AH Final Exam
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for further teaching? a)Oatmeal with cream b)White toast and jam c)Pancakes with syrup d)Scrambled eggs
a)Oatmeal with cream
Clinical features of multiple sclerosis usually include: a)Paresthesias and visual defects b)Ptosis and seizures c)Rigidity and papilledema d)Progressive ascending paralysis and urinary tract infections
a)Paresthesias and visual defects
All of the following patients are at risk for developing acute gastritis except the patient with a)Uncontrolled vomiting secondary to chemotherapy b)Osteoarthritis taking the maximum dose of tylenol daily c)Lupus, taking prednisone d)An alcohol addiction
b)Osteoarthritis taking the maximum dose of tylenol daily
The nurse assessing a patient with abdominal pain notes rebound tenderness when palpating midway between the right iliac crest and umbilicus. This is document as positive: a)Cullen's sign b)McBurney's sign c)Rovsing's sign d)Blumberg's sign
d)Blumberg's sign
A client admitted with acute renal failure progresses from oliguric to the diuretic phase of the disorder. What primary problems might you expect this client to exhibit? a)Hypovolemia and electrolyte loss b)Hypovolemia with decreasing urine output c)Hypervolemia and electrolyte excess d)Hypervolemia with concentrated urine
a)Hypovolemia and electrolyte loss
A client has a lump removed from his femur. The pathology report reads Grade 4 sarcoma. The nurse correctly realizes that a grade 4 reading indicates: a)Poorly differentiated anaplastic cells b)The presence of benign tumor formation c)Spread of the cancer to adjacent structures d)An increased number of hyperplastic cells
a)Poorly differentiated anaplastic cells
A client, 64 years old, is diagnosed with colon cancer and is being treated with chemotherapy. His hemoglobin 7.5; hematocrit 27%; RBCs 2 million; WBCs 9500; neutrophils 40%; platelet count 230,000. What symptoms would be an expected finding? a)Elevated temperature b)Tendency to bruise easily c)Tarry stools d)Fatigue
d)Fatigue
Which of the following nursing diagnoses would rank as most important in the planning of care for a client who is receiving multiple drug chemotherapy for metastatic breast cancer in the 2 weeks after the chemotherapy has begun? a)Potential for infection b)Impaired skin integrity c)Self-esteem disturbance d)Activity intolerance
a)Potential for infection
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? a)Ineffective airway clearance related to edema of the respiratory passages b)Disturbed sleep pattern related to facility environment c)Impaired physical mobility related to the disease process d)Risk for infection related to breaks in the skin
a)Ineffective airway clearance related to edema of the respiratory passages
During exacerbations of anemia A patient who suffered major abdominal trauma in an accident asks the nurse why they are receiving famotidine (Pepcid). The nurse explains the medication will a)Inhibit development of stress ulcers b)Lower the risk for pylori infection c)Prevent aspiration of gastric contents d)Decreased nausea and vomiting
a)Inhibit development of stress ulcers
Which menu choice for the patient with diverticulosis is best for preventing diverticulitis? a)Roast beef, canned green beans, mashed potatoes, egg custard b)Navy bean soup and vegetable salad c)Broth, gelatin, tea or coffee without creamer d)Baked potato with low-fat sour cream, canned peaches
b)Navy bean soup and vegetable salad
A client has had a partial gastrectomy for acute gastritis. The nurse knows that the teaching regarding the use of vitamin B12 injections to treat pernicious anemia is understood when a client states, "I must take the drug: a)Monthly for the rest of my life b)Until my symptoms subside c)Weekly x6 weeks, then monthly for a year d)During exacerbations of anemia
a)Monthly for the rest of my life
After severe burns to 30% of the body, a client requires premedication with an analgesic prior to debridement. The nurse is aware that the medication and route that would be most appropriate for this client would be: a)Morphine sulfate IV b)oxycodone/aspirin orally c)Codeine sulfate SQ d)Meperidine hydrochloride IM
a)Morphine sulfate IV
A common side effect of radiation therapy that is not associated with the effect of radiation in the treatment field is: a)Fatigue b)Pericarditis c)Skin reactions d)Alopecia
a)Fatigue
A nurse is caring for a client experiencing spinal shock after a spinal cord injury. Which clinical manifestation indicates the resolution of spinal shock? a) Return of reflex activity b) Normalization of the pupillary reflex c) Return of bowel and bladder continence d) Tingling in the extremities below the lesion
a) Return of reflex activity
When providing discharge instructions to a client following a laparoscopic cholecystectomy at an outpatient surgical center, the nurse recognizes that teaching has been effective when the client states: a)"I may have some mild pain from the procedure, but severe pain may indicate a problem." b)"I will always need to maintain a low-fat diet since I no longer have a gallbladder." c)"I should plan to limit my activities and not return to work for 4-6 weeks." d)"I can expect drainage from the incisions for a few days."
a)"I may have some mild pain from the procedure, but severe pain may indicate a problem."
After receiving the change of shift report, which of these patients should the nurse assess first? a)A patient with smoke inhalation who has wheezes and altered mental status b)A patient with 40% total body surface area burns who is receiving IV fluids at 500mL/hr c)A patient with abdominal burns who is complaining of a pain level of 8/10 d)A patient with full-thickness leg burns who has a dressing change scheduled
a)A patient with smoke inhalation who has wheezes and altered mental status
In spite of aggressive medical interventions, a client with acute renal failure remains oliguric. His intake has been 3500ml and his urinary output 250ml for the past 24 hours. In order to assess the most serious potential complication in this situation, the nurse should: a)Auscultate breath sounds b)Palpate the bladder c)Evaluate the weight trends d)Loof for neck distended veins
a)Auscultate breath sounds
Your postoperative patient with stage 4 uterine sarcoma has lung metastasis but negative lymph node biopsies on the path report. The patient asks how uterine cancer could have spread to the lungs. The nurse's response is based on the understanding that: a)Cancer can spread to distal organs via the bloodstream b)Cancer spreads by continuous extension c)The lung lesions are likely a second primary site. Lungs are separated from the pelvic area by the diaphragm d)Cancer only spreads via the lymphatic route
a)Cancer can spread to distal organs via the bloodstream
Which of the following is always present in prerenal acute renal failure? a)Decrease in glomerular filtrate rate b)Urine output less the 500ml/day c)Decrease in metabolic waste products d)Absence of urine output
a)Decrease in glomerular filtrate rate
An adult client is receiving radiation therapy to the throat. Which complaint by the client should be reported immediately? a)Difficulty swallowing b)Dry mouth c)Nausea d)Redness in the area
a)Difficulty swallowing
A client with Bell's palsy has all of the following problems. Which is the greatest immediate concern? a)The client cannot close their eye on the affected side b)Chewing on the unaffected side is difficult c)The client has socially isolated themselves because of their appearance d)The client shows early signs of muscle tone loss on the affected side
a)The client cannot close their eye on the affected side
Your client asks you what the difference is between benign and malignant tumors. Which of the following would be a true statement about benign neoplasms? a)They may retain some structure and or functions of the cells from which they develop b)They have no harmful effects on the host c)They can invade surrounding tissues and metastasis to distant areas d)They are under control of body homeostatic mechanisms
a)They may retain some structure and or functions of the cells from which they develop
Your oncology patient receiving chemotherapy has lab tests drawn that show hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. This is indicative of: a)Tumor lysis syndrome b)SIADH c)Superior vena cava syndrome d)Myelosupression
a)Tumor lysis syndrome
When caring for a client immediately following an incisional cholecystectomy for cholelithiasis, the nurse's priority intervention with the patient is: a)Turning, coughing, and deep breathing q2h, while awake b)Ambulating within the first six hours of returning to the nursing unit c)Monitoring H&H for bleeding q2hr for the first 12hrs post-op d)Straining all urine for gallstones
a)Turning, coughing, and deep breathing q2h, while awake
When caring for a client with hepatitis A, the nurse should take special precautions to: a)Use gloves when removing the client's bedpan b)Wear mask and gown before entering the room c)Prevent contact with blood d)Admit patient to negative airflow room
a)Use gloves when removing the client's bedpan
A client returns from the OR with a partial-thickness skin graft on the left arm. The donor tissue was taken from the left hip. In planning immediate postoperative care, which interventions would the nurse include? Select all that apply. a)Administer pain medication every 4 hours as ordered for pain at the donor site. b)Monitor the pulse in the left arm every 4 hours c)Encourage the client to ambulate as desired on the first postoperative day d)Elevate the left arm and provide complete rest of the grafted area e)Perform ROM exercises to the left arm every 4 hours f)Change the dressing on the graft site every 8 hours
a, b, d
A multidisciplinary oncology team of physicians, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. a)Decreased platelets b)Decreased WBCs c)Increased platelets d)Decreased RBCs e)Increased WBCs f)Increased RBCs
a, b, d
A patient with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. a)Keeping the linens wrinkle-free under the patient b)Preventing unnecessary pressure on the lower limbs c)Limiting bladder catheterization to once every 12 hours d) Turning and repositioning the patient at least every 2 hours e) Ensuring that the patient has a bowel movement at least once a week
a, b, d
A nurse is calling report to the med-surg floor for a client with acute diverticulitis . Which symptoms does the nurse anticipate? (select all that apply) a)Cramping pain in the left lower abdominal quadrant b)Interval of diarrhea c)Hicupping d)Heartburn e)Bowel irregularity f)Esophagitis
a, b, e
The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply. a)Platelets 75,000 (150K-400k) b)Amylase 250 (15-45) c)Ammonia 96 (15-45) d)Prothrombin time 22 seconds (11-13 seconds) e)Potassium 4.0 (3.5-5.1) f)Albumin 7.2 (3.4-5.4)
a, c, d
The nurse is reviewing the orders for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which intervention would the nurse expect to be ordered for the client? Select all that apply. a)Give hydromorphone IV as prescribed for pain b)Give small, frequent high-calorie meals c)Maintain NPO status d_Maintain the client in a supine and flat position e)Encourage coughing and deep breathing
a, c, e
A patient presents to the ED with right facial droop and drooling. A diagnosis of Bell's palsy is confirmed by a neurological exam and magnetic resonance imaging (MRI). When instructing the spouse on the interventions needed to care for the client, the nurse knows that the education has been effective when the spouse makes which of the following statements? Select all that apply. a)I will buy a clothing protector for feedings b)I will obtain a walker in case symptoms progress c)I will instill eye drops to prevent symptoms of dry eyes d)I will watch for further symptoms of a stroke e)I will reinforce that symptoms are probably temporary f)I will provide sunglasses during the daytime
a, c, e, f
A nurse is caring for a terminally ill cancer client who is being transferred to hospice care. Which information regarding hospice care would the nurse include in the teaching plan? Select all that apply. a)Bereavement care is provided to the family b)Hospice care is provided only in hospice centers c)The focus of care is on controlling symptoms and relieving pain d)Care is provided in the home, independent of physicians e)Services are provided based on third-party insurance reimbursement f)A multidisciplinary team provides care
a, c, f
A patient with metastatic colon cancer experiences severe vomiting after each chemotherapy administration. An important nursing intervention would be to: a)Offer dry crackers and carbonated fluids during chemotherapy b)Administer prescribed antiemetic 1 hour prior to treatments c)Have the patient eat large meals when nausea is not present d)Teach about the importance of nutrition during treatment
b)Administer prescribed antiemetic 1 hour prior to treatments
The primary pathophysiologic mechanism involved in acute pancreatitis is: a)Ischemia b)An autodigestive process c)An infectious process d)An autoimmune response
b)An autodigestive process
An ER nurse completes the intake assessment on a 59 yo patient who fell asleep while smoking in bed. Findings are: soot around the mouth and nose, black-tinged sputum, a 5% BSA deep partial thickness burn to the anterior thorax, pink/red mucous membranes and nail beds, vitals of T-98F, HR-94, RR-20, BP-118/76, O2-99%. Based on this information the nurse's priority is to? a)Notify the healthcare provider for potential infection risk b)Apply oxygen for possible carbon monoxide poisoning c)Medicate the patient for pain d)Begin NS infusion for hypovolemic shock
b)Apply oxygen for possible carbon monoxide poisoning
The nurse has been teaching self-care to a client who is receiving teletherapy to the facial area. Which of the following client actions indicates a need for further teaching? a)Gently cleaning mouth and teeth with a sponge b)Applying lotion and powder to the radiated area c)Sitting next to his wife and holding hands d)Resting between activities
b)Applying lotion and powder to the radiated area
A client has undergone an endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse should place the highest priority on which item as part of the client's care plan? a)Monitoring the client's oral temperature b)Assessing for the return of the gag reflex c)Giving warm gargles for a sore throat d)Monitoring complaints of heartburn
b)Assessing for the return of the gag reflex
A client with chronic hepatitis B is being discharged in 2 days. The nurse includes all of the following in discharge teaching except: a)Follow a well-balanced diet with a multivitamin b)Avoid alcohol for the next two weeks c)Stress the need for adequate periods of rest d)Instruct that semen, saliva, and blood contain the hepatitis antigen, discuss lifestyle implications, and the need for follow-up lab/appointments with primary provider
b)Avoid alcohol for the next two weeks
In teaching a client with peptic ulcer disease about nutritional management of the disorder, which dietary modification does the nurse recognize is most important? a)Maintenance of meals that are high in protein, low in carbs b)Avoidance of foods that cause discomfort for the client c)Elimination of milk and milk products from the diet d)Avoidance of raw fruits, vegetables, and highly ???
b)Avoidance of foods that cause discomfort for the client
All of the following are risk factors for breast cancer except: a)Hormone replacement therapy b)Breastfeeding for 1 year or more c)Night shift work d)Obesity
b)Breastfeeding for 1 year or more
5) When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient's hand. Which action should the nurse take next? a)Assess for hyperventilation b)Check the calcium level of the chart c)Ask the patient about any arm pain d)Notify the health care provider immediately
b)Check the calcium level of the chart
Which of the following clients is at most risk for developing post renal failure a)Client taking nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis pain b)Client diagnosed with renal calculi c)Client with congestive heart failure d)Client recovering from glomerulonephritis
b)Client diagnosed with renal calculi
The nurse assess the client with cholecystitis for the development of obstructive jaundice, which would be evidenced by: a)Light amber urine, dark brown stools, yellow skin b)Dark-colored urine, clay-colored stools, itchy skin c)Inadequate absorption of fat-soluble vitamin K d)Straw-colored urine, putty-colored stools, yellow sclerae
b)Dark-colored urine, clay-colored stools, itchy skin
When evaluating fluid loss in a burned client, the nurse should recognize that the relationship between burn BSA and fluid loss is: a)Unrelated b)Directly proportional c)Inversely proportional d)Equal
b)Directly proportional
The nurse is collecting a 24-hour urine sampling for creatinine clearance on a client with acute glomerulonephritis. While making rounds, the nurse learns that the clients family discarded a urine void. The nurse should: a)Extend the collection time to replace the lost voiding b)Discard the collected urine obtain a new bottle, and begin collection again c)Record the information in the client's chart and continue collection d)Continue the collection as ordered by the physician
b)Discard the collected urine obtain a new bottle, and begin collection again
A patient complains of gas pain and abdominal distention after a small bowel resection. Which nursing action is best to implement? a)Administer the ordered IV morphine sulfate b)Encourage the patient to ambulate c)Instill a mineral oil retention enema d)Offer the ordered promethazine (Phenergan) suppository
b)Encourage the patient to ambulate
A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a)Drink adequate fluids to maintain normal hydration b)Fistulas can form between the bowel and the bladder c)Empty the bladder before and after sexual intercourse d)Bacteria in the perianal area can enter the urethra
b)Fistulas can form between the bowel and the bladder
A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information with the nurse include in the response? a)Dietary sources of fiber should be limits b)Fluid should be increased to prevent impaction or bowel obstruction c)Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives d)Use of this type of laxative to prevent constipation does not cause adverse effects
b)Fluid should be increased to prevent impaction or bowel obstruction
The initial cause of hypovolemia during the emergent phase of the burn injury is: a)Decreased vascular oncotic pressure b)Increased capillary permeability c)Fluid loss from denuded skin surfaces d)Loss of sodium to the interstitium
b)Increased capillary permeability
Laboratory findings that the nurse would expect in the client with persistent vomiting include: a)Increased pH; decreased chloride and hematocrit b)Increased pH and Hct; decreased K c)Decreased pH and Hct; increased Na d)Decreased pH and K; increased Hct
b)Increased pH and Hct; decreased K
The nurse is assessing the client who has had a total gastrectomy and notes bright red blood in the NG tube and abdominal distention. What does the nurse do next? a)Irrigate the NG tube b)Inform the surgeon of these findings c)Record the normal post-op findings on the electronic record d)???
b)Inform the surgeon of these findings
The client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively, the client is receiving continuous bladder irrigation. The nurse notices that the client is complaining of lower abdominal discomfort and the Foley has not drained in the past thirty minutes. To help validate her suspicions, the nurse performs all of the following assessments. Which has priority? a)Check to see if the bladder irrigation fluid is correct b)Palpate for bladder distension c)Check for a change in the color of the drainage d)Question the client about the quality and intensity of his pain
b)Palpate for bladder distension
The nurse would expect a client in the acute phase of hepatitis to exhibit all of the following symptoms except: a)Dark frothy urine b)Shortness of breath c)Yellowing of the sclera d)Loss of appetite
b)Shortness of breath
Upon assessment of your client with lung cancer, the nurse finds neck vein distention, facial edema, and headache. The nurse understands that these signs indicate: a)Paraneoplastic syndrome b)Superior vena cava syndrome c)Increased ADH secretion d)DVTs of the upper extremities
b)Superior vena cava syndrome
The nurse manager on the oncology unit is assessing the knowledge level of the staff in regard to safety requirements for the patient receiving internal radiation therapy. Which observation by the nurse manager indicates that further instruction is necessary? a)The dietitian provides a low residue diet for the patient b)The PT is ambulating the patient in the hall c)The housekeeping staff calls for radiation safety personnel to inspect the room when the patient is discharged d)The registered nurse uses gloves when emptying the bedpan
b)The PT is ambulating the patient in the hall
A client is brought to the ER after a severe burn caused by a fire at home. The burns are extensive, covering more than 45% of the total body surface area. When planning the care of this client, the nurse includes regular assessments for tissue perfusion. One of the best indicators of adequate perfusion is: a)Capillary refill of 2 seconds b)Urine output > 0.5 mL/kg/hr c)Clear breath sounds d)Jugular venous distention
b)Urine output > 0.5 mL/kg/hr
A patient is diagnosed as having a bowel tumor. The nurse should monitor the patient for which complications of this type of tumor? Select all that apply. a)Flatulence b)Peritonitis c)Hemorrhage d)Fistula formation e)Bowel perforation f)Lactose intolerance
b, c, d, e
A nurse is caring for a client following gastric bypass surgery. At the 6 week appointment, the client reports symptoms of nausea, abdominal pain and cramping following meals, and shakiness and sweating up to 3 hours later. Which nursing interventions would help reduce the symptoms and be included in the plan of care? Select all that apply. a)Ingest fluids at the end of meals b)Reduce high concentrated sugars c)Limit sodium intake d)Eat small, frequent meals
b, d
During the early emergent phase of burn injury, the patient's laboratory results would most likely include: a) Decreased hematocrit, increased serum sodium, increased serum potassium, increased urine specific gravity b) Increased Hct, Decreased Na, Decreased K, Decreased USG c) Increased Hct, Decreased Na, Increased K d) Decreased Hct, Decreased serum albumin, decreased Na, Increased K
c) Increased Hct, Decreased Na, Increased K
Two months ago, an adult client experienced a complete transection injury at L-4. The nurse plans a client education program in anticipation of the client's discharge one week from now. The nurse would assign the highest priority to teaching strategies for: a) Managing dysreflexic episodes b) Transferring in and out of automobiles c) Maintaining bowel and bladder elimination d) Creating alternatives for sexual expression
c) Maintaining bowel and bladder elimination
The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the IV route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? a)A clotting time of 10 minutes b)An ammonia level of 20 c)A platelet count of 50,000 d)A WBC count of 5000
c)A platelet count of 50,000
A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient's: a)Hemoglobin b)Activity level c)Albumin level d)Temperature
c)Albumin level
A client is undergoing a course of chemotherapy. He is in the clinic for periodic lab checks. The nurse reviews his laboratory data and notes the following hematology values: hemoglobin-15, hematocrit-43%, RBCs-5 million, WBCs-7500, neutrophils-40%, platelet count-30K. What nursing care is indicated in relation to these lab values? a)Plan a meal high in iron b)Plan for frequent rest periods throughout the day c)Avoid invasive procedures and injections d)Implement protective isolation precautions
c)Avoid invasive procedures and injections
The nurse caring for a patient with cirrhosis recognizes all of the following as signs of portal hypertension except: a)Hemorrhoids b)Ascites c)Bleeding gums d)Esophageal varices
c)Bleeding gums
When assessing the patient with darker skin for jaundice, which part of the body does the nurse examine? a)Cheek b)Palms of hands c)Conjunctiva of the eye d)Soles of the feet
c)Conjunctiva of the eye
A patient with Addison's disease comes to the ED with complaints of nausea, vomiting, diarrhea, and fever. The nurse would expect the physician to write an order for: a)Parenteral injection of ACTH b)IV administration of vasopressors c)IV administration of hydrocortisone d)IV administration of D5W with 20 mEq KCl
c)IV administration of hydrocortisone
A client receiving peritoneal dialysis (PD) has outflow that is 100ml less than inflow for two consecutive exchanges. Which of the following actions would be best for the nurse to take first? a)Continue to monitor third exchange b)Check client's blood pressure c)Irrigate dialysis catheter d)Change client's position
d)Change client's position
A client with mild iatrogenic Cushing syndrome is on an alternate-day regimen of corticosteroid therapy. The nurse explains to the patient that this regimen: a)Maintains normal adrenal hormone balance b)Prevents ACTH release from the pituitary gland c)Minimizes hypothalamic-pituitary-adrenal suppression d)Prevents circulatory overload
c)Minimizes hypothalamic-pituitary-adrenal suppression
The nurse is assisting with a liver biopsy on a client with liver enlargement. After the procedure, the nurse positions the client: a)In a reverse Trendelenburg b)On his left side c)On his right side d)In a semi-fowler's position
c)On his right side
Which action will the nurse include in the pain care for a patient who is being admitted with Clostridium difficile? a)Teach the patient about why antibiotics will not be used b)Order a bland diet with no dairy products for the patient c)Place the patient in a private room on contact isolation d)Educate the patient about proper food storage
c)Place the patient in a private room on contact isolation
During surgery, a client lost an excessive amount of blood and his blood pressure was 80/40 for 40 minutes. The type of acute renal failure he is at risk for is: a)Hemorrhagic b)Hypovolemic c)Prerenal d)Postrenal
c)Prerenal
The three interacting factors that influence cancer development include all of the following except: a)Exposure to carcinogens b)Immune function c)Presence of proto-oncogenes d)Genetic predisposition
c)Presence of proto-oncogenes
The nurse is reviewing the orders for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which intervention would the nurse question? a)Incentive spirometer use every hour while awake b)IV morphine for pain as needed c)Regular diet with six meals a day d)Elevate head of bed to at least 30 degrees
c)Regular diet with six meals a day
A 42 year old female is concerned about her cancer risks. She reveals that she has been married for 18 years, has 2 children, smokes one pack of cigarettes per day, and drinks one beer with her husband after work almost every day. She is 30 lb. overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What behavioral changes should the nurse instruct the client to make first? a)Stop drinking beer, decrease fiber in diet, and use sun protection b)Increase intake of salt-cured food, lose weight, and stop smoking c)Stop smoking, use sun protection, and lose weight d)Decrease fat in the diet, increase alcohol consumption, and use sunscreen every day
c)Stop smoking, use sun protection, and lose weight
A client is receiving vesicant chemotherapy treatment. During the infusion, the patient complains of pain at the IV site. The priority nursing action is: a)Elevate the arm and apply warm packs b)Check for adequate blood return c)Stop the infusion d)Slow the rate of infusion
c)Stop the infusion
A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which occurrence? (select all that apply) a)Constipation b)Decreased clotting time c)Trousseau's sign d)Fractures e)Drowsiness and lethargy f)Cardiac arrhythmias
c, d, f
Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? a)"Do you have any abdominal distention?" b)"What foods affect your bowel patterns?" c)"Have you been passing a lot of gas?" d)"How long have you had abdominal pain?
d)"How long have you had abdominal pain?
The nurse on a medical nursing unit has been notified of an external disaster with an estimated 30 clients being brought to the emergency department. The nurse is asked to develop a list of clients on the unit that could be discharged. Which client would the nurse place at the top of the triage list for discharge? a)A 54 year old client with draining venous leg ulcer and a temperature of 100.8F b)A 76 year old client with chronic obstructive pulmonary disease with an O2 saturation of 87% while wearing oxygen at 2L/minute c)An 82 year old client who underwent cardiac catheterization 3 hours ago and whose cardiac monitor shows new S-T elevation d)A 39 year old client who underwent laparoscopic cholecystectomy 24 hours ago and reports right shoulder pain rated as a 4 on a scale of 0 to 10
d)A 39 year old client who underwent laparoscopic cholecystectomy 24 hours ago and reports right shoulder pain rated as a 4 on a scale of 0 to 10
A client with a peptic ulcer in the duodenum would probably describe the associated pain as: a)An ache radiating to the left side b)A generalized abdominal pain intensified by moving c)An intermittent colicky flank pain d)A gnawing sensation relieved by food
d)A gnawing sensation relieved by food
The nurse is teaching a client with symptoms of a bladder infection on the use of phenazopyridine (Pyridium). Which statement indicates additional teaching is required? a)My urine will turn orange and may stain clothes b)Once the discomfort is relieved, I should stop this medication c)This medicine can cause nausea, so I should take it with meals to prevent GI upset d)After I complete all of this medication, I need to return to the clinic for a urine culture
d)After I complete all of this medication, I need to return to the clinic for a urine culture
Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a)Calcium b)Potassium c)Bilirubin d)Amylase
d)Amylase
A client is hospitalized with vomiting of "coffee ground" emesis of unknown cause. The client is very anxious about the source of the bleeding and asks the nurse whether its possible to find the cause. The nurse's response is based on the knowledge that the diagnostic test that can most accurately identify the cause of the bleeding is: a)Barium contrast studies b)A gastric analysis c)An angiography d)An endoscopic procedure
d)An endoscopic procedure
The nurse uses many precautions during the administration of vesicant chemotherapeutic primarily to prevent the major complication: a)Bone marrow suppression b)Septicemia c)Nausea d)Extravasation
d)Extravasation
A client is brought to the ER after a severe burn caused by a fire at home. The burns are extensive, covering more than 45% of the total body surface area. The nurse reviews the laboratory results and would most likely expect to find which abnormality? a)Sodium level of 140 b)Potassium level of 4 c)WBC of 8000 d)Hematocrit of 65%
d)Hematocrit of 65%
A client with hepatic failure complains of itchiness and scratches himself even when he's sleeping. Which abnormality is the itching related to? a)Elevated serum ammonia b)Folic acid deficiency c)Hypokalemia d)Increased bilirubin levels
d)Increased bilirubin levels
The following laboratory data findings are anticipated for a client who has end-stage renal disease: a)Higher than normal platelets b)Higher than normal pH c)Lower than normal BUN d)Lower than normal Hgb
d)Lower than normal Hgb
Which nursing action will the nurse include in the plan of care for 35-year-old male patient admitted with an exacerbation of ulcerative colitis? a)Restrict fluid intake b)Increase dietary fiber intake c)Ambulate four times daily d)Monitor stools for blood
d)Monitor stools for blood
An adult client has just returned to the nursing care until following a gastroscopy. Which of the following is part of this post-procedure care? a)Limit visitors for the first 4 hours b)Clear liquid diet for 24 hours when able to swallow c)Keep HOB flat post procedure for 8 hours d)NPO until return of gag reflex
d)NPO until return of gag reflex
Which assessment finding of a 42 year old patient who had a bilateral adrenalectomy is the HIGHEST priority and requires rapid action by the nurse? a)The blood glucose is 176 b)The lungs have bibasilar crackles c)The patient reports 5/10 incisional pain d)The blood pressure is 86/50
d)The blood pressure is 86/50
The nurse reads in the medical record that a client's tumor is at stage T2, N0, M0. The nurse concludes that this staging indicates which of the following about the client's status? a)There is an advanced tumor with metastasis b)There is an advanced tumor with indication of involvement of lymph nodes but no indication of metastasis c)The client has an advanced tumor with indication of metastasis but no indication of involvement of lymph nodes d)The client has a measurable tumor with no indication of metastasis or involvement of nodes
d)The client has a measurable tumor with no indication of metastasis or involvement of nodes
A patient who has advanced cirrhosis is receiving lactulose. Which finding by the nurse indicates that the medication is effective? a)The patient denies nausea or anorexia b)The patient has 1 to 4 stools daily c)The patient's bilirubin level decreases d)The patient is alert and oriented
d)The patient is alert and oriented
A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatments will be done to relieve the obstruction? Select all that apply. a)Insertion of a foley catheter b)Analysis of the urinary stone c)IV opioid analgesics d)Insertion of a nephrostomy tube e)Placement of a urethral stent with ureteroscopy
d, e
