Lippincott Test 4
100. A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply. 1. Change the feeding apparatus every 24 hours. 2. Use a higher volume of formula because the formula may be too hypotonic. 3. Slow the administration rate. 4. Use a diluted formula, gradually increasing the volume and concentration. 5. Anticipate changing to a lactose-free formula
1345
147. Which of the following client statements indicates that the client with hepatitis B understands discharge teaching? 1."I will not drink alcohol for at least 1 year." 2."I must avoid sexual intercourse. 3."I should be able to resume normal activity in a week or two." 4."Because hepatitis B is a chronic disease, I know I will always be jaundiced.
1
Which of the following goals is most important for a client with acute pancreatitis? 1. The client reports minimal abdominal pain. 2. The client regains a normal pattern for bowel movements. 3. The client limits alcohol intake to two to three drinks per week. 4. The client maintains normal liver function.
1
A client is recovering from abdominal sugery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract: 1. Compression. 2. Lavage. 3. Decompression. 4. Gavage.
3
The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? 1. Stimulation of peristalsis of the bowel. 2. Reduced peripheral edema and ascites. 3. Reduced serum ammonia levels. 4. Prevention of hemorrhage.
3
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications? 1. Hypostatic pneumonia. 2. Pulmonary hypertension. 3. Orthostatic hypotension. 4. Fluid imbalances.
4
Which of the following clients is at greatest risk for obtaining adequate nutrition? 1. The client with diabetic peripheral neuropathy. 2. The client recovering from a femur fracture. 3. The client who is breast-feeding. 4. The client with burns to 45% of the body.
4
26. Which of the following dietary instructions would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? 1. Avoid crash dieting. 2. Restrict carbohydrate intake. 3. Eat six small meals a day. 4. Decrease sodium in the diet.
1
29. The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What infor- mation is most important to communicate to the physician? 1. The client has had a 3-kg weight gain over 2 days. 2. The client has nausea. 3. The client now has a temperature of 99°F (37.2°C) orally. 4. The client has fatigue.
1
33. The nurse is teaching a client with viral hepatitis about preventing transmission of the disease. The nurse should focus teaching on; 1. Proper food handling. 2. Insulin syringe disposal. 3. Alpha-interferon. 4. Use of condoms.
1
57. The client with cirrhosis receives 100 ml of 25% serum albumin IV. Which finding would best indicate that the albumin is having its designed effect? 1. Increased urine output. 2. Increased serum albumin level. 3. Decreased anorexia. 4. Increased ease of breathing.
1
57. Using a sliding-scale schedule, the nurse is preparing to administer an evening dose of regular insulin to a client who is receiving total parenteral nutrition (TP). Which action is most appropriate for the nurse to take to determine the amount of insulin to give? 1. Base the dosage on the glucometer reading of the client's glucose level obtained immediately before administering the insulin. 2. Base the dosage on the fasting blood glucose level obtained earlier in the day 3. Calculate the amount of TPN fluid the client has received since the last dose of insulin and adjust the dosage accordingly. 4. Assess the client's dietary intake for the evening meal and snack and adjust the dosage accordingly.
1
60. TPN is prescribed for a client with Crohn's disease. Which of the following indicate the TPN solution is having an intended outcome? 1. There is increased cell nutrition. 2. The client does not have metabolic acidosis. 3. The client is hydrated. 4. The client is in a negative nitrogen balance.
1
60. The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy, Which of the following would be an indication that hepatic encephalopathy is developing? 1. Decreased mental status. 2. Elevated blood pressure. 3. Decreased urine output. 4. Labored respirations.
1
61. A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client's ability to metabolize the TP solution adequately by monitoring the client for which of the following signs? 1. Tachycardia. 2. Hypertension. 3. Elevated blood urea nitrogen concentration. 4. Hyperglycemia.
1
64. The nurse administers fat emulsion solution during TPN as prescribed based on the understand- ing that this type of solution: 1. Provides essential fatty acids. 2. Provides extra carbohydrates. 3. Promotes effective metabolism of glucose. 4. Maintains a normal body weight.
1
65. The nurse is preparing a client for a paracen tesis. The nurse should: 1. Have the client void immediately before the procedure. 2. Place the client in a side-lying position. 3. Initiate an IV line to administer sedatives. 4. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.
1
90. A health care provider has been exposed to hepatitis B through a needlestick. Which of the fol- lowing drugs should the nurse anticipate adminis- tering as postexposure prophylaxis? 1. Hepatitis B immune globulin. 2. Interferon. 3. Hepatitis B surface antigen. 4. Amphotericin B.
1
A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an IV infusion of dextrose 5% in half-normal saline solution at 120 mL/h. After 3 days of this regimen, the nurse should observe the client for which of the following metabolic conditions? 1. Ketosis. 2. Hyperglycemia. 3. Metabolic syndrome. 4. Lactic acidosis.
1
The nurse is preparing a client for paracentesis. Which of the following activities should the nurse complete in preparation for this test? 1. Have the client void before the procedure. 2. Scrub the client's abdomen with Betadine solution. 3. Position the client supine. 4. Put the client on nothing-by-mouth (NPO) status 4 hours before the procedure.
1
23. When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which of the following nursing interventions would be most appropriate for this client? Select all that apply. 1. Placing the client in a side-lying position. 2. Administering morphine sulfate for pain as needed. 3. Maintaining the client on a high-calorie, high-protein diet. 4. Monitoring the client's respiratory status, 5. Obtaining daily weights.
145
120. During an emergency, a physician has asked for IV calcium to treat a client with hypocalcemia. The nurse should: 1. Hand the physician calcium chloride for IV use. 2. Check with the physician for the complete prescription. 3. Hand the physician calcium gluconate for IV use. 4. Hand the physician the kind of calcium available on the unit.
2
125. Which of the following laboratory values for a client with cirrhosis who has developed ascites should the nurse report to the health care provider? 1. Decreased aspartate aminotransferase. 2. Hypoalbuminemia. 3. Hyperkalemia. 4. Decreased alanine aminotransferase.
2
140. The nurse assesses a client who is receiving a tube feeding. Which of the following situations Would require prompt intervention from the nurse? 1. The client is sitting upright in bed while the feeding is infusing. 2. The feeding that is infusing has been hanging for 8 hours. 3. The client has a gastric residual of 25 mL. 4. The feeding solution is at room temperature.
2
151. A client has extreme fatigue, is malnourished and laboratory tests reveal a hemoglobin level of 8.5 g/dL. (85 g/L). The nurse should specifically ask the client about the intake of food high in which of the following nutrients? 1. Vitamins A, E, and C. 2. Vitamins B6, B12, and folate, iron, and copper. 3. Thiamine, riboflavin, and niacin. 4. Vitamins A and B.
2
18, The nurse monitors the client with pancreatitis early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis? 1. Severity of intestinal hemorrhage. 2. Vasodilating effects of kinin peptides. 3. Tendency toward heart failure. 4. Frequent incidence of acute tubular necrosis.
2
19, A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 bpm, respirations of 28/ min, and Gray Turner's sign. What action Would the nurse perform first? 1. Assess the urine output. 2. Place an intravenous line. 3. Position on the left side. 4. Insert a nasogastric tube.
2
39. The nurse should teach the client with viral hepatitis to: 1. Limit caloric intake and reduce weight. 2. Increase carbohydrates and protein in the diet. 3. Avoid contact with others and sleep in a separate room. 4. Intensify routine exercise and increase strength.
2
45. Which of the following expected outcomes would be appropriate for a client with viral hepatitis? The client will: 1. Demonstrate a decrease in fluid retention related to ascites. 2. Verbalize the importance of reporting bleeding gums or bloody stools. 3. Limit use of alcohol to two to three drinks per week. 4. Restrict activity to within the home to prevent disease transmission.
2
51. A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects? 1. Constipation. 2. Hyperkalemia. 3. Irregular pulse. 4. Dysuria.
2
63. A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client's spouse how to administer this medication. Which of the following statements would indicate that the client has understood the information? 1. "I'll take it with Maalox." 2. "TIl mix it with apple juice." 3. "I'll take it with a laxative." 4. "IIl mix the crushed tablets in some gelatin."
2
66. Which of the following adverse effects occur when there is too rapid an infusion of TPN solution? 1. Negative nitrogen balance. 2. Circulatory overload. 3. Hypoglycemia. 4. Hypokalemia.
2
70. The nurse should institute which of the following measures to prevent transmission of the hepatitis C virus to health care personnel? 1. Administering hepatitis C vaccine to all health care personnel. 2. Decreasing contact with blood and blood contaminated fluids. 3. Wearing gloves when emptying the bedpan. 4. Wearing a gown and mask when providing direct care.
2
82. Which of the following should the nurse include in the plan of care to ensure adequate nutri tion for a very active, talkative, and easily distractible client who is unable to sit through meals? 1. Direct the client to the room to eat. 2. Offer the client nutritious finger foods. 3. Ask the client's family to bring the client's favorite foods from home. 4. Ask the client about food preferences.
2
A child's plan of care lists increasing protein intake as a goal. Which of the following foods that the child likes should the nurse encourage the child to eat? 1. A bacon, lettuce, and tomato sandwich. 2. Fruit-flavored yogurt. 3. Nacho chips and salsa. 4. Crackers with butter and jelly.
2
A client has been diagnosed with early alcoholic cirrhosis. The client should be taught that changing which of the following behaviors could potentially reverse the pathologic changes occurring in the liver? 1. Do not become fatigued. 2. Avoid drinking alcohol. 3. Eliminate smoking. 4. Eat a high-carbohydrate, low-fat diet.
2
A client has been diagnosed with viral hepatitis. Which of the following goals is most appropriate for the client? 1. Achieve control of abdominal pains. 2. Increase activity levels gradually. 3. Be able to breathe without difficulty. 4. Experience relief from edema.
2
After a nasogastric (NG) tube has been inserted, the nurse can most accurately determine that the tube is in the proper place if which of the following can be demonstrated? 1. The client is no longer gagging or coughing. 2. The pH of the aspirated fluid is measured. 3. Thirty milliliters of normal saline can be injected without difficulty. 4. A whooshing sound is auscultated when 10 mL of air is inserted.
2
The nurse teaches the client with cirrhosis that the expected outcome of taking lactulose is: 1. One regular bowel movement a day. 2. Two to three soft stools per day. 3. Four to five loose stools per day. 4. Five to six loose stools per day.
2
When planning the care for a client diagnosed with hepatitis A, which of the following nurs- in interventions should the nurse include? Select all that apply. 1. Implementing an exercise program. 2. Providing relief from nausea and vomiting. 3. Administering pain medication. 4. Encouraging multiple small meals daily. 5. Planning frequent rest periods.
245
114. A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions to manage which of the following problems? 1. Drug and alcohol abuse. 2. Risk for injury. 3. Severe pain. 4. Ineffective airway clearance.
3
129. Which of the following statements best explains why the nurse should evaluate gastric residual before administering the client's next enteral feeding? 1. To determine how well nutrients are being absorbed. 2. To determine if the client is receiving enough feeding. 3. To prevent overdistention of the stomach. 4. To prevent mixing undigested formula with partially digested formula.
3
166. The infusion rate of total parenteral nutrition (TN) is tapered before being discontinued. This is done to prevent which of the following complications? 1. Essential fatty acid deficiency. 2. Dehydration. 3. Rebound hypoglycemia. 4. Malnutrition.
3
20. A client is admitted with acute necrotizing pancreatitis Lab results have been obtained, and a peripheral IV has been inserted. Which of the following prescriptions from a health care provider should the nurse question? 1. Infuse a 500-mL normal saline bolus. 2. Calcium gluconate 90 mg in 100 mL. NS. 3. Total parenteral nutrition (TPN) at 72 mL/h. 4. Placement of a Foley catheter.
3
28. The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by doing which of the following? 1. Recording daily fluid intake. 2. Performing glucose fingerstick tests twice a dav. 3. Observing stools for steatorrhea. 4. Testing urine for ketones.
3
34. A client has a positive serologic test for anti HEV (hepatitis C virus). The nurse should instruct the client 1. How to self-administer alpha interferon 2. That the HCV will resolve in approximately 3 months. 3. That is a follow-up appointment for HCV geno. type testing is required. 4. To take alpha interferon as prescribed
3
40. The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which of the following discharge instructions is appropriate for the client? 1. Spray the house to eliminate infected insects. 2. Tell family members to try to stay away from the client 3. Tell family members to wash their hands frequently. 4. Disinfect all clothing and eating utensils.
3
43. Interferon alfa-2b (Intron A) has been pre- scribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects? 1. Retinopathy. 2. Constipation. 3. Flulike symptoms. 4. Hypoglycemia.
3
47. The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which serum lab value that is a potential precipitating factor for hepatic encephalopathy? 1. Aldosterone. 2. Creatinine. 3. Potassium. 4. Protein.
3
50. A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for: 1. Hypermagnesemia. 2. Hypernatremia. 3. Hypokalemia. 4. Hypocalcemia.
3
50. The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? 1. Peripheral edema. 2. Ascites. 3. Anorexia. 4. Jaundice.
3
55. The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. Which action should the nurse take first? 1. Clean the insertion site and redress the area. 2. Document assessment findings in the client's chart. 3. Obtain a culture specimen of the drainage. 4. Notify the physician.
3
59. The health care provider instructs a client with alcohol induced cirrhosis to stop drinking alcohol. The expected outcome of this intervention is 1. Absence of delirium tremens. 2. Having a balanced diet. 3. Improved liver function. 4. Reduced weight.
3
61. A client's serum ammonia level is elevated. and the physician prescribes 30 mL of lactulose. Which of the following is an adverse effect of this drug? 1. Increased urine output. 2. Improved level of consciousness. 3. Increased bowel movements. 4. Nausea and vomiting.
3
64. The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching? 1. "I should eat a high-protein, high-carbohydrate diet to provide energy. 2. "It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin. 3. "I should avoid constipation to decrease chances of bleeding. 4. 'If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured."
3
66. A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: 1. Institute range-of-motion (ROM) exercise every 4 hours. 2. Massage the abdomen once a shift. 3. Use an alternating air pressure mattress. 4. Elevate the lower extremities.
3
A nurse is assessing a client with viral hepatitis. The client reports that the appetite is poor and the presence of food causes nausea. The nurse should encourage the client to eat: 1. High-fat foods at each meal. 2. Foods high in protein. 3. The majority of the calories in the morning during small frequent snacks. 4. A low-calorie diet with numerous snacks.
3
The client with a nasogastric (NG) tube has abdominal distention. Which of the following measures should the nurse do first? 1. Call the physician. 2. Irrigate the NG tube. 3. Check the function of the suction equipment. 4. Reposition the NG tube.
3
48. A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? 1."He must have been eating too many foods with salt in them. Salt pulls water with it." 2."The swelling in his ankles must have moved up closer to his heart so the fluid circulates better 3. "He must have forgotten to take his daily water pill.» 4. blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels
4
67. The nurse is planning a staff development program on how to care for clients with hepatitis A. Which of the following precautions should the nurse indicate as essential when caring for clients with hepatitis A? 1. Gowning when entering a client's room. 2. Wearing a mask when providing care. 3. Assigning the client to a private room. 4. Wearing gloves when giving direct care.
4
When infusing total parenteral nutrition (TPN), the nurse should assess the client for which of the following complications? 1. Essential amino acid deficiency. 2. Essential fatty acid deficiency. 3. Hyperglycemia. 4. Infection.
4
27, Pancreatic enzyme replacements are pre- scribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? 1. Three times daily between meals. 2. With each meal and snack. 3. In the morning and at bedtime. 4. Every 4 hours, at specified times.
2
32. Which of the following is normal for a client during the icteric phase of viral hepatitis? 1. Tarry stools. 2. Yellowed sclera, 3. Shortness of breath. 4. Light, frothy urine
2
56. Which of the following positions wowld.be appropriate for a client with severe ascites? 1. Fowler's. 2. Side-lying. 3. Reverse Trendelenburg. 4. Sims.
1
80. A client has just returned from surgery for a gastrectomy. The nurse should position the client in which position? 1. Prone. 2. Supine. 3. Low Fowler's. 4. Right or left Sims'
3
42. What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis? 1. "Don't worry. It's normal to feel that way." 2. "Your friends are probably afraid of contracting hepatitis from you." 3. "I'm sure you're imagining that!" 4.Tell me more about your feelings of Isolation
4
44. The nurse is preparing a community education program about preventing hepatitis B infection. Which of the following would be appropriate to incorporate into the teaching plan? 1. Hepatitis B is relatively uncommon among college students. 2. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. 3. Good personal hygiene habits are most effec- tive at preventing the spread of hepatitis B. 4. The use of a condom is advised for sexual intercourse.
4
59. A nurse is assisting with the removal a of central venous access device (CVAD). The nurse should instruct the client to: 1. Turn to the left side. 2. Exhale slowly and evenly. 3. Turn to the right side. 4. Take a deep breath and hold it.
4
121. Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed? 1. Provide the client with oral hygiene. 2. Offer the client liquids to drink. 3. Encourage the client to cough and deep breathe. 4. Auscultate the client's bowel sounds.
1
17. The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions: She becomes upset when Her physician persists in asking her about the alcohol rate. The nurse should explain that the reason for these questions is that: 1.There is a strong link between alcohol use and acute pancreatitis. 2. Alcohol intake can interfere with the tests used to diagnose pancreatitis. 3. Alcoholism is a major health problem, and all clients are questioned about alcohol intake. 4. The physician must obtain the pertinent facts, regardless of religious beliefs.
1
21. Which of the following medications would the nurse question for a client with acute pancreatitis? 1. Furosemide (Lasix) 20 mg IV push 2. Imipenem (Primaxin) 500 mg IV. 3. Morphine sulfate 2 mg IV push. 4. Famotidine (Pepcid) 20 mg IV push.
1
24. The nurse notes that a client with acute pan- creatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? 1. The client may be developing hypocalcemia. 2. The client is experiencing a reaction to meperidine (Demerol). 3. The client has a nutritional imbalance. 4. The client needs a muscle relaxant to promote rest.
1
25. A client is receiving Propantheline bromide in the management of acute pancreatitis. Which of the following would indicate that the nurse should discuss withholding the medication with the physician? 1. Absent bowel sounds. 2. Increased urine output. 3. Diarrhea. 4. Decreased heart rate.
1
46. The client has sore nares while a nasogastric (NG) tube is in place. Which of the following nurs- ing measures would be most appropriate to help alleviate the client's discomfort? 1. Reposition the tube in the nares. 2. Irrigate the tube with a cool solution. 3. Apply a water-soluble lubricant to the nares. 4. Have the client change position more frequently.
3
36. A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse, "When will my strength return?" Which of the following responses by the nurse is most appropriate? 1. "Your fatigue should be gone by now. We will evaluate you for a secondary infection. 2. "Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment regimen is complete." 3. "It is important for vou to increase your activity level. That will help decrease your fatigue." 4. "It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months."
4
41. The client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to: 1. Increase mobility. 2. Learn new self-care skills. 3. Adapt to new levels of energy. 4. Gradually increase activity tolerance.
4
37. The nurse is developing a plan of care for lhe client with viral hepatitis. The nurse should instruct the client to: 1. Obtain adequate bed rest. 2. Increase fluid intake. 3. Take antibiotic therapy as prescribed. 4. Drink 8 o2 (240 mL) of an electrolyte solution every dav.
1
38. When planning care for a client with viral hepatitis, the nurse should review laboratory reports for which of the following abnormal laboratory values? 1. Prolonged prothrombin time. 2. Decreased blood glucose level. 3. Elevated serum potassium level. 4. Decreased serum calcium level.
1
46. A client with cirrhosis is receiving lactulose. During the assessment, the nurse notes increased confusion and asterixis. The nurse should: 1. Assess for gastrointestinal (GI) bleeding. 2. Hold the lactulose. 3. Increase protein in the diet. 4. Monitor serum bilirubin levels.
1
52. What diet should be implemented for a client who is in the early stages of cirrhosis? 1. High-calorie, high-carbohydrate. 2. High-protein, low-fat. 3. Low-fat. low-protein. 4. High-carbohydrate, low-sodium
1
Which of the following is an early indication that a client has developed hypocalcemia? 1. Tingling in the fingers. 2. Depressed reflexes. 3. Ventricular dysrhythmias. 4. Memory changes.
1
49. A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply. 1. Preventing constipation. 2. Administering lactulose to reduce blood ammonia levels. 3. Monitoring coordination while walking. 4. Checking the pupil reaction. 5. Providing food and fluids high in carbohydrate. 6. Encouraging physical activity.
12345
59. A nurse is assessing a client who has a poten- tial diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply. 1. Excessive alcohol use. 2. Gallstones. 3. Abdominal trauma. 4. Hypertension. 5. Hyperlipidemia with excessive triglycerides. 6. Hypothyroidism.
1235
58. A client with a Sengstaken-Blakemore tube has a sudden drop in SpO, and increase in respiratory rate to 40 breaths/min. The nurse should do which of the following in order from first to last? 1. Affirm airway obstruction by the tube. 2. Remove the tube. 3. Deflate the tube by cutting with bedside scissor 4. Apply oxygen via face mask.
1324
The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? 1. The client with cirrhosis who became confused and disoriented during the night. 2. The client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted. 3. The client with acute pancreatitis who is requesting pain medication. 4. The client with hepatitis B who has questions about discharge instructions.
1324
54, Which of the following health promotion activities would be appropriate for the nurse to sug- gest that the client with cirrhosis add to the daily routine at home? 1. Supplement the diet with daily multivitamins 2. Abstain from drinking alcohol. 3. Take a sleeping pill at bedtime 4. Limit contact with other people whenever possible.
2
56. Total parenteral nutrition (TPN) is prescribed for a client with who has recently had a small and large bowel resection, and who is currently not taking anything by mouth. The nurse should: 1. Administer TPN through a nasogastric or 2. Handle TPN using strict aseptic technique. 3. Auscultate for the presence of bowel sounds prior to administering TPN. 4. Designate a peripheral intravenous (IV) site for TPN administration.
2
58. A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: 1. An isotonic dextrose solution. 2. A hypertonic dextrose solution. 3. A hypotonic dextrose solution. 4. A colloidal dextrose solution
2
62. Which of the following interventions should the nurse include in the client's plan of care to prevent complications associated with TN administered through a central line? 1. Use a clean technique for all dressing changes. 2. Tape all connections of the system 3. Encourage bed rest. 4. Cover the insertion site with a moisture-proof dressing.
2
147. Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply. 1."Limit your caloric intake so that you don't become overweight. 2."An adequate intake of protein is important to your health." 3. "I encourage you to eat small, frequent meals.» 4."Restrict your fluid intake to 1,000 mL/day." 5. "Limit your alcohol intake to one glass of wine daily."
23
. 53. A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply. 1. Avoid lotions containing calamine. 2. Add baking soda to the water in a tub bath. 3. Keep nails short and clean. 4. Rub the skin when it itches with knuckles instead of nails. 5. Massage skin with alcohol 6. Increase sodium intake in diet
234
24. When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which of the following foods? Select all that apply. 1. Bacon. 2. Cooked dry beans. 3. Peanut butter. 4. Yogurt. 5. Apple.
234
35. A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John's Wort for a "bit of depression," and takes Tylenol for frequent headaches. The nurse should do which of the following? Select all that apply. 1. Instruct the client that the wine with meals can be beneficial for cardiovascular health. 2. Instruct the client to ask the health care provider about taking any other medications as they may interact with medications the client is currently taking. 3. Instruct the client to increase the protein in his diet and eat less frequently. 4. Advise the client of the need for additional testing for HIV. 5. Encourage the client to obtain sufficient rest.
245
145. The nurse is obtaining a nursing history of a client suspected of having hepatitis C. The nurse should ask the client if he has: 1. Drunk contaminated water. 2. Traveled to India. 3. Had a tattoo. 4. Eaten shellfish.
3
63. The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last? 1. Change dressing per institutional policy. 2. Culture drainage at insertion site. 3. Notify physician. 4. Position rolled towel under client's back parallel to the spine.
3421
136. When giving a client a tube feeding, the nurse should: 1. Warm the feeding solution before administration. 2. Place the client in a left side-lying position. 3. Aspirate residual gastric contents before the feeding and discard. 4.Verify position of the tube before beginning feeding.
4
150. A client is admitted with acute pancreatitis. The nurse should monitor which of the following laboratory values? 1. Decreased urine amylase level. 2. Increased calcium level. 3. Decreased glucose level. 4. Increased serum amylase and lipase levels.
4
22. The nurse should monitor the client with acute pancreatitis for which of the following complications? 1. Heart failure. 2. Duodenal ulcer. 3. Cirrhosis, 4. Pneumonia.
4
30. The nurse is assessing a client with hepatitis and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which of the following statements by the client requires further instruction by the nurse? 1. "I require increased periods of rest." 2. "I follow a low-fat, high-carbohydrate diet." 3. "I eat dry toast to relieve my nausea. 4. "I take acetaminophen (Tylenol) for arthritis pain."
4
31. College freshmen are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on the need for: 1. Water sanitation. 2. Single dormitory rooms. 3. Vaccination for hepatitis D 4. Safe sexual practices.
4
65. Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy? 1. Glycosuria. 2. A 1-to 2-1b (0.45- to 0.9-kg) weight gain. 3. Decreased appetite. 4. Elevated temperature.
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68. After completing assessment rounds, which of the following should the nurse discuss with the physician first? 1. A client with cirrhosis who is depressed and has refused to eat for the past 2 days. 2. A client with stable vital signs that has been receiving IV cipro following a cholecystec- tomy for 1 day and has developed a rash on the chest and arms. 3. A client with pancreatitis whose family requests to speak with the physician regarding the treatment plan. 4. A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular.
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A client is receiving total parenteral nutrition (TV). The nurse notices that the bag of TPN solu- tion has been infusing for 24 hours but has 300 mL of solution left. The nurse should: 1. Continue the infusion until the remaining 300 mL is infused. 2. Change the filter on the tubing and continue with the infusion. 3. Notify the physician and obtain prescriptions to alter the flow rate of the solution. 4. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.
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The nurse is reviewing the chart information for a client with increased ascites, the data includes the following: temp 37.2, HR 118, RR 26, BP 128/76, O2 89% on room air. Which action should receive priority by the nurse? 1. Assess heart sounds. 2. Obtain a prescription for blood culture, 3. Prepare for a paracentesis. 4. Raise the head of the bed.
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