that act directly on functioning kidney tissue
obstruction of the flow of urine. Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal and include hypovolemia and decreased cardiac output. Conditions that produce AKI by directly acting on functioning kidney tissue are classified as intrarenal.
A client admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this client? Spinach Tofu Multigrain bagel Blueberries
tofu Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, low-residue, high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, and blueberries are not low-residue.
A client's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply. "Have you ever been tested for diabetes?" "Would you say that you eat a particularly high-fat diet?" "How many alcoholic drinks do you typically consume in a week?" "Have you ever been diagnosed with gallstones?" "Does anyone in your family have cystic fibrosis?"
"Have you ever been tested for diabetes?" "Would you say that you eat a particularly high-fat diet?" "How many alcoholic drinks do you typically consume in a week?" "Have you ever been diagnosed with gallstones?" Eighty percent of clients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes and high-fat consumption are also associated with pancreatitis. Cystic fibrosis is not a noted etiologic factor for pancreatitis.
Which statement by the client who is performing self-catheterization indicates a need for further teaching? "I will need a sterile catheter kit each time I self-catheterize." "I should lubricate the catheter before insertion." "I will wash my catheter will hot soapy water." "I should perform self-catheterization every 4 to 6 hours."
"I will need a sterile catheter kit each time I self-catheterize." Clients who self-catheterize use clean technique in the home setting.
A nurse is aware that both the sympathetic and parasympathetic portions of the autonomic nervous system affect GI motility. What are the actions of the sympathetic nervous system? Select all that apply. Creates an inhibitory effect on the GI tract Causes blood vessel constriction Decreases gastric motility Relaxes the sphincters Increases secretary activities
Creates an inhibitory effect on the GI tract Causes blood vessel constriction Decreases gastric motility Generally, the sympathetic nervous system inhibits the gastrointestinal tract and the parasympathetic nerve stimulates the tract, increasing peristalsis and secretary activities.
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) Disseminated intravascular coagulation Malnutrition Hypercoagulation Hypoglycemia Ascites
DIC, ascites, and malnutrition Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.
25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms? Lymphoma Hemophilia Leukemia Hepatic dysfunction
hepatic dysfunction Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic dysfunction. Liver dysfunction can lead to decreased amount of factors needed for coagulation and hemostasis. The majority of hemophiliacs are diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or leukemia.
A client with sickle cell disease is treated for a thrombotic event. Which organs or body systems does the nurse recognize as being at greatest risk for thrombosis in a client with sickle cell disease? Select all that apply. Spleen Central nervous system Liver Cardiac system Lungs
spleen, CNS, and lungs Any organ can be the site of a thrombotic event in sickle cell disease; however, the lungs, central nervous system, and the spleen are at greatest risk due to these areas having slower circulation. The liver is often involved in sequestration in adults, and hemolysis may occur. Anemia affects the heart.
The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: gastroesophageal reflux disease (GERD). bariatric surgery. diverticulitis. total gastrectomy.
total gastrectomy If a total gastrectomy is performed, injection of vitamin B12 will be required for life, because intrinsic factor, secreted by parietal cells in the stomach, binds to vitamin B12 so that it may be absorbed in the ileum. Bariatric surgery, diverticulitis and GERD do not necessitate total gastrectomy and subsequent vitamin B12 supplementation.
The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze from the patient's rectum and intravenous site. The nurse contacts the provider expecting a prescription for blood work to evaluate protein C level. an infusion of protein S factor. vitamin K injections. a laboratory test to determine factor X level.
vitamin K injections The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, and protein C and protein S (anticoagulation factors). Thus, liver disease and vitamin K deficiency are commonly associated with impaired hemostasis.
Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks has a history of controlled hypertension with a blood pressure of 138/88 mm Hg has a history of fluid overload as a result of heart failure has been on aminoglycosides for the past 6 days
was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure. Because of this delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed. The blood pressure of 138/88 mm Hg controlled by medication would not cause acute kidney injury, nor would fluid overload from exacerbation of heart failure.
