Adult 1 - Exam 2
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
Encourage fluid intake up to 4000 mL every day.
A client presents to the clinic reporting vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?
Infection with Helicobacter pylori
A patient is being discharged home after hospitalization with hypocalcemia. Which statement by the patient indicates she understood the dietary instructions?
"I will be sure to eat lots of cheese, tofu and spinach."
You have completed diet teaching with a patient who has hypernatremia. Which statement by the patient causes concern?
"I'm glad I can still eat sandwiches with bologna."
A client with a diagnosis of peptic ulcer disease has just been prescribed omeprazole. How should the nurse best describe this medication's therapeutic action?
"This medication will reduce the amount of acid secreted in your stomach."
A nurse is planning care for a patient who is hyperventilating. The patient's arterial blood gas values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3- 26 mEq/L (26 mmol/L). Which question would the nurse ask when developing this patient's plan of care?
"You appear anxious. What is causing your distress?"
The nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety?
Check for blood return.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?
Check the patient's blood pressure.
The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?
Checking the client's capillary blood glucose levels regularly
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Daily weight
________ fluids remove water from the extracellular space into the intracellular space
Hypotonic
A client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer?
My pain resolves when I have something to eat."
A patient is experiencing hypercalcemia and has developed renal calculi. What is the affect on the phosphate level in hypercalcemia?
Phosphate level decreases
A client with cancer of the tongue has had a radical neck dissection. What nursing assessment should the nurse prioritize?
Respiratory status and airway clearance
A nurse assesses a patient's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next?
Stop the infusion of intravenous fluids.
A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care?
The client will be monitored closely to detect malignant changes.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
The patellar and triceps reflexes are absent.
A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
Use a combination of at least two accepted methods for confirming placement.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? Correct!
Use the push-pause method to flush the CVAD after giving medications.
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on?
0.9% Normal Saline
A patient with cerebral edema would most likely be order what type of solution?
3% Saline
A client who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the client is alert. What is the client's priority need at this time?
An effective means of communicating with the nurse
A nurse is caring for a patient who has just experienced a 90-s tonic-clonic seizure. The patient's arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). What action would the nurse take first?
Apply oxygen by mask or nasal cannula.
A nurse teaches a patient who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this patient's teaching?
Avoid carrying your grandchild with the arm that has the central catheter."
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
Digoxin (Lanoxin) 0.25 mg/day
A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer?
Early diagnosis and treatment of gastroesophageal reflux disease
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
Infuse the KCl at a rate of 10 mEq/hour.
A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions?
Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance
A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is most appropriate?
Keep the client in semi-Fowler position for 1 hour after feedings
A client is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?
Keep the vent lumen above the client's waist.
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
Mental status
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
Metabolic acidosis
The nurse's comprehensive assessment of a client includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
Presence of a painless sore with raised edges
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete?
Presence of the Chvostek's sign
The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions?
Prevent aspiration
The nurse is caring for a client with a duodenal ulcer and is relating the client's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply.
Secretion of mucus Absorption of nutrients Movement of nutrients into the bloodstream
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?
Skim milk
A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem?
Smokes one pack of cigarettes daily.
A nurse is caring for an 83-year-old client who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the client's health complaint?
Stomach emptying takes place more slowly.
A client who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the client's condition is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence?
Tachycardia, hypotension, and tachypnea
A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client?
Take no NSAIDs within 48 hours of the test
A patient has a phosphate level of 5.6. The doctor orders the patient to take Phoslo. What education will you provide to this patient regarding this medication?
Take the medication with a meal or right after
The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). The nurse should address which of the following topics when providing health education? Select all that apply.
The procedure carries a risk for dumping syndrome The client's vagus nerve may be altered
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
There are crackles throughout both lung fields.
A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it?
Erosion of the lining of the stomach or intestine
An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?
Fluids must be increased to facilitate the evacuation of the stool.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
Respiratory alkalosis
The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?
Avoid taking aspirin to treat pain or fever