Med-Surg: Lewis Ch 27, Chapter 30: Nursing Management- Lower Respiratory Problems, Lower respiratory problems, Stress: Peritonitis, Gastro 5, LP 9, GI, Chapter 24 IBS, Chapter 57: Care of Patients with Inflammatory Intestinal Disorders, Gastro/ Muscu...

Ace your homework & exams now with Quizwiz!

D. covers the mouth and nose when coughing.

1. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB A. demonstrates correct use of a nebulizer. B. reports daily to the public health department. C. washes dishes and personal items after use. D. covers the mouth and nose when coughing.

The nurse is caring for an older patient recovering from a bleeding ulcer. Which manifestations should the nurse use to determine whether the patient is experiencing peritonitis? Standard Text: Select all that apply. 1. confusion 2. bradycardia 3. restlessness 4. abdominal discomfort 5. decreased urinary output

1. confusion 3. restlessness 4. abdominal discomfort 5. decreased urinary output Reason: Patients who are older, chronically debilitated, or immunosuppressed may present with few of the classic signs of peritonitis. Increased confusion and restlessness, decreased urinary output, and vague abdominal complaints may be the only manifestations present. Bradycardia is not a manifestation of peritonitis in an older patient.

A patient with peritonitis develops a temperature of 103° F (39.4° C), is restless, has blood pressure of 85/45 and has a urinary output of 76 mL in 8 hours. The nurse should develop a plan of care related to which health problem? 1. hypovolemic shock 2. inflammation 3. third spacing 4. bowel dysfunction

1. hypovolemic shock Reason: The patient experiencing peritonitis may develop an abscess, which can lead to shock. The patient developing shock may present with oliguria, hypotension, fever, restlessness, confusion, and hypovolemia. The symptoms do not indicate inflammation, third spacing, or bowel dysfunction.

A patient with chronic diarrhea has been advised by the healthcare provider to avoid foods containing sorbitol and mannitol. What should the nurse instruct the patient to avoid consuming for this health problem? Standard Text: Select all that apply. 1. mints 2. honey 3. pear juice 4. apple juice 5. orange juice

1. mints 3. Pear juice 4. Apple juice Reason: Apple and pear juice and mints may contain sorbitol or mannitol, which are sugars that are not absorbed and can cause osmotic draw, increasing diarrhea. Orange juice is not identified as a food item that aggravates chronic diarrhea.

A patient is prescribed a low-residue diet. What foods should the nurse instruct the patient to avoid while on this diet? 1. wine, vinegar, beer, liquor 2. rice, grains, pasta 3. canned vegetables 4. chilled fruit gelatin desserts

1. wine, vinegar, beer, liquor Reason: Alcohol is not permitted on a low-residue diet. Foods allowed include rice, grains, pasta, canned vegetables, and chilled fruit gelatin desserts.

C. Percussion is dull in left lower lobe

13. Which assessment finding alerts the nurse to the possibility of pneumonia in a client with chronic bronchitis? A. Pulse oximetry reading of 92% B. Shallow respirations of 32/min C. Percussion is dull in left lower lobe D. Wheezes are audible over right and left bronchi

A. An air leak is present at the chest tube insertion site or in the thoracic cavity.

14. The chest tube drainage system of the client 36 hours after a pneumonectomy has continuous bubbling in the water seal chamber (chamber 2). When you clamp the chest tube close to the client's dressing, the bubbling stops. What is your interpretation of this finding? A. An air leak is present at the chest tube insertion site or in the thoracic cavity. B. An air leak is present somewhere in the drainage system. C. The suction pressure applied to the system is too high. D. The suction pressure applied to the system is too low.

A. yellow-tinged skin.

15. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops A. yellow-tinged skin. B.changes in hearing. C. orange-colored urine. D. thickening of the nails.

The nurse teaches a patient with Crohn disease about surgery to create a continent ileostomy. Which patient statements indicate that teaching has been effective? Standard Text: Select all that apply. 1. "I will need to change my diet." 2. "Stool will collect in an internal pouch." 3. "Stool will not leak through the stoma." 4. "I will use a catheter to drain the stool." 5. "I will need to change the bag every day."

2. "Stool will collect in an internal pouch." 3. "Stool will not leak through the stoma." 4. "I will use a catheter to drain the stool." Reason: In a continent ileostomy an intra-abdominal reservoir is constructed and a nipple valve formed from the terminal ileum before it is brought to the surface of the abdominal wall. Stool collects in the internal pouch; the nipple valve prevents it from leaking through the stoma. A catheter is inserted into the pouch to drain the stool. An ostomy bag does not need to be worn with a continent ileostomy.

A patient with Crohn disease is instructed to ingest a low-residue diet. Which dietary choices indicate that the patient needs additional information about this eating plan? Standard Text: Select all that apply. 1. corn flakes 2. poppy seed roll 3. tapioca pudding 4. steamed broccoli 5. whole grain bread

2. Poppy seed roll 4. steamed broccoli 5. whole grain bread Reason: Raw or cooked seeds, cooked vegetables, and whole grain breads should be avoided on a low-residue diet. Cereals such as corn flakes and desserts such as tapioca are permitted on a low-residue diet.

The nurse has instructed the patient who is experiencing diarrhea associated with irritable bowel syndrome on dietary changes to prevent diarrhea. The nurse knows the patient understands the dietary changes if the patient selects which menu choices? 1. yogurt, crackers, and sweet tea 2. salad with chicken, whole wheat crackers 3. bacon, tomato, lettuce with mayonnaise, and a soft drink 4. tuna on white bread and green grapes

2. Salad with chicken, whole wheat crackers Reason: Salad and whole wheat crackers may decrease diarrhea due to increased fiber. Bacon, tomato, lettuce with mayonnaise and soft drink is high in fat and the soft drink is hyperosmolar, both contributing to diarrhea. Dairy increases diarrhea. Foods high in carbohydrates increase diarrhea. Green grapes may increase diarrhea.

After learning that a patient has abdominal pain that occurs at least 3 days per month over the last 3 months, the nurse suspects that a patient is experiencing irritable bowel syndrome. What findings did the nurse use to make this clinical decision? Standard Text: Select all that apply. 1. abdominal pain that is relieved by eating 2. abdominal pain that improves with defecation 3. abdominal pain that is associated with a change in stool form 4. abdominal pain that is associated with a change in bowel frequency 5. abdominal pain that improves with physical activity and limiting food intake

2. abdominal pain that improves with defecation 3. abdominal pain that is associated with a change in stool form 4. abdominal pain that is associated with a change in bowel frequency Reason: Irritable bowel syndrome is diagnosed based on the presence of abdominal pain or discomfort at least 3 days per month in the past 3 months that has at least two of the following characteristics: (1) improved with defecation, (2) associated with a change in frequency of elimination, (3) or associated with a change in stool form. Abdominal pain that is relieved by eating is not a characteristic of irritable bowel syndrome. Abdominal pain that improves with physical activity and limiting food intake is not characteristic of irritable bowel syndrome.

An older patient is diagnosed with severe acute diverticulitis. What treatment should the nurse expect to be prescribed for this patient? Standard Text: Select all that apply. 1. complete bed rest 2. intravenous fluids 3. nothing by mouth 4. aspirin or NSAIDs for pain 5. intravenous cefoxitin (Mefoxin)

2. intravenous fluids 3. nothing by mouth 5. intravenous cefoxitin (Mefoxin) Reason: Severe, acute attacks of diverticulitis often necessitate hospitalization and treatment with intravenous fluids and antibiotics such as cefoxitin (Mefoxin) a second-generation cephalosporin. The patient initially may be NPO. There is no need for the patient to be on complete bed rest. There is no specific recommendation for pain medications for acute diverticulitis.

The nurse is preparing to assess a patient with diverticulitis. Which area of the patient's abdomen should the nurse expect to palpate a mass? 1. upper-right quadrant 2. lower-left quadrant 3. area of McBurney point 4. epigastric region

2. lower-left quadrant Reason: Diverticulitis can manifest as a palpable mass in the left lower quadrant as a result of the inflammatory response. A mass in the upper-right quadrant could involve a disorder of the liver or transverse colon. McBurney point is palpated to elicit rebound tenderness pain characteristic of appendicitis. A mass in the epigastric region could indicate a disorder of the stomach or pancreas.

A. Azithromycin (Zithromax)

3. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first? A. Azithromycin (Zithromax) B. Acetaminophen (Tylenol) C. Guaifenesin (Robitussin) D. Codeine phosphate (Codeine)

The nurse is providing care to a patient admitted with acute diarrhea. What intervention would assist in this patient's care? 1. Provide a normal diet as tolerated. 2. Hold all medications until the diarrhea stops. 3. Provide clear liquids in small amounts. 4. Encourage normal activities of daily living in the hospital room.

3. Provide clear liquids in small amounts Reason: Fluid replacement is of primary importance in managing the patient with diarrhea. Solid food is withheld in the first 24 hours of acute diarrhea to rest the bowel. The nurse should provide antidiarrheal medication as prescribed. Because of the potential for orthostatic hypotension, this patient should be instructed to move slowly and not engage in normal activities of daily living until the blood pressure is assessed.

A patient with irritable bowel syndrome asks the nurse, "Why did the doctor order something for depression?" How should the nurse respond? 1. "Didn't the doctor tell you that you are depressed?" 2. "Depression can be caused by irritable bowel syndrome." 3. "Did the doctor not give you an opportunity to ask questions?" 4. "These medications help with the symptoms associated with your bowel problem."

4. "These medications help with the symptoms associated with your bowel problem." Reason: Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors (SSRIs), may help relieve abdominal pain associated with IBS. There is no indication the patient is depressed. Bowel disorders do not usually cause depression. The patient is asking for clarification, and asking whether the doctor provided the opportunity to ask questions does not address the patient's concern.

C. Using standard and airborne precautions until a chest x-ray shows no evidence of tuberculosis

4. The client has a productive cough, fever, and chills and a history of night sweats. The client's PPD test is negative. Which is the nurse's best intervention related to infection prevention? A. Using standard precautions alone because the client does not have tuberculosis B. Using standard and airborne precautions because the client has tuberculosis C. Using standard and airborne precautions until a chest x-ray shows no evidence of tuberculosis D. Using only airborne precautions because the client is taking penicillin for another infection

The nurse is providing medications to a patient with diverticular disease. Which medication should the nurse question for this patient? 1. docusate (Colace) 2. metronidazole (Flagyl) 3. trimethoprim-sulfamethoxazole (Bactrim) 4. bisacodyl (Dulcolax) suppository

4. bisacodyl (Dulcolax) sppository Reason: Although a stool softener such as docusate (Colace) may be prescribed, it is important to note that laxatives can further increase intraluminal pressure in the colon and should be avoided for the patient with diverticular disease. Systemic broad-spectrum antibiotics effective against usual bowel flora are prescribed to treat acute diverticulitis. Oral antibiotics such as metronidazole (Flagyl) or trimethoprim-sulfamethoxazole (Septra, Bactrim) may be prescribed if manifestations are mild.

A patient is diagnosed with gastroenteritis. The nurse should assess which serum laboratory value first? 1. sodium 2. bicarbonate 3. calcium 4. potassium

4. potassium Reason: Electrolyte and acid‒base imbalances may result from gastroenteritis. Extensive vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach. When diarrhea predominates, metabolic acidosis is more likely. Potassium is lost in either case, which leads to hypokalemia. Sodium, bicarbonate, and calcium are not the primary electrolyte lost with gastroenteritis.

B. puts on a surgical face mask before visiting the patient.

5. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member A. washes the hands before entering the patient's room. B. puts on a surgical face mask before visiting the patient. C. brings food from a "fast-food" restaurant to the patient. D. hands the patient a tissue from the box at the bedside.

B. increased vocal fremitus on palpation.

6. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find A. hyperresonance on percussion. B. increased vocal fremitus on palpation. C. fine crackles in all lobes on auscultation. D. asymmetric chest expansion on inspection.

D. Weak, nonproductive cough effort

8. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? A. Resting pulse oximetry (SpO2) of 85% B. Respiratory rate of 28 C. Large amounts of greenish sputum D. Weak, nonproductive cough effort

A 28yearold female client is diagnosed with inflammatory disease of the small bowel. When the client describes numerous daily bowel movements but denies the presence of bloody stool, the nurse realizes that this client was most likely diagnosed with: A) Crohn's disease. B) Ulcerative colitis. C) Chronic diarrhea. D) Gastroenteritis.

A client is hospitalized during an acute exacerbation of symptoms related to Crohn's. The nurse shows an understanding of the need for bowel rest by discussing with the client that he: A) Will be recieving total parental nutrition (TPN). B) Will be getting only a soft diet until the diarrhea subsides. C) Should select foods that are high in potassium. D) May find a highcalorie, lowfat, highfiber diet helpful.

A patient diagnosed with peptic ulcer disease (PUD) asks if surgery will be necessary. How should the nurse respond? A) "The administration of the appropriate medications makes surgery rarely necessary." B) "Surgery is required in about 50% of cases." C) "Surgery has a higher success rate than medication therapy alone." D) "If you take your medications and follow the prescribed diet, surgery isn't usually needed."

A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. Which of the following information should the occupational health nurse provide to the staff nurse? a. Use and adverse effects of isoniazid (INH) b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine

After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a client continues to have positive sputum smears for acid-fast bacilli (AFB). Which of the following actions should the nurse take next? a. Ask the client whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the client for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.

Following assessment of a client with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which of the following information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

The nurse is caring for a client who had a thoracotomy 1 hour ago and reports incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which of the following actions is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the client to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.

The nurse is caring for a client who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment? a. Paradoxical chest movement b. The complaint of chest wall pain c. A heart rate of 110 beats/minute d. A large bruised area on the chest

The nurse is caring for a client with a possible pulmonary embolism who has symptoms of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60 mm Hg, and respirations of 42 breaths/minute. Which of the following actions should the nurse implement first? a. Elevate the head of the bed to 45-60 degrees. b. Administer the ordered pain medication. c. Notify the client's health care provider. d. Offer emotional support and reassurance.

The nurse is caring for a client with bacterial pneumonia who has pleurisy. Which of the following actions should the nurse implement to promote airway clearance? a. Assist the client to splint the chest when coughing. b. Educate the client about the need for fluid restrictions. c. Encourage the client to wear the nasal oxygen cannula. d. Instruct the client on the pursed lip breathing technique.

The nurse is caring for a client with pneumonia who has symptoms of a sharp pain "whenever I take a deep breath." Which of the following actions should the nurse take next? a. Listen to the client's lungs. b. Administer the PRN morphine. c. Have the client cough forcefully. d. Notify the client's health care provider.

The nurse is teaching a client who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications. Which of the following findings should the nurse instruct the client to report to the health care provider? a. Yellow-tinged skin b. Changes in hearing c. Orange-coloured sputum d. Thickening of the fingernails

The nurse observes an unregulated care provider doing all the following activities when caring for a client with a pulmonary embolism. Which of the following actions should cause the nurse to intervene with the client's care? a. Lowers the head of the client's bed to 10 degrees. b. Splints the client's chest during coughing. c. Helps the client to ambulate to the bathroom. d. Assists the client to a bedside chair for meals.

Which nursing action is essential to reduce the patient's risk of developing a postsurgical infection at the site of a permanent colostomy? A) Change the dressing as ordered by the surgeon. B) Administer intravenous antibiotics as prescribed. C) Assesse the patient's understanding of the importance of infection control measures. D) Instruct the patient in the proper technique for handling hygiene of the colostomy site.

Which of the following information should the nurse include in the teaching plan for a client who is receiving rifampin for treatment of tuberculosis? a. "Your urine, sweat, and tears will be orange coloured." b. "Read a newspaper daily to check for changes in vision." c. "Take vitamin B6 daily to prevent peripheral nerve damage." d. "Call the health care provider if you notice any hearing loss."

41. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. The nurse explains to the patient that a. this type of colostomy is usually temporary. b. soft, formed stool can be expected as drainage. c. the drainage is liquid at this site but less odorous than at higher sites. d. colostomy irrigations can help regulate the drainage from the proximal stoma.

A Rationale: A loop or double-barrel stoma is usually temporary. Cognitive Level: Application Text Reference: p. 1069 Nursing Process: Implementation NCLEX: Physiological Integrity

41. A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the nurse the reason for the test. Which response should the nurse give? a. The skin test will determine if you have a tuberculosis infection. b. The skin test will indicate whether you have active tuberculosis. c. The skin test is used to decide which antibiotic therapy will work best. d. The skin test is done prior to notification of the public health department.

A Rationale: A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the patient has TB, the nurse should focus on the patient, rather than on the public health concerns. Cognitive Level: Application Text Reference: p. 571 Nursing Process: Implementation NCLEX: Physiological Integrity

18. After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). The nurse discusses the treatment regimen with the patient with the knowledge that a. directly observed therapy (DOT) will be necessary if the medications have not been taken correctly. b. the positive sputum smears indicate that the patient is experiencing toxic reactions to the medications. c. twice-weekly administration may be used to improve compliance with the treatment regimen. d. a regimen using only INH and rifampin (Rifadin) will be used for the last 4 months of drug therapy.

A Rationale: After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. The nurse will need to initiate DOT if the patient has not been consistently taking the medications. Toxic reactions to the medications would not result in a positive sputum smear. Twice-weekly medication administration is not one of the options for therapy. INH and rifampin are used for the last 4 months of drug therapy only if the initial four-drug regimen has been effective as evidenced by negative sputum smears. Cognitive Level: Application Text Reference: pp. 571-572 Nursing Process: Implementation NCLEX: Physiological Integrity

31. The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an automobile accident if a. the breath sounds on one side are decreased. b. there are wheezes audible throughout both lungs. c. there is a sucking sound with each patient breath. d. paradoxic movement of the chest is noted.

A Rationale: Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest movement is associated with flail chest. Cognitive Level: Application Text Reference: p. 586 Nursing Process: Assessment NCLEX: Physiological Integrity

4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to a. splint the chest when coughing. b. maintain fluid restrictions. c. wear the nasal oxygen cannula. d. try the pursed-lip breathing technique.

A Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange in patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia. Cognitive Level: Application Text Reference: p. 568 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of these ordered medications should the nurse give first? a. Azithromycin (Zithromax) b. Acetaminophen (Tylenol) c. Guaifenesin (Robitussin) d. Codeine phosphate (Codeine)

A Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. Cognitive Level: Application Text Reference: pp. 563, 566 Nursing Process: Implementation NCLEX: Physiological Integrity

45. All of the following orders are received for a patient who has just been admitted with probable bacterial pneumonia and sepsis. Which one will the nurse accomplish first? a. Obtain blood cultures from two sites. b. Give ciprofloxin (Cipro) 400 mg IV. c. Send to radiology for chest radiograph. d. Administer aspirin suppository.

A Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last. Cognitive Level: Application Text Reference: p. 566 Nursing Process: Implementation NCLEX: Physiological Integrity

35. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. fills the irrigating container with 1000 to 2000 ml of lukewarm tap water. d. inserts the irrigation tubing no further than 4 to 6 inches into the stoma.

A Rationale: Irrigating container should be hung 18 to 24 inches above the stoma. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment

16. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored urine. d. thickening of the nails.

A Rationale: Noninfectious hepatitis is a toxic effect of INH, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. Cognitive Level: Application Text Reference: pp. 572-573 Nursing Process: Implementation NCLEX: Physiological Integrity

15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the nurse include in the patient teaching plan? a. "Take vitamin B6 daily to prevent peripheral nerve damage." b. "Read a newspaper daily to check for changes in vision." c. "Schedule an audiometric examination to monitor for hearing loss." d. "Avoid wearing soft contact lenses to avoid orange staining."

A Rationale: Peripheral neurotoxicity associated can be prevented by taking vitamin B6 when being treated with INH. Visual changes, hearing problems, and orange staining are adverse effects of other TB medications. Cognitive Level: Application Text Reference: p. 573 Nursing Process: Planning NCLEX: Physiological Integrity

11. The nurse observes a nursing assistant doing all the following activities when caring for a patient with right lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant a. turns the patient over to the right side. b. splints the patient's chest during coughing. c. elevates the patient's head to 45 degrees. d. assists the patient to get up to the bathroom.

A Rationale: Positioning the patient with the left (or "good" lung) down will improve oxygenation. The other actions are appropriate for a patient with pneumonia. Cognitive Level: Application Text Reference: p. 569 Nursing Process: Implementation NCLEX: Physiological Integrity

19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of INH. b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. recommendation guidelines for bacille Calmette-Guérin (BCG) vaccine.

A Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection. Cognitive Level: Application Text Reference: p. 572 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

40. A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Check the patient's O2 saturation. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

A Rationale: The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. The re is no indication that the oxygen saturation has decreased The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. Cognitive Level: Application Text Reference: p. 597 Nursing Process: Assessment NCLEX: Physiological Integrity

6. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness, anorexia, and chills. The vital signs include temperature 101° F (38.3° C), pulse 130, respirations 34, and blood pressure (BP) 82/50. Of the following collaborative interventions, which one should the nurse implement first? a. Infuse 1000 ml of lactated Ringer's solution over 30 minutes. b. Administer IV ketorolac (Toradol) 15 mg. c. Give IV ceftriaxone (Rocephin) 1 g. d. Obtain a computed tomography (CT) scan of the abdomen with and without contrast.

A Rationale: The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. Cognitive Level: Application Text Reference: pp. 1044-1045 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse is teaching a patient about the major risk factors for peptic ulcer disease (PUD). Which risk factors should the nurse discuss? (Select all that apply.) A) Chronic H. pylori infection B) Use of aspirin and NSAIDs C) Cigarette smoking D) Dietary intake of dairy products E) Stress

A, B, C Chronic H. pylori infection is one of the major risk factors for PUD. The use of aspirin and NSAIDs is one of the major risk factors for PUD. Cigarette smoking stimulates acid production, contributing to duodenal ulcer formation and PUD. Dietary intake does not seem to cause PUD. The role of stress is uncertain in PUD.

The client has been diagnosed with gastroesophageal reflux (GERD) that has resulted from a relaxation of the lower esophageal sphincter (LES). When providing instructions to assist with managing the condition, the nurse includes: Select all that apply. A) Limit last food intake to 4 hours before bedtime. B) Eat largest meal of the day at midday. C) Sleep in a bed with the head elevated 6 to 8 inches. D) Develop a daily exercise routine.

A, B, C, D

The nurse is reviewing the dietary recommendations with a client recovering from an acute episode of diverticular disease. The nurse identifies the following for inclusion in the discussion: Select all that apply. A) Ingesting at least 25 to 30 grams of fiber daily as is recommended for adults. B) Eating oatmealbased cereals as breakfast and snack foods. C) Avoiding eating fresh grapes because the skins can be problematic. D) Including raisins in the diet as a good source of iron to offset poor iron absorption. E) Incorporating both soluble and insoluble fiber into the daily diet

A, B, C, E

Discharge teaching for the client with peptic ulcer disease (PUD) is being planned. The nurse includes the following in the educational information provided to the client: Select all that apply. A) Implement strategies to discontinue the use of any tobacco product. B) Check with health care provider before taking overthecounter medications containing aspirin. C) Follow a bland, lowfat, highprotein diet with six small meals daily. D) Avoid ingestion of any form of alcoholic beverage E) Good handwashing practices will minimize the risk of transmission to family.

A, B, E

The nurse is reviewing dietary recommendations with a patient recovering from an acute episode of diverticular disease. The nurse identifies which topics for inclusion in the discussion? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected. A) Incorporating both soluble and insoluble fiber into the daily diet B) Including raisins in the diet as a good source of iron to offset poor iron absorption C) Ingesting at least 25 to 30 grams of fiber daily, as recommended for adults D) Eating oatmealbased cereals as breakfast and snack foods E) Avoiding foods such as nuts or strawberries

A, C, D, E Once the acute phase has passed, dietary recommendations include eating a diet high in both soluble and insoluble fiber. For patients recovering from acute diverticular disease, foods containing small seeds, nuts, and foods with skins such as raisins are restricted because they may become lodged in a diverticulum and cause inflammation and an exacerbation of diverticulitis. The recommended fiber consumption for the general public of the United States is 25 to 30 grams and should be stressed for the person with diverticular disease. Oatmeal is a highfiber food recommended for patients with diverticular disease. For patients recovering from acute diverticular disease, foods containing small seeds, nuts, and foods with skins such as grapes are restricted because they may become lodged in a diverticulum and cause inflammation and an exacerbation of diverticulitis.

The nurse notes new onset confusion in an older-adult client in a long-term care facility. The client is normally alert and oriented. In which order should the nurse take the following actions? a. Obtain the oxygen saturation. b. Check the client's pulse rate. c. Document the change in status. d. Notify the health care provider.

ABDC

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."

ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response. DIF: Applying/Application REF: 1180 KEY: Ulcerative colitis| coping MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 liter of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided. DIF: Applying/Application REF: 1173 KEY: Inflammatory bowel disorder| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Insert the obturator and attempt to reinsert the tracheostomy tube. b. Position the patient in an upright position with the neck extended. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag until the health care provider arrives.

ANS: A The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula - Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon. DIF: Understanding/Comprehension REF: 1181 KEY: Ulcerative colitis MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis. DIF: Remembering/Knowledge REF: 1170 KEY: Inflammatory bowel disorder| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids. DIF: Applying/Application REF: 1181 KEY: Crohn's disease| bowel care MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client. DIF: Applying/Application REF: 1179 KEY: Ostomy care| psychosocial response| coping MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."

ANS: B Toilet paper can irritate the sensitive perineal skin, so warm water rinses or soft cotton washcloths should be used instead. Although aloe vera may facilitate healing of superficial abrasions, it is not an effective skin barrier for diarrhea. Skin barriers such as zinc oxide and vitamin A and D ointment help protect the rectal area from the excoriating effects of liquid stools. Patting the skin is recommended instead of rubbing the skin dry. DIF: Applying/Application REF: 1179 KEY: Bowel care| inflammatory bowel disorder MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A 33-year-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible. DIF: Cognitive Level: Apply (application) REF: 990 | 991 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will plan to a. give stool softeners. b. administer IV fluids. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

ANS: B A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have a colonoscopy because of the risk for perforation and peritonitis.

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated. DIF: Cognitive Level: Apply (application) REF: 975 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign. d. Grey-Turners signt.

ANS: B Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Deep tenderness at McBurneys point (halfway between the umbilicus and the right iliac crest), known as McBurneys sign, is a sign of acute appendicitis. DIF: Cognitive Level: Understand (comprehension) REF: 973 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who has had a total proctocolectomy and permanent ileostomy tells the nurse, "I cannot bear to even look at the stoma. I do not think I can manage all these changes." Which is the best action by the nurse? a. Develop a detailed written plan for ostomy care for the patient. b. Ask the patient more about the concerns with stoma management. c. Reassure the patient that care for the ileostomy will become easier. d. Postpone any patient teaching until the patient adjusts to the ileostomy.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy.

A patient who has ulcerative colitis has a proctocolectomy and ileostomy. Which information will the nurse include in patient teaching? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to a. check the pilot balloon after inflation to ensure that it is firm. b. use a manometer to ensure cuff pressure is at an appropriate level. c. check the amount of cuff pressure ordered by the health care provider. d. fill the balloon until minimal air leakage around the cuff is auscultated.

ANS: B Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? a. The student preoxygenates the patient for 1 minute before suctioning. b. The student puts on clean gloves and uses a sterile catheter to suction. c. The student inserts the catheter about 5 inches into the tracheostomy tube. d. The student applies suction for 10 seconds while withdrawing the catheter.

ANS: B Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients.

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? a. Assessing the patient's risk for aspiration b. Suctioning the tracheostomy when needed c. Educating the patient about self-care of the tracheostomy d. Determining the need for replacement of the tracheostomy tube

ANS: B Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen

ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm. DIF: Applying/Application REF: 1172 KEY: Ulcerative colitis| hydration MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, "I am having trouble swallowing this pill." Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.

ANS: C Asacol is the oral formula for mesalamine and is produced as an enteric-coated pill that should not be crushed, chewed, or broken. Asacol is not available as a suspension or elixir. If the client is unable to swallow the Asacol pill, a mesalamine enema (Rowasa) may be administered instead, with a provider's order. DIF: Applying/Application REF: 1176 KEY: Ulcerative colitis| medication safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I'll ride my bike or take a long walk at least three times a week." b. "I must try to include at least 25 grams of fiber in my diet every day." c. "I will take a laxative nightly at bedtime to avoid becoming constipated." d. "I should use my legs rather than my back muscles when I lift heavy objects."

ANS: C Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining. DIF: Applying/Application REF: 1187 KEY: Diverticulitis| medication MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Health Promotion and Maintenance

A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patients symptoms? a. What type of foods do you eat? b. Is it possible that you are pregnant? c. Can you tell me more about the pain? d. What is your usual elimination pattern?

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patients symptoms. DIF: Cognitive Level: Apply (application) REF: 971 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and a. ask the patient to say a few sentences. b. monitor for signs of respiratory distress. c. have the patient drink a small amount of grape juice and observe for coughing. d. auscultate the lungs for crackles after having the patient take a few sips of water.

ANS: C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patients health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded. DIF: Cognitive Level: Apply (application) REF: 970 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Following an exploratory laparotomy and bowel resection, a patient who has a nasogastric tube to suction complains of nausea and stomach distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence or absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient.

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to a. clean the inner cannula of the tracheostomy tube before deflation. b. deflate the cuff during the inhalation phase of the respiratory cycle. c. suction the patient's mouth and trachea before deflation of the cuff. d. insert exactly the same volume of air into the cuff during reinflation.

ANS: C The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.

After teaching a client with diverticular disease, a nurse assesses the client's understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet. DIF: Applying/Application REF: 1187 KEY: Diverticular disease| nutritional requirements MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A patient has a large bowel obstruction that occurred as a result of diverticulosis. When assessing the patient, the nurse will plan to monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention

ANS: D Abdominal distention is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction.

A patient who recently has been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about a. barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may be helpful in reducing your symptoms." b. "You should avoid eating between meals to reduce acid secretion." c. "Vigorous physical activities may increase the incidence of reflux." d. "It will be helpful to keep the head of your bed elevated on blocks."

ANS: D Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I eat small meals throughout the day and have a bedtime snack."

ANS: D GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Peanut butter sandwich d. Cherry gelatin and fruit

ANS: D Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

Which question from the nurse would help determine if a patients abdominal pain might indicate irritable bowel syndrome? a. Have you been passing a lot of gas? b. What foods affect your bowel patterns? c. Do you have any abdominal distention? d. How long have you had abdominal pain?

ANS: D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria. DIF: Cognitive Level: Apply (application) REF: 972 | eTable 43-3 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which patient should the nurse assess first after receiving change-of-shift report? a. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool c. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patients abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses. DIF: Cognitive Level: Analyze (analysis) REF: 974 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A 45-year-old patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102 F (38.3 C), pulse 120, respirations 32, and blood pressure (BP) 82/54. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1 liter of lactated Ringers solution over 30 minutes.

ANS: D The priority for this patient is to treat the patients hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. DIF: Cognitive Level: Apply (application) REF: 973 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The health care provider inserts a chest tube in a client with a hemo-pneumothorax. When monitoring the client after the chest tube placement, which of the following findings is of greatest concern? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

The nurse is caring for a client who has just had a thoracentesis. Which of the following information is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.

The nurse is caring for a client with a pleural effusion who is scheduled for a thoracentesis. Which of the following actions should the nurse implement prior to the procedure? a. Start a peripheral intravenous line to administer the necessary sedative drugs. b. Position the client sitting upright on the edge of the bed and leaning forward. c. Remove the water pitcher and remind the client not to eat or drink anything for 6 hours. d. Instruct the client about the importance of incentive spirometer use after the procedure.

The nurse is conducting a chest assessment on a client with pneumococcal pneumonia. Which of the following findings should the nurse expect to assess? a. Vesicular breath sounds b. Increased tactile fremitus c. Dry, nonproductive cough d. Hyper-resonance to percussion

The nurse is performing tuberculosis (TB) screening in a clinic that has many clients who have immigrated to Canada. Before doing a TB skin test on a client, which of the following questions is most important for the nurse to ask? a. "Is there any family history of TB?" b. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" c. "How long have you lived in the Canada?" d. "Do you take any over-the-counter (OTC) medications?"

Which of the following nursing actions is most effective in preventing aspiration pneumonia in clients who are at risk? a. Turn and reposition immobile clients at least every 2 hours. b. Place clients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in clients who are immuno-suppressed. d. Provide for continuous subglottic aspiration in clients receiving enteral feedings.

7. A 23-year-old woman is being evaluated in the emergency department for acute lower abdominal pain and vomiting. During the nursing history, the most helpful question by the nurse to obtain information regarding the patient's condition is a. "What type of foods do you usually eat?" b. "Can you tell me about your pain?" c. "What is your usual elimination pattern?" d. "Is it possible that you are pregnant?"

B Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most. Cognitive Level: Application Text Reference: p. 1044 Nursing Process: Assessment NCLEX: Physiological Integrity

22. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. puts on a surgical face mask before visiting the patient. c. brings food from a "fast-food" restaurant to the patient. d. hands the patient a tissue from the box at the bedside.

B Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. Cognitive Level: Application Text Reference: p. 574 Nursing Process: Implementation NCLEX: Physiological Integrity

32. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurse's first action should be to a. have the patient use the incentive spirometer. b. medicate the patient with the ordered morphine. c. splint the patient's chest during coughing. d. assist the patient to sit up at the bedside.

B Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given. Cognitive Level: Application Text Reference: pp. 591, 594 Nursing Process: Implementation NCLEX: Physiological Integrity

16. While obtaining a nursing history from a patient with IBD, the nurse recognizes that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing a. weight loss. b. bloody stools. c. abdominal pain and cramping. d. disease onset at age 20.

B Rationale: Because ulcerative colitis affects the colon, blood in the stools is more common with this form of IBD. Weight loss, abdominal pain and cramping, and onset at age 20 are consistent with both Crohn's disease and ulcerative colitis. Cognitive Level: Comprehension Text Reference: p. 1051 Nursing Process: Assessment NCLEX: Physiological Integrity

7. The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is normally alert and oriented. Which action should the nurse take next? a. Check the patient's pulse rate. b. Obtain an oxygen saturation. c. Notify the health care provider. d. Document the change.

B Rationale: New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change in status. Cognitive Level: Application Text Reference: p. 565 Nursing Process: Implementation NCLEX: Physiological Integrity

3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. hyperresonance on percussion. b. increased vocal fremitus on palpation. c. fine crackles in all lobes on auscultation. d. asymmetric chest expansion on inspection.

B Rationale: Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion. Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric chest expansion is not typical with pneumonia. Cognitive Level: Application Text Reference: p. 565 Nursing Process: Assessment NCLEX: Physiological Integrity

17. Sulfasalazine (Azulfidine) is prescribed for a patient who has been diagnosed with ulcerative colitis. The nurse recognizes that teaching about this drug has been effective when the patient says, a. "The medication will prevent infections that cause the diarrhea." b. "The medication suppresses the inflammation in my large intestine." c. "I will need lab tests to be sure that I can still fight infections." d. "I will take the sulfasalazine as an enema or suppository."

B Rationale: Sulfasalazine suppresses the inflammatory process that causes the symptoms of ulcerative colitis. It is not used to treat infections. Laboratory tests for immune suppression are needed for the immunosuppressant medications used for ulcerative colitis. Sulfasalazine is an oral medication, although the active portion of the medication (5-ASA) may be given rectally. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Evaluation NCLEX: Physiological Integrity

36. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The international normalized ratio (INR) is prolonged. b. The central line is disconnected. c. The oxygen saturation is 90%. d. The BP is 88/56.

B Rationale: The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. Cognitive Level: Application Text Reference: p. 601 Nursing Process: Assessment NCLEX: Physiological Integrity

29. The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 ml of blood in the collection chamber. c. severe pain with each deep patient inspiration. d. subcutaneous emphysema at the insertion site.

B Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. Cognitive Level: Application Text Reference: p. 586 Nursing Process: Assessment NCLEX: Physiological Integrity

13. A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the disease can be transmitted to others until a. the chest x-ray shows resolution of the tuberculosis. b. three sputum smears for acid-fast bacilli are negative. c. TB medications have been taken for 6 months. d. sputum cultures on 3 consecutive days are negative.

B Rationale: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest x-rays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment. Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum smears are usually done to establish that treatment has been effective. Cognitive Level: Application Text Reference: p. 574 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

12. A patient is admitted to the emergency department for evaluation of right lower-quadrant abdominal pain with nausea and vomiting. The patient has a white blood cell count (WBC) of 14,000/l with a shift to the left. Which of these actions is appropriate for the nurse to take? a. Encouraging the patient to take sips of clear liquids b. Applying an ice pack to the right lower quadrant c. Checking for rebound tenderness every 30 minutes d. Teaching the patient how to cough and deep breathe

B Rationale: The patient's clinical manifestations are consistent appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain and the patient is not likely to retain information at this point. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Implementation NCLEX: Physiological Integrity

9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to a. turn and reposition immobile patients at least every 2 hours. b. position patients with altered consciousness in lateral positions. c. monitor frequently for respiratory symptoms in patients who are immunosuppressed. d. provide for continuous subglottic aspiration in patients receiving enteral feedings.

B Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonias in immune compromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. Cognitive Level: Application Text Reference: p. 567 Nursing Process: Planning NCLEX: Safe and Effective Care Environment

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? A.Suction the tracheostomy opening. B.Maintain the airway with a sterile hemostat. C.Use an Ambu bag and mask to ventilate the patient. D.Insert the tracheostomy tube obturator into the stoma.

B.Maintain the airway with a sterile hemostat. As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? A.Assessing the need for suctioning B.Suctioning the patient's oropharynx C.Assessing the patient's swallowing ability D.Maintaining appropriate cuff inflation pressure

B.Suctioning the patient's oropharynx Providing the individual has been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.

After the nurse has received change-of-shift report about the following four clients, which client should be assessed first? a. A 77-year-old client with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old client with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old client who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old client who was admitted the previous day with pneumonia and has a temperature of 37.9°C (100.2°F)

The health care provider writes a prescription for bacteriological testing for a client who has a positive tuberculosis skin test. Which of the following actions should the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the client for 3 days. d. Instruct the client to expectorate three specimens as soon as possible.

The nurse is caring for a client in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first? a. Position the client so that the right chest is dependent. b. Keep the head of the client's bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

The nurse is caring for a client who has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which of the following actions should the nurse take first? a. Assist the client to sit up at the bedside. b. Splint the client's chest during coughing. c. Medicate the client with the prescribed morphine. d. Have the client use the prescribed incentive spirometer.

The nurse is caring for a client who has just been admitted with pneumococcal pneumonia has a temperature of 38.7°C (101.7°F) with a frequent cough and symptoms of severe pleuritic chest pain. Which of the following prescribed medications should the nurse give first? a. Guaifenesin b. Acetaminophen c. Azithromycin d. Codeine phosphate

The nurse is caring for a client who is hospitalized with active tuberculosis (TB) and the nurse observes a family member who is visiting the client. Which of the following actions by the visitor should cause the nurse to intervene? a. Washes hands before entering the client's room b. Hands the client a tissue from the box at the bedside c. Puts on a surgical face mask before visiting the client d. Brings food from a "fast-food" restaurant to the client

The nurse is caring for a client with right lower-lobe pneumonia who has been treated with intravenous (IV) antibiotics for 2 days. Which of the following assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The client coughs up small amounts of green mucus. c. The client's white blood cell (WBC) count is 9 ́ 10^9/L. d. Increased tactile fremitus is palpable over the right chest.

The nurse is providing teaching to a client with pneumonia. Which of the following client statements indicate a good understanding of the discharge instructions given by the nurse? a. "I will call the doctor if I still feel tired after a week." b. "I will need to use home oxygen therapy for 3 months." c. "I will continue to do the deep-breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

The nurse is providing teaching to a client with pulmonary tuberculosis (TB) regarding the transmission of TB. Which of the following client actions indicate that the teaching has been effective? a. Demonstrates correct use of a nebulizer. b. Washes dishes and personal items after use. c. Covers the mouth and nose when coughing. d. Reports daily to the public health department.

Which of the following information obtained by the nurse about a client who has human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest x-ray showed infiltrates in the upper lobes. c. The client is being treated with antiretrovirals for HIV infection. d. The client has a cough that is productive of blood-tinged mucus.

33. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the health care provider of a possible pneumothorax. d. take no further action with the collection device.

C Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled. Cognitive Level: Application Text Reference: p. 591 Nursing Process: Implementation NCLEX: Physiological Integrity

17. An alcoholic and homeless patient is diagnosed with active TB. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Giving the patient written instructions about how to take the medications b. Teaching the patient about the high risk for infecting others unless treatment is followed c. Arranging for a daily noontime meal at a community center and give the medication then d. Educating the patient about the long-term impact of TB on health

C Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient. Cognitive Level: Application Text Reference: pp. 572, 575 Nursing Process: Implementation NCLEX: Physiological Integrity

44. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90. b. Pain level is 5/10 with a deep breath. c. Oxygen saturation is 89%. d. Respiratory rate is 24 when lying flat.

C Rationale: Oxygen saturation would be expected to improve after a thoracentesis; a saturation of 89 indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority. Cognitive Level: Application Text Reference: p. 596 Nursing Process: Assessment NCLEX: Physiological Integrity

21. The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "How long have you lived in the United States?" b. "Is there any family history of TB?" c. "Have you received the BCG vaccine for TB?" d. "Do you take any over-the-counter (OTC) medications?"

C Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test; another method for screening (such as a chest x-ray) will be used in determining whether the patient has a TB infection. The other information may also be valuable but is not as pertinent to the decision about doing TB skin testing. Cognitive Level: Application Text Reference: p. 572 Nursing Process: Assessment NCLEX: Physiological Integrity

9. Following an exploratory laparotomy and bowel resection, a patient has an NG tube to suction but complains of nausea and stomach distention. The nurse irrigates the tube PRN as ordered, but the irrigating fluid does not return. The first action by the nurse should be to a. notify the patient's health care provider. b. auscultate for bowel sounds. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

C Rationale: Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence of absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient. Cognitive Level: Application Text Reference: p. 1045 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the best time for the nurse to collect the specimen? a. After the patient rinses the mouth with mouthwash b. As soon as the order is received from the health care provider c. Right after the patient gets up in the morning d. After the skin test is administered

C Rationale: Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no need to wait until the tuberculin skin test is administered. Cognitive Level: Application Text Reference: p. 572 Nursing Process: Implementation NCLEX: Physiological Integrity

5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia? a. 24-year-old patient who has had temperatures ranging from 100.6° to 101° F b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours c. 50-year-old patient who has an oxygen saturation of 91% on room air d. 72-year-old patient with a pulse of 102 and a blood pressure (BP) of 90/56

C Rationale: The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria. The other patients do not meet the criteria for discharge. Cognitive Level: Application Text Reference: p. 563 Nursing Process: Planning NCLEX: Physiological Integrity

26. An hour after a left upper lobectomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 ml of bloody drainage and a large air leak. Which action should the nurse take first? a. Assist the patient to deep breathe and cough. b. Milk the chest tube gently to remove any clots. c. Medicate the patient with the ordered morphine. d. Notify the surgeon about the large air leak.

C Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 ml is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy. Cognitive Level: Application Text Reference: p. 594 Nursing Process: Implementation NCLEX: Physiological Integrity

42. After being treated for a respiratory tract infection with a 10-day course of antibiotics, a 69-year-old patient calls the clinic and tells the nurse about developing frequent, watery diarrhea. The nurse anticipates that the patient will need to a. prepare for colonoscopy by taking laxatives. b. have blood drawn for blood cultures. c. bring a stool specimen in to be tested for C. difficile. d. schedule a barium enema to check for inflammation.

C Rationale: The patient's age and history of antibiotic use suggest a C. difficile infection. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. Cognitive Level: Application Text Reference: pp. 1036-1037 Nursing Process: Planning NCLEX: Physiological Integrity

What is the priority nursing assessment in the care of a patient who has a tracheostomy? A.Electrolyte levels and daily weights B.Assessment of speech and swallowing C.Respiratory rate and oxygen saturation D.Pain assessment and assessment of mobility

C.Respiratory rate and oxygen saturation The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

The nurse is assessing a client who has just arrived after an automobile accident and the nurse notes that the breath sounds are absent on the right side. Which of the following actions should the nurse anticipate? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

The nurse is caring for a client who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement? a. Document the presence of a large air leak b. Obtain and attach a new collection device c. Notify the surgeon of a possible pneumothorax d. Take no further action with the collection device

The nurse is caring for a client with pneumonia has a fever of 38.4°C (101.1°F), a nonproductive cough, and an oxygen saturation of 89%. The client is very weak and needs assistance to get out of bed. Which of the following nursing diagnoses is priority? a. Hyperthermia related to increase in metabolic rate (illness) b. Impaired transfer ability related to insufficient muscle strength c. Ineffective airway clearance related to retained secretions d. Ineffective breathing pattern related to respiratory muscle fatigue

The nurse is caring for clients with active tuberculosis (TB) who misuse alcohol and/or are homeless. Which of the following interventions by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Educating the client about the long-term impact of TB on health b. Giving the client written instructions about how to take the medications c. Teaching the client about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community centre and giving the medication then

Which of the following information about a client who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

Which of the following prescriptions should the nurse implement first for a client who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer Aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin 400 mg IV. d. Obtain blood cultures from two sites.

A patient is hospitalized during an acute exacerbation of symptoms related to Crohn's disease. The nurse shows an understanding of the need for bowel rest by providing which instruction? A) "Select foods that are high in potassium." B) "You should eat a soft diet until the diarrhea subsides." C) "You may find a highcalorie, lowfat, highfiber diet helpful." D) "Expect to be started on total parenteral nutrition (TPN)."

D During an acute exacerbation of IBD, particularly Crohn's disease, the patient is allowed no food taken orally. During this period of "bowel rest," total parenteral nutrition (TPN) is usually prescribed.

20. During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases the patient's tolerance of the drug by a. cooling the solution to 80° F before administration. b. keeping the patient flat in bed for 1 hour after the infusion is completed. c. diluting the amphotericin B in 500 ml of sterile water. d. giving diphenhydramine (Benadryl) 1 hour before starting the infusion.

D Rationale: Administration of an antihistamine before giving the amphotericin B will reduce the incidence of hypersensitivity reactions. Cooling the solution and keeping the patient flat after infusion are not indicated. Amphotericin B does not need to be diluted in 500 ml of fluid, although the nurse should ensure adequate hydration in the patient receiving this drug. Cognitive Level: Application Text Reference: p. 575 Nursing Process: Implementation NCLEX: Physiological Integrity

6. A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. ineffective airway clearance related to thick secretions. c. impaired transfer ability related to weakness. d. impaired gas exchange related to respiratory congestion.

D Rationale: All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. Cognitive Level: Application Text Reference: p. 566 Nursing Process: Diagnosis NCLEX: Physiological Integrity

14. A patient diagnosed with irritable bowel syndrome (IBS) tells the nurse, "My friends tell me this problem is all in my head." In caring for the patient, the nurse should a. discuss the new medications that are available to treat the condition. b. inform the patient that IBS has a specific, identifiable cause. c. explain that modifications to increase dietary fiber can control the symptoms. d. encourage the patient to express feelings and ask questions about IBS.

D Rationale: Because psychologic and emotional factors can impact on the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Although new medications are available, discussion of these medications does not address the patient's concerns with what friends think or say. There is no specific cause for IBS. Modifications in fiber intake may help some patients but might also increase bloating and gas pain. In addition, discussion of fiber does not address the patient's feelings. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Psychosocial Integrity

14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. reports daily to the public health department. c. washes dishes and personal items after use. d. covers the mouth and nose when coughing.

D Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB. Cognitive Level: Application Text Reference: p. 574 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

30. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. complaints of severe pain. b. heart rate of 110 beats/min. c. a large bruised area on the chest. d. paradoxic chest movement.

D Rationale: Paradoxic chest movement indicates that the patient may have flail chest, which will severely compromise gas exchange and can rapidly lead to hypoxemia. Severe pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange. Cognitive Level: Application Text Reference: pp. 586, 588 Nursing Process: Assessment NCLEX: Physiological Integrity

8. Following discharge teaching, the nurse evaluates that the patient who was admitted with pneumonia understands measures to prevent a reoccurrence of the pneumonia when the patient states, a. "I will increase my food intake to 3000 calories a day." b. "I will need to use home oxygen therapy for 3 months." c. "I will seek medical treatment for any upper respiratory infections." d. "I will do deep-breathing and coughing exercises for the next 6 weeks."

D Rationale: Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep breathing and coughing exercises or both for 6 to 8 weeks after discharge. Although caloric needs are increased during the acute infection, 3000 calories daily will lead to obesity and increase the risk for pneumonia. Patients with acute lower respiratory infections do not usually require home oxygen therapy. Upper respiratory infections require medical treatment only when they fail to resolve in 7 days. Cognitive Level: Application Text Reference: p. 569 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

29. While obtaining a nursing history from a 55-year-old patient scheduled for a colonoscopy, the nurse will be most concerned about a. lifelong constipation. b. nausea and vomiting. c. history of an appendectomy. d. recent blood in the stools.

D Rationale: Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a clinical manifestation of colorectal cancer, but lifelong constipation is not an indication. Nausea and vomiting are not common clinical manifestations of problems with the distal GI tract. An appendectomy is not a risk factor for cancer of the colon. Cognitive Level: Application Text Reference: pp. 1064-1065 Nursing Process: Assessment NCLEX: Physiological Integrity

10. A patient is brought to the emergency department following an automobile accident in which blunt trauma to the abdomen occurred. The patient is splinting the abdomen and complaining of pain, and bowel sounds are decreased. Peritoneal lavage returns brown drainage. Based on the results of the lavage, the nurse plans for a. preparation for a paracentesis. b. administration of pain medications. c. continued monitoring of the patient's condition. d. immediate preparation of the patient for surgery.

D Rationale: Return of brown drainage suggests perforation of the bowel and the need for immediate surgery. Paracentesis is not a treatment for abdominal trauma and may spread infection. Administration of pain medication and/or continued monitoring may be indicated for a negative finding with peritoneal lavage. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Planning NCLEX: Physiological Integrity

28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the nurse should a. position the patient so that the right chest is dependent. b. administer high-flow oxygen using a non-rebreathing mask. c. cover the sucking chest wound with an occlusive dressing. d. tape a nonporous dressing on three sides over the chest wound.

D Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The patient should receive oxygen, but this will have no effect on the development of tension pneumothorax. Cognitive Level: Application Text Reference: p. 586 Nursing Process: Implementation NCLEX: Physiological Integrity

10. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. Increased vocal fremitus is palpable over the right chest. c. The patient coughs up small amounts of green mucous. d. The patient's white blood cell (WBC) count is 9000/µl.

D Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. Cognitive Level: Application Text Reference: p. 569 Nursing Process: Evaluation NCLEX: Physiological Integrity

20. After teaching a patient with IBD about recommended dietary modifications, the nurse identifies a need for further instruction when the patient chooses from the menu a. spaghetti with tomato sauce. b. poached eggs and crisp bacon. c. boiled shrimp and white rice. d. ham hocks and beans.

D Rationale: The patient is taught to avoid high-fiber foods such as beans. In addition, high-fat foods such as ham may trigger diarrhea in some patients. The other choices are appropriate for a patient with IBD. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Resting pulse oximetry (SpO2) of 85% b. Respiratory rate of 28 c. Large amounts of greenish sputum d. Weak, nonproductive cough effort

D Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. Cognitive Level: Application Text Reference: p. 568 Nursing Process: Diagnosis NCLEX: Physiological Integrity

44. After a patient with IBD has had dietary teaching, which food choice by the patient indicates that the teaching has been successful? a. Oatmeal with cream, whole wheat toast, and a banana b. Corn tortilla taco with chicken, lettuce, tomato, and cheese c. Roast beef, mashed potatoes, and a tossed green salad d. Chicken sandwich with mayonnaise on white bread

D Rationale: This choice is consistent with the appropriate high-protein, low-residue diet. Oatmeal, whole wheat toast, green salad, corn tacos, lettuce, and tomato are all high-fiber choices and likely to worsen symptoms. Cognitive Level: Application Text Reference: pp. 1056-1057, 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity

A patient with Crohn's disease is demonstrating the nursing diagnosis Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patient's plan of care? A) A lowcalorie, highmilk diet B) A lowcalorie, lowresidue diet C) The DASH diet D) A normal, wellbalanced diet

D The DASH diet is appropriate for the patient wanting to lower elevated blood pressure. It is a balanced diet but may have some restrictions not necessary for the patient with Crohn's disease.

The best method for determining the risk of aspiration in a patient with a tracheostomy is to a. consult a speech therapist for swallowing assessment. b. have the patient drink plain water and assess for coughing c. assess for change of sputum color 48 hours after patient drinks small amount of blue dye. d. suction above the cuff after the patients eats or drinks to determine presence of food in trachea.

a. consult a speech therapist for swallowing assessment. Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated with the use of blue dye. A teaspoon of water colored with blue dye is swallowed by the patient. Respiratory secretions are then monitored for 24 hours for appearance of the dye, which would indicate aspiration. Recent studies, however, do not support the sensitivity of this test. It is therefore no longer recommended. Instead, clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids, not plain water. Ability to swallow should be assessed with the cuff deflated, inasmuch as cuff inflation may interfere with swallowing ability.

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete. b. Providing a means of communication for the patient during the procedure. c. Assessing the patient's oxygenation saturation before, during and after suctioning. d. Administering pain and/or antianxiety medication 30 minutes before suctioning.

c. Assessing the patient's oxygenation saturation before, during and after suctioning. Rationale: A patient with a tracheostomy is at risk for hypoxemia after suctioning. Therefore, it is imperative to monitor the patient's oxygen status before, during, and after suctioning. Remember the protocol for airway, breathing, and circulation (ABCs) when prioritizing.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? a. Notify the physician immediately. b. Place the patient in the prone position to facilitate drainage. c. Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions. d. Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds.

d. Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds. Rationale: Immediately after surgery, the patient with a laryngectomy requires frequent suctioning by means of the laryngectomy tube. Secretions typically change in amount and consistency over time. Secretions may initially be copious and blood-tinged secretions and then diminish and thicken. Normal saline bolus through the tracheostomy tube is not recommended to assist with removal of thickened secretions because it causes hypoxia and damage to the epithelial cells.

Med-Surg: Lewis Ch 27, Chapter 30: Nursing Management- Lower Respiratory Problems, Lower respiratory problems, Stress: Peritonitis, Gastro 5, LP 9, GI, Chapter 24 IBS, Chapter 57: Care of Patients with Inflammatory Intestinal Disorders, Gastro/ Muscu...

Related study sets

ARCH 249 Exam 2 Connect Questions

U.S. History Ch 6.3

IT1030 Final

ch 24 The Occupational Safety and Health Administration

MGMT 495 Ch. 3

BUS 100 Exam 2

Exam 1 Quizzes

Health and Life Insurance Test Final

Who was Socrates?

Personal Financial Literacy: Unit 4

A&P 2 Chapter 19

MKTG 409 Chapter 13 Pride

Ch. 23 - The Digestive System

hematology surgery #8

Unit 1: Element, compound, solution, or heterogeneous mixture?

Contraception Part 3

Quiz 7: Language

vitendawili

ServSafe Flashcards: Chapter 7

Human Development Theories Chapter 6, Social Role Theory