EXAM 4 HEMO IMM GI GU
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:
"It indicates if a cancer is present.
A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?
"You must have the second one in 1 month and the third in 6 months."
A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?
"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."
A client who was involved in an MVA which resulted in paraplegia is working toward living at home. The client is currently developing an individualized CIC schedule, preferring not to wear a leg bag. What is the maximum amount of urine the client should allow to collect before catheterization?
350 mL
The nurse is providing care for a client who has experienced a type I hypersensitivity reaction. What client is having this type of reaction?
A child with an anaphylactic reaction after a bee sting
The critical care nurse is monitoring the client's urine output and drains following renal surgery. What should the nurse promptly report to the primary provider?
Absence of drain output
A 24-hour urine collection is scheduled to begin at 8:00 am. When should the nurse initiate the procedure?
After discarding the 8:00 am specimen
The nurse is caring for a young woman who is struggling with weight loss issues, without apparent physical cause. Which is the most likely nursing assessment for this nutritional disorder in which normal body weight is not maintained?
Anorexia nervosa
The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?
Anticholinergic
The nurse is preparing to start an IV for a client who is combative. What precautionary measure should the nurse take in order to avoid a needlestick?
Ask for assistance
A child has been transported to the emergency department (ED) after a severe allergic reaction. How should the nurse evaluate the client's respiratory status?
Assess breath sounds. Measure the child's oxygen saturation by oximeter. Monitor the child's respiratory pattern. Assess the child's respiratory rate.
The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client?
Assisting the client to turn, cough, and deep breathe every 2 hours
caring for a client with type 2 diabetes who take metformin to manage glucose levels. the client may be most at risk for which vitamin deficiency?
B12
The nurse is caring for a client who has had diarrhea for 3 days. What major problems associated with severe or prolonged diarrhea should the nurse monitor for when caring for this client?
Dehydration Electrolyte imbalances Vitamin deficiencies
Diagnostic testing of an adult client reveals renal glycosuria. The nurse should recognize the need for the client to be assessed for what health problem?
Diabetes mellitus
A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace?
Disposing of sharps appropriately and not recapping needles
What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?
Endoscopic retrograde cholangiopancreatography (ERCP)
A client diagnosed w/ a lymphatic disorder asks the nurse why the lymphatic system is so important. Which of the following would the nurse be correct in identifying as potential complications of a compromised lymphatic system?
Fluid distribution problems Tender, painful enlargement of lymph nodes Weakened immunity
A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the client reviews the initial orders and notes an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason?
Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.
The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?
Hyperactive
A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client?
Infection typically occurs due to ingestion of contaminated food and water
The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options
Inspection Auscultation Percussion Palpation
A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
Loss of 2.2 lb (1 kg) in 24 hours
A client is brought to the renal unit from the PACU status postresection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this client?
Managing postoperative pain
The nurse is assessing a new client with complaints of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder?
Megaloblastic anemia
Which of the following is considered a bulk-forming laxative?
Metamucil
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
One part of the intestine telescopes into another portion of the intestine.
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program?
Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care.
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?
Perform meticulous perineal care daily with soap and water
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike. What complication does the nurse determine may be occurring at this time?
Peritonitis
A pt had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The patient takes pantoprazole for frequent heartburn. What type of anemia is this patient at risk for?
Pernicious anemia
A client is admitted to a healthcare facility with minor lacerations on the leg. The nurse observes swelling in the tissues surrounding the affected area. A blood clot is suspected. The nurse should know that which of the following is the first step when the formation of a blood clot begins?
Platelets break down and migrate to the injured area
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):
Protrusion of the upper stomach into the lower portion of the thorax.
A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action?
Send the client for a spinal x-ray study
Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?
SpO2 at 90% with fine crackles in the lung bases
The nurse is reviewing the client's urinalysis results. The finding that is most suggestive of dehydration of the client is...
Specific gravity 1.035
Which of the following nursing actions is most important in caring for the client following lithotripsy?
Strain the urine carefully for stone fragments.
Which statement accurately reflects current stem cell research?
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white cells.
The nurse is caring for a client with recurrent urinary tract infections. Which of the following body structures would the nurse instruct as the most frequent cause of women's urinary tract infections?
The urethra
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?
Weakness, diaphoresis, diarrhea 90 minutes after eating
The nurse is assigned to care for a patient in the oliguric phase of kidney failure. When does the nurse understand that oliguria is said to be present?
When the urine output is less than 30 mL/h
Which is a symptom of hemochromatosis?
bronzing of the skin
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?
diaphoresis, vomiting, and diarrhea
Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?
duodenum
A client is experiencing some secretion abnormalities, for which diagnostics are being performed. Which substance is typically reabsorbed and not secreted in urine?
glucose
A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis?
hemophilia
Which cells have the lifespan of 1 to 2 days and perform phagocytosis?
leukocytes
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
recent food ingest
A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for?
the onset of a bacterial infection
A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
Change in bowel habits
The nurse is completing a routine urinalysis using a dipstick. The test reveals an increased specific gravity. The nurse should suspect which condition?
Decreased fluid intake
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?
Gastroesophageal reflux disease
A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed that the client is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?
HIV encephalopathy
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage
A pt w/ a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the pt for which of the following complications of therapy?
Immunosuppression
During a client's scheduled home visit, an older adult client has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?
Increased fluid and fiber intake
Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow?
Monitoring the stool passage and its color
A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms?
Pyridium
When interviewing a client with internal hemorrhoids, what would the nurse expect the client to report?
Rectal bleeding
A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has had not ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action?
Report signs and symptoms of obstruction to the health care provider.
A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis?
Risk for Infection Related to Possible Rupture of Appendix
older adult client is exhibiting many signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?
Stool for occult blood
caring for a client who is undergoing bone marrow aspiration to determine the blood cell formation status. What intervention should the nurse provide to the client during the test?
Support the client and monitor the status.
Which type of lymphocyte is responsible for cellular immunity?
T lymphocyte
A client who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1ºF (38.4ºC). How should the nurse best respond to the client?
Tell the client to report to the ED for further assessment
A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem?
The client's polyps constitute a risk factor for cancer.
The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?
The nursing assistant places the drainage bag on the client's abdomen for transport.
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
Urge
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
Urine output of 250 ml/24 hours
A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:
Western blot test for confirmation of diagnosis.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?
White blood cell (WBC) count of 20,000/mm3
A client has discussed therapy for HIV-positive status. The goal of antiretroviral therapy is to:
keep the CD4 cell count above 350/mm3 and viral load undetectable.
A client with sickle cell anemia has a
low hematocrit
A client has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, the client has an inability to fight infection because bone marrow is unable to produce a sufficient amount of:
lymphocytes
A teenaged client arrives at the clinic and he attended 2 weeks of summer camp last month and now is not feeling well with complaints of sore throat, fever, and very tired. The nurse observes white exudate on the tonsils. What test does the nurse anticipate the physician will order for this client?
monospot test
