HCC Elimination Assessment

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

-Soy milk

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?

-Sudden decrease in abdominal pain

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

RLQ

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention?

-A client who reports urinary frequency

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

-Alcohol use disorder

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

-Assist the client to the left Sims' position.

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

-Auscultate the site for a bruit.

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?

-BUN 45 mg/dL and creatinine 8 mg/dL

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

-Bladder infection

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

-Blood

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?

-Decreased potassium level

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

-I only need to catheterize myself twice every day.

A nurse is reviewing the provider's prescriptions for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?

-Insert nasogastric tube

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

-Purulent dialysate outflow

A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?

-"You should report any tendon discomfort you experience while taking this medication."

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

-4.0

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching?

-"I will continue taking my Coumadin as prescribed."

A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?

-"I will make a list of my favorite beverages."

A nurse is caring for a patient who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

-Check the catheter tubing for kinks or twisting.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

-Check the client's medical record for the provider's prescription.

A nurse is caring for a client who came to the emergency department with abdominal distension and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

-Check to see if the suction equipment is working.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?

-Confusion

A charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

-Lubricates the first 2.5 to 5 cm (2 in) of the catheter. (should be the first 15-17.5 cm (6-7 in) for males)

A nurse is caring for a client receiving hemodialysis. A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow-up? (INCORRECT)

-Lung sounds -AV fistula site assessment -Weight -Presence of bruit and thrill

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

-Nausea and vomiting

A nurse is assessing a client who has a urine output of 250 mL in a 24 hr period. Which of the following descriptive terms should the nurse place in the client's electronic record?

-Oliguria

A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

35 mL/hr

A nurse is preparing to administer dextrose 5% in water (D5W) 150 mL IV to infuse over 3 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 gtt/min

A nurse is caring for a client who is receiving hemodialysis. The nurse is reviewing the client's data to report to the provider. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Green Boxes: -Implement seizure precautions -Obtain an electrolyte panel Yellow Box: -Disequilibrium Syndrome Grey Boxes: -Neurological status -Nausea and vomiting

A nurse is caring for a client who has impaired renal function. Which of the following findings should the nurse notify the provider?

-Urine output of 175 mL in the past 8 hr

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)

-Discontinue suction when assessing for peristalsis -Irrigate the NG tube with 0.9% sodium chloride irrigation solution -Place sequential compression devices on the bilateral lower extremities -Reposition the client from side to side every 2 hr

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

-Discontinue the existing line.

A nurse is monitoring a client who has acute kidney injury. Which of the following laboratory findings should the nurse expect?

-Elevated BUN

A nurse is assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

-Overflow incontinence

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

-Paralytic ileus

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

-Passage of flatus.

A nurse is planning care for a client who has diverticulitis. The nurse should plan to monitor the client for which of the following complications of diverticulitis?

-Peritonitis

A nurse is reviewing laboratory findings for four clients. Which of the following clients has manifestations of acute kidney injury?

-Serum creatinine 6 mg/dL

A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain. Select the 5 client findings that require immediate follow-up.

-WBC count 17,000/mm3 -Abdomen rigid with decreased bowel sounds -No dialysis for 24 hr -Potassium 7.0 mEq/L -Crackles throughout lungs

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse implement to ensure proper dialysate exchange?

-Warm the dialysate solution prior to instillation

A nurse is preparing to obtain a daily weight from a client who has chronic kidney disease. Which of the following actions should the nurse implement?

-Weigh the client after he has voided.

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

-cold and numb numbness distal to the fistula site

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, " Why do I have to be concerned about protein?" Which of the following responses should the nurse make?

-"A low-protein diet reduces the risk for uremia."

A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?

-"Abdominal bloating might occur."

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

-"Before the examination, your provider will give you a sedative that will make you sleepy."

A nurse is providing teaching to a client who has renal failure and an elevated phosphorus level. The provider instructed the client to take aluminum hydroxide 300 mg PO three times daily. For which of the following adverse effects should the nurse inform the client?

-Constipation

A nurse is teaching a client who has a new prescription for aluminum hydroxide to treat heartburn. The nurse should instruct the client to monitor for and report which of the following adverse reactions?

-Constipation

-A nurse is caring so a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take?

-Continue to monitor the client.

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

-Decompress the stomach.

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority?

-Gag reflex

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

-Lower the height of the solution container.

A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply.)

-Lubricate index finger. -Insert suppository just beyond the internal sphincter.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

-Obtain vital signs for both clients.

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

-Potassium

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

-Prior to percussing the abdomen

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hr as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?

-"This medication relieves nausea by promoting gastric emptying."

A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?

-"You should anticipate pain in the first week during the inflow of dialysate."

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

-1,720 mL

A nurse is caring for a client who is postoperative following an appendectomy and is prescribed D5 lactated Ringer's at 150 mL/hr by continuous IV infusion for 12 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

-50 gtt/min

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz of broth. The nurse should record how many mL of intake on the client's record?

-740 mL

A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?

-A client who is 3 days postoperative following a gastric bypass surgery

A nurse is teaching a client who has chronic kidney disease about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following information should the nurse include in the teaching?

-CAPD requires the client to follow fewer dietary and fluid restrictions than hemodialysis requires.

A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

-Daily weight

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

-Decrease the client's fluid intake.

A nurse is teaching a client following a cystoscopy about his new prescription for tamsulosin. Which of the following adverse effects should the nurse include in the teaching?

-Dizziness

A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

-Hyperkalemia

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

-Increase ambulation.

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

-Inspection -Auscultation -Superficial palpation -Deep palpation

A nurse is planning care for a patient who has cystitis. Which of the following interventions should the nurse include in the plan?

-Instruct the client to avoid drinking carbonated beverages.

A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse should instruct the client to increase dietary intake of which of the following substances?

-Iron

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

-Lower left quadrant

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients?

-Protein -Phosphorus -Sodium

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

-The client should follow a high-fiber diet to establish bowel regularity.

A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?

-Vancomycin

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

-"The laxative helps eliminate the barium."

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?

-"The microwave in my kitchen can warm the solution before I use it."

A nurse is teaching a client who has a new prescription for ciprofloxacin to treat an uncomplicated UTI. Which of the following instructions should the nurse include?

-"Monitor for tendon pain."

A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of the following instructions should the nurse include?

-"Reduce intake of foods high in potassium."

A nurse is teaching a client who has a new prescription for docusate. Which of the following information should the nurse include in the teaching?

-"Take this medication with a full glass of water."

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply.)

-Relief of urinary retention -Measurement of residual urine after urination -An open perineal wound

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

-Senna

A nurse is caring for a client who has chronic kidney disease (CKD) and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I just take the antacid magaldrate my husband has at home?" The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following?

-Serum phosphorus levels

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

-Shakiness and diaphoresis

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

-Slow the flow of the enema solution briefly.

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings?

-Slurred speech -Bone pain -Pruritus

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid?

-Tomatoes -Bananas -Raisins

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

-"Eating yogurt can help decrease the amount of gas that I have."

The nurse is discharging a client from the hospital who has a new prescription for furosemide. Which of the following client statements indicates an understanding of the teaching?

-"I need to limit my sun exposure and wear sunscreen while on this medication."

A nurse at a provider's office is instructing a client who is scheduled for an outpatient barium swallow. Which of the following statements by the client indicated an understanding of the teaching?

-"I should expect light-colored stools after the procedure."

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

-"I will be certain to take enteric-coated medications."

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

-"I will need to wipe my perineal area from back to front after urination."

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

-"It might take up to 3 days for the medication to work."

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?

-Diabetes mellitus

A nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications?

-Dialysis disequilibrium

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

-Encourage fluid intake at and between meals.

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

-Encourage the client to hold her breath when feeling the urge to urinate.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply)

-Excessive laxative use -Ignoring the urge to defecate -Inadequate fluid intake

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

-Grilled chicken breast with white rice

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

-Headache, restlessness

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following?

-Hirschsprung's disease

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

-Hold the container of solution 30 cm (12 in) above the anus.

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

-Hyperkalemia

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

-Increase dietary intake of raw vegetables.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

-Purplish-colored stoma

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?

-Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.

A nurse is caring for a client who is taking sucralfate. Which of the following outcomes indicates a therapeutic effect of the medication?

-Relief of gastrointestinal pain.

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

-Relief of heartburn

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

-Urinary Tract Infection

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?

-Urine output is less than 400 mL per 24 hr.