Exam Three Practice Questions

a client is hospitalized with UC reports 10-20 small diarrhea stools per day, with abdominal pain before defecation. the client appears depressed and underweight and is uninterested in self-care or suggested therapies. what is the priority nursing concept to consider when planning interventions for this client? A. elimination B. nutrition C. pain D. Adherence

A

The nurse determines a patient undergoing ileostomy surgery understands the procedure when the patient states

"I should only have to change the pouch every 4 to 7 days."

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (SATA) A. persistent abdominal pain B. marked abdominal distention C. diarrhea that is loose or liquid D. Colicky, severe, intermittent pain E. profuse vomiting that relieves abdominal pain

A. and B.

Assessment finds suggestive of peritonitis include (SATA) A. Rebound tenderness B. a soft, distended abdomen C. Dull, intermittent abdominal pain D. shallow respirations with bradypnea E. Observing that the patient is lying still

A. and E.

The client has portal hypertension and hepatic encephalopathy secondary to liver disease and is being treated with lactulose. which lab result with nurse check first to see if medication has desired effect?

Ammonia level

A client with end-stage liver disease is talking about being on the transplant list. which statement by the client is cause for greatest concern? A. I have a family history of diabetes B. I had symptoms of asthma when I was a kid C. I guess I should cut back on alcohol consumption D. I am not very good at taking prescribed medication

C

An older adult clients tells the HH nurse that he puts 17 g of polyethylene glycol in a large cup of coffee every morning. which assessment is the nurse most likely to perform first? A. assess signs of dehydration or electrolyte imbalance B. assess for s/s of overdose and then call poison control C. ask client to describe frequency and consistency of bowel movements D. ask client what he understands about the purpose of the medication

C

The nurse is caring for a client who was admitted for advanced cirrhosis. the client has massive ascites, peripheral dependent edema in the lower extremities, N/V, and dyspnea related to pressure on the diaphragm. which indicator is most reliable for tracking fluid retention? A. auscultating the lung fields for crackles every day B. measuring the abdominal girth every morning C. performing daily weights with the same amount of clothing D. Checking extremities for pitting edema and comparing baseline

C

A client with chronic HEP C has been taking the antiviral medication ledipasvir-sofosbuvir daily for the past month. which information gathered during a home visit is the most important for the nurse to communicate to the HCP? A. the client reports frequent headaches B. The client complains of feeling chronically tired C. The client occasionally misses a dose of the medication D. The client always takes the medication just before eating

C.

A client with chronic pain reports to the charge nurse that the other others have not been responding to requests for pain medications. what is the charge nurses initial action? A. Check the medication administration records for past several days B. ask nurse educator to provide in service training about pain management C. perform a complete pain assessment on the client and take a pain hx D. have a conference with the staff nurses to assess their care of this client

D

In contrast to diverticulitis, the patient with diverticulosis

Often has no symptoms

An important consideration in selecting an O2 delivery device for the patient with ARF, hypoxemic, is:

base the selection on the patient's condition and amount of FIO2 needed

The most common early sign of ARDS the nurse may see is:

dyspnea and tachypnea

In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease

often recurs after surgery, while ulcerative colitis is curable with a colectomy

The nurse is caring for a client who was recently admitted for severe diverticulitis. which task is appropriate to delegate or assign for the care of this client? A. tell the unit secretary to call radiology and schedule a barium enema B. ask the LPN to give PRN laxative when client reports constipation C. instruct nursing student to help client ambulate up and down the hall D. tell UAP to save stool to test for occult blood

D

While transferring a dirty laundry bag, an UPA sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and AIDS; the need source is unknown. place the following in order for the UAP: 1. have blood tests performed per protocol 2. complete and file an incident report 3. perform a thorough aseptic hand washing 4. Report to the occupational nurse 5. follow up for lab results and counseling 6. Begin prophylactic drug therapy

3, 4, 1, 6, 2, 5

What signs and symptoms distinguish hypoxemic from hypercapnic respiratory failure (SATA) A. cyanosis B. tachypnea C. morning headache D. paradoxical breathing E. use of pursed-lip breathing

A B D

The nurse is caring for an older woman with hepatic cancer. UAP informs the nurse the patients LOC is diminished compared with earlier in this shift. prioritize the steps of assessment and intervention related to this patients change in mental status 1. take vitals (pulse, RR, BP, Temp) 2. Check responsiveness and LOC 3. obtain blood glucose reading; give glucose per protocol 4. check electrolyte values 5. check ammonia level 6. check pulse ox and administer O2 as needed

2, 6, 1, 3, 4, 5

For clients coming to the ambulatory care G.I. clinic, which task would be most appropriate to have the LPN do? 1. Teaching a client self care for an ulcer 2. Helping the HCP incise and drain a pilonidal cyst 3. Evaluate a client's response to sitz baths for an anorectal abscess. 4. Describing the basic pathophysiology of an anal fistula

2

The nurse must rearrange the room assignments for clients. Which clients would be best to put in the same room? Select all that apply. 1. A 35-year-old woman with copious intractable nausea and vomiting 2. A 43-year-old woman who underwent cholecystectomy 2 days ago 3. A 53-year-old woman with pain related to alcohol-associated pancreatitis 4. A 62-year-old woman with colon cancer receiving chemotherapy and radiation 5. A 70-year-old woman with stool culture results that show Clostridium difficile 6. A 55-year-old woman who is having symptoms after an exposure to norovirus

2 and 3

the nurse is caring for an obese post-op client who underwent surgery for bowel resection. as the client is moving in bed he comments, "something popped open." upon exam, the nurse notes wound evisceration. place the steps in order for handling this complication 1. Cover intestine with sterile moist gauze 2. stay calm and stay with client 3. check vitals, especially BP and pulse 4. have a colleague gather sterile supplies and contact HCP 5. put client in semi-fowlers with knees slightly flexed 6. prepare client for surgery as ordered

2, 5, 3, 4, 1, 6

The nurse is teaching the client and family how to perform colostomy irrigation. place the following info in the correct order: 1. hang the container at about shoulder heigh 2. allow solution to flow slowly and steadily for 5-10 min 3. Don clean gloves and put 500 to 1000 ml of Luke warm H2O in the container 4. lube the stoma cone and gently insert tip into stoma 5. clean, rinse, and dry the skin and apply a new drainage pouch 6. allow 15-20 min for initial evacuation; then the client should walk for 30-45 min for second evacuation

3, 1, 4, 2, 6, 5

Nursing management of the patient with acute pancreatitis include (SATA) A. administering pain meds B. checking for signs of hypocalcemia C. providing a diet low in carbs D. giving insulin based on the sliding scale E. monitoring for infection, particularly respiratory

A B E

Place the steps for performing colostomy care in the correct order: 1. fit the pouch snugly around the stoma 2. Assess color and appearance of stoma 3. wash skin wild mild soap and rinse with warm water 4. apply a skin barrier to protect the peristome skin 5. Dry the skin carefully 6. Don a pair of clean gloves and remove the old pouch

6, 2, 3, 5, 4, 1

the nurse is preparing to administer TPN through a central line. place the following steps for administration in correct order 1. thread the IV tubing through the infusion pump 2. check the solution for cloudiness or turbidity 3. connect the tubing to the central line, using aseptic technique 4. select and flush the correct tubing and filter 5. set the infusion pump at the prescribed rate 6. confirm the order for TPN before administration

6, 2, 4, 1, 3, 5

A client underwent an exploratory laparotomy 2 days ago. the HCP should be called immediately for why physical examination? A. abdominal distention and rigidity B. displacement of NG C. absent or hypoactive bowel sounds D. nausea and occasional vomiting

A

A patient with Hepatitis A is in the acute phase. the nurse plans care for the patient based on the knowledge that: A. itching is a common problem with jaundice in the acute phase B. the patient is most likely to transmit the disease during this phase C. GI symptoms are not as severe in A as B D. Extrahepatic symptoms of glomerulonephritis and polyarteritis are common in this phase

A

In the care of a client with acute viral hepatitis, which task should be delegated to the UAP A. empty the bedpan while wearing gloves B. playing games or engaging the client in diversional activity C. monitor dietary preferences D. report S/S of jaundice

A

The nurse hears in hand-off report that, 1 hr ago, the HCP requested the client to be given the max dose of magnesium hydroxide. which instruction is the nurse most likely to give to the UAP? A. client will frequently need assistance to bathroom for bowel evacuation B. Client may experience dizziness when ambulating or changing position C. Client is frequently vomiting and may need linen and gown changes D. client needs to be encouraged and assisted to eat and drink as much as possible

A

The nurse is caring for a client with cirrhosis and portal HTN. which statement by the client is cause for greatest concern? A. Im very constipated and have been straining during bowel movements B. I can't button my pants anymore because my belly is so swollen C. I have a tight sensation in my lower legs when I forget to put my feet up D. when I sleep, I have to sit in a recliner so that I can breathe more easily

A

A patient with acute hepatitis B is being discharged. the discharge teaching plan should include instructions to: A. avoid alcohol for 3 weeks B. use a condom during sexual intercourse C. have family members get an injection of immunoglobulin D. follow a low-protein, moderate carb, moderate fat diet

B

The patient with advanced cirrhosis asks why the abdomen is so swollen. the nurse response is based on the knowledge that: A. a lack of clotting factors promotes the collection of blood in the abdominal cavity B. portal HTN and hypolalbuminemia cause a fluid shift into the peritoneal space C. Decreased peristalsis in GI tract contributes to gas formation and distention of the bowel D. BIle salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid

B

When a client is being prepared for a colonoscopy procedure, which tasks is most suitable to delegate to UAP A. explaining the need for a clear liquid diet B. reinforcing NPO status C. administering laxatives as needed D. administering an enema to prepare the bowel

B

The nurse is caring for a patient with suspected acute cholecystitis would anticipate (SATA) A. ordering a low sodium diet B. administration of IV fluids C. monitoring of liver function tests D. administration of antiemetics for patients with nausea E. insertion of an indwelling catheter to monitor urinary output

B C D

The nurse is caring for a client who was admitted to the med-surge unit for observation after being in ED for blunt trauma to abdomen. which can be delegated to UAP A. check clients skill temp and report if cool B. check urometer every hr and observe for red or pink tinged urine C. check vital signs every hour and report all values D. check clients pain and report worsening of pain or discomfort

C

The nurse is caring for a client with a NG tube. which task can be delegated to the UAP? A. remove the NG tube at the prescribed time B. secure the tape if the client accidentally dislodges it C. disconnect the suction to allow ambulation to toilet D. Reconnect the suction after the client has ambulated

C

The nurse is supervising a nursing student who is caring for a client who had a cholecstecomy. There is a T-tube in place. the nurse would intervene if the student performs which action? A. maintains client in semi fowlers B. checks amount, color, and consistency of drainage C. Gently aspirates the drainage from the tube D. inspects the skin around the tube for redness or irritation

C

the nurse is providing post-op care for a client who underwent laparoscopic cholecystectomy. what should the nurse report immediately to the HCP A. the client cannot void 5 hrs post-op B. the client reports shoulder pain C. the client reports RUQ pain D. output does not equal input for first few hours

C

The charge nurse is reviewing the medication administration records for several clients. Which situation needs to be brought to the attention of prescribing health care provider? A. a client with gastroesophageal reflux disease is receiving magnesium hydroxide B. an older adult client with new onset constipation is getting psyllium three times a day C. A client who needs a bowel prep is getting polyethylene glycol-electrolyte solution D. a client with abdominal pain secondary to diverticulitis is getting bisacodyl

D