Exam 2 prepU

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer: spironolactone (Aldactone). phytonadione (Mephyton). furosemide (Lasix). warfarin (Coumadin).

phytonadione (Mephyton). Explanation: Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client's PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer phytonadione (vitamin K1) to promote prothrombin synthesis. Spironolactone and furosemide are diuretics and have no effect on bleeding or clotting time. Warfarin is an anticoagulant that prolongs PT.

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply. Enlarged liver size Ascites Accelerated behaviors and mental processes Hemorrhoids Excess storage of vitamin C

Enlarged liver size Ascites Hemorrhoids Early in the course of cirrhosis, the liver tends to be large, and the cells are loaded with fat. The liver is firm and has a sharp edge that is noticeable on palpation. Portal obstruction and ascites, late manifestations of cirrhosis, are caused partly by chronic failure of liver function and partly by obstruction of the portal circulation. The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and shunting of blood from the portal vessels into blood vessels with lower pressures. These distended blood vessels form varices or hemorrhoids, depending on their location. Because of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, and K), signs of deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Additional clinical manifestations include deterioration of mental and cognitive function with impending hepatic encephalopathy and hepatic coma, as previously described.

The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms? Place the client in semi-Fowler's position. Encourage the client to deep breathe and cough. Instruct the client on the proper use of an incentive spirometer. Encourage the client to ambulate frequently.

Place the client in semi-Fowler's position. Explanation: A client with severe biliary colic is in extreme pain and has a very difficult time taking a deep breath due to severe pain on inspiration. Placing the client in upright or semi-Fowler's position best promotes adequate breathing and best supports the client's function. Ambulation, deep breathing and coughing, and incentive spirometry may be too difficult or impossible for the client with severe biliary colic symptoms.

A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client? "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." "As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid." "The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment." "The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus."

"Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." Explanation: The stomach, which stores and mixes food with secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. The stomach does not turn food directly into acid and the esophagus is not highly alkaline. Pancreatic enzymes are not synthesized in a highly acidic environment.

The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? "If the health care provider massages over the exact painful area, the pain will disappear." "The area may determine the severity of the pain." "This determines the pain medication to be ordered." "Often the area of pain is referred from another area."

"Often the area of pain is referred from another area." Explanation: Pain can be a major symptom of disease. The location and distribution of pain can be referred from a different area. If a client points to an area of pain and has other symptoms associated with a certain disease, this is valuable information for treatment.

The nurse is educating a group of women on the prevention of osteoporosis. The nurse recognizes the education as being effective when the group members make which statement? "We need to increase aerobic exercise." "We need to consume a low-calcium, high-phosphorus diet." "Estrogen deficiency increases bone density." "We need an adequate amount of exposure to sunshine."

"We need an adequate amount of exposure to sunshine." Explanation: The only accurate statement is related to getting an adequate amount of exposure to sunshine. Aerobic exercise, such as swimming, does not prevent osteoporosis. The exercise needs to be weight bearing. A diet low in calcium and high in phosphorus will increase the risk forosteoporosis. Estrogen deficiency is linked to decreased bone mass.

The nurse is assisting a client to drain his continent ileostomy (Kock pouch). The nurse should insert the catheter how far through the nipple/valve? 2 in. 3 in. 4 in. 5 in.

2in. Explanation: The nurse should insert the lubricated catheter about 2 inches (5 cm) through the nipple/valve. Please refer to the section on care of ileostomy.

After teaching a group of students about intestinal obstruction, the instructor determines that the teaching was effective when the students identify which of the following as a cause of a functional obstruction? Volvulus Intussusception Tumor Abdominal surgery

Abdominal surgery Explanation: In functional obstruction, the intestine can become adynamic from an absence of normal nerve stimulation to intestinal muscle fibers. For example, abdominal surgery can lead to paralytic ileus. Mechanical obstructions result from a narrowing of the bowel lumen with or without a space-occupying mass. A mass may include a tumor, adhesions (fibrous bands that constrict tissue), incarcerated or strangulated hernias, volvulus (kinking of a portion of intestine), intussusception (telescoping of one part of the intestine into an adjacent part), or impacted feces or barium.

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A pattern of distinct exacerbations and remissions Severe diarrhea An absence of blood in stool Involvement of the rectal mucosa

An absence of blood in stool Bloody stool is far more common in cases of UC than in Crohn's. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohn's) and clients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohn's often has a more prolonged and variable course.

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring? Infection Bowel perforation Colonic polyp Rectal fissure

Bowel perforation Explanation: Immediately after the test, the patient is monitored for signs and symptoms of bowel perforation (e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs).

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.) Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Testing the stool for occult blood Assessing level of consciousness Assessing pupillary response

Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Testing the stool for occult blood Explanation: In pelvic fracture, the nurse should palpate the peripheral pulses, especially the dorsalis pedis pulses of both lower extremities; absence of a pulse may indicate a tear in the iliac artery or one of its branches. To assess for urinary tract injury, the patient's urine is analyzed for blood.

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. Hypertension Diarrhea Decreased bowel sounds Tachycardia Diaphoresis

Dumping syndrome is manifested by hypotension, diarrhea, tachycardia, and diaphoresis. The client often reports a feeling of fullness, nausea, and vomiting. Because of the rapid movement of water to the stomach and intestines, bowel sounds would most likely be increased.

The orthopedic nurse should assess for signs and symptoms of Volkmann contracture if a client has fractured which of the following bones? Femur Humerus Radial head Clavicle

Humerus Explanation: The most serious complication of a supracondylar fracture of the humerus is Volkmann ischemic contracture, which results from antecubital swelling or damage to the brachial artery. This complication is specific to humeral fractures.

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. Anticholinergic medications Increased fiber intake Enemas on alternating days Reduced fat intake Fluid reduction

Increased fiber intake Reduced fat intake Explanation: Clients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.

When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first? Palpation Inspection Auscultation Percussion

Inspection Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.

The nurse is caring for a patient who has ascites as a result of hepatic dysfunction. What intervention can the nurse provide to determine if the ascites is increasing? (Select all that apply.) Measure urine output every 8 hours. Assess and document vital signs every 4 hours. Measure abdominal girth daily. Perform daily weights. Monitor number of bowel movements per day.

Measure abdominal girth daily. Perform daily weights. Explanation: Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy.

A client has been diagnosed with a rotator cuff tear. What are the options for treating this condition? Select all that apply. NSAIDs activity modification and joint rest arthroscopic surgery traction

NSAIDs activity modification and joint rest arthroscopic surgery Explanation: NSAIDs, modifying activities and resting the joint, arthroscopic surgery, and open acromioplasty with tendon repair are all options. Traction is not an option.

A nurse suspects a client has a fat emboli after a femur fracture. What are the significant client signs and symptoms to support the suspicion of the nurse? Select all that apply. Petechiae on the chest Substernal chest pain Bradycardia Hypoxia Bradypnea

Petechiae on the chest Substernal chest pain Hypoxia Explanation: Symptoms of fat embolism are consistent with impaired oxygen transport in the alveoli such as substernal chest pain and hypoxia. Petechiae on the chest, head or neck can occur with the fat embolism. Tachycardia nd tachypnea would occur not bradycardia or bradypnea.

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply. Regular bone density testing A high-calcium diet Use of falls prevention precautions Use of corticosteroids as prescribed Weight-bearing exercise

Regular bone density testing A high-calcium diet Use of falls prevention precautions Weight-bearing exercise Explanation: Health promotion measures after an older adult's hip fracture include weight-bearing exercise, promotion of a healthy diet, falls prevention, and bone density testing. Corticosteroids have the potential to reduce bone density and increase the risk for fractures.

What assessment findings of the leg are consistent with a fracture of the femoral neck? Shortened, adducted, and externally rotated Shortened, abducted, and internally rotated Adducted and internally rotated Abducted and externally rotated

Shortened, adducted, and externally rotated Explanation: With fractures of the femoral neck, the leg is shortened, adducted, and externally rotated.

What is a major concern for the nurse when caring for a patient with chronic pancreatitis? Pain Weight loss Nausea Mental status changes

Weight loss Weight loss is a major problem in chronic pancreatitis. More than 80% of patients experience significant weight loss, which is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack (Bope & Kellerman, 2011).

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to: low platelet count. low sodium level. decreased prothrombin time. low hemoglobin.

low platelet count. Explanation: Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.

When caring for a client with cirrhosis, which symptoms should a nurse report immediately? Select all that apply. change in mental status signs of GI bleeding anorexia and dyspepsia diarrhea or constipation

signs of GI bleeding, change in mental status Explanation: The nurse reports any change in mental status or signs of GI bleeding immediately because they indicate secondary complications.

Which of the following describes failure of the ends of a fractured bone to unite in normal alignment? Nonunion Delayed union Malunion Subluxation

Nonunion Explanation: Nonunion results from failure of the ends of a fractured bone to unite in normal alignment. Delayed union occurs when there is prolonged healing for union of the fracture. In malunion, there is flawed union of fractured bone. Subluxation is a partial dislocation of the articulating surfaces.

Which factor may contribute to compartment syndrome? Hemorrhage Macular lesion Venous thromboembolus Disuse syndrome

Hemorrhage Explanation: The normal pressure of a compartment can be altered in cases of fracture by the force of the injury itself or by development of edema or hemorrhage at the site of the injury. Venous thromboemboli are another early complication of fracture, but they are not related to compartment syndrome. Macular lesion is caused by the accumulation of blood under the skin, as occurs with trauma such as bone fracture. Disuse syndrome mostly occurs in hip fracture.

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? Infusion of intravenous heparin IV administration of albumin STAT administration of vitamin K by the intramuscular route IV administration of octreotide (Sandostatin)

IV administration of octreotide (Sandostatin) Explanation: Octreotide —a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not given and heparin would exacerbate, not alleviate, bleeding. Reference:

A nurse is caring for a client who has been admitted to the hospital with diverticulitis. What would be appropriate nursing diagnoses for this client? Select all that apply. Acute Pain Related to Increased Peristalsis and GI Inflammation Activity Intolerance Related to Generalized Weakness Bowel Incontinence Related to Increased Intestinal Peristalsis Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea Impaired Urinary Elimination Related to GI Pressure on the Bladder

Acute Pain Related to Increased Peristalsis and GI Inflammation Activity Intolerance Related to Generalized Weakness Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea Clients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The client is unlikely to experience fecal incontinence and urinary function is not directly influenced.

A patient is suspected to have pancreatic carcinoma and is having diagnostic testing to determine insulin deficiency. What would the nurse determine is an indicator for insulin deficiency in this patient? (Select all that apply). An abnormal glucose tolerance Glucosuria Hyperglycemia Elevated lipase level Hypoglycemia

An abnormal glucose tolerance Glucosuria Hyperglycemia Explanation: An important sign, if present, is the onset of symptoms of insulin deficiency: glucosuria, hyperglycemia, and abnormal glucose tolerance. Therefore, diabetes may be an early sign of carcinoma of the pancreas.

The primary source of microorganisms for catheter-related infections are the skin and which of the following? Catheter hub Catheter tubing IV fluid bag IV tubing

Catheter hub Explanation: The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day.

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). What actions would the nurse perform while the client receives PN? Select all that apply. Weigh the client every day. Check blood glucose level every 6 hours. Cover insertion site with a transparent dressing that is changed daily. Use clean technique for all catheter dressing changes. Document intake and output.

Weigh the client every day. Check blood glucose level every 6 hours. Document intake and output. Explanation: When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes.

A client with a fractured femur is admitted to the nursing unit. Which assessment finding requires follow up by the nurse? Select all that apply. "I cannot seem to catch my breath." "I have a pins-and-needles sensation in my toes." Dorsiplantar weak and unequal bilaterally T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90% Both feet warm with capillary refill < 3 seconds

"I cannot seem to catch my breath." "I have a pins-and-needles sensation in my toes." Dorsiplantar weak and unequal bilaterally T 101.2 degrees F; HR 110; RR 28; pulse oximetry 90% Explanation: Fat embolism syndrome and compartment syndrome are complications of a fracture, especially of the long bones. Dyspnea, tachycardia, tachynea, fever, and low pulse oximetry would be indicators of fat embolism syndrome. Paresthesia (pins-and-needles sensation), limited motion, and motor weakness would be indicators of compartment syndrome. Capillary refill less than 3 seconds is a normal finding.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? Elevate the affected extremity. Contact the nursing supervisor. Administer oxygen. Contact the health care provider.

Administer oxygen. Explanation: The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the health care provider after administering oxygen.

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? Use clean technique and wear a mask during dressing changes. Change the dressing no more than weekly. Apply antibiotic ointment around the site with each dressing change. Irrigate the insertion site with sterile water during each dressing change.

Change the dressing no more than weekly. Explanation: CVAD dressings are changed every 7 days unless the dressing is damp, bloody, loose, or soiled, in which case they should be changed more often. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not normally used.

A group of students is reviewing information about the liver and associated disorders. The group demonstrates understanding of the information when they identify which of the following as a primary function of the liver? Breakdown amino acids Convert urea into ammonia Excrete bile Break down coagulation factors

Excrete bile Explanation: The liver forms and excretes bile, synthesizes amino acids from the breakdown of proteins, converts ammonia into urea, and synthesizes the factors needed for blood coagulation.

The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be Diarrhea Hemorrhoids Fecal incontinence Dark, tarry stools

Fecal incontinence Explanation: The nurse should anticipate fecal incontinence as one of the assessment findings. Other possible assessment findings include constipation and abdominal distention.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? Intrinsic factor Hydrochloric acid Histamine Liver enzyme

Intrinsic factor Explanation: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

Which of the following is an enzyme secreted by the gastric mucosa? Pepsin Trypsin Ptyalin Bile

Pepsin Explanation: Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.

A patient is admitted to the hospital with possible cholelithiasis. What diagnostic test of choice will the nurse prepare the patient for? X-ray Oral cholecystography Cholecystography Ultrasonography

Ultrasonography Explanation: Ultrasonography has replaced cholecystography (discussed later) as the diagnostic procedure of choice because it is rapid and accurate and can be used in patients with liver dysfunction and jaundice. It does not expose patients to ionizing radiation. Reference:

What symptoms of perforation might the nurse observe in a client with an intestinal obstruction? Select all that apply. sudden, sustained abdominal pain abdominal distention sudden drop in body temperature intermittent, severe pain

sudden, sustained abdominal pain abdominal distention Explanation: Abdominal distention, fever, and sudden, sustained abdominal pain are the symptoms of perforation in a client with intestinal obstruction.

A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. Administering diuretics Administering calcium channel blockers Implementing fluid restrictions Implementing a 1500 kcal/day restriction Enhancing client positioning

Administering diuretics, implementing fluid restrictions, enhancing client positioning. Explanation: Administering diuretics, implementing fluid restrictions, and enhancing client positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

Management of a patient with ascites includes nutritional modifications and diuretic therapy. Which of the following interventions would a nurse expect to be part of patient care? Select all that apply. Aldactone, an aldosterone-blocking agent would be used. Zaroxolyn would be the thiazide diuretic of choice. A daily weight change of 0.5 pounds would require health care provider notification. Daily salt intake would be restricted to 2 grams or less. The diuretic will be held if the serum sodium level decreases to <134 m Eq/L.

Aldactone, an aldosterone-blocking agent would be used. Daily salt intake would be restricted to 2 grams or less. The diuretic will be held if the serum sodium level decreases to <134 m Eq/L. Explanation: Lasix, a loop diuretic, combined with Aldactone is the most effective regimen to control ascites. The serum sodium level should not drop below 134 mEq/L. A daily weight change of 1.1 lb (those without peripheral edema) or 2.2 lbs (those with peripheral edema) should be reported.

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing actions relevant to what potential complications? Select all that apply. Dumping syndrome Clotted or displaced catheter Pneumothorax Hyperglycemia Line sepsis

Clotted or displaced catheter Pneumothorax Hyperglycemia Line sepsis Explanation: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

Which of the following type of fracture is associated with osteoporosis? Compression Stress Oblique Simple

Compression Explanation: Compression fractures are caused by compression of vertebrae and are associated frequently with osteoporosis. Stress fractures occur with repeated bone trauma from athletic activities, most frequently involving the tibia and metatarsals. An oblique fracture runs across the bone at a diagonal angle of 45 to 60 degrees. A simple fracture (closed fracture) is one that does not cause a break in the skin.

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? Assessment of blood pressure and assessment for headaches and visual changes Assessments for signs and symptoms of venous thromboembolism Daily weights and abdominal girth measurement Blood glucose monitoring q4h

Daily weights and abdominal girth measurement Explanation: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth? Electrical stimulation Administration of low-dose heparin Joint fusion Administration of antibiotics

Electrical stimulation Explanation: Delayed union may require surgical interventions to promote bone growth and correct the incorrect union. If necessary, prepare the client for use of electrical stimulation measures that promote bone growth, or for a bone graft. Administration of low-dose heparin would be used to prevent pulmonary embolism. Joint fusion may be used in the case of avascular necrosis. Administration of antibiotics would be used for the potential of infection or to treat an actual infection.

A client is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? Prime the tubing with 20 mL of normal saline. Keep the vent lumen above the client's waist. Maintain the client in a high Fowler position. Have the client pin the tube to the thigh.

Keep the vent lumen above the client's waist. Explanation: The blue vent lumen should be kept above the client's waist to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way anti-reflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, the nurse does not prime the tubing, maintain the client in a high Fowler position, or have the client pin the tube to the thigh.

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy. Provide the client with educational materials that match the client's learning style. Encourage the client to write down these concerns and questions to bring forward to the surgeon. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse. A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the client's psychosocial and learning needs. Reassurance does not address the client's questions, and education may or may not alleviate anxiety.

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care? Measure and record drainage. Monitor drainage for change in color. Titrate the suction every hour. Feed the client via the G tube as prescribed.

Measure and record drainage. Explanation: This drainage should be measured and recorded because it is a significant indicator of GI function. The nurse should indeed monitor the color of the output, but fluid balance is normally the priority. Frequent titration of the suction should not be necessary and feeding is contraindicated if the G tube is in place for drainage.

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu? Omelet with green peppers, onions, mushrooms, and cheese with milk Pancakes with butter and honey, and orange juice Ham and cheese sandwich, baked beans, potatoes, and coffee Baked chicken with sweet potato french fries, cornbread, and tea

Pancakes with butter and honey, and orange juice Explanation: Teach clients to select a diet high in carbohydrates with protein intake consistent with liver function. The client should identify foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure). The client with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia concentration. The other choices are all higher in protein. The client's ascites indicates that a low-sodium diet is needed, and the other choices are all high in sodium.

The nurse is conducting a musculoskeletal assessment of a client in a nursing home. The client is unable to dorsiflex the right foot or extend the toes. The nurse evaluates this finding as an injury to which nerve? Sciatic Peroneal Femoral Achilles

Peroneal Explanation: Injury to the peroneal nerve as a result of pressure may cause foot drop or the inability to dorsiflex the foot and extend the toes.

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume? Protein-rich foods Potassium-rich foods High-fiber foods High-fat foods

Potassium-rich foods Explanation: The nurse should encourage the client with diarrhea to consume potassium-rich foods. Excessive diarrhea causes severe loss of potassium. The nurse should also instruct the client to avoid high-fiber or fatty foods because these foods stimulate gastrointestinal motility. The intake of protein foods may or may not be appropriate depending on the client's status.

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply. Altered nutrition, more than body requirements, related to decreased activity and bed rest Risk for injury related to altered clotting mechanisms Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Urinary incontinence related to general debility and muscle wasting Disturbed body image related to changes in appearance, sexual dysfunction, and role function

Risk for injury related to altered clotting mechanisms Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Disturbed body image related to changes in appearance, sexual dysfunction, and role function Explanation: Risks for injury, activity intolerance, and disturbed body image are priority nursing diagnoses. The appropriate nursing diagnosis related to nutrition would be altered nutrition, less than body requirements, related to chronic gastritis, decreased gastrointestinal motility, and anorexia. Urinary incontinence is not generally a concern with hepatic cirrhosis.

A nurse suspects that a client is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which assessment support the nurse's suspicion? Select all that apply. Shakiness Reports of feeling flushed Tachycardia Dry, hot skin Weakness Confusion

Shakiness Tachycardia Weakness Confusion Explanation: Signs and symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate. The client with hypogylcemia will not report feeling flushed or having hot, dry skin.

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? Stress on the weakened bone must be avoided. Increased heart rate enhances perfusion and bone healing. Bed rest results in improved outcomes in clients with osteomyelitis. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

Stress on the weakened bone must be avoided. Explanation: The client with osteomyelitis has bone that is weakened by the infective process and must be protected by avoidance of stress on the bone.This risk guides the choice of activity in a client with osteomyelitis. Bed rest is not normally indicated, however. Maintenance of prediagnosis ADLs may be an unrealistic short-term goal for many clients.

A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure? The need to protect the incision postprocedure The use of moderate sedation The need to infuse 50% dextrose during the procedure The use of general anesthesia

The use of moderate sedation Explanation: Moderate sedation, not general anesthesia, is used during ERCP. D50 is not given and the procedure does not involve the creation of an incision.

A nurse is caring for a client who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply. To remove gas from the stomach To administer clotting factors to treat a GI bleed To remove toxins from the stomach To open sphincters that are closed To diagnose GI motility disorders

To remove gas from the stomach To remove toxins from the stomach To diagnose GI motility disorders Explanation: GI intubation may be performed to decompress the stomach and remove gas and fluid, lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility and other disorders, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. GI intubation is not used for opening sphincters that are not functional or for administering clotting factors.

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.) Until bowel sound is present Until flatus is passed Until peristalsis is resumed Until the patient stops vomiting Until the tube comes out on its own

Until bowel sound is present Until flatus is passed Until peristalsis is resumed Explanation: Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene.

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply. diuretics albumin sodium dextrose solution

diuretics albumin Explanation: Diuretics are given if circulating fluid is excessive. IV albumin may be given to pull fluid trapped in the peritoneum back into the circulation. Sodium would not be used to treat excessive fluid accumulation. Blood glucose levels can be elevated in clients with acute pancreatitis; therefore, glucose solutions would not be administered nor would they be used to treat excessive fluid accumulation.

A client comes to the clinic and informs the nurse that he is there to see the physician for right upper abdominal discomfort, nausea, and frequent belching especially after eating a meal high in fat. What disorder do these symptoms correlate with? Hepatitis Biliary colic Cholelithiasis Cholecystitis

Cholelithiasis Explanation: Initially, with cholelithiasis clients experience belching, nausea, and right upper quadrant discomfort, with pain or cramps after high-fat meal. Symptoms become acute when a stone blocks bile flow from the gallbladder. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain called biliary colic. The symptoms do not correlate with hepatitis.

Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region obstruct the common bile duct. Which of the following clinical manifestations would indicate a common bile duct obstruction associated with a tumor in the head of the pancreas? Choose all that apply. Clay-colored stools Dark urine Jaundice Pruritis Weight gain

Clay-Colored stools Dark urine Jaundice Pruritis The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result if the tumor obstructs the entry of bile to the gastrointestinal tract. Abdominal discomfort or pain and pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.

Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.) "You may cross your legs at the ankles only." "Place pillows between your legs when you lay on your side." "Avoid bending forward when sitting in a chair." "Use a raised toilet seat and high-seated chair." "It is okay to briefly flex the hip to put on your clothes."

"Place pillows between your legs when you lay on your side." "Avoid bending forward when sitting in a chair." "Use a raised toilet seat and high-seated chair." Explanation: The client following post hip replacement should not cross the legs, even at the ankle. He or she should avoid bending forward when sitting in a chair, avoid flexing the hip when dressing, and use a raised toilet seat. A pillow should be placed between the legs when side-lying.

The nurse is assessing a client with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply. Alterations in mood Agitation Decreased deep tendon reflexes Report of headache Insomnia

Alterations in mood Agitation Insomnia The earliest symptoms of hepatic encephalopathy include both mental status changes and motor disturbances. The client appears confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and has restlessness and insomnia at night. To assess for mental deterioration, the nurse will assess general behavior, orientation, and speech as well as cognitive abilities and speech patterns.

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values is most characteristic of Paget disease? An elevated level of parathyroid hormone and low calcitonin levels A low serum alkaline phosphatase level and a low serum calcium level An elevated serum alkaline phosphatase level and a normal serum calcium level An elevated calcitonin level and low levels of parathyroid hormone

An elevated serum alkaline phosphatase level and a normal serum calcium level Explanation: Clients with Paget disease have normal blood calcium levels. Elevated serum alkaline phosphatase concentration and urinary hydroxyproline excretion reflect the increased osteoblastic activity associated with this condition. Alterations in PTH and calcitonin levels are atypical.

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply. Systemic infection Complex regional pain syndrome Deep vein thrombosis Compartment syndrome Fat embolism

Deep vein thrombosis Compartment syndrome Fat embolism Explanation: Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.) Encouraging bed rest to decrease the metabolic rate Assisting the patient into the prone position Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered Administering prophylactic antibiotics

Encourage bed rest to decrease metabloic rate, withholding oral feedings to limit the realease of secretin, administering parenteral opioid analgesics as ordered Explanation: The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased (Marx, 2009). Nonpharmacologic interventions such as proper positioning (not prone), music, distraction, and imagery may be effective in reducing pain when used along with medications. In addition, oral feedings are withheld to decrease the secretion of secretin.

A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response? Educate the client about the link between alcohol use and pancreatitis. Ensure that the client knows the importance of attending follow-up appointments. Refer the client to social work or spiritual care. Encourage the client to connect with a community-based support group.

Encourage the client to connect with a community-based support group. Explanation: After the acute attack has subsided, some clients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Referral to Alcoholics Anonymous as appropriate or other support groups is essential. The client already has an understanding of the effects of alcohol, and follow-up appointments will not necessarily result in lifestyle changes. Social work and spiritual care may or may not be beneficial.

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? Sudden increase in random blood glucose readings Increased abdominal girth accompanied by decreased level of consciousness Fever, increased heart rate and decreased blood pressure Abdominal pain unresponsive to analgesics

Fever, increased heart rate and decreased blood pressure Explanation: Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test? Stool will be yellow for the first 24 hours postprocedure. The barium may cause diarrhea for the next 24 hours. Fluids must be increased to facilitate the evacuation of the stool. Slight anal bleeding may be noted as the barium is passed.

Fluids must be increased to facilitate the evacuation of the stool. Explanation: Postprocedural client education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements, because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected.

Which condition is a metabolic bone disease characterized by inadequate mineralization of bone? Osteoporosis Osteomyelitis Osteomalacia Osteoarthritis

Osteomalacia Explanation: Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. Osteoporosis is characterized by reduction of total bone mass and a change in bone structure that increases susceptibility to fracture. Osteomyelitis is an infection of bone that comes from extension of soft-tissue infection, direct bone contamination, or hematogenous spread. Osteoarthritis (OA), also known as degenerative joint disease, is the most common and frequently disabling of the joint disorders. OA affects the articular cartilage, subchondral bone, and synovium.

An older adult client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis, which objective is most appropriate? Maintaining protein levels Maintaining vitamin levels Promoting weight-bearing exercises Promoting range-of-motion (ROM) exercises

Promoting weight-bearing exercises Explanation: When the mechanical stressors of weight bearing are absent, disuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures.

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to? Referred pain Rebound pain Rovsing sign Cremasteric reflex

Rovsing sign Explanation: When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the right lower quadrant, this is referred to as a positive Rovsing sign and suggests acute appendicitis. Referred pain indicates pain in another area but is not necessarily manipulated by the examiner. Rebound pain is indicated when the pain of palpation is worse when the pressure is off of the site. The cremasteric reflex is a superficial reflex that is present in male clients.

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. Splenic vein Inferior mesenteric vein Gastric vein Inferior vena cava Saphenous vein

Splenic vein Inferior mesenteric vein Gastric vein Explanation: This portal venous system is composed of five large veins: the superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins, which eventually form the vena portae that enters the liver. The inferior vena cava is not part of the portal system. The saphenous vein is located in the leg.

Identify descriptors of the pathophysiologic process seen in osteomalacia. Select all that apply. There is a deficiency of activated vitamin D (calcitriol). Calcium and phosphate are not moved to the bones. The bone mass is structurally weaker, and bone deformities occur. Excessive osteoclastic activity causes the bones to become soft and bowed initially; later, the bones thicken but are not well formed, making the bones weak and prone to fracture.

There is a deficiency of activated vitamin D (calcitriol). Calcium and phosphate are not moved to the bones. The bone mass is structurally weaker, and bone deformities occur. Explanation: In the pathophysiologic process seen in osteomalacia, there is a deficiency of activated vitamin D (calcitriol), calcium and phosphate are not moved to the bones, the bone mass is structurally weaker, and bone deformities occur.

A client who is 24 hours post op from laparoscopic cholecystectomy calls the nurse and reports pain in the right shoulder. How should the nurse respond to the client's report of symptoms? "Apply a heating pad to your shoulder for 15 minutes hourly as needed." "Come into the emergency room as soon as possible." "Take an over the counter analgesic as needed." "Place your shoulder in a sling to avoid moving it."

"Apply a heating pad to your shoulder for 15 minutes hourly as needed." Explanation: Pain in the right shoulder may occur after laparoscopic cholecystectomy due to migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure. The nurse should instruct the client to apply a heating pad to the shoulder for 15 to 20 minutes every hour as needed for pain relief. The nurse should not instruct the client to take analgesic medication-this is a medical order performed by the health care provider only. This scenario is not life threatening and the client does not need to go to the emergency department. It is also not necessary for the client to place the shoulder in a sling as this is not an injury-related condition.

A client has a nasogastric tube for continuous tube feeding. The nurse does all the following every shift to verify placement (select all options that apply): Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents Confirms the tip of the tube with radiology Inserts 30 mL of tap water through the nasogastric tube

Compares exposed tube length with original measurement Visually assesses the color of the aspirate Checks the pH of the gastric contents Explanation: The nasogastric tube must be checked every shift for placement when a client is receiving continuous feedings. Recommended methods are comparing the exposed nasogastric tube length to the original measurement, visually assessing the color of the aspirate, and checking the pH of the gastric contents with a pH sensor. Confirming tube placement with radiology is costly and may be performed at the time of initial insertion. Inserting tap water through the nasogastric tube does not verify placement.

A patient sustains an open fracture of the left arm after an accident at the roller skating rink. What does emergency management of this fracture involve? (Select all that apply.) Covering the area with a clean dressing if the fracture is open Immobilizing the affected site Splinting the injured limb Asking the patient if he or she is able to move the arm Wrapping the arm in an ace bandage

Covering the area with a clean dressing if the fracture is open Immobilizing the affected site Splinting the injured limb Explanation: Immediately after injury, if a fracture is suspected, the body part must be immobilized before the patient is moved. Adequate splinting is essential. Joints proximal and distal to the fracture also must be immobilized to prevent movement of fracture fragments. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a sterile dressing to prevent contamination of deeper tissues.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. Daily weights Intake and output monitoring Calorie counts for oral nutrients Daily transparent dressing changes Strict bedrest

Daily weights Intake and output monitoring Calorie counts for oral nutrients Explanation: For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.

A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider? Large, wide stools Milky white stools Three stools during an 8-hour period of time Streaks of blood present in the stool

Streaks of blood present in the stool Explanation: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the client to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify accordingly.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals? Encouraging the client to turn from side to side and to assume a prone position Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation Minimizing movement of the flexor muscles of the hip Encouraging the client to sit in a chair for at least 8 hours a day

Encouraging the client to turn from side to side and to assume a prone position Explanation: The nurse encourages the client to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for clients with BKAs. The nurse also discourages sitting for prolonged periods of time.

A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse? Ensure that a large tourniquet is in the room. Document the receiving report from the transferring nurse. Delegate the gathering of enough pillows for proper positioning and comfort. Review the physician's orders for type and frequency of pain medication.

Ensure that a large tourniquet is in the room. Explanation: The client with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the client hemorrhages. Documenting the receiving report is important but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication, but again, this is not the highest priority, because any hemorrhaging by the client needs to be addressed first.

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action? Inform the surgeon of this finding. Explain the risks of flexion contracture to the client. Transfer the client to a sitting position. Encourage the client to perform active ROM exercises with the residual limb.

Explain the risks of flexion contracture to the client. Explanation: The residual limb should not be placed on a pillow, because a flexion contracture of the hip may result. There is no acute need to contact the client's surgeon. Encouraging exercise or transferring the client does not address the risk of flexion contracture.

A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause? Diet high in red meat Upper GI bleed Hemorrhoids Use of iron supplements

Hemorrhoids Explanation: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.

A client has ascites. Which of the following interventions would the nurse prepare to assist with implementing to help the client control this condition? Select all that apply. Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt Mobilizing the client every 2 hours Taking the client's weight every 3 to 4 days

Instructing the client to remove salty and salted foods from the diet Administering prescribed spironolactone (Aldactone) Assisting with placement of a transjugular intrahepatic portosystemic shunt Explanation: The goal of treatment for the client with ascites is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all ordinary canned and frozen foods that are not specifically prepared for low-sodium diets should be avoided. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a method of treating ascites in which a cannula is threaded into the portal vein by the transjugular route. In clients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system. This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Therefore, bed rest may be a useful therapy, especially for clients whose condition is refractory to diuretics. Other measures include assessment and documentation of intake and output, abdominal girth, and daily weight to assess fluid status.

A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. Masks Clean gloves Skin antiseptic Alcohol wipes Sterile gauze pads Extension set tubing

Masks Skin antiseptic Alcohol wipes Sterile gauze pads Explanation: When preparing to perform a dressing change to a central venous access site, sterile technique is essential. The nurse would need to gather masks (for self and the client) to reduce the possibility of airborne contamination, sterile gloves, skin antiseptic such as tincture of 2% iodine or chlorhexadine, sterile gauze to clean the area, sterile water or saline to clean the area after cleaning with the skin antiseptic, and alcohol wipes to clean the catheter ports. Extension set tubing is not routinely changed with dressing or tubing changes. Sterile, not clean, gloves are used.

A patient is diagnosed with osteomyelitis of the right leg. What signs and symptoms does the nurse recognize that are associated with this diagnosis? (Select all that apply.) Pain Erythema Fever Leukopenia Purulent drainage

Pain Erythema Fever Explanation: When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical and laboratory manifestations of sepsis (e.g., chills, high fever, rapid pulse, general malaise). The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the pressure of the collecting purulent material (i.e., pus). When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no manifestations of sepsis. The area is swollen, warm, painful, and tender to touch.

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply. Pneumonia Necrosis of the humerus Skin breakdown Sepsis Delirium

Pneumonia Skin breakdown Sepsis Delirium Explanation: Complications in clients with hip fractures are often related to the client's age. During the first 24 to 48 hours following surgery for hip fracture, atelectasis or pneumonia can develop as a result of the anesthesia. Thromboemboli are possible, as is sepsis. Elderly clients are also at risk for delirium in hospital settings because of the stress of the trauma, unfamiliar surroundings, sleep deprivation, and medications. An elderly client with decreased mobility is at risk for skin breakdown. Necrosis is a potential complication of the surgery, but the complication would be with the femur, not the humerus.

A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems? Contractile spasms of the gallbladder decreases appetite and leads to malnutrition. Inflammation of the gallbladder causes pain and impacts gastric motility. Reduced or absent bile as a result of obstruction impacts digestion. Increased bile as a result of inflammation leads to indigestion.

Reduced or absent bile as a result of obstruction impacts digestion. Explanation: Digestion is impacted by cholecystitis because an obstruction of the gallbladder results in reduced or absent bile. Contractile spasms and inflammation of the gallbladder leads to pain, not problems with digestion.

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply. Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Evaluate for masses in the large colon Administer nutritional substances

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances Explanation: Gastrointestinal intubation is used to decompress the stomach and remove gas and fluids, lavage the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. Because gastrointestinal intubation involves the insertion of a tube into the stomach, beyond the pylorus into the duodenum or jejunum, it could not be used to evaluate for masses in the large colon.

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? A complete blood count including differential Serum antibodies for H. pylori A sigmoidoscopy Gastric analysis

Serum antibodies for H. pylori Explanation: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client? Strive to achieve maximum weight-bearing capabilities. Gradually strengthen the affected muscles through weight training. Support the affected extremity with external supports such as splints. Limit reliance on assistive devices in order to build strength.

Support the affected extremity with external supports such as splints. Explanation: During nursing care, the affected extremities must be supported and handled gently. External supports (splints) may be used for additional protection. Prescribed weight-bearing restrictions must be followed. Assistive devices should be used to strengthen the unaffected extremities.

The nurse is completing a morning assessment of a client with cirrhosis. Which information obtained by the nurse will be of most concern? The skin on the client's abdomen has multiple spider-shaped blood vessels. The client has gained 2 kg from the previous day. The client reports nausea and anorexia. The client's hands flap back and forth when the arms are extended.

The client's hands flap back and forth when the arms are extended. Explanation: Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy. It indicates that the client has hepatic encephalopathy and, if untreated, a hepatic coma may occur.

A group of students are reviewing information about osteoporosis in preparation for a class discussion. The students demonstrate a need for additional review when they state which of the following as a risk factor? Excess caffeine intake Prolonged corticosteroid use Hypothyroidism Prolonged immobility

Hypothyroidism Explanation: Factors associated with an increased risk for osteoporosis include: family history of osteoporosis, chronic low calcium intake, excessive intake of caffeine, tobacco use, Cushing's syndrome, prolonged use of high doses of corticosteroids, prolonged periods of immobility, hyperthyroidism, hyperparathyroidism, eating disorders, malabsorption syndromes, breast cancer (especially if treated with chemotherapy that suppresses estrogen, excluding Tamoxifen, which may reduce the risk of fractures), renal or liver failure, alcoholism, lactose intolerance, and dietary deficiency of vitamin D and calcium.

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? Serum calcium Serum lipase Serum bilirubin Serum amylase

Serum lipase Explanation: Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes (Feldman et al., 2010). In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.

The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract? The breakdown of food particles into cell form for digestion The maintenance of fluid and acid-base balance The absorption into the bloodstream of nutrient molecules produced by digestion The control of absorption and elimination of electrolytes

The absorption into the bloodstream of nutrient molecules produced by digestion Explanation: Primary functions of the GI tract include the breakdown of food particles into molecular form for digestion; the absorption into the bloodstream of small nutrient molecules produced by digestion; and the elimination of undigested unabsorbed food stuffs and other waste products. Nutrients must be broken down into molecular form, not cell form. Fluid, electrolyte, and acid-base balance are primarily under the control of the kidneys.

A nurse is caring for a client who needs a nasogastric (NG) tube for a tube feeding. What is the safe method for the nurse to use to measure the appropriate length of the NG tube? A length of 50 cm (20 in) The distance measured from the nose to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process The distance measured from the tragus of the ear to the xiphoid process

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Explanation: Using the nose-earlobe-xiphoid process measurement will prevent inserting the tube into the lower esophagus. The average measurement for adults is 22 to 26 inches, so 50 cm would be too short. The nurse needs to include the measurement of nose to ear in the calculation, not just nose to xiphoid process. The distance from the tragus to the xiphoid process would fall short.

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? Transjugular intrahepatic portosystemic shunting (TIPS) Vasopressin (Pitressin) Sclerotherapy Balloon tamponade

Transjugular intrahepatic portosystemic shunting (TIPS) Explanation: A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.

The client has just been diagnosed with osteomyelitis. What are possible causes of osteomyelitis? Select all that apply. Trauma, such as penetrating wounds or compound fractures Vascular insufficiency in clients with diabetes or peripheral vascular disease Surgical contamination, such as pin sites of skeletal traction Progressive osteoporosis

Trauma, such as penetrating wounds or compound fractures Vascular insufficiency in clients with diabetes or peripheral vascular disease Surgical contamination, such as pin sites of skeletal traction Explanation: The following are all causes of osteomyelitis: trauma, such as penetrating wounds or compound fractures; vascular insufficiency in clients with diabetes or peripheral vascular disease; and surgical contamination, such as pin sites of skeletal traction. Osteoporosis is not a cause of osteomyelitis.

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statement should the nurse include when responding to the client? Select all that apply. "Immobilization of the fracture will promote healing by maximizing contact of bone fragments." "Fractured bones require a good blood supply and adequate nutrition for healing." "Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized." "Adults heal faster than children because adult bodies are physiologically more mature." "Corticosteroids will decrease the bone and soft tissue inflammation associated with the fracture."

"Immobilization of the fracture will promote healing by maximizing contact of bone fragments." "Fractured bones require a good blood supply and adequate nutrition for healing." "Weight bearing stimulates healing of the long bones of the leg, if the fracture is stabilized." Explanation: Factors that enhance fracture healing include immobilization of the fracture fragments, sufficient blood supply, proper nutrition, and weight bearing for stabilized long bones of the lower extremities. Older adults heal more slowly. Corticosteroids inhibit the repair rate and can cause osteoporosis.

A nurse is preparing a client for endoscopic retrograde cholangiopancreatography (ERCP). The client asks what this test is used for. Which statements by the nurse explains how ERCP can determine the difference between pancreatitis and other biliary disorders? Select all that apply. "It can evaluate the presence and location of ductal stones and aid in stone removal." "It is used in the diagnostic evaluation of acute pancreatitis." "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." "It can assess for ecchymosis in the body."

"It can evaluate the presence and location of ductal stones and aid in stone removal." "It can assess the anatomy of the pancreas and the pancreatic and biliary ducts." "It can detect unhealthy tissues in the pancreas and assess for abscesses and pseudocysts." Explanation: ERCP can determine the difference between pancreatitis and other biliary disorders and is generally used in chronic pancreatitis. It is particularly useful in diagnosis and treatment of clients who have symptoms after biliary tract surgery, clients with intact gallbladders, and clients for whom surgery is particularly hazardous. It can be used to assist with the removal of stones. ERCP is a useful tool in providing anatomic details about the pancreas and biliary ducts. It can evaluate the presence and location of ductal stones and detect changes in the anatomy of the client with pancreatitis, such as obstruction in the pancreatic duct and tissue necrosis due to premature release of pancreatic enzymes, and assess for abscesses and pseudocysts and atrophy of the glands in the body. ERCP is rarely used in the diagnostic evaluation of acute pancreatitis because the clients is acutely ill; however, it may be valuable in treating gallstone pancreatitis.

A patient is admitted to the hospital with a possible common bile duct obstruction. What clinical manifestations does the nurse understand are indicators of this problem? (Select all that apply.) Amber-colored urine Clay-colored feces Pruritus Jaundice Pain in the left upper abdominal quadrant

Clay-colored feces Pruritus Jaundice Explanation: Jaundice occurs in a few patients with gallbladder disease, usually with obstruction of the common bile duct. The bile, which is no longer carried to the duodenum, is absorbed by the blood and gives the skin and mucous membranes a yellow color. This is frequently accompanied by marked pruritus (itching) of the skin. The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored.

The nurse is asking the client with acute pancreatitis to describe the pain. What pain symptoms does the client describe related to acute pancreatitis? Dull pain, points to epigastric area Sharp, stabbing pain in the left lower quadrant of the abdomen Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back Severe abdominal pain that radiates to the right shoulder

Severe mid-abdominal to upper abdominal pain radiating to both sides and to the back The most common complaint of clients with pancreatitis is severe mid-abdominal to upper abdominal pain, radiating to both sides and straight to the back. The other answers are not pain that is usually associated with acute pancreatitis.

A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes a number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalogram (EEG) is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy? Stage 1 Stage 2 Stage 3 Stage 4

Stage 2 Explanation: The signs listed in the question plus disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy. Refer to Table 25-2 in the text.

The nurse is teaching the client about the upcoming endoscopic retrograde cholangiopancreatography (ERCP). Although the nurse instructs on several pertinent points of care, which is emphasized? The client will fast prior to the procedure. The client will have moderate sedation. The client will receive antibiotics before and after the procedure. The client will change positions frequently throughout the procedure.

The client will change positions frequently throughout the procedure. Explanation: It is essential that the client understands that cooperation is essential in changing positions throughout the procedure to prevent injury of the gastrointestinal tract. All of the other options are also correct but do not carry a risk for injury if not completed.

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? Dry skin Slowed heart beat Diarrhea Hyperglycemia

Diarrhea Explanation: Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia.

The primary nursing intervention that will control swelling while treating a musculoskeletal injury is: Apply cold (moist or dry). Immobilize the injured area. Elevate the affected area. Apply an elastic compression bandage.

Elevate the affected area. Explanation: Elevation is used to control swelling. It is facilitated by cold, immobilization, and compression. Refer to Box 42-1 in the text.

The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply. The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours). The health care provider will be able to determine if there is a presence of bowel disease. The client must have bowel cleansing prior to the procedure.

The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours). Explanation: The client should be NPO for 8 hours prior to the examination. Before the introduction of the endoscope, the client is given a local anesthetic gargle or spray. Midazolam (Versed), a sedative that provides moderate sedation with loss of the gag reflex and relieves anxiety during the procedure, is administered. Temporary loss of the gag reflex is expected; after the client's gag reflex has returned, lozenges, saline gargle, and oral analgesic agents may be offered to relieve minor throat discomfort.

A nurse is reviewing a client's laboratory results. Which laboratory study is most relevant to treating a client who has sustained a pelvic fracture? Urine myoglobin Urinalysis Type and crossmatch Serum ethanol

Type and crossmatch Explanation: Because of the rich blood supply to the pelvis, fractures to this area can result in significant blood loss. Type and crossmatch is a priority laboratory test in preparing for fluid replacement. Urine isn't commonly analyzed for myoglobin with this injury unless the mechanism was a crush injury; even then, urinalysis isn't as high a priority as type and crossmatch. Urinalysis and serum ethanol, although part of a trauma workup, aren't relevant to treatment of a pelvic fracture.