ATI Practice Q's

A nurse working in the ED is caring for a client who has sustained a fracture of the femur following a motor vehicle crash. Which of the following images indicates a commuted fracture

-Picture answer. 1st pictures, bone has fragmented into several pieces

Melena:

Black, tarry stools.

What is the cause of a 'non-mechanical' bowel obstruction? A. A tumor or twisting of the bowel B. Constipation. C. General anesthesia, narcotics, and handling of the bowel during surgery. D. Adhesions

C. General anesthesia, narcotics, and handling of the bowel during surgery.

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include

Ensure the client lies flat for 4-8 hours

The use of metroclopramide:

GI stimulant to Treat GERD and Antiemetic

The potential electrolyte imbalances w/use of aluminum hydroxide w/magnesium hydroxide:

Hypophosphatemia & hypermagnesiemia

gentamicin

Impaired kidney function is an adverse effect of gentamicin.

A nurse is caring for a client who has MS. Which of the following findings should the nurse expect

Intention tremors

A nurse is caring for a client who is recovering from a stroke and has right sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions

Remind the client to look consciously at both sides of his meal tray

PY test:

Test in which a client's breath is analyzed after consuming 14 C-urea capsules to detect Helicobacter pylori, the bacteria associated with peptic ulcer disease.

Serious Side effects of ranitidine (Zantac):

neutropenia, Agranulocytosis, Thrombocytopenia Aplastic anemia

aspirin

the nurse should not use an ___________ in the collection pouch to control odor, as this can cause an ulceration to the stoma

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions?

"I should call my doctor if I experience a decrease in my vision"

A nurse is teaching a client who has parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?

"I should expect that this medication can cause me to be drowsy."

A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?

"I should stop eating raw clams." Hepatitis A is transmitted via the fecal-oral route through consumption of contaminated fruits, vegetables, water, milk, or uncooked shellfish.

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? "May I go with my family to the visitor's lounge?" "I'll see my friends when I get home." "My dad is coming to visit. Can you fix my hair for me?" "I told my cousins I'm in protective isolation."

"May I go with my family to the visitor's lounge?" This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include?

"Monitor your body temperature and report any elevations promptly."

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching?

"PCP results from an impaired immune system."

A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? "Move between the bed and the wheelchair once every 2 hours." "Make sure that your caregiver massages your skin daily." "Use a rubber ring when sitting at the bedside." "Shift your weight in the wheelchair every 15 minutes."

"Shift your weight in the wheelchair every 15 minutes." This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements by the family indicates an understanding of the teaching?

"The drugs used to treat Alzheimer's disease can help delay cognitive changes"

A nurse is teaching a client who has human immunodeficiency virus about the early manifestations of acquired immune deficiency syndrome. Which of the following statements should the nurse include in the teaching?

"You can expect a persistent fever and swollen glands."

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply. 1. Obtain adequate rest to reduce stimulation. 2. Eat small, frequent meals throughout the day. 3. Take all medications on time as ordered. 4. Sit up for one hour when awakened at night. 5. Stay away from crowded areas.

1, 2, 3, 4. The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? 1. Promptly assess the client for potential perforation. 2. Tell the assistant to change thermometers and retake the temperature. 3. Plan to give the client acetaminophen (Tylenol) to lower the temperature. 4. Ask the assistant to bathe the client with tepid water.

1. A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a physician's order; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (Select all that apply)

1. Crepitus with joint movement 2. Decreased range of motion of the affected joint 3. Involvement of smaller joints of the body 4. Joint pain that resolves with rest

A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. 1. Administering an antacid hourly until nausea subsides. 2. Monitoring the client's vital signs. 3. Notifying the physician of the client's symptoms. 4. Initiating oxygen therapy. 5. Reassessing the client in an hour.

2, 3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client's vital signs and notify the physician of the client's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.

The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply. 1. The client has a sore throat. 2. The client has a temperature of 100 ° F (37.8 ° C). 3. The client appears drowsy following the procedure. 4. The client has epigastric pain. 5. The client experiences hematemesis.

2, 4, 5. Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the procedure.

The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: 1. Involvement with his job will keep the client from becoming bored. 2. A relaxed environment will promote ulcer healing. 3. Not keeping up with his job will increase the client's stress level. 4. Setting limits on the client's behavior is an important nursing responsibility.

2. A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Being involved with his work may prevent boredom; however, this client is upset and argumentative. Not keeping up with his job will probably increase the client's stress level, but the nurse's response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client's behavior; clients must make the decision to make lifestyle changes.

Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: 1. Demonstrate appropriate use of analgesics to control pain. 2. Explain the rationale for eliminating alcohol from the diet. 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. 4. Eliminate contact sports from his or her lifestyle.

2. Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? 1. Ineffective coping related to fear of diagnosis of chronic illness. 2. Deficient knowledge related to unfamiliarity with significant signs and symptoms. 3. Constipation related to decreased gastric motility. 4. Imbalanced nutrition: Less than body requirements related to gastric bleeding.

2. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. The data do not support the other diagnoses.

The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? 1. The client awaiting hiatal hernia repair at 11 am. 2. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests. 3. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain. 4. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.

3, 4, 2, 1 The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery.

When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply. 1. Epigastric pain at night. 2. Relief of epigastric pain after eating. 3. Vomiting. 4. Weight loss. 5. Melena.

3, 4, 5. Vomiting and weight loss are common with gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs during the night and is frequently relieved by eating.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? 1. Bland foods. 2. High-protein foods. 3. Any foods that are tolerated. 4. Large amounts of milk.

3. Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.

A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? 1. The client has not been including enough fiber in his diet. 2. The client needs to increase his daily exercise. 3. The client is experiencing an adverse effect of the aluminum hydroxide. 4. The client has developed a gastrointestinal obstruction.

3. It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? 1. Before meals. 2. With meals. 3. At bedtime. 4. When pain occurs.

3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.

A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? 1. "I should take my antacid before I take my other medications." 2. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." 3. "My antacid will be most effective if I take it whenever I experience stomach pains." 4. "It is best for me to take my antacid 1 to 3 hours after meals."

4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.

A client with peptic ulcer disease is taking ranitidine (Zantac). What is the expected outcome of this drug? 1. Heal the ulcer. 2. Protect the ulcer surface from acids. 3. Reduce acid concentration. 4. Limit gastric acid secretion.

4. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretory, or proton-pump inhibitors, such as omeprazole (Prilosec), help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate (Carafate), protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? 1. Conduct physical activity in the morning so that he can rest in the afternoon. 2. Have the family agree to perform the necessary yard work at home. 3. Give up jogging and substitute a less demanding hobby. 4. Incorporate periods of physical and mental rest in his daily schedule.

4. It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful.

A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? 1. An intestinal obstruction has developed. 2. Additional ulcers have developed. 3. The esophagus has become inflamed. 4. The ulcer has perforated.

4. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause midepigastric pain. The development of additional ulcers or esophageal inflammation would not cause a rigid, boardlike abdomen.

A nurse teaches a client experiencing heartburn to take 1 ½ oz of Maalox when symptoms appear. How many milliliters should the client take? ________________________ mL. .

45 mL

Enlarged lymph nodes

A nurse in an oncology clinic is assessing a clinet who has early stage Hodgkin's lymphoma. Which of the following findings should the nurse suspect?

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client?

A progressive, circular rash

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? A. Hypertension B. Excessive thirst C. Fever D. Diaphoresis

A. A client experiencing fluid volume overload will exhibit hypertension. B. A client experiencing hyperglycemia will exhibit excessive thirst. C. A client who has an infection will have an increased temperature. D. CORRECT: The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis. other potential manifestations of hypoglycemia can include weakness, anxiety, confusion. and hunger.

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? A. A client who has epistaxis B. A client who has amyotrophic lateral sclerosis C. A client who has pneumonia D. A client who has emphysema

A. A client who has epistaxis Rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred? A. Elevated blood pressure B. Bowel sounds increased in frequency and pitch C. Rigid abdomen D. Emesis of undigested food

A. A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. B. Intestinal peristalsis increases in frequency and intensity as the bowel attempts to move intestinal contents past the obstructed area. Bowel sounds are silent with a bowel perforation C. CORRECT: Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure. or hypotension, results. D. Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A. A client who is 48 hr postoperative following a total hip arthroplasty B. A client who is 8 hr postoperative following an open surgical appendectomy C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A. A client who is 48 hr postoperative following a total hip arthroplasty Rationale: The nurse should identify that the client who has undergone a total hip replacement surgery is at greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devises or antiembolic stockings and by administering anticoagulant medications.

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use

A. A high-calorie diet can contribute to heart disease and obesity but it does not cause chronic pancreatitis. B. A prior gastrointestinal illness does not cause or contribute to chronic pancreatitis. C. tobacco use can contribute to heart disease and increases the risk of cancer development. but it does not cause chronic pancreatitis. D. CORRECT: Alcohol consumption is one of the major causes of chronic pancreatitis in the U.S. Long-term alcohol use disorder produces hyper secretion of protein in pancreatic secretions. The result is protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.

A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. "This procedure is performed to measure the presence of acid in your esophagus." B. "This procedure can determine how well the lower part of your esophagus works." C. "This procedure is performed while you are under general anesthesia." D. "This procedure can determine if you have colon cancer."

A. A pH probe study, which involves the insertion of a specially designed probe into the distal esophagus. is performed to monitor for the presence of acid in the normally alkaline esophagus. B. CORRECT: An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. C. An EGD is performed while the client receives moderate sedation. D. A colonoscopy is performed to detect colon cancer.

A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is used to do which of the following? A. To visualize polyps in the colon B. To detect an ulceration in the stomach C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen

A. A sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where polyps are found. B. CORRECT: An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction. C. Identifying an obstruction in the biliary tract is performed during endoscopic retrograde cholangiopancreatography (ERCP). D. The measurement of free air, which is a gas, is obtained using fluoroscopy or an x-ray, not an EGD.

Which of the following is an appropriate nursing intervention for a pt. who has GERD? A. Advise pt. to remain upright after meals. B. Withhold fluids during meal time. C. Administer the appropriate immunoglobulin. D. Give the prescribed steroids with half a glass of milk.

A. Advise pt. to remain upright after meals.

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement? A. Airborne B. Neutropenic C. Contact D. Droplet

A. Airborne Rationale: The nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure filtered through a high-efficiency particulate air (HEPA) filter. Members of the healthcare team should not enter the client's room without wearing an N95 respirator mask.

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? A. Apply supplemental oxygen. B. Increase the rate of IV fluids. C. Administer pain medication. D. Initiate cardiac monitoring.

A. Apply supplemental oxygen. Rationale: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect? A. Blood-tinged sputum B. Decreased tactile fremitus C. Resonance with percussion D. Peripheral edema

A. Blood-tinged sputum Rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

A. CORRECT: A major complication following a liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk for bleeding. Along with the prothrombin time (PT), the activated partial thromboplastin time (aPTT) and the platelet count should be monitored. Liver dysfunction causes the production of blood clotting factors to be reduced, which leads to an increased incidence of bruising nosebleeds, bleeding from wounds, and gastrointestinal bleeding. This is due to a deficient absorption of vitamin K from the gastrointestinal tract caused by the inability of liver cells to use vitamin K to make prothrombin. B. Serum lipase is monitored to detect pancreatic disease and does not need to be monitored prior to this procedure. C. Bilirubin is monitored to detect biliary obstruction and does not need to be monitored prior to this procedure. D. Calcium is monitored to detect kidney failure or pancreatitis and does not need to be monitored prior to this procedure.

A nurse is caring for a client who has celiac disease. which of the following foods should the nurse remove from the client's meal tray? A. Wheat toast B. Tapioca pudding C. Hard-boiled egg D. Mashed potatoes

A. CORRECT: Celiac disease is an autoimmune disorder characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and should be removed from the clients tray. B. Tapioca pudding is rich in dairy and does not contain gluten. Therefore, it is an acceptable food to include in the clients diet. C. A hard-boiled egg does not contain gluten and is a good source of protein. Therefore, it is an acceptable food to include in the client's diet. D. Mashed potatoes do not contain gluten and are a good source of protein and potassium. Therefore mashed potatoes are an acceptable food to include in the clients diet.

A nurse is caring for a client who has a history of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following laboratory tests to determine the possibility of recent excessive alcohol use? A. Gamma-gluramyl transferase (GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT]

A. CORRECT: The GGT laboratory test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use. B. ALP is elevated in biliary obstruction and most forms of liver dysfunction. It does not differentiate between alcohol and other causative factors for liver disease. C. The serum bilirubin test is used to detect the function of the liver and its ability to excrete bilirubin. Elevated levels can determine liver disease or biliary tract disease. D. The largest concentration of the enzyme ALT is found in liver tissue. However. it is also present in kidney, heart. and skeletal muscle tissues. Because it is elevated in various toes of tissue damage. it is not helpful in identifying excessive alcohol use.

A nurse is caring for a client who is 4 hr postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? A. Right shoulder pain B. Urine output 20 mL/hr C. Temperature 38.4 degrees C (101.1 degrees F) D. Oxygen saturation 92%

A. CORRECT: The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. Mild analgesics and a recumbent position can help with client comfort. B. Urine output following surgery should be at least 30 mL/hr. Less than this amount can indicate hypovolemia or renal complications and should be reported to the provider immediately. C. A temperature greater than 38.4. C (101.1 F) can indicate infection and should be reported to the provider immediately. D. An oxygen saturation of less than 95% can indicate an impaired gas exchange following surgery and should be reported to the provider immediately.

A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hepatitis A? A. Children B. Older adults C. Women who are pregnant D. Middle-aged men

A. CORRECT: The hepatitis A virus can be contracted from the feces. bile, and blood of infected clients. The usual mode of transmission is the fecal-oral route. Children and young adults are the two groups most often affected by the hepatitis A virus. Typically, a child or young adult acquires the infection at school, through poor hygiene, hand-to-mouth contact, or another form of close contact. B. Older adults are not often affected by or at risk for developing hepatitis A. C. Women who are pregnant are not often affected by or at risk for developing hepatitis A. D. Middle-aged men are not often affected by or at risk for developing hepatitis A.

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should the nurse anticipate returning to the expected reference range within 72 hr after treatment begins? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

A. Elevated aldolase levels are caused by inflammation of the muscles, also known as myositis. The levels of aldolase are not affected by pancreatic disorders. B. Lipase levels in clients who have pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase. C. CORRECT: Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days. D. Lactic dehydrogenase (LDH) increases are typically seen in clients who have anemia, leukemia, or liver damage.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Transjugular intrahepatic portal-systemic shunt placement

A. Endoscopic sclerotherapy is the injection of a sclerotherapy agent during endoscopy to target esophageal varies that are actively bleeding. This promotes thrombosis, which eventually leads to sclerosis. B. A liver lobectomy is used for a client who has localized cancer of a lobe of the liver. This is not appropriate for a client experiencing rapidly progressive liver failure. C. CORRECT: Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high. even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients. D. A transjugular intrahepatic portal-systemic shunt is placed to treat esophageal varies through placement of a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension. It is not used for fulminant hepatic failure.

A nurse in the emergency dependent is caring for a client who has bleeding esophageal varies. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

A. Famotidine is an H2 receptor antagonist used to treat stress ulcers. B. Esomeprazole is a proton pump inhibitor used to treat gastrointestinal reflux disease. C. CORRECT: Vasopressin constricts the splanchnic bed and decreases portal pressure. Vasopressin also constricts the distal esophageal and proximal gastric veins, which reduces inflow into the portal system and is used to treat bleeding varies. D. Omeprazole is a proton pump inhibitor used to treat duodenal and gastric ulcers.

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chicken B. Mashed potatoes C. Dinner roll D. Tapioca pudding

A. Fried chicken

What should the nurse advise a pt. who has diverticulosis to eat? A. High fiber foods. B. Low fiber foods. C. Low carb foods. D. High carb foods

A. High fiber foods.

A nurse is assessing a client who is in the early stages of hepatitis A. which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale feces

A. Jaundice is a late manifestation of hepatitis A. B. CORRECT: Anorexia is an early manifestation of hepatitis A and is often severe. It is thought to result from the release of a toxin by the damaged liver or by the failure of the damaged liver cells to detoxify an abnormal product. C. Dark urine is a late manifestation of hepatitis A. D. Pale feces is a late manifestation of hepatitis A.

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the clients recent laboratory findings and recognizes that which of the following findings will place the client at risk for complications? A. Low platelet count B. Low sodium level C. Decreased prothrombin time D. Low hemoglobin

A. Low platelet count ?

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments? A. Presence of gag reflex B. Pain level rating using a 0-10 scale C. Hydration status D. Appearance of the IV insertion site

A. Presence of gag reflex Rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

Which of the following symptoms will a nurse observe most commonly in clients with pancreatitis? A. Severe, radiating abdominal pain B. Black, tarry stools and dark urine C. Increased and painful urination D. Increased appetite and weight gain

A. Severe, radiating abdominal pain

A nurse is preparing a community education program about hepatitis B. Which of the following statements should the nurse include in the teaching? A. "A hepatitis B immunization is recommended for those who travel, especially military personnel." B. "A hepatitis B immunization is given to infants and children." C. "Hepatitis B is acquired by earring foods that are contaminated during handling." D. "Hepatitis B can be prevented by using good personal hygiene habits and proper sanitation."

A. The hepatitis A vaccine is recommended for those who travel, especially military personnel It is also recommended for other at-risk groups. B. CORRECT: Hepatitis B immune globulin is given as part of the standard childhood immunizations. It can be administered as early as birth. especially in infants born to hepatitis B Surface antigen (HBSAg) negative mothers. These infants should receive the second dose between 1 and 4 months of age. C. Hepatitis A is acquired by eating fruits. vegetables, shellfish. or other foods that are contaminated during handling. Hepatitis B is acquired by exposure to blood or body fluids from an infected person. D. Good personal hygiene habits and proper sanitation can help prevent the spread of hepatitis A.

A nurse is assessing a client who is experiencing perforation of a peptic ulcer. Which of the following manifestations should the nurse expect? A. Increased blood pressure B. Decreased heart rate C. Yellowing of the skin D. Boardlike abdomen

A. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including hypotension. B. The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of shock, including tachycardia. C. The nurse should expect a client who has liver disease to exhibit jaundice, or yellowing of the skin. D. CORRECT: The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? A. Vanilla pudding B. Apple juice C. Diet ginger ale D. Clear liquids

A. Vanilla pudding contains sugar, which can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. B. The sugar content of apple juice can cause diarrhea due to hyperosmolarity. Clear liquids should be given as the first oral feeding. C. The client should avoid carbonated beverages because they can distend the stomach. causing pressure on the internal sutures or staples. Pressure can cause leaking into the peritoneum resulting in peritonitis. D. CORRECT: Clear liquids. such as water or broth. can be given for the first oral feedings. but should be limited to only 30 mL (1 oz) per feeding. Water does not contain sugar. which could cause diarrhea due to hyperosmolarity.

A nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks. which of the following foods should the nurse recommend? A. Foods high in vitamin C B. Foods low in fat C. Foods high in fiber D. Foods low in calories

A. Vitamin C functions as an antioxidant as well as a coenzyme. It can be associated with prevention of cancer of the stomach. esophagus and colon. However, it does not improve or prevent acute diverticulitis attacks. B. Low-fat foods do not improve or prevent acute diverticulitis attacks. C. CORRECT: The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract. D. Low-calorie foods do not improve or prevent acute diverticulitis attacks.

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A. Watery with blood and mucus B. Hard and black or tarry C. Dry and streaked with blood D. Loose with visible fatty streaks

A. Watery with blood and mucus

A nurse is assisting the provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (Select all that apply.) A. Wear goggles and mask during the procedure. B. Cleanse the procedure area with an antiseptic solution. C. Instruct the client to take deep breaths during the procedure. D. Position the client laterally on the affected side before the procedure. E. Apply pressure to the site after the procedure.

A. Wear goggles and mask during the procedure. B. Cleanse the procedure area with an antiseptic solution. E. Apply pressure to the site after the procedure. Rationale: Wear goggles and mask during the procedure is correct. The nurse and provider should wear goggles and a mask to reduce the risk of exposure to pleural fluid. Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk of infection, which is increased due to the invasive nature of the procedure. Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk of bleeding at the procedure site.

A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? A. A full pitcher of water is sitting on the clients bedside table within the clients reach. B. The disposable feeding bag from the previous day at 1000, and contains 200 mL of feeding. C. The client is lying on the right side with a visible dependent loop in the feeding tube. D. The head of the bed is elevated 20 degrees.

A. the nurse should monitor the clients intake and output and should observe the client for manifestations of dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of water at the clients bedside does not require intervention by the nurse. B. The clients feeding bag should be changed every 24 hrs. The 200 mL remaining in the bag is sufficient to last until the bag needs to be changed. Because the rate is 75 mL/hr, the nurse will need 150 mL to cover the 2 hr until the bag needs to be changed. The 50 mL left in the bag will ensure that the bag does not run dry, causing air to enter the clients stomach. C. This observation does not require intervention because the feeding is not by gravity, but by a pump. and is set at a constant rate. The clients side-lying position will not affect the pump's rate of flow unless the client is lying on the tubing. D. CORRECT: The head of the bed should be elevated at least 30. (Semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation.

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? Zoster vaccine Acyclovir Amoxicillin Infliximab

Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication, because it inhibits replication of the virus that causes herpes zoster.

A Nurse is caring for a client who is 72 hours postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

Administer an oral does of gabapentin to the client

A nurse is caring for a client who is 72 hour postop following an above the knee amputation and reports phantom limb pain. Which of the following actions should the nurse take

Administer an oral dose of gabapentin -This is to help minimize phantom limb pain

A nurse in the emergency department is assessing a client who has myasthenia gravis. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurse's prority?

Assist with Tensilon test

A nurse in the Ed is assessing a client who has myasthenia graves. The client reports recent increasing muscle weakness and the nurse suspects the client is experiencing a myasthenic crisis. Which of the following actions is the nurses priority

Assist with tensilon test

A nurse is teaching a group of young adult clients about health promotion techniques to reduce the risk of skin cancer. Which of the following instructions should the nurse include? Apply a broad-spectrum sunscreen 5 min before sun exposure. Wear a sun visor instead of a hat when outside in the sun. Avoid exposure to the midday sun. Use a tanning booth instead of sunbathing outdoors.

Avoid exposure to the midday sun. The nurse should instruct clients to avoid skin exposure to the sun, especially during the midday hours of 1000 to 1600 because sun rays are the strongest at that time.

The nurse is providing care for a patient who has peritonitis. The patient expresses anxiety about the impending surgery. Which of the following actions should the nurse take? A. "Why are you feeling so anxious?" B. "Tell me more about your concerns." C. "You should distract yourself by reading a magazine" D. "You have nothing to worry about. Your surgeon is excellent." E. "Others who have had this procedure have had great results."

B. "Tell me more about your concerns."

A nurse is providing care to a client who is 1 day post paracentesis. The nurse observes clear, pale-yellow fluid leaking from the puncture site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site B. Apply a dry, sterile dressing C. Attach an ostomy back D. Place the client in a supine position

B. Apply a dry, sterile dressing

Which of the following is an appropriate nursing intervention for a pt. who has an inguinal hernia? A. Turn, cough, & deep breath every hour while awake to prevent pneumonia. B. Avoid prolonged standing. C. Decrease fiber intake to control diarrhea. D. Monitor your stools for occult blood.

B. Avoid prolonged standing.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider? A. Fluctuation of drainage in the tubing with inspiration B. Continuous bubbling in the water seal chamber C. Drainage of 75 mL in the first hour after surgery D. Several small, dark-red blood clots in the tubing

B. Continuous bubbling in the water seal chamber Rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while she is waiting for instructions from the provider.

A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased oxygen saturation C. Urinary retention D. Increased pain level

B. Decreased oxygen saturation Rationale: Using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia due to airway obstruction.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds

B. Elevated temperature Rationale: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

Which dietary modification is utilized for a patient diagnosed with acute pancreatitis? A. High-protein diet B. Elimination of Coffee C. Low carbohydrate diet D. High-fat diet

B. Elimination of Coffee

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? A. Lateral position with a pillow at the back and over the chest to support the arm B. High-Fowler's position with the arms supported on the over-bed table C. Semi-Fowler's position with pillows supporting both arms D. Supine position with the head of the bed elevated to 15°

B. High-Fowler's position with the arms supported on the over-bed table Rationale: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the over-bed table.

What should the nurse advise a pt. who has diverticulitis to eat? A. High fiber foods. B. Low fiber foods. C. Low carb foods. D. High carb foods

B. Low fiber foods.

Which of the following promotes rest and healing of the bowel in a pt. who has ulcerative colitis? A. High fiber diet B. Maintaining NPO status as ordered C. Low carb diet D. Avoiding licorice and caffeine

B. Maintaining NPO status as ordered

Which of the following is a priority for a pt. who is hemorrhaging from a perforated duodenal ulcer? A. Administer the sedative prior to the PY test. B. Monitor for shock. C. Position the pt. on his back with a pillow under his right ribs and his right hand under his head. D. Guiac his stool

B. Monitor for shock.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? A. Nasal cannula B. Nonrebreather mask C. Simple face mask D. Partial rebreather mask

B. Nonrebreather mask Rationale: The nurse should use a non-rebreather mask for a client in respiratory distress to provide the highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to initiating the feeding, which of the following actions should the nurse take first? A. Flush the tube with water. B. Place the client in semi-Fowler's position. C. Cleanse the skin around the tube site. D. Aspirate the tube for residual contents.

B. Place the client in semi-Fowler's position.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider. A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. Pursed-lip breathing with exertion

B. Productive cough with green sputum Rationale: When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take? A. Use clean technique when suctioning the client's endotracheal tube. B. Use a rotating motion when removing the suction catheter. C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube. D. Suction the client's endotracheal tube every 2 hr.

B. Use a rotating motion when removing the suction catheter. Rationale: The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include? A. "Ringing in the ears is an adverse effect of this medication." B. "Have your skin test repeated in 4 months to show a positive result." C. "Expect your urine and other secretions to be orange while taking this medication." D. "Remember to take this medication with a sip of water just before your first bite of each meal."

C. "Expect your urine and other secretions to be orange while taking this medication." Rationale: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur including jaundice, fatigue or malaise.

You are assigned to a client who is recovering from abdominal surgery. She tells you that the client in the next room has chronic hepatitis and she is afraid she will catch it. Which answer would best help this client? A. "Don't worry. That kind of hepatitis can only be transmitted sexually" B. "There are many kinds of hepatitis. Do you know which one she has?" C. "Hospital staff always use precautions to prevent any possibility of transmission of infectious diseases to other clients" D. "There is no problem, that client is not a carrier of the disease"

C. "Hospital staff always use precautions to prevent any possibility of transmission of infectious diseases to other clients" ??

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma." B. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage." C. "I should remove the old twill ties after the new ties are in place." D. "I should apply suction while inserting the catheter into my tracheostomy tube."

C. "I should remove the old twill ties after the new ties are in place." Rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

Which of the following is an appropriate nursing intervention for a pt. who has gastritis? A. Lavage the NG tube with iced saline. B. Give sucralfate with meals and follow it with antacids. C. Advise the pt. to avoid irritating foods such as spicy foods. D. Advise the pt. to drink milk every two hours.

C. Advise the pt. to avoid irritating foods such as spicy foods.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A. Blood pressure B. Capillary refill C. Arterial blood gases D. Heart rate

C. Arterial blood gases Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? A. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube

C. Artificial airway cuff leak Rationale: An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A. Extra drainage system B. Suture removal kit C. Container of sterile water D. Nonadherent pads

C. Container of sterile water Rationale: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.

The physician orders cholestyramine (questran) for the client with cirrhosis. The nurse determines that the drug is effective when the client exhibits which of the following? A. Reduced serum ammonia levels B. Improved clotting ability C. Decreased complaints of pruritus D. Improved serum protein levels

C. Decreased complaints of pruritus

The nurse is providing care for a patient who just had a paracentesis to treat ascites. Which of the following findings indicate that the procedure was effective? A. Increased heart rate B. Presence of a fluid wave C. Decreased shortness of breath D. Post procedure weight unchanged from pre procedure weight

C. Decreased shortness of breath

Which of the following nursing diagnosis might be appropriate for a pt with ulcerative colitis? A. Pain R/T the passage of stones. B. Risk for injury from falling R/T dizziness and low BP immediately after meals. C. Fatigue R/T blood loss caused by frequent bloody stools. D. Risk of injury R/T auto digestion of the pancreas.

C. Fatigue R/T blood loss caused by frequent bloody stools.

A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of cullens sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the clients back. B. Palpate the clients Right lower quadrant C. Inspect the skin around the umbilicus D. Auscultate the area below the clients scapula

C. Inspect the skin around the umbilicus

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? A. Maintain a high-fat diet and drink at least 3 L of fluid a day. B. Maintain a high sodium, high-calorie diet C. Maintain a high carbohydrate, low-fat diet D. Maintain a high-fat, high-carbohydrate diet

C. Maintain a high carbohydrate, low-fat diet

Which of the following is an appropriate nursing intervention for a patient who has had an EGD? A. Give food and water as soon as the test is completed. B. Enemas until clear. C. Monitor for hemorrhage r/t organ perforation. D. Administer a sedative.

C. Monitor for hemorrhage r/t organ perforation.

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A. Pallor B. Insertion site pain C. Persistent cough D. Temperature 37.3° C (99.1° F)

C. Persistent cough Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is persistent cough because this indicates a tension pneumothorax, which is a medical emergency.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? A. Schedule respiratory treatments following meals. B. Have the client sit up in a chair for 2-hr periods three times per day. C. Provide a diet that is high in calories and protein. D. Combine activities to allow for longer rest periods between activities.

C. Provide a diet that is high in calories and protein. Rationale: The nurse should provide the client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

The nurse notes that the clients total bilirubin is 1.0 mg/dl. Which action by the nurse is correct? A. Access the clients sclerae for evidence of jaundice B. Check the clients stool for presence of occult blood C. Record the results as normal D. Test the clients urine for blood.

C. Record the results as normal

Which of the following should the nurse advise a pt who has ulcerative colitis to call the doctor for? A. Occasional abdominal cramping B. Nine mucous bloody stools per day. C. Signs of colon perforation and peritonitis. D. Diarrhea.

C. Signs of colon perforation and peritonitis.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? A. Hyperkalemia B. Dyspnea C. Tachycardia D. Candidiasis

C. Tachycardia The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect? A. Decreased fremitus B. SaO2 95% on room air C. Temperature 38.8° C (101.8° F) D. Bradypnea

C. Temperature 38.8° C (101.8° F) Rationale: An elevated temperature is an expected finding for a client who has bacterial pneumonia.

Which of the following is a true statement regarding regional enteritis (Crohn's disease)? A. It has a progressive disease pattern B. It is characterized by lower left quadrant abdominal pain. C. The clusters of ulcers take on a cobble stone appearance. D. The lesions are in continuous contact with one another.

C. The clusters of ulcers take on a cobble stone appearance.

A college student is diagnosed with Hepatitis A (HAV). Which of the following actions by the nurse best accomplishes the goal of reducing potential transmission of HAV? A. The nurse dons a mask and gown when providing direct care B. The nurse maintains the client in private room at all times C. The nurse preforms vigorous handwashing after leaving the room. D. The nurse wears gloves whenever entering the clients room

C. The nurse preforms vigorous handwashing after leaving the room.

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first

Check position of the weights and ropes -First action should be assessment to investigate cause of the muscle spasms

A nurse is caring for a client who has a full arm cast and reports pain of 8 out of 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first

Check the circulation of the affected extremity

A nurse is caring for a client who has a full arm cast and reports pain of an 8 on a scale from 0 to 10 that is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Check the circulation of the affected extremity

A nurse is caring for a client in balanced suspension skeletal traction who reports intermittent muscle spasms. Which of the following actions should the nurse take first?

Check the position of the weights and ropes

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

Clear drainage from the nose

A nurse is caring for a client who has basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider

Clear drainage from the nose

A nurse is performing a pain assessment on a postoperative client. Which of the following should the nurse use to determine the severity of the client's pain?

Client's report of pain on a standardized pain scale

A nurse is assessing a client who has new diagnosis of osteoporosis. Which of the following findings should the nurse expect

Crepitus with joint movement, decreased range of motion of the affected joint, joint pain that resolves with rest

The nurse is providing discharge teaching for a patient who has chronic hepatitis C. Which of the following statements by the patient indicates an understanding of the teaching? A. "I will decrease my intake of calories." B. "I will need treatment for 3 months" C. "I will avoid alcohol until i am no longer contagious" D. "I will avoid medications that contain acetaminophen"

D. "I will avoid medications that contain acetaminophen"

A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? A. "I will monitor my heart rate every day while taking this medication." B. "I will make sure I have this medication with me at all times." C. "I will need to carefully rinse my mouth after I take this medication." D. "I will take this medication every night even if I don't have symptoms."

D. "I will take this medication every night even if I don't have symptoms." Rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

A client is diagnosed with Hepatitis A (HAV). Which of the following should the nurse include in client education? A. "This type of hepatitis can now be cured by using a new medication every day for 12 weeks." B. "You cannot transmit this type of Hepatitis to others unless you have unprotected sex." C. "It's just fine to continue working as a food handler as long as you wear gloves." D. "You and everyone in your household should preform good handwashing."

D. "You and everyone in your household should preform good handwashing."

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? A. Provide a quiet environment. B. Encourage use of incentive spirometry every 1 to 2 hr. C. Obtain a blood sample for electrolyte study. D. Administer heparin via continuous IV infusion.

D. Administer heparin via continuous IV infusion. Rationale: Using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A. Cromolyn sodium B. Prednisone C. Fluticasone/salmeterol D. Albuterol

D. Albuterol Rationale: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse is completing an admission assessment of a client who has pancreatitis. which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder

D. Epigastric pain radiating to left shoulder

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. A history of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked

D. Hand spasms present when blood pressure is checked "trouso's sign"

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patients increased risk of bleeding. The nurse recognizes that this risk is related to the patients inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K

D. Inability of the liver to use vitamin K

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A. Decreased bowel sounds B. Oxygen saturation 92% C. CO2 24 mEq/L D. Intercostal retractions

D. Intercostal retractions Rationale: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? A. Arterial pH 7.50 B. PaCO2 25 mmHg C. SaO2 92% D. PaO2 58 mm Hg

D. PaO2 58 mm Hg Rationale: The nurse should expect the client who has acute respiratory failure to have lower partial pressures of oxygen.

The nurse is providing care for a patient who has acute Hepatitis B. Which of the following findings should the nurse expect? A. Joint pain B. Obstipation C. Periumbilical discoloration D. Right upper quadrant tenderness

D. Right upper quadrant tenderness

A nurse is caring for a client who had a Paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A. Client report of upper chest pain B. Decreased urine output C. Pallor D. Temperature elevation

D. Temperature elevation

A nurse working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax? A. Collapsed neck veins on the affected side B. Collapsed neck veins on the unaffected side C. Tracheal deviation to the affected side D. Tracheal deviation to the unaffected side

D. Tracheal deviation to the unaffected side Rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A. pH 7.50, PO2 95 mm Hg, PaCO2 25 mmHg, HCO3- 22 mEq/L B. pH 7.50, PO2 87 mm Hg, PaCO2 35 mmHg, HCO3- 30 mEq/L C. pH 7.30, PO2 90 mm Hg, PaCO2 35 mmHg, HCO3- 20 mEq/L D. pH 7.30, PO2 80 mmHg, PaCO2 55 mmHg, HCO3- 22 mEq/L

D. pH 7.30, PO2 80 mmHg, PaCO2 55 mmHg, HCO3- 22 mEq/L Rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.

You are working in the paracentesis clinic. Which of the following clients is most likely to have an adverse reaction to the lidocaine local anesthetic? A. Asian (Chinese) B. African american C. Caucasian D. Hispanic (Puerto rican) E. Native american (Navajo)

E. Native american (Navajo)

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes a facial flushing and a blood pressure of 220/110 mmhg. Which of the following actions should the nurse take first

Elevate the HOB -Pt is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. Change to an upright position will result in rapid postural hypotension

A nurse is caring for a client who is postoperative following a craniotomy. Which of the following interventions is the priority action for the nurse to take?

Elevate the head of the bed 30 degrees

A nurse is assessing a client who is quadriplegic secondary to a cervical fracture at vertebral level CS. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mm Hg. Which of the following actions should the nurse take first?

Elevate the head of the client's bed

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to include?

Ensure the client lies flat for 4 to 8 hours

A nurse is caring for a client who has admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take

Establish IV access

A nurse is caring for a client who was admitted for status epilepticus and is on seizure precautions. Which of the following actions should the nurse plan to take?

Establish IV access

Esophagogastro-duodenoscopy:

Examination of the esophagus, stomach, and duodenum through an endoscope to inspect, treat, or obtain specimens from any of the upper GI structures.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE?

Exercise

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect?

Finger contractures

A nurse is caring for a client who has a retinal detachment. Which of the following reports about the affected eye should the nurse expect?

Flashes of bright light

A nurse is caring for a client who has retinal detachment. Which of the following reports about the affected eye should the nurse expect

Flashes of bright light

Barium swallow:

Fluoroscopic observation of a client swallowing a flavored barium solution and its progress down the esophagus to detect structural abnormalities of the esophagus as well as swallowing discoordination and oral aspiration.

A nurse is reviewing postop instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of instructions

I should call my doctor if I experience a decrease in my vision

A nurses providing teaching regarding a new prescription for carbidopa-levodopa for a client who has parkinson disease. which of the following client statements indicates an understanding of the treatment

I should expect my urine to be a darker color

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect

Impulsive behavior

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

Impulsive behavior

A nurse is working in the emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images indicates a comminuted fracture.

Injury that cause the bone to fragment into several pieces.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Intention tremors

A nurse is assessing a client who has a lesion on his skin. Which of the following findings is a clinical manifestation of a malignant melanoma? Rough, dry, scaly lesion Firm nodule with crust Pearly papule with ulcerated center Irregularly shaped lesion with blue tones

Irregularly shaped lesion with blue tones Malignant melanomas are irregularly shaped and can be blue, red, or white in tone. They often occur on the client's upper back and lower legs.

A community health nurse is providing teaching about malignant melanoma to a group of clients. The nurse should inform the group that which of the following traits places a client at risk for developing malignant melanoma? Brown eyes Light skin Black hair Dark skin

Light skin Light skin and less pigmentation place a client at risk for developing malignant melanoma.

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority

Maintain a PaCO2 of approximately 35 mm hg

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35 mmHg

A nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority?

Maintain a PaCO2 of approximately 35mm Hg

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take

Monitor capillary refill at least every 4 hours

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

Monitor capillary refill at least every 4 hours --To monitor for vascular compromise

A nurse is caring for a client who has advancing ALS. Which of the following interventions is the nurses priority

Monitor pulse oximetry findings

A nurse is caring for a client who has advancing amyotrophc lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

Monitor pulse oximetry findings -The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible

A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include?

Move head slowly to decrease vertigo

A nurse is developing a teaching plan for a client who has menieres disease. Which of the following instructions should the nurse include

Move head slowly to decrease vertigo

The prototype drug for proton pump inhibitors:

Omeprazole (prilosec)

A nurse in the emergency department is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer?

Osmotic diuretics via IV bolus

A nurse in the ED is assessing a client who reports sudden, severe eye pain with blurred vision. The provider determines the client has primary angle-closure glaucoma. Which of the following medications should the nurse administer

Osmotic diuretics via IV bolus -Such as mannitol to reduce intraocular pressure and prevent damage to the eye

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? Cadaver skin Pig skin Amniotic membranes Beef collagen

Pig skin Heterografts are obtained from an animal, usually a pig.

A nurse is teaching an assistive personnel about providing care to a client who is postop following a total hip arthroplasty. Which of the following instructions should the nurse include?

Place an abductor pillow between the client's legs when turning the patient

A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider?

Potassium 3.0 mEq/L

A nurse is caring for a client who is admitted with ascending guillain-barre syndrome. The nurse should give priority to which of the following assessment findings?

Presence of adventitious breath sounds

Percutaneous liver biopsy:

Procedure in which a small core of liver tissue is obtained by placing a needle directly into the liver through the lateral abdominal wall.

Endoscopic retrograde cholangio-pancreatography:

Procedure in which an endoscope is used to visualize the common bile duct and the pancreatic and hepatic ducts through the ampulla of Vater in the duodenum.

A nurse is teaching a client who has Raynaud's disease. Which of the following information should the nurse include in the teaching?

Protect against the cold by wearing layers of clothing.

Barium enema:

Radiographic study used to identify polyps, tumors, inflammation, strictures, and other abnormalities of the colon after instilling barium solution rectally.

A nurse in the emergency department is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer?

Recombinant tissue plasminogen activator

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect?

Reddish-purple skin lesions

A nurse is providing teaching for a client who is prescribed alendronate for osteoporosis. Which of the following information should the nurse include in the teaching

Remain upright for 30 minutes after taking this medication

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt, the nurse should take which of the following actions?

Remind the client to look consciously at both sides of his meal tray

When caring for a client who has multiple sclerosis, the nurse should recognize that this disorder is characterized by:

Remissions and exacerbations

One hour after application of a cast for an ulnar fracture, a client reports a pain level of 8 on a scale from 0-10 that is unrelieved by analgesics and the application of a cold pack. The client's fingers are pale and numb. Based on the client's report which of the following actions should the nurse take first?

Report the findings to the primary care provider

A nurse is caring for a client who is 8 hours postoperative following a craniotomy. Which of the following actions should the nurse take?

Report wound drainage greater than 50 mL/8hrs

A nurse is caring for a client who is 8hr postop following a craniotomy. Which of the following actions should the nurse take

Report wound drainage greater than 50 ml/8hr

A nurse is assessing a client who has a possible head injury following a motor vehicle crash. The nurse should recognize that which of the following indicates increasing intracranial pressure

Restlessness

A nurse is assessing a client who has a possible head injury following a motor-vehicle crash. The nurse should recognize that which of the following findings indicates increasing intracranial pressure

Restlessness

A nurse is caring for client who has human immunodeficiency virus. Which of the following types of isolation should the nurse implement to prevent transmission of HIV?

Standard Precautions

A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition

Stroke the client's inner thigh

A nurse is caring for a client who has spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition

Stroke the clients inner thigh

A nurse is planning care for a client who has been admitted for treatment of a malignant melanoma of the upper leg without metastasis. The nurse should plan to prepare the client for which of the following procedures? Curettage External radiation therapy Regional chemotherapy Surgical excision

Surgical excision

A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? Partial-thickness burn Stage III pressure ulcer Surgical incision Dehisced sternal wound

Surgical incision With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse indicates in the clients education teaching plan

Take medication at a consistent time each day to maintain therapeutic blood levels

A nurse is teaching a client who has epilepsy and is to start therapy with phenytoin. Which of the following instructions should the nurse include in the clients medication teaching plan?

Take medications at a consistent time each day to maintain therapeutic blood levels

Ultrasonography:

Technique that uses high-frequency sound waves to show the size and location of organs and to outline structures and abnormalities.

Radionuclide imaging:

Technique used to detect lesions in organs using a radioactive natural or synthetic element that is injected intravenously or ingested orally.

A nurse is providing teaching for a client and his family about the diagnosis and treatment of Alzhemiers disease. Which of the following statements by the family indicates an understanding of the teaching

The drugs used to treat Alzheimers disease can help delay cognitive changes

A nurse is teaching an assistive personnel about standard precautions when caring for a client who has vancomycin resistant Enterococcus of the urine. Which of the following images of personal protection equipment should the nurse recommend the AP to use when caring for this client?

The nurse should don clean gloves when caring for a client who has vancomycin-resistant enterococcus of the urine. This protects the nurse form coming in contact with bodily fluids contaminated with the bacteria of the client.

A nurse is providing teaching for a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

The nurse should teach the client to sit with the hips at a 90 degree angle or less with the knees slightly lower than the hips to avoid hip dislocation.

The action of H2 Receptor Antagonists :

They block histamine and reduce gastric acid production

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? First-degree frostbite Second-degree frostbite Third-degree frostbite Fourth-degree frostbite

Third-degree frostbite When a client has third-degree frostbite, the skin of the affected area has small blisters that are blood-filled and the skin does not blanch.

A nurse is providing teaching for a client who is prescribed alendronate (Fosamax) for osteoporosis. Which of the following information should the nurse include in the teaching?

This medication should be taken before breakfast and in an upright position maintained for 30 minutes

A nurse in the ED is caring for a client after suddenly losing consciousness and falling in her home. The provider determines the client had an embolic stroke. Which of the following medications should the nurse administer

Tissue plasminogen activator

A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole? Ulceration Blanching of surrounding skin Dimpling Fading of color

Ulceration Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect

Ulnar deviation

A nurse is assessing a client who has rheumatoid arthritis. Which of the following assessment findings should the nurse expect?

Ulnar deviation

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect?

Unilateral, localized, nodular skin lesions

A nurse is instructing an assistive personnel on proper care of a client who has had a total hip arthroplasty. Which of the following instructions should the nurse include?

Use an abductor pillow between the clients legs if the client becomes restless

A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing? Vitamin B1 Calcium Vitamin C Potassium

Vitamin C A diet high in protein and vitamin C is recommended because these nutrients promote wound healing.

A nurse is teaching a client who has acute pyelonephritis. Which of the following instructions should the nurse include in the teaching?

You should complete the entire cycle of antibiotic therapy

i will continue to talk to him even when he is sleeping

a hospice nurse is providing education about pallative care to the partner of a client who has end-stage liver cancer. Which of the following statements by the partner indicates an understanding of teaching

a fresh fruit basket

a nurse is admitting a client who has multiple myeloma and a WBC count of 2,200 mm3; which of the following foods should the nurse prohibit the family members from bringing to the client

remind the client to use na electric razor

a nurse is planning pcare for a client who has cancer and has developed thrombocytopenia following chemotherapy; which of hte following precautions should the nurse offer to minimize the adverse effecs of thrombocytopenia

the drainage tubes are removed at the same time as the stiches

a nurse is providing discharge teahing to a client who is postoperative following a right mastectomy for breast cancer; the client will be discharged with two Jackson-Pratt drains; which of the following infrmation should the nurse include in the teaching

you might experience manifestations of menopause

a nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer; which of hte following information should the nurse include in the teaching

The serious side effects associated with ondansetron (Zofran):

arrhythmias, hypotension, & extrapyramidal effects

The diet restrictions that should be taught for treatment of peptic ulcers:

avoiding Highly acidic, Spicey foods, alcohol, & caffeine

Method ondansetron (Zofran) prevents nausea & Vomiting:

blocks 5-HT3 Serotonin receptors

The drug that used to be the prototype for H2 receptor Antagonists:

cimetidine (Tagamet)

The common adverse effects of magnesium hydroxide:

cramps, Diarrhea, and nausea Caused by overactive GI activity

Reason omeprazole should not be crushed or chewed:

enteric Coated granules & Acid labile

A nurse is providing teaching regarding a new prescription for carbidopa-levodopa for a client who has Parkinson's disease. Which of the following client statements indicates an understanding of the teaching?

f

The prototype drug for H2 Receptor antagonists:

ranitidine (Zantac)

The reason omeprazole dose may need to be adjusted in Asians:

the duration Of action is lengthened

A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include?

Limit fluid intake

stop the infusion

a nurse is monitoring for a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site and the nurse notes fluid leaking around the catheter. which of the following actions should the nurse take first?

vaginal bleeding

a nurse is obtaining a health history from a client who has cancer of the cervix; which of the following manifestations should the nurse expect

I can have only liquids for 2 days before the surgery

a nurse is providing postoperative teaching for a client who has colorectal cancer and is to undergo placement of a colostomy with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching?

I need to protect the area from sunlight

a nurse is providing teaching to a client who has cancer and is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of teaching?

it is important to always wear shoes take your temperature twice daily avoid using tampons

a nurse on an oncology unit is providing discharge reaching to an adolescent female client who received a bone marrow transplant for leukemia; which of the following information should the nurse include in the teaching

A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action?

relieve the client's pain

tingling of an extremity

several chemotherapeutic agents might cause peripheral neuropathy. One of the major manifestations of peripheral neuropathy is numbness and _____________

1/3 full

the nurse should empty the collection pouch when it is 1/3 full to prevent the excess weight of the urine causing the pouch to separate from the skin

massage

the nurse should instruct the client that ___________ might cause friction to the radiatiated skin, causing skin breakdown

tingling of the hands and feet

a nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected fidning of peripheral neuropathy?

change the collection pouch in the early morning

a nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer; which of the following interventions should the nurse include in the plan of care?

pancytopenia

a nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse affects should the nurse anticipate from the chemotherapy?

overexposure to sun light

a nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for hte client developing skin cancer?

the client uses tobacco

a nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer

over 50 years of age

a nurse is collecting a health history from a female client whi is undergoing screening for breast cancer; which of the following factors should the nurse identify for placing the client at the greatest risk for developing breast cancer?

normal use/ nonstrenuous exercise

the nurse should instruct the client that ________________ is appropriate before the provider removes the drainage tubes; more strenuous exercise can begin following the removal of the drains

same time

the nurse should instruct the client that the provider will remove the drainage tubes at the ______________ the stiches are removed, usually within 7-10 days

avoid heat exposure

the nurse should instruct the client to _______________- to the radiated area, which might lead to skin breakdown

twice each day

the nurse should instruct the client to empty the drainage tubes are record the amount of drainage _________________

baths

the nurse should instruct the client to take ___________ until the provider removes the drainage tubes and stiches

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?

"Apply a warm compress to the lesions."

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned abouth the skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of following responses should the nurse give?

"Apply moisturizer after bathing the lesions with warm water."

A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? "I will be on a special shower table." "The water temperature will be very cool to ease my pain." "The nurse will use a firm-bristled brush to remove loose skin." "The nurse will use scissors to open small blisters."

"I will be on a special shower table." The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature and there is a lower risk of wound infection.

A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of the sexually transmitted infection (STI)?

"I will bring my sexual partner in for treatment."

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome. Which of the following statements by the client's partner indicate the need for further teaching?

"I'll clean up blood spills immediately with hot water."

A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give?

"It sounds like you are unsure what to say to your partner."

A nurse is teaching a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include the teaching?

"HIV can be transmitted to anyone who has had contact with the infected blood."

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

"I can expect this medication to turn my skin orange."

A nurse in a provider's office is providing teaching to a client who has a recent diagnosis of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client requires further teaching?

"I can take this medication with aspirin."

A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen when she states which of the following?

"I will apply a mattress cover to my bed."

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching.

"Wash your genitalia using an antimicrobial soap"

A nurse is teaching a newly licensed nurse about caring for a client who has a new left arteriovenous fistula. Which of the following statements should the nurse make?

Avoid taking blood pressure on the client's left arm

A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings should indicate to the nurse that the client is experiencing acute kidney rejection?

Blood pressure 160/90 mmHg

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input, and his abdomen is distended. Which of the following actions should the nurse take?

Change the client's position

A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify which of the following findings is the priority?

Dysrhythmias

A nurse is caring for a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection?

Erythema at the incision site

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of the following actions?

Have the client wear a surgical mask

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?

I should not smoke.

A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following statements indicates an understanding of the information?

I will feel the urge to urinate following this procedure.

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following statements should indicate to the nurse the need for additional teaching?

I will use a vaginal douche daily

thrombocytopenia

__________________ is a decrease in the client's blood platelet count, which places the client at an increased risk of bleeding due to the blood's inability to clot; therefore, the nurse should institute bleeding precautions

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions? Papules Macules Wheals Vesicles

Papules A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.

A nurse is teaching a newly licensed nurse about collecting a 24-hr urine specimen for creatinine clearance. Which of the following instructions should the nurse include?

Place signs in the bathroom as a reminder about the test in progress.

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory tests can indicate arthritis?

Rheumatoid factor

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? Hemoglobin 10 g/dL Sodium 132 mEq/L Albumin 3.6 g/dL Potassium 4.0 mEq/dL

Sodium 132mEq/L This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.

A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? Edema in the burned extremities Severe pain at the burn sites Urine output of 30 mL/hr Temperature of 39.1° C (102.4° F)

Temperature of 39.1° C (102.4° F) An elevated temperature is an indication of infection and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.

A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the following statements should the nurse make?

You should not ejaculate for 24 hours prior to the PSA test

A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make?

You will need to be on bed rest following the procedure

dysuria pelivic/ chest pain unexplained weight loss

__________ are manifestations of cancer of the cervix

intermittent blood in urine

_____________ might indicate the manifestation of bladder cancer

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects?

peritonitis

A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include?

back pain

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first?

check the client's electrolyte values

A nurse is assessing a client who is postoperative following a tranurethral rescetion of the prostate (TURP). After the nurse discontinues the client's urinary catheter, which of the following findings should the nurse report to the provider?

decreased urine output

A nurse is teaching a client who is preoperative for a cystoscopy. Which of the following statements should the nurse make?

expect to have pink-tinged urine after this procedure

A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. The nurse should recognize that which of the following findings is a manifestation of bladder trauma?

hematuria

facial edema

a nurse is caring for a client who has lung cancr that has metastasized; which of the following findings indicates the client is developing superior vena cava syndrome?

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will requires which of the following treatments?

Heat paraffin therapy applied to the client's joints

A nurse is assesing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? IV I III II

II With a stage II pressure ulcer, there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer might become infected. The client might report pain, and there might be a small amount of drainage.

A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following actions?

Identify if a client has been infected with mycobacterium tuberculosis

A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate and elevation in which of the following laboratory tests?

IgE (immunoglobulin E)

A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? Immobilize the limb at the level of the heart. Apply a tourniquet to the affected limb. Use a sterile scapula to incise the wound. Apply ice to the skin over the snakebite wound.

Immobilize the limb at the level of the heart The emergency management of a client who has a snakebite focuses on limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.

A nurse is teaching a client about manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions?

Increased mucus secretion The nurse should instruct that the client that increased mucus secretion is a manifestation of histamine release.

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? Hyponatremia Leukopenia Hyperchloremia Elevated BUN

Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine.

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses by the nurse is appropriate? Basal cell carcinomas Melanomas Actinic keratoses Squamous cell carcinomas

Melanomas

bone pain

____________ might indicate a late manifestation of metastasis of lymphoma; bone and joint pain are early manifesetations of leukemia

numbness in the hands

______________ is a manifestation of spinal cord compression that can result if cancer spreads to the spinal cord

stomatitis

______________, an inflammation of hte mucous membranes of hte mouth, is not a manifestation of thrombocytopenia

superior vena cava syndrome

_______________ is a medical emergency resulting from a partial occlusion of the superior vena cava, leading to a decreased bllod flow through the vein

superior vena cava syndrome

_______________ is a partial occlusion of the SVC; it leads to alterations in client's vascular flow, not cardiac arrhythmias

neutorpenia

_______________, a decreased WBC count, places a client at an increased risk for infection, and hte nurse should monitor for visitors who are ill

Hodgkin's lymphoma

_______________- is a malignancy of lymphoid tissue found in the lymph nodes, spleen, liver, and bone marrow

muscle cramps

_________________ might indicate the client has syndrome of inappropriate antidiuretic hormone and might occur with cancer metastasis to the brain

nonproductive cough

a _____________ migh occur because of narrowed ariways and swollen lymph glands; a productive cough might indicate lung cacner

The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed

a nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide?

A nurse is providing dietary teaching a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet?

calcium A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement dietary calcium.