med surg II
A client has sought care due to recent dark-colored stools. A fecal occult blood test has been ordered. The nurse should give what instructions to the client? A."Take no NSAIDs w/in 72 hours of the test." B."Take prescribed medications as usual." C."Avoid over-the-counter (OTC) vitamin C supplements." D."Do not use fiber supplements before the test."
A. "Take no NSAIDs w/in 72 hours of the test." *can cause a false-positive result; red meats, aspirin, turnips & horseradish also have same effect
A client w/ an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on a medical unit. The nurse observes that the client expresses anger & irritation when the call bell isn't answered immediately. Which response would be the most appropriate? A. "You seem like you're feeling angry. Is that something that we could talk about?"' B. "Try to remember that stress can make your symptoms worse." C. "Would you like to talk about the problem w/ the nursing supervisor?" D. "I can see you're angry. I'll come back when you've calmed down."
A. "You seem like you're feeling angry. Is that something that we could talk about?"' *offer to listen to client to fully understand client; acknowledge feelings
A client w/ HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea? A. Administer antidiarrheal medications on a scheduled basis, as prescribed. B. Encourage the client to eat three balanced meals & a snack at bedtime. C. Increase the client's oral fluid intake. D. Encourage the client to increase his or her activity level.
A. Administer antidiarrheal medications on a scheduled basis, as prescribed. *increased oral fluid may exacerbate diarrhea, small & frq meals may be beneficial, & it's unrealistic to inc activity while pt has frq diarrhea
A nurse is implementing the care plan of diarrhea r/t enteric pathogens of human immunodeficiency virus infections. Which interventions are needed to reach the goal of resuming usual bowel habits? Select all that apply. A. Administer antimicrobials. B. Restrict fluid to 1500 mL/50.7 fl oz daily. C. Implement a BRAT diet D. Administer antitussives E. Establish normal bowel pattern
A. Administer antimicrobials. D. Administer antitussives E. Establish normal bowel pattern
A nurse is performing the admission assessment of a client who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. A. Current medication regimen B. Identification of client's support system C. Immune system function D. Genetic risk factors for HIV E. History of sexual practices
A. Current medication regimen B. Identification of client's support system C. Immune system function E. History of sexual practices
A female client who is HIV negative arrives for a gynecologist appointment & reports that her husband, who is HIV positive, no longer wants to wear a latex condom. Which alternative treatments would the nurse recommend to reduce the likelihood of HIV transmission? Select all that apply. A. Dental dam B. Polyurethane female condom C. Microbicidal vaginal suppository D. Non-latex male condoms E. Pre-exposure prophylaxis
A. Dental dam B. Polyurethane female condom E. Pre-exposure prophylaxis
A clinic nurse is caring for a client admitted w/ acquired immunodeficiency syndrome (AIDS). The client is experiencing a progressive decline in cognitive, behavioral, & motor functions. These symptoms are most likely related to the onset of which complication? A. Human immunodeficiency virus (HIV) encephalopathy B. B-cell lymphoma C. Kaposi sarcoma D. Wasting syndrome
A. Human immunodeficiency virus (HIV) encephalopathy *HIV encephalopathy: characterized by a progressive decline in cognitive, behavioral, & motor fx
A nurse is planning the care of a client w/ acquired immunodeficiency syndrome (AIDS) who is admitted to the unit w/ Pneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this client? A. Ineffective airway clearance B. Impaired oral mucous membranes C. Imbalanced nutrition: Less than body requirements D. Activity intolerance
A. Ineffective airway clearance *airway & breathing take top priority because immediacy of health consequences *ABC's
A nurse is caring for a client who is scheduled for a colonoscopy & whose preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A. Inflammatory bowel disease B. Intestinal polyps C. Diverticulitis D.Colon cancer
A. Inflammatory bowel disease *lavage solution: contraindicated in pts w/ intestinal obstruction & IBD
Since the emergence of the human immunodeficiency virus (HIV), there have been significant changes in epidemiologic trends. Members of which group are most affected by new cases of HIV? A. Male-to-male sexual contact B. Heterosexual contact C. Male-to-male sexual contact w/ injection drug use D. People 25 to 29 years of age
A. Male-to-male sexual contact
A nurse is assessing the skin integrity of a client who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces? A. Perianal region & oral mucosa B. Sacral region & lower abdomen C. Scalp & skin over the scapulae D. Axillae & upper thorax
A. Perianal region & oral mucosa *MM & perineal region vulnerable to skin breakdown/fungal infection
A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client w/ human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply. A. Potential drug toxicities B. Needed dietary changes C. Potential drug interactions D. Sleep pattern disturbances E. Adherence requirements
A. Potential drug toxicities (rashes & hypersensitivity reactions) C. Potential drug interactions (supplements & vitamins) E.Adherence requirements (daily use is needed to be effective)
A nurse is completing the nutritional status of a client who has been admitted w/ AIDS-related complications. What components should the nurse include in this assessment? Select all that apply. A. Serum albumin level B. Weight history C. White blood cell count D. Body mass index E. Blood urea nitrogen (BUN) level
A. Serum albumin level B. Weight history D. Body mass index E. Blood urea nitrogen (BUN) level
The nurse is applying standard precautions in the care of a client who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. A. Using appropriate personal protective equipment B. Placing clients in negative pressure isolation rooms C. Placing clients in positive pressure isolation rooms D. Using safe injection practices E. Performing hand hygiene
A. Using appropriate personal protective equipment D. Using safe injection practices E. Performing hand hygiene
A client has been brought to the emergency department w/ abdominal pain & is diagnosed w/ appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond? A."Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery." B."The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." C."Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." D."Your small intestine will adapt over time to the absence of your appendix."
A."Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery."
A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure? A.Colonoscopy B.Barium enema C.ERCP D.Upper gastrointestinal fibroscopy
A.Colonoscopy *tissue biopsy may be obtained/removed & evaluated in a colonoscopy
A client has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the client's gastrointestinal function? Select all that apply. A.Decreased motility B.Increased sphincter tone C.Increased enzyme release D.Inhibition of secretions E.Increased peristalsis
A.Decreased motility B.Increased sphincter tone D.Inhibition of secretions *norepinephrine decreases GI motility, secretions, & sphincter muscle tone
On admission to a medical unit, a client w/ human immunodeficiency virus (HIV) tests positive for benzodiazepine. The client denies using this medication. Which medication is likely causing a false-positive result? A.Efavirenz B.Doravirine C.Nevirapine D.Etravirine
A.Efavirenz
A nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? A.Inspection, auscultation, percussion, & palpation B.Inspection, palpation, auscultation, & percussion C.Inspection, percussion, palpation, & auscultation D.Inspection, palpation, percussion, & auscultation
A.Inspection, auscultation, percussion, & palpation
An APN is assessing the size & density of a client's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented? A.Percussion B.Auscultation C.Inspection D.Rectal examination
A.Percussion
A nurse is caring for an 83-year-old client who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the client's health issues? A.Stomach emptying takes place more slowly. B.The villi and epithelium of the small intestine become thinner. C.The esophageal sphincter becomes incompetent. D.Saliva production decreases.
A.Stomach emptying takes place more slowly. *delayed gastric emptying occurs in older adults; may contribute to nausea
A medical client's CA 19-9 levels have become available & they are significantly elevated. How should the nurse best interpret this diagnostic finding? A.The client may have cancer, but other GI disease must be ruled out. B.The client most likely has early-stage colorectal cancer. C.The client has a genetic predisposition to gastric cancer. D.The client has cancer, but the site is unknown.
A.The client may have cancer, but other GI disease must be ruled out. *elevated CA 19-9 levels could also be due to conditions like colorectal/lung/gallbladder cancer; gallstones; pancreatitis; CF; liver dz
A nurse is working w/ a client who was diagnosed w/ HIV several months earlier. This client will be considered to have AIDS when the CD4+ T-lymphocyte cell count drops below what threshold? A. 75 cells/mm3 of blood B. 200 cells/mm3 of blood C. 325 cells/mm3 of blood D. 450 cells/mm3 of blood
B. 200 cells/mm3 of blood *when CD4 T-cell levels drop below 200 cells/mm3, the person is said to have AIDS
A nurse is performing an admission assessment on a client w/ stage 3 human immunodeficiency virus (HIV). After assessing the client's gastrointestinal system & analyzing the data, which nursing diagnosis is most likely to be the priority? A. Acute abdominal pain B. Diarrhea C. Bowel incontinence D. Constipation
B. Diarrhea *diarrhea is a problem in many HIV & AIDS pts
A nurse is performing the initial assessment of a client who has a recent dx of systemic lupus erthematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? A. Petechiae B. Erythematous rash C. Jaundice D. Skin sloughing
B. Erythematous rash *butterfly rash: commonly seen in SLE
A client who has acquired immunodeficiency syndrome (AIDS) has been admitted for the treatment of Kaposi sarcoma. Which nursing diagnosis should the nurse associate w/ this complication of AIDS? A. Risk for disuse syndrome related to Kaposi sarcoma B. Impaired skin integrity related to Kaposi sarcoma C. Diarrhea related to Kaposi sarcoma D. Impaired swallowing related to Kaposi sarcoma
B. Impaired skin integrity related to Kaposi sarcoma *cutaneous signs: first manifestations of HIV; brownish pink-deep purple; flat/raised
A client w/ HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A. Appropriate use of prophylactic antibiotics B. Importance of personal hygiene C. Signs & symptoms of wasting syndrome D. Strategies for adjusting antiretroviral dosages
B. Importance of personal hygiene *infection control
A client w/ human immunodeficiency virus (HIV) is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this client should expect the health care provider to prescribe which medication for the management of the client's diarrhea? A. Fluoxetine B. Octreotide acetate C. Levofloxacin D. Valganciclovir
B. Octreotide acetate
A nurse is assessing a client w/ HIV who has been admitted w/ pneumonia. In assessing the client, which of the following observations takes immediate priority? A. Oral temperature of 37.2°C (99°F) B. Tachypnea & restlessness C. Frequent loose stools D. Weight loss of 0.45 kg (1 lb) since yesterday
B. Tachypnea & restlessness *sx of altered respiratory status & need priority STAT
A client has come to the clinic reporting blood in the stool. A fecal occult blood test is performed but is negative. Based on the client's history, the health care provider suggests a colonoscopy, but the client refuses, citing a strong aversion to the invasive nature of the test. What other test might theprovider order to check for blood in the stool? A. laparoscopic intestinal mucosa biopsy B. fecal immunochemical test (FIT) C.Computed tomography (CT) D.Magnetic resonance imagery (MRI)
B. fecal immunochemical test (FIT) *more accurate than guaiac testing (FOBT); useful for client
A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A."Abdominal ultrasound is very safe, but it can't be performed if you're pregnant." B."Abdominal ultrasound poses no known safety risks of any kind." C."Current guidelines state that a person can have up to 3 ultrasounds per year." D."Current guidelines state that a person can have up to 6 ultrasounds per year."
B."Abdominal ultrasound poses no known safety risks of any kind."
A nurse auscultated a client's abdomen & noted 1 or 2 bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds? A.Normal B.Hypoactive C.Hyperactive D.Paralytic ileus
B.Hypoactive
A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow? A.Temporal lobe B.Medulla oblongata C.Cerebellum D.Pons
B.Medulla oblongata
Results of a client's preliminary assessment prompted an examination of the client's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding? A.Perform a focused abdominal assessment. B.Prepare to meet the client's psychosocial needs. C.Liaise with the nurse practitioner to perform an anorectal examination. D.Encourage the client to adhere to recommended screening protocols.
B.Prepare to meet the client's psychosocial needs. *cancer may be present; prepare emotional needs
A client has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test? A.Impaired dentition related to gingivitis B.Risk for impaired skin integrity related to peptic ulcers C.Imbalanced nutrition: Less than body requirements related to enzyme deficiency D.Diarrhea related to Clostridium difficile infection
B.Risk for impaired skin integrity related to peptic ulcers *H. pylori bacteria causes PUD
The nurse is caring for a client w/ gastrointestinal symptoms who reports being under a significant amount of stress at home and at work. Which gastrointestinal effect of stress should the nurse anticipate is affecting this client? A.Increased gastric acid secretion B.Slowed peristalsis C.Increased enteric blood flow D.Relaxed sphincter muscles
B.Slowed peristalsis *stress stimulates SNS (slows GI motility)
A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education? A.The client should drink at least 2 liters of fluid in the next 12 hours. B.The client can resume a normal routine immediately. C.The client should expect fecal urgency for several hours. D.The client can expect some scant rectal bleeding.
B.The client can resume a normal routine immediately.
A client is in the primary infection stage of human immunodeficiency virus (HIV). Which statement regarding this client's current health status is most accurate? A.The client's HIV antibodies are successfully, but temporarily, killing the virus. B.The client is infected w/ HIV but lacks HIV-specific antibodies. C.The client's risk for opportunistic infections is at its peak. D.The client may or may not develop long-standing HIV infection.
B.The client is infected w/ HIV but lacks HIV-specific antibodies.
A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A.Sigmoid colon B.Upper GI tract C.Large intestine D.Anus or rectum
B.Upper GI tract *blood in lower GI tract is bright/dark red
A client w/ systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? A. "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." B. "I'll try to be as physically active as possible between flare-ups." C. "I'll make sure to monitor my body temperature on a regular basis." D. "I'll stop taking my steroids when I get relief from my symptoms."
C. "I'll make sure to monitor my body temperature on a regular basis." *fever can signal exacerbation & should be reported to the HCP
A client w/ a recent diagnosis of HIV infect ion expresses an interest in exploring alternative & complementary therapies. How should the nurse best respond? A. "Complementary therapies generally have not been app roved, so clients are usually discouraged from using them." B. "Researchers have not looked at the benefits of alternative therapy for clients w/ HIV, so we suggest that you stay away from these therapies until there is solid research data available." C. "Many clients w/ HIV use some type of alternative therapy &, as w/ most health treatments, there are benefits & risks." D. "You'll need to meet w/ your doctor to choose between an alternative approach to treatment & a medical approach.
C. "Many clients w/ HIV use some type of alternative therapy &, as w/ most health treatments, there are benefits & risks." *open-ended, supportive approach & emphasize need to communicate w/ HCP
A client underwent an antibody test for human immunodeficiency virus (HIV) as part of a screening process & has just been told that the results were positive. Which anticipatory guidance regarding the next step should the nurse provide to the client? A. The client will be started on fluoxetine in 1 month. B. Antiretroviral therapy will begin w/in 3 months. C. Follow-up testing will be promptly performed to confirm the result. D. The client will be monitored for signs & symptoms of HIV to determine the need for treatment.
C. Follow-up testing will be promptly performed to confirm the result.
A nurse is assessing the abdomen of a client just admitted to the unit with suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding? A.Abdominal lesions are usually due to age-related skin changes. B.Integumentary diseases often cause GI disorders. C. GI diseases often produce skin changes. D. The client needs to be assessed for self-harm
C. GI diseases often produce skin changes.
A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A. rRemain NPO for 6 hrs postprocedure B. Administer a fleet enema to cleanse the bowel of barium C. Increase fluid intake to evacuate barium D. Avoid dairy products for 24 hrs postprocedure
C. Increase fluid intake to evacuate barium
The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? A.In a knee-chest position (lithotomy position) B.Lying prone w/ legs drawn toward the chest C.Lying on the left side w/ legs drawn toward the chest D.In a prone position w/ two pillows elevating the buttocks
C. Lying on the left side w/ legs drawn toward the chest *allows for best visualization
A client w/ AIDS is admitted to the hospital w/ AIDS-related wasting syndrome & AIDS-related anorexia. What drug has been found to promote significant weight gain in clients w/ AIDS by increasing body fat stores? A. Psyllium B. Momordica charantia C. Megestrol D. Ranitidine
C. Megestrol
A client w/ systemic lupus erythematosus (SLE) asks the nurse why the client has to come to theoffice so often for "check-ups." Which rationale for frequent office visits would be best for the nurse to mention? A. Seeing the client face to face B. Ensuring that the client is taking medications as prescribed C. Monitoring the disease process & how well the prescribed treatment is working D. Drawing blood work every month
C. Monitoring the disease process & how well the prescribed treatment is working
A client's primary infection w/ HIV has subsided & an equilibrium now exists between HIV levels and the client's immune response. This is known as what physiologic state? A. Static stage B. Latent stage C. Viral set point D. Window period
C. Viral set point
A nurse is caring for a client hospitalized w/ AIDS. A friend comes to visit the client & privately asks the nurse about the risk of contracting HIV when visiting the client. What is the nurse's best response? A."Do you think that you might already have HIV?" B."Your immune system is likely very healthy." C."AIDS isn't transmitted by casual contact." D."You can't normally contract AIDS in a hospital setting."
C."AIDS isn't transmitted by casual contact." *transmitted blood & bodily fluids
A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation? A."You'll need to fast for at least 18 hours prior to your test." B."Starting today, take over-the-counter (OTC) stool softeners twice daily." C."You'll need to have enemas the day before the test." D."For 24 hours before the test, insert a glycerin suppository every 4 hours."
C."You'll need to have enemas the day before the test." *preparation includes emptying & cleaning the lower bowel; low residue diet 1-2 days before test
An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test? A.Stool will be yellow for the first 24 hours' postprocedure. B.The barium may cause diarrhea for the next 24 hours. C.Fluids must be increased to facilitate the evacuation of the stool. D.Slight anal bleeding may be noted as the barium is passed.
C.Fluids must be increased to facilitate the evacuation of the stool. *inc fluids to flush out the barium solution
A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause? A.Diet high in red meat B.Upper GI bleed C.Hemorrhoids D.Use of iron supplements
C.Hemorrhoids *bright red streaking blood indicates lower GI bleed
A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT? A.Gastroesophageal reflux disease (GERD) B.Peptic ulcers C.Hemorrhoids D. Recurrent n/v
C.Hemorrhoids *contraindicated if there is hemorrhoidal bleeding
The nurse is caring for a client with a duodenal ulcer and is relating the client's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A.Secretion of hydrochloric acid (HCl) B.Reabsorption of water C.Secretion of mucus D.Absorption of nutrients E.Movement of nutrients into the bloodstream
C.Secretion of mucus D.Absorption of nutrients E.Movement of nutrients into the bloodstream
The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract? A.The breakdown of food particles into cell form for digestion B.The maintenance of fluid and acid-base balance C.The absorption into the bloodstream of nutrient molecules produced by digestion D.The control of absorption and elimination of electrolytes
C.The absorption into the bloodstream of nutrient molecules produced by digestion
A client has come into the free clinic asking to be tested for human immunodeficiency virus (HIV) infection. The client asks the nurse how the test works. The nurse responds that if the testing shows that antibodies to the acquired immunodeficiency syndrome (AIDS) virus are present in the blood, this indicates that the client has which of the following? A. Immunity to HIV B. An intact immune system C. An AIDS-related complication D. An HIV infection
D. An HIV infection *positive test results indicates AIDS antibodies are in blood; doesn't imply immunity to HIV
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, which instruction should the nurse give the attendees? A. Apply the condom prior to erection. B. A condom may be reused w/ the same partner if ejaculation has not occurred. C. Use skin lotion as a lubricant if alternatives are unavailable. D. Hold the condom during withdrawal so it doesn't come off.
D. Hold the condom during withdrawal so it doesn't come off. *condom should be rolled over hard penis, not prior to an erection before any kind of sex; hold tip to squeeze out air *don't use baby oil, skin lotion, petroleum jelly/cold cream to lubricate condom; can cause latex deterioration/condom breakage
A client has a diagnosis of AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate? A. Position the client in the high Fowler position whenever possible. B. Temporarily eliminate animal protein from the client's diet. C. Make sure the client eats at least two servings of raw fruit each day. D. Obtain a stool culture to identify possible pathogens.
D. Obtain a stool culture to identify possible pathogens.
A nurse is providing ongoing care for a client who is positive for human immunodeficiency virus (HIV), & assessment reveals a client w/ a newly delayed & shortened speech pattern. The client, who previously had no neurological or motor deficits, has forgotten that they are in the hospital & has trouble getting out of bed. Which problem is the client most likely experiencing related to these signs & symptoms? A.Cryptococcal meningitis B.Cytomegalovirus retinitis C.Peripheral neuropathy D.Subcortical neurodegenerative disease
D. Subcortical neurodegenerative disease *HAND: subtle changes in memory, language, & problem solving
The nurse is providing a client with the supplies necessary to perform two hemoccult tests on the client's stool. What instruction should the nurse give this client? A."If possible, fast for 12 hours before collecting a sample." B."Take all your medications except the antihypertensive ones." C."Don't eat highly acidic foods 72 hours before you start the test." D."Mail the paper slides to the clinic once you've collected the samples."
D."Mail the paper slides to the clinic once you've collected the samples."
An 18-year-old client who is pregnant has tested positive for human immunodeficiency virus (HIV) & asks the nurse if her baby is going to be born w/ HIV. Which response by the nurse is the best? A."Your baby has a one in four chance of being born w/ HIV." B."Your health care provider is likely the best one to answer that question." C. "If the baby is HIV-positive, we can't do anything until after the birth, so try not to worry." D."Your baby could contract HIV before, during, or after delivery."
D."Your baby could contract HIV before, during, or after delivery." *mother-baby HIV transmission can occur in utero, at birth/through nursing; don't downplay client's concerns
A nurse is caring for a client w/ recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy. How should the nurse in the radiology department prepare this client? A.Insert a nasogastric tube. B.Administer a micro Fleet enema at least 3 hours before the procedure. C.Have the client lie in a supine position for the procedure. D.Apply local anesthetic to the back of the client's throat.
D.Apply local anesthetic to the back of the client's throat. *preparation: spraying/gargling local anesthetic; pt should be positioned on side in case of emesis
A client will be undergoing a urea breath test for the detection of Helicobacter pylori. Which instruction should the nurse give to the client to prepare for this test? A.Ingest a capsule of carbon-labeled urea ingested three days before the test. B.Take prescribed antibiotics one month before the test. C.Fast for 12 hours before the test. D.Avoid taking cimetidine 24 hours before the test.
D.Avoid taking cimetidine 24 hours before the test. *carbon capsule is taken at time of test; avoid antibiotics 1 month before test
A nurse is performing an abdominal assessment of an older adult client. When collecting & analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A.Increased gastric motility B.Decreased gastric pH C.Increased gag reflex D.Decreased mucus secretion
D.Decreased mucus secretion
The nurse is caring for a client who has a diagnosis of AIDS. Inspection of the client's mouth reveals the new presence of white lesions on the client's oral mucosa. What is the nurse's most appropriate response? A.Encourage the client to gargle with salt water twice daily. B.Attempt to remove the lesions with a tongue depressor. C.Make a referral to the unit's dietitian. D.Inform the primary provider of this finding
D.Inform the primary provider of this finding
A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider? A.Large, wide stools B.Milky white stools C.Three stools during an 8-hour period of time D.Streaks of blood present in the stool
D.Streaks of blood present in the stool
A client with a recent hx of intermittent bleeding is undergoing capsule endoscopy to determine the source of bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe? A.The entire peritoneal cavity can be visualized. B.The test allows for painless biopsy collection. C.The capsule is endoscopically placed in the intestine. D.The test is noninvasive.
D.The test is noninvasive. *capsule is swallowed to visualize GI tract
