GI/nutrition
Assessment for hepatic encephalopathy? Select all that apply. 1. Ask if the client knows what day it is 2. Ask the client to extend the arms 3. Assess for telangiectasia (spider nevi) 4. Determine if the conjunctiva is jaundiced 5. Note amylase and lipase serum levels
1,2
The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? 1. Left flank radiating to the left groin area 2. Left upper quadrant radiating to the back 3. Periumbilical area shifting to the right lower quadrant 4. Right upper quadrant radiating to the right shoulder
2
The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? 1. Assess mental status and orientation 2. Give on an empty stomach for rapid effect 3. Hold if 3 soft stools occur in a day 4. Mix with fruit juice to improve flavor
3
Ginutrition #78 Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348604
c
The nurse is providing initial nutritional teaching for a client with a new ileostomy. Which foods in the initial postoperative teaching plan are most important for the nurse to instruct the client to avoid? Select all that apply. 1. Apple slices 2. Bananas 3. Broccoli with cheese 4. Multigrain bagel 5. Scrambled eggs with oatmeal 6. White rice
1,3,4,5
The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis? 1. "My pain is a burning sensation in my upper abdomen." 2. "My pain is an 8 out of 10 and on my left side below my belly button." 3. "My pain is excruciating in my lower abdomen above my right hip." 4. "My pain is intermittent in my abdomen and right shoulder."
3
A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client? 1. Encourage client to eat bulk-forming foods such as whole grain bread 2. Encourage rest, fluids, and acetaminophen for the fever 3. Make an appointment for the client with the health care provider today 4. Take 2 tablets of loperamide followed by 1 tablet after each loose stool
3
The nurse prepares to admit a client for worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's laboratory results, the nurse anticipates which assessment findings? Select all that apply. Click on the exhibit button for additional information. Exhibit: Laboratory results Albumin 1.5 g/dL (15 g/L) Ammonia 112 mcg/dL (80 µmol/L) International Normalized Ratio (INR) 1.9 Bilirubin 22 mg/dL (376 µmol/L) Platelets 55,000/mm3 (55 × 109/L) 1. Ascites 2. Bruising 3. Constipation 4. Itching 5. Lethargy
1,2,4,5
A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply. 1. Checks for residual every 4 hours 2. Places client in semi-Fowler's position 3. Plugs the air vent if gastric content refluxes 4. Provides mouth care every 4 hours 5. Turns off suction when auscultating bowel sounds
1,3
A client diagnosed with cirrhosis is experiencing pruritus. Which actions will the nurse take to promote comfort and minimize pruritus? Select all that apply. 1. Apply cool, wet cloths to skin 2. Encourage hot showers 3. Gently apply calamine lotion 4. Promote the use of cotton gloves 5. Request that the client cut nails short
1,3,4,5
The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1. Encourage adequate sodium intake 2. Place client in semi-Fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distraction
2,4,5
The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority? 1. Administer promethazine 25 mg suppository 2. Infuse normal saline 100 mL/hour 3. Insert nasogastric tube to low suction 4. Maintain nothing-by-mouth (NPO) status
4
Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis? 1. Metronidazole 500 mg IV every 8 hours 2. Nasogastric (NG) tube to suction 3. Nothing by mouth (NPO) 4. Prepare for barium enema in AM
4
The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses (NDs) are appropriate to include in the client's care plan? Select all that apply. 1. Acute pain 2. Dysfunctional gastric motility 3. Imbalanced nutrition, less than body requirements 4. Ineffective self-health management 5. Risk for infection
1,2,3,5
The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? Select all that apply. 1. Elevate the head of the hospital bed 2. Instruct the client to avoid tobacco and caffeine 3. Offer small, frequent, low-fat meals 4. Provide a girdle to reduce the hernia 5. Teach the client to avoid lifting or straining
1,2,3,5
The nurse understands that which of the following body substances are modes of transmission for hepatitis B? Select all that apply. 1. Blood 2. Feces 3. Saliva 4. Semen 5. Urine 6. Vaginal secretions
1,3,4,6
A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statements by the nurse correctly answer the client's question? Select all that apply. 1. "No food or drink is allowed 8 hours prior to the test." 2. "Prophylactic antibiotics are taken as prescribed." 3. "Smoking must be avoided after midnight." 4. "The day prior to the procedure your diet will be clear liquids." 5. "You will drink polyethylene glycol as directed the day before."
1,4,5
A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client? 1. Crackers and cheddar cheese 2. Hard-boiled egg with tomatoes 3. Steamed fish and potatoes 4. Tortilla chips with avocado dip
3
The nurse teaching a group of clients about celiac disease will include which meal in the teaching plan? 1. Baked salmon with rice, steamed vegetables, and dinner roll 2. Breaded pork chops, corn on the cob, and steamed snow peas 3. Grilled chicken, green beans, and mashed potatoes 4. Spaghetti with Italian tomato sauce and meatballs
3
When caring for a client immediately after a laparoscopic cholecystectomy, which nursing intervention has the highest priority? 1. Apply anti-thromboembolism stockings 2. Assist with ambulation 3. Place client in the Sims' position 4. Teach about the importance of a low-fat diet
3
A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider (HCP) requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply. 1. Immediately place the client on nothing-by-mouth (NPO) status 2. Obtain informed consent for the procedure 3. Place the client in high Fowler's position 4. Request that the client empty the bladder 5. Take baseline vital signs and weight
3,4,5
An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss. The nurse's response is based on an understanding of which of the following? 1. Fasting for 7 days is not likely to cause health problems 2. Fasting spares protein in favor of fat metabolism 3. Fasting will help control hunger pangs in the long term 4. Initial weight loss during fasting is primarily from fluid loss
4
The nurse determines that further teaching is needed if a client with constipation makes which statement? Select all that apply. 1. "I will go to the restroom when I have the urge to have a bowel movement." 2. "I will increase my exercise to at least 3 times a week." 3. "I will increase my intake of fruits and vegetables." 4. "I will increase tea or coffee consumption to stimulate the bowel." 5. "I will use a laxative every other day if needed."
4,5
The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply. 1. Albumin 2. Ammonia 3. Bilirubin 4. Prothrombin time 5. Sodium
2,3,4
The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? 1. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place 2. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing 3. Hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma 4. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
1
The nurse is teaching a client with newly diagnosed lactase deficiency about dietary management. Which statements by the client indicate a correct understanding of this condition? Select all that apply. 1. "I can still eat cheese and yogurt as long as they don't make me feel sick." 2. "I should take a daily calcium and vitamin D supplement." 3. "Most dairy products should be eliminated from my diet, but ice cream is okay." 4. "My lactase enzyme supplement should be taken with meals containing dairy." 5. "This means that I have developed an allergy to milk."
1,2,4
Which lifestyle and nutritional strategies can help clients reduce and manage the signs and symptoms of gastroesophageal reflux disease? Select all that apply. 1. Avoid caffeine, chocolate, and peppermint 2. Choose foods that are low in fat 3. Eat 3 meals a day with minimal or no snacking 4. Minimize intake of dairy products 5. Sip water with meals
1,2,5
The nurse assesses a client who has followed a vegan diet for several years. Which client statement would indicate a possible complication resulting from a vegan diet? 1. "I have had some visual disturbances while driving at night." 2. "I have had trouble falling asleep over the past few months." 3. "Scaly patches of skin are developing on my elbows and knees." 4. "Sometimes my hands and feet get a tingling sensation."
4
The nurse is assessing a client who had an esophagogastroduodenoscopy (EGD) 2 hours ago. Which finding requires an immediate report to the health care provider? 1. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg 2. Gag reflex has not returned 3. Sore throat when swallowing 4. Temperature spike to 101.2 F (38.4 C)
4
The nurse is caring for a client with acute pancreatitis. Which subjective and objective assessments would the nurse report immediately? 1. Client is lying with knees drawn up to the abdomen and trunk flexed 2. Client states, "My lips are tingling and numb." 3. Foul-smelling, fatty stool 4. Temperature of 102.2 F (39 C) and increasing abdominal pain
4
The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's best action? 1. Administer an antibacterial agent and assess for further signs of infection 2. Document the findings and continue to monitor for changes 3. Measure the stoma and apply a larger pouching device 4. Report the findings to the health care provider (HCP) immediately
4
The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy. Which statement by the client indicates that further teaching is required? 1. "I can resume a regular diet but will avoid fatty foods for several weeks after surgery." 2. "I can return to work within a week of surgery." 3. "I will report to the health care provider if my temperature is higher than 101 F (38.3 C)." 4. "Tomorrow I can remove the puncture site bandages and take a bath."
4
A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal? 1. 450 kcal/day 2. 625 kcal/day 3. 860 kcal/day 4. 1,000 kcal/day
2
The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply. 1. Do you have black tarry stool? 2. Do you use intravenous (IV) illicit drugs? 3. How much alcohol do you typically drink? 4. Were you recently immunized for pneumonia? 5. What over-the-counter drugs do you take?
2,3,5
The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1. Black tarry 2. Bright red bloody 3. Light gray "clay-colored" 4. Small, dry, rocky-hard masses
1
The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome? 1. Meals should be small and low in carbohydrate content 2. Fluids should be encouraged with each meal 3. Take a multivitamin with iron and calcium supplements daily 4. You will need to take your cobalamin injection monthly
1
The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? 1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells 2. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping 3. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 4. Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L)
1
The nurse is caring for a client who has undergone a colonoscopy. Which client assessment finding should most concern the nurse? 1. Abdominal cramping 2. Frequent, watery stools 3. Positive rebound tenderness 4. Recurring flatus
3
A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? 1. Phosphorus 2.0 mg/dL (0.65 mmol/L), potassium 2.9 mEq/L (2.9 mmol/L), magnesium 1.0 mEq/L (0.5 mmol/L) 2. Phosphorus 5.0 mg/dL (1.61 mmol/L), potassium 3.5 mEq/L (3.5 mmol/L), magnesium 2.0 mEq/L (1.0 mmol/L) 3. Random blood glucose 60 mg/dL (3.3 mmol/L), sodium 120 mEq/dL (120 mmol/L), calcium 7.0 mg/dL (1.75 mmol/L) 4. Random blood glucose 100 mg/dL (5.6 mmol/L), sodium 140 mEq/dL (140 mmol/L), calcium 10.0 mg/dL (2.50 mmol/L)
1
A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction? 1. "I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times." 2. "I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup." 3. "I'll squeeze the JP bulb from side-to-side as I hold it in my hand." 4. "While the JP bulb is totally compressed, I'll clean the spout with alcohol and replace the plug."
1
A client comes to the clinic for a follow up visit following a Billroth II surgery (gastrojejunostomy). The client reports occasionally experiencing sweating, palpitations, and dizziness 30 minutes after eating. What action should the nurse take? 1. Check serum blood glucose 2. Encourage dry foods with a low carbohydrate content 3. Take vital signs lying and standing 4. Teach the client to sit up after eating
2
A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take? 1. Assess the client's vital signs 2. Check the client's blood glucose 3. Report the findings to the health care provider 4. Slow down the rate of infusion
2
An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? 1. "I will refer you to the dietitian." 2. "It should take about 6-8 weeks before you see improvement in your symptoms." 3. "Tell me what you had to eat yesterday." 4. "You must not be following your diet."
3
The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with intravenous (IV) albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider? 1. Albumin 2.5 g/dL (25 g/L) 2. INR 1.4 3. Potassium 3.0 mEq/L (3.0 mmol/L) 4. Sodium 131 mEq/L (131 mmol/L)
3
The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective? 1. "I may have one alcoholic drink a day, but no more." 2. "I may take aspirin instead of acetaminophen for fever or pain." 3. "I should avoid straining while having a bowel movement." 4. "I should eat a protein- and sodium-restricted diet."
3
A client is admitted to the emergency room with right lower quadrant pain and suspected acute appendicitis. Which health care provider prescription should the nurse implement first? 1. Administer 5-325 mg hydrocodone/acetaminophen PO for pain 2. Draw blood for complete blood count and electrolyte levels 3. Obtain urine specimen for urinalysis 4. Start intravenous (IV) line with normal saline 100 mL/hr
4
A client is admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? 1. Decreased albumin 2. Elevated troponin 3. Hyperkalemia 4. Hypocalcemia
4
A client is taking morphine sulfate for acute pain. Which statement will best assist the client worried about nausea and vomiting while taking this medication? 1. "Nausea and vomiting rarely occur with this medication." 2. "Nausea and vomiting rarely occur when you are up and walking." 3. "Take the medication on an empty stomach." 4. "Tolerance develops quickly and persistent nausea is rare."
4
A client with abdominal pain and vomiting is feeling dizzy and "out of it." The blood pressure is 153/83 mm Hg and pulse is 70/min supine; blood pressure is 119/81 mm Hg and pulse is 90/min sitting. What should the nurse do next? 1. Anticipate administering normal saline intravenous fluids 2. Complete the orthostatic vital signs by having the client stand 3. Document that orthostatic vital signs are "within normal limits" 4. Perform further neurological assessment with tandem walking
1
A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L). What is thepriority action by the nurse? 1. Collect peritoneal fluid for culture and sensitivity 2. Heat the remaining dialysate fluid and increase the dwell time 3. Place the client in high Fowler's position 4. Prepare to administer regular insulin intravenously
1
During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1. Abdominal distension 2. Absolute constipation 3. Colicky abdominal pain 4. Frequent vomiting 5. Pain during defecation
1,3,4
During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply. 1. Assess the client's hand movements with the arms extended 2. Compare current mental status findings with those from previous shifts 3. Contact the health care provider to request a blood draw for ammonia level 4. Encourage the client to ambulate in the hallway 5. Hold the client's morning dose of lactulose
1,2,3
Which interventions would the nurse expect to be included in the care plan for a client with acute diverticulitis who has acute pain rated 8/10, nausea and vomiting, blood pressure 126/64 mm Hg, apical pulse 102/min, respirations 20/min, and temperature 101.2 F (38.4 C)? Select all that apply. 1. Administration of morphine sulfate 2 mg via intravenous (IV) push 2. Instructions to avoid straining 3. Maintenance of nothing-by-mouth (NPO) status 4. Placement of an IV line and infusion of normal saline 75 mL/hr 5. Protection of the skin from diarrhea by insertion of a rectal tube
1,2,3,4
A client with ulcerative colitis (UC) reports abdominal pain, 10 bloody stools per day, and decreased appetite. The client states, "What's the point of taking medication? It doesn't help anyway." Which nursing diagnoses (NDs) are appropriate to include in the client's plan of care? Select all that apply. 1. Acute pain 2. Altered nutritional status 3. Hopelessness 4. Noncompliance 5. Risk for deficient fluid volume
1,2,3,5
Which of the following nursing interventions would the nurse implement when caring for a client newly diagnosed with acute viral hepatitis? Select all that apply. 1. Administer antiemetic medications as needed 2. Encourage a good breakfast and small, frequent meals 3. Promote rest periods alternating with periods of activity 4. Provide a diet high in protein and low in fat 5. Teach the client to abstain from alcohol
1,2,3,5
A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply. 1. Drink plenty of fluids 2. Exercise regularly 3. Follow a low-residue diet 4. Include whole grains, fruits, and vegetables in the diet 5. Increase intake of red meat
1,2,4
A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action? 1. Hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour 2. Hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr 3. Hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr 4. Hang lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr
2
During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the health care provider (HCP) immediately? 1. Brick red with slight moisture noted 2. Dusky with moderate edema present 3. Pink with slight oozing of blood 4. Rosy with no stool produced
2
The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client. Which instructions should the nurse include when teaching the client about this test? 1. "After the test, you may notice your stools are tarry black for a few days." 2. "During the test, a series of x-rays will be taken to assess the function of the small bowel." 3. "The HCP will use an endoscope to visualize your small bowel." 4. "Your examination is scheduled for 8:00 AM. Please drink all of the polyethylene glycol by midnight."
2
The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration? 1. Serum albumin level and body weight 2. Serum potassium and phosphate 3. Symptoms of dumping syndrome 4. White blood cell count and neutrophils
2
The nurse is caring for an alert client with jaundice, scleral icterus, and a bilirubin level of 12.3 mg/dL (210 µmol/L). Which instruction would be most important to include when delegating the client's morning hygiene tasks to unlicensed assistive personnel? 1. Do not leave the client alone in the shower 2. Use cool water in the shower 3. Use hot water in the shower 4. Wash client with antibacterial soap
2
The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? 1. Administer docusate and teach the client to avoid straining during defecation 2. Give pain medications and instructions related to pain control 3. Remove the rectal dressing and check the client for bleeding 4. Teach the client how to self-administer a sitz bath 2-3 times daily
2
The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? Select all that apply. 1. Avoid small, frequent meals 2. Can have a cup of coffee with each meal 3. Eat a low-residue, high-protein, high-calorie diet 4. Increase fluid intake to at least 2000 mL/day 5. Medication should be continued even after the resolution of symptoms 6. Take daily vitamin and mineral supplements
3,4,5,6
When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply. 1. Flank pain radiating to the groin 2. High-protein food ingestion before the onset of pain 3. Low-grade fever with chills 4. Pain at the umbilicus 5. Right upper-quadrant (RUQ) pain radiating to the right shoulder
3,5
A client with a history of cirrhosis has a new prescription for lactulose 30 mL four times a day. What does the nurse explain to the client about this medication? 1. It will decrease intestinal absorption of ammonia 2. It will facilitate diuresis of excess fluid 3. It will promote renal excretion of bilirubin 4. It will reduce portal pressure contributing to esophageal varices
1
An obese client is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? 1. Coffee, tea, flavored club soda 2. Diet soft drinks, tea, water 3. Diet tea, low-fat milk, vegetable juice 4. Sports drinks, unsweetened juice, coffee
1
The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the health care provider? 1. Abdominal pain has progressed to the left upper quadrant 2. Hemoglobin of 11.2 g/dL (112 g/L) 3. Lying on side with knees drawn up to abdomen and trunk flexed 4. White blood cell count of 12,000/mm3 (12.0 x 109/L)
1
The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? 1. Absent bowel sounds 2. Borborygmi sounds 3. High-pitched and gurgling sounds 4. Swishing or buzzing sounds
1
Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy? 1. "I will avoid eating foods such as broccoli and cauliflower." 2. "I will empty the pouch when it is one-half full of stool." 3. "I will irrigate the colostomy to promote regular bowel movements." 4. "I will restrict my fluid intake to 2,000 milliliters of fluid a day."
1
Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? (Select all that apply.) 1. "Avoid foods that may cause epigastric distress such as spicy or acidic foods." 2. "It is best if you refrain from consuming alcohol products." 3. "Report black tarry stools to your health care provider immediately." 4. "Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days." 5. "You may take over-the-counter drugs such as aspirin if you have mild epigastric pain."
1,2,3,4
The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question? 1. Begin a sugar-free, clear liquid diet 2. Insert nasogastric tube for uncontrolled nausea 3. Place client in low Fowler position during mealtimes 4. Start morphine via patient-controlled analgesia
2
The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? 1. Client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching 2. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness 3. Client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up 4. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria
2
The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? 1. The client will contact the United Ostomy Association of America 2. The client will look at and touch the stoma 3. The client will read the materials provided on ostomy care 4. The client will verbalize methods to control gas and odor
2
A client is being discharged today following a partial gastrectomy. Instructions for recuperating at home would include which of the following? Select all that apply. 1. Avoid high fiber foods 2. Avoid intake of fluids with meals 3. Consume low-carbohydrate meals 4. Have small, frequent meals 5. Maintain a sitting-up position after eating
2,3,4
An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which bestindicates that the client is responding to treatment? 1. Serum albumin of 3.6 g/dL (36 g/L) 2. The client consumes 90% of meals 3. Weight gain of 2 lb (0.9 kg) in 2 weeks 4. White blood cell count of 15,000/mm3 (15 x 109/L)
3
The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin
3
A client with a brain injury had a percutaneous endoscopic gastrostomy tube placed 2 weeks ago. At the rehabilitation facility, the client became agitated and pulled the tube out. The nurse then inserted a Foley urinary catheter to maintain the opening. Which action is essential before the nurse can use the Foley urinary catheter to instill the feeding formula? 1. Aspirate gastric contents with a pH of 6 2. Confirm placement by instilling a bolus of air and auscultating a stomach "whoosh" sound 3. Measure the catheter length and ensure that 12 in (30.5 cm) extend beyond the stoma 4. Obtain imaging confirmation of tube placement
4
The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? 1. Beans, yogurt, and a fruit cup 2. Beef, broccoli, and a glass of wine 3. Eggs, a bagel, and black coffee 4. Steak, tomato basil soup, and cornbread
4
The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal does the client choose to indicate that teaching has been effective? 1. Chicken salad with lettuce on French bread, chocolate pudding, and milk 2. Fat-free yogurt, carrot sticks, apple slices, and diet soda 3. Ham, steamed carrots, green beans, gelatin dessert, and iced tea 4. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice
4
Which nursing interventions for a client recovering from a gastroduodenostomy (Billroth I) are contraindicated? Select all that apply. 1. Applying a sequential compression device and antiembolism stockings 2. Encouraging turn, cough, and deep-breathing exercises every 2 hours 3. Keeping the head of the bed raised and positioned at a 45-degree angle 4. Repositioning and irrigating a clogged nasogastric tube as needed 5. Teaching the importance of small, frequent, high-carbohydrate meals
4,5