MEDSURG

A client is being taught how to care for an ileostomy appliance. Which should the nurse emphasize as most important when applying a new bag? A. The bag should fit snugly. B. The bag should be long enough. C. Drying powder should be used in the bag. D. The bag should have an air vent.

A. The bag should fit snugly. Drainage from an ileostomy is constant and liquid, and it contains enzymes; bag must fit snugly to prevent extrusion of this fluid into the abdomen and excoriation or actual digestion of the skin.

The home care nurse visits a client diagnosed with hepatitis. It is most important for the nurse to intervene if the client makes which statement? A. "I will take acetaminophen when I get a headache." B. "I do not drink wine with meals anymore." C. "I keep my fingernails short." D. I wash my hands before I eat."

A. "I will take acetaminophen when I get a headache." Acetaminophen is contraindicated because it is hepatotoxic; instruct client to avoid all medications unless prescribed by the HCP.

After cholecystectomy, a patient is returned to the unit with a NGT connected to low intermittent suction, an IV of D5W, a T-tube in place, and a Penrose drain. the nurse understands that the purpose of the Penrose drain includes which of the following? A. Remove accumulated bile and blood after surgery. B. Permit irrigation of the peritoneum with an antibiotic solution. C. Provide access to the cystic duct postop. D. Provide a route for alimentation.

A. Remove accumulated bile and blood after surgery. Duct must be allowed to drain; bile would otherwise drain in the surrounding tissue, be very caustic, and cause problems for the patient.

The nurse instructs a client how to increase folic acid in the diet. The nurse determines teaching is effective if the client makes which statement? A. "I like oatmeal for breakfast." B. "My favorite lunch is a spinach salad." C. "I will eat more grapes, apples, and bananas each day." D. I will eat more chicken."

B. "My favorite lunch is a spinach salad." Spinach contains 108 mg per half-cup serving; other folate-rich sources include organ meats, broccoli, asparagus, milk, orange juice.

The nurse assesses the elderly client at the long-term care facility. The client tells the nurse, "I have recently developed constipation." It is most important for the nurse to take which action? A. Encourage the client to eat more grains and fruits. B. Determine the frequency and characteristics of the bowel movements. C. Instruct the client to increase fluid intake. D. Teach the client about the importance of exercise.

B. Determine the frequency and characteristics of the bowel movements. Assessment; number of bowel movements varies from 1-3 per day to 3/week; nurse should first determine frequency and characteristics of the client's bowel movements before determining the appropriate interventions.

The nurse cares for a patient after an appendectomy. The day after surgery, the patient has severe abdominal pain, a temperature of 101 degrees F, and a rigid abdomen. The nurse suspects that the patient is experiencing which of the following? A. Anesthesia intolerance B. Abnormal pain tolerance C. Infection of the peritoneal sac D. Bladder distention

C. Infection of the peritoneal sac Peritonitis can be caused by ruptured appendix; s/s include severe abdominal pain, abdominal rigidity, decreased bowel sounds, N/V, increased temperature, shock, paralytic ileus; monitor VS, administer abx and IVs, NGT to suction, NPO, surgery to correct cause.

The nurse cares for the client diagnosed with acute cholecystitis. The client states, "My stomach hurts all the way up to my right shoulder. I am nauseated and have vomited twice." Which order should the nurse carry out first? A. Insert NG tube and attach to intermittent low suction. B. Trimethobenzamide 200 mg rectally 3x/daily. C. Morphine 15 mg IM q4h PRN. D. NPO

C. Morphine 15 mg IM q4h PRN. Address pain to make client more comfortable before performing other orders.

The nurse cares for a patient after a traditional cholecystectomy. It is MOST important for the nurse to position the patient in which of the following positions? A. Side-lying with bed flat. B. Supine with bed flat. C. Semi-Fowler's D. Knees elevated

C. Semi-Fowler's Semi-Fowler's is optimal for the patient because it will allow her to take the necessary deep breaths that are important to prevent PNA after surgery.

The clinic nurse monitors a client recovering from hepatitis D. The nurse understands which of the following indicates the client is recovering from the illness? A. Serum asparate aminotransferase B. Hepatitis B surface antigen C. Serum cholesterol D. BUN

A. Serum asparate aminotransferase Enzymes that are released from liver due to damaged cells; elevated in liver damage; normal is 10-40 U/L

The nurse cares for a patient 18 hours after a gastrectomy. The nurse is MOST concerned if which of the following is observed? A. The Levin's tube is attached to low continuous suctioning. B. The patient's output during the previous 6 hours was 500cc. C. The patient asks for pain medication. D. The patient performs deep breathing every 2 hours.

A. The Levin's tube is attached to low continuous suctioning. Levin's tube is a single lumen tube with no air vent, suction should be intermittent, continuous suction appropriate for a Salem tube.

The nurse understands which of the following is the principal reason for the use of enzyme inhibitors (Diamox) in a patient with pancreatitis? A. Pancreatic enzymes are irritating to the liver. B. Pancreatic enzymes escape into interstitial tissue. C. Pancreatic enzymes are missing and must be replaced. D. Pancreatic enzymes are inactivated and must be enhanced.

B. Pancreatic enzymes escape into interstitial tissue. Interstitial pancreatitis is characterized by a swelling of the gland and the escape of its digestive enzymes, lipase and amylase, into the surrounding tissues and into the peritoneal cavity, causing necrosis; Diamox helps inactivate these enzymes to help minimize the damage they would cause to normal tissue.

The nurse assesses a client in the outpatient clinic with a diagnosis of R/O ulcerative colitis. During the history, the nurse expects the client to make which statement? A. "I feel an intermittent sharp pain in my lower abdomen." B. "I feel an intermittent gnawing pain in my lower abdomen." C. "I feel an intermittent cramping pain in my lower abdomen." D. " I feel a constant crushing pain in my lower abdomen."

C. "I feel an intermittent cramping pain in my lower abdomen." Pain is usually described as cramping and intermittent; important that the nurse assess character and intensity or pain; pain due to ulcerative colitis usually occurs prior to defecation; obtain diet history and assess for bowel sounds and for areas of tenderness.

The nurse obtains a history from a client suspected of having cirrhosis. Which statement, if made by the client to the nurse, should the nurse recognize as most directly related to a client's development of cirrhosis? A. "For the past several weeks I have not slept for more than 5 hours a night." B. "Since my spouse left me 5 years ago, I have been eating terribly." C. "I have been drinking about a fifth of vodka a day for the last few months." D. "My spouse was a heavy smoker, and I am concerned about second-hand smoke."

C. "I have been drinking about a fifth of vodka a day for the last few months." Alcohol has a toxic effect on liver, which causes liver inflammation; s/s include N/V, anorexia, weight loss, flatulence, fatigue, HA, ascites, jaundice, and spider angiomas.

The nurse cares for a patient after the physician performed a sigmoid colostomy due to cancer. The nurse instructs the patient about how to care for the stoma. The nurse knows that teaching is successful if the patient makes which of the following statements? A. "I will drape the area and wash the stomas with hexachlorophrene soap." B. "I will clean the stoma vigorously with alcohol wipes and pat dry." C. "I will clean around the stoma with soap and water and pat dry." D. "I will drape the area and cleanse the stoma with povidone iodine."

C. "I will clean around the stoma with soap and water and pat dry." Provides adequate cleaning with limited irritation; observe for skin breakdown

the nurse cares for a client with a diagnosis of ulcerative colitis. When reviewing the client's record, the nurse expects to find which lab value? A. RBS 4 million/mm3 B. Platelet count 75,000/mm3 C. Hgb 18.2 g/dL D. WBC 15,000/mm3

D. WBC 15,000/mm3 Due to inflammation, WBCs and erythrocyte sedimentation rate will be elevated; sodium, potassium, and chloride may be decreased due to frequent diarrhea.

The nurse teaches a client who has undergone a laparoscopic cholecystectomy prior to discharge. The nurse should include which instruction? A. Begin light exercise immediately. B. Limit diet to liquid and soft foods for 3 days. C. Contact HCP if there is pain in the right shoulder. D. remove adhesive strips over puncture wounds in 5 days.

A. Begin light exercise immediately. May begin walking immediately; avoid lifting heavy objects (more than 5 lbs) for 1 week.

The home care nurse visits a client diagnosed with diverticulitis. The physician orders a clear liquid diet, and the nurse instructs the family about the appropriate foods. The nurse should intervene if the client's family makes which of the following statements? A. "Grandpa can have his daily glass of prune juice." B. "My husband really likes apple juice." C. "My dad drinks cranberry juice in the evening." D. "Grandpa can eat a cherry popsicle with me."

A. "Grandpa can have his daily glass of prune juice." Clear liquid diet allows clear liquids (liquids that the nurse can see through or foods that are fluid at room temperature); prune juice allowed on a full liquid diet; diverticulitis is infection and inflammation of the diverticulum; signs include regular bowel function with episodes of diarrhea, crampy pain in LLQ, and low-grade fever.

The nurse cares for a client after a traditional cholecystectomy. The nurse contacts the HCP if which observation is made? A. 800 mL bloody drainage the first day postop B. The client frequently reports abdominal pain during the first 24 hours. C. NG tube connected to intermittent suction the first day post op. D. Temperature elevation to 100 degrees F the evening of surgery.

A. 800 mL bloody drainage the first day postop This amount of drainage after a cholecystectomy would indicate hemorrhage; 50 mL is an appropriate amount of drainage.

A client has a gastroscopy performed and a gastric aspirate taken for analysis. The nurse understands the purpose of a gastric aspirate includes which reason? A. Assess acid secretion and bacterial activity in the stomach. B. Inhibit acid secretion in the stomach. C. Assess mucus-producing capacity of the stomach. D. Introduce gastric-irritating substances.

A. Assess acid secretion and bacterial activity in the stomach. Taking a gastric aspirate and analyzing its pH and microbial content will show if there is infection, or if there is excess acid in the stomach

The nurse instructs the client with a sigmoid colostomy how to irrigate the colostomy. Which action does the nurse include in teaching? A. Dilate the stoma gently with gloved finger. B. Irrigate the colostomy using 30 mL of normal saline. C. Continue the irrigations until no stool is returned. D. Returns should occur 5-10 min after instilling water.

A. Dilate the stoma gently with gloved finger. Dilating the stoma gently with a gloved finger is part of routine colostomy irrigation procedure.

The school nurse in informed that a 6th grader has been diagnosed with hepatitis A. It is MOST important for the nurse to teach the parents of the classmates to observe the children for which symptom? A. Fatigue B. Increased appetite C. Tarry stools D. Pallor

A. Fatigue Symptoms include fatigue, anorexia, RUQ pain, pruritus, jaundice

Immediately following liver biopsy, the nurse places the client in which position? A. On the right side B. On the left side C. Prone D. Supine

A. On the right side After a liver biopsy, it is important to prevent leakage of fluid or hemorrhage from occurring; because of this, the ideal position is to lie directly on the liver with the ribs pushing on the liver; place a pillow under costal margin; determine prothrombin time, aPTT, and platelet count prior to procedure; report abnormal findings to HCP.

the nurse cares for a client admitted with a diagnosis of acute pancreatitis. An IV is begun and the nurse inserts a NGT and attaches it to intermittent low suction. The nurse gives frequent oral hygiene and administers morphine for reports of pain. Which client behavior indicates to the nurse the medication is effective? A. The client sleeps for one hour. B. The client frequently changes position in bed. C. The client states there is less nausea. D. The client does not report thirst.

A. The client sleeps for one hour. Acute pancreatitis causes severe abdominal pain; pain increases body metabolism, which increases secretion of pancreatic and gastric enzymes; client sleeping indicates morphine is effective; important to evaluate the effectiveness of the medication.

The nurse instructs the client about how to increase calories in the diet. The nurse determines teaching is effective if the client makes which statement? A. "I will broil all my meats." B. "I will eat bread at all my meals." C. "I will snack frequently on nuts and dried fruits." D. "I will only use low-fat salad dressings."

C. "I will snack frequently on nuts and dried fruits." Adds calories; also spread butter and/or cream cheese on rolls and add butter to foods.

The nurse cares for clients in the outpatient clinic. The nurse obtains a history on a client reporting diarrhea. It is most important for the nurse to follow up on which client statement? A. "I eat a lot of processed foods." B. "I've been taking cephalexin for the last week." C. "I eat small meals 4 to 6 times per day. D. "I prefer to eat my food cold."

B. "I've been taking cephalexin for the last week." Oral antibiotics given for infections may alter the natural flora of the GI tract; this change in normal flora, especially the lack of lactobacillus, often causes diarrhea.

The nurse cares for a patient diagnosed with cholelithiasis. It is MOST important to instruct the client to avoid which of the following foods? Select all that apply. A. Apples B. Cabbage C. Lettuce D. Cheese E. Chocolate F. Carrots

B- avoid gas-forming vegetables such as onions, broccoli, radishes, beans D- high in cholesterol/fat; also avoid freid, fatty foods, cream butter, whole milk E- also egg yolks and avocado

A nurse obtains a history from a client suspected of having a duodenal ulcer. The nurse expects the client to make which statement? A. "I have been vomiting bright red blood." B. "I have abdominal pain and tenderness." C. "I have frequent loose stools every day." D. "I have increased pain after eating."

B. "I have abdominal pain and tenderness." Duodenal ulcer is erosion of the mucosal wall of the duodenum; epigastric pain is the most common symptom; pain occurs 2-3 hours after eating, and food intake relieves the pain.

The nurse in the same day surgery prepares a client for discharge after conventional herniorrhaphy. The nurse should intervene if the client makes which statement? A. "I should not strain when having a bowel movement." B. "I should cough and deep breathe every two hours." C. "I can walk up and down the stairs as soon as I get home." D. "I should call the HCP if I have an elevated temperature."

B. "I should cough and deep breathe every two hours." Due to hernia repair, should avoid coughing; deep breathing does not present a problem.

The nurse cares for the client receiving enteral feedings through a NG tube. The HCP orders isosorbide 2.5 mg sublingual as needed for chest pain. The nurse instructs the client's spouse about the correct administration of the medication. The nurse determines teaching is effective if the client's spouse makes which statement? A. "I should irrigate the tube with 50 mL of water before giving this medication." B. "I should place the tablet under the client's tongue." C. "I should dissolve this medication in warm water prior to instilling it." D. "I should ask the HCP to change the medication to a liquid form."

B. "I should place the tablet under the client's tongue." Isosorbide is an antianginal; sublingual administration is for treatment of angina; PO administration given to prevent angina; buccal or sublingual medication given as ordered to clients with NG tube.

The nurse in the outpatient clinic is counseling a client with a diagnosis of cholecystitis. The nurse determines teaching is successful if the client makes which of the following statements? A. "I really like a lot of cream on my oatmeal." B. "We eat a lot of broiled fish and chicken." C. "I can't wait to eat the chocolates my children gave me." D. "My favorite dish is broccoli with cheese sauce."

B. "We eat a lot of broiled fish and chicken." Broiled lean meats are high in protein and low in fat; cooked fruits, non gas-forming vegetables, bread also allowed.

The nurse on the surgical unit cares for several clients with new colostomies. Immediately after surgery, the nurse identifies which of the following stomas is expected? A. A stoma is bluish and dry B. A stomas is beefy-red C. A stoma is gray and small D. A stoma is dark and pulsating

B. A stomas is beefy-red Immediately following surgery, the stoma, which is part of the intestine, is brought out to the abdominal wall and appears beefy-red.

The nurse performs discharge teaching for a client with a diagnosis of hepatitis B. Which precaution to prevent the transmission of hepatitis B is included in the teaching? A. Burn used paper tissues. B. Abstain from unprotected sexual intercourse. C. Use special disinfectant in toilet. D. Avoid touching family members.

B. Abstain from unprotected sexual intercourse. Sexual contact is one way to transmit hepatitis B; unless a prospective partner is immune to hepatitis B, by virtue of either having had the disease or having received the vaccination, client should avoid unprotected sexual intercourse with that person.

The nurse monitors a client recovering from hepatitis B. The nurse understands this client has developed which type of immunity? A. Antigen B. Active acquired C. Antibody D. Passive acquired

B. Active acquired This client has actively acquired immunity, which means since the client had the disease, the client produced antibodies to fight the disease; another example of actively acquired immunity is immunization.

After inserting a needle into the ventrogluteal muscle to inject vitamin K, which action does the nurse take next? A. Instructs the client to contract the muscle. B. Administers the vitamin K slowly. C. Spreads the skin with the thumb and index finger. D. Pulls back the needle while injecting slowly.

B. Administers the vitamin K slowly. Medications should be given slowly for better absorption.

The nurse understands that the primary reason for maintaining a constant rate of infusion with parenteral nutrition is to prevent which complication? A. The risk of fluid overload. B. An unstable blood glucose level. C. Potential clotting of the catheter. D. Electrolyte imbalance.

B. An unstable blood glucose level. The potential problem of administration of parenteral nutrition is the high glucose concentration; body must produce insulin to respond to the glucose level; rate should be kept constant using an infusion pump.

The nurse instructs the client about appropriate foods for a high-protein diet. The nurse determines teaching is effective is the client chooses which menu? A. Chef salad, crackers, and iced tea B. Broiled fish, cream of tomato soup topped with grated cheese, and custard C. Peanut butter and jelly sandwich, chips, and fruit drink D. Turkey sandwich with lettuce and tomato, potato salad, and milk

B. Broiled fish, cream of tomato soup topped with grated cheese, and custard All foods contain protein; increase protein by adding skim milk to soup, add grated cheese to foods, use peanut butter as spread on fruits and vegetables, use yogurt as topping for fruit and cake.

The nurse cares for a client with a Sengstaken-Blakemore tube to treat bleeding esophageal varices. The client suddenly develops respiratory distress. Which action does the nurse take first? A. Auscultate breath sounds. B. Cut the balloon port on the Sengstaken-Blakemore tube. C. Obtain and record blood pressure and pulse. D. Contact the HCP.

B. Cut the balloon port on the Sengstaken-Blakemore tube. Keep a pair of scissors at bedside; cutting the port will deflate the balloon and allow the nurse to remove the tube.

Which symptom of liver disease should the nurse expect to see in a client with Laennec's cirrhosis? A. Cloudy urine B. Dark urine C. Orange-colored stools D. Tarry stools

B. Dark urine Normally bilirubin is not excreted in urine; urine with abnormal bilirubin is mahogany-colored and has yellow foam when shaken.

After a gastrectomy for stomach cancer, which of the following is the nurse's MOST important consideration in the management of the NGT? A. Irrigate the tube immediately. B. Do not irrigate the tube. C. Irrigate the tube with normal saline only. D. Irrigate the tube with sterile water only.

B. Do not irrigate the tube. Do not irrigate the tube unless it was specifically ordered because irrigating the tube can put pressure on the suture line.

The nurse identifies which diet best meets the nutritional needs of the client newly diagnosed with cirrhosis? A. High in calories plus vitamin supplements B. High in protein and high in carbs C. High in calcium and low in fat D. High in iron and low in salt

B. High in protein and high in carbs Clients with cirrhosis can be malnourished (possibly due to excessive alcohol use), a high protein diet is important.

The health care provider orders a clear liquid diet after an appendectomy. The nurse explains to the client a clear liquid diet was ordered for which reason? A. Provide adequate calories. B. Relieve thirst and maintain fluid balance. C. Stimulate the GI tract so the client will have bowel movements. D. Provide complete nutrition.

B. Relieve thirst and maintain fluid balance. Offer clear fluids or foods that are fluid at body temperature; requires minimal digestion and leaves minimal residue; clear liquids are the initial feeding after surgery or parenteral nutrition.

The nurse instructs the client about the bowel preparation required prior to a sigmoidoscopy. The nurse identifies teaching is successful if the client makes which statement? A. "I can not eat 8 hours prior to the test." B. "I will be asleep when this test is performed." C. "I will have an enema the morning of the test." D. "I will have nasogastric suction decompression."

C. "I will have an enema the morning of the test." Sigmoidoscopy is direct visualization of sigmoid colon, rectum, and anal canal; tap water enema or Fleet's given until returns are clear the morning of the procedure.

The nurse gives discharge instructions to a family of a client diagnosed with hepatic encephalopathy. The nurse determines further teaching is necessary if the family makes which statement? A. "We should contact the HCP is our parent is restless at night." B. "Lactulose will cause our parent to have 2-3 stools per day." C. "Our parent should eat meat at every meal." D. "Lactulose may cause bloating and cramps."

C. "Our parent should eat meat at every meal." A low-protein, high-calorie diet; instruct family to observe for and report mental changes.

The home care nurse visits a client with a diagnosis of ulcerative colitis. The client reports perineal irritation due to frequent stools. Which suggestion by the nurse is best? A. Apply a heat lamp to the perineal area 3x/day. B. Use protective plastic bed pads. C. Clean the perineal area with soap and water after each bowel movement. D. Increase roughage in the diet to prevent frequent stools.

C. Clean the perineal area with soap and water after each bowel movement. Keeps the skin free of stool; sitz baths; apply petroleum jelly or vitamin A and D ointment.

The nurse understands the most common reason for insertion of a NG tube in a postop client diagnosed with a duodenal ulcer includes which reason? A. Take samples of gastric acid. B. Assess the stomach for bleeding. C. Decompress the stomach. D. Permit saline irrigations.

C. Decompress the stomach. The stomach is decompressed postoperatively to prevent distention and pressure on the suture lines.

A client is scheduled for bowel surgery, and the HCP orders a low-residue diet as a part of the bowel prep. The nurse instructs the client about foods allowed on a low-residue diet. The nurse determines the teaching is effective if the client chooses which menu? A. Bouillon, grilled cheese, and grapes B. Corned beef, buttered peas, and custard C. Roast lamb, buttered rice, and sponge cake D. Strained cream of asparagus soup, bacon and tomato sandwich, and a sugar cookie

C. Roast lamb, buttered rice, and sponge cake Foods allowed include well-cooked tender meats (roast lamb), fish, and poultry; milk and mild cheeses, juices without pulp (no prune juice), canned fruit and ripe bananas; white bread or refined bread.

The nurse reviews the records of a client diagnosed with Laennec's cirrhosis. The nurse expects to find which lab value? A. Serum albumin 4.0 g/dL B. Serum aspartate aminotransferase 38 units C. Serum alanine amino-transaminase 600 units D. Serum lactate dehydrogenase 150 units

C. Serum alanine amino-transaminase 600 units Elevation indicates liver damage; normal 5-35 units

The nurse cares for a patient post-appendectomy, and a full liquid diet is ordered. The nurse determines that the patient's breakfast is appropriate if it includes A. only strained clear liquids B. as much fruit as desired C. cooked cereal D. yogurt and bananas

C. cooked cereal Full liquid diet includes milk and milk products (pudding, custards), all vegetable juices, all fruit juices, refrained or strained cereals, eggs in custard, butter, margarine, and cream.

The nurse prepares the client for a sigmoidoscopy. The nurse should notify the HCP if the client makes which statement? A. "I took my blood pressure medication with a sip of water this morning." B. "I haven't eaten any fruits or vegetables since the day before yesterday." C. "I had good results from the tap water enema this morning." D. "I hope that this is easier than the barium enema I had two days ago."

D. "I hope that this is easier than the barium enema I had two days ago."D. "I hope that this is easier than the barium enema I had two days ago." Barium makes it difficult to visualize the colon; no barium studies for three days before sigmoidoscopy.

The home care nurse makes a visit to a client receiving enteral feeding through a gastrostomy tube. the client's daughter reports the client has frequent loose stools. Which of the following statements, if made by the daughter to the nurse, warrants further investigation? A. "My dad gets 300 cc of formula in one hour." B. "I warm the formula in a basin of hot water." C. "I hang a new bag and tubing every 24 hours." D. "It's so easy to give liquid medicine through the tube."

D. "It's so easy to give liquid medicine through the tube." Many liquid medication contain sorbitol; if client has an allergy to sorbitol, will cause diarrhea; nurse needs to determine what medication the client is receiving and if the medications contain sorbitol.

The nurse performs preoperative teaching for a patient scheduled for a colostomy. The nurse explains to the patient that 24 hours after surgery the colostomy drainage will be which of the following? A. A large amount of bloody output B. A large amount od liquid stool C. Formed stool with water D. A scant amount of bright bloody drainage

D. A scant amount of bright bloody drainage Small amount of bleeding at stoma expected; report excessive amounts of bleeding.

To prepare a client for a paracentesis, it is essential for the nurse to take which action? A. Administer a cleansing enema B. Premedicate the client with a narcotic analgesic. C. Restrict the client's intake of fluids. D. Instruct the client to empty the bladder.

D. Instruct the client to empty the bladder. Procedure involves removal of fluid from the client's abdomen through a trocar, client may have bladder injured by the procedure if it is not empty and small.

The nurse on he surgical unit cares for a patient after an ileostomy. Which of the following actions should the nurse take first? A. Empty the ileostomy bag from the bottom. B. Apply lotion to the skin around the stoma. C. Cover the ileostomy with 3 layers of gauze. D. Measure the output and record it in the chart.

D. Measure the output and record it in the chart. Assessment; output from the ileostomy is liquid and may be copious; important to assess patient's intake and output.

The nurse instructs the family of the client diagnosed with hepatitis A how to prevent the spread of the disease. It is most important for the nurse to include which instruction? A. The family should not share eating utensils and drinking glasses. B. Do not come in contact with client's blood. C. Do not donate blood during the next year. D. No special precautions are required because the family treated with gamma globulin.

D. No special precautions are required because the family treated with gamma globulin. Hepatitis A is spread by fecal-oral route; client should wash hands before eating and after using the toilet.

The spouse of a client with hepatitis B is given hepatitis B immune globulin (HBIg). The nurse understands this offers which type of protection? A. Complete B. Active acquired C. Antigen D. Passive acquired

D. Passive acquired Immune serums such as HBIg contain gamma globulins in a concentration of about 16% and are obtained from hepatitis B-immune persons from the general population; provides rapid but short-lived protection against hepatitis B; close contacts of a client with hepatitis B receive this immunization by intramuscular injection; treatment is usually repeated from 28 to 30 days.

The nurse understands which of these factors is the MOST likely source of hepatitis D? A. Eating infected shellfish B. Overly exerting oneself C. Practicing poor hygiene D. Receiving a blood transfusion

D. Receiving a blood transfusion Hepatitis D coinfects with Hepatitis B; spread by contact with blood and body fluids.

The nurse cares for a client with an NG tube in place. The client reports discomfort in the back of the throat. Which action by the nurse is best? A. Move the tube out 2 inches. B. Change feedings to full liquids. C. Reinsert tube into other nostril. D. Spray with viscous lidocaine solution.

D. Spray with viscous lidocaine solution. Viscous lidocaine is a local anesthetic; spraying it on the irritated surface may relieve the discomfort in the back of the client's throat.

The nurse cares for an elderly client admitted with a diagnosis of hepatitis A. The client is anorexic, reports weakness, is incontinent of urine, and involuntary of stool. The nurse determines that care is appropriate if which observation is made? A. The staff caring for the client follows standard precautions. B. the client is offered more frequent feeding during the afternoon and evening hours. C. The nurse maintains the client on strict bedrest. D. The nurse places the client on contact precautions.

D. The nurse places the client on contact precautions. Hepatitis A is spread by fecal-oral route; contact precautions required due to fecal incontinence; instruct client in importance of good handwashing.

The nurse performs a home care visit with a diagnosis of right-sided cerebrovascular accident. The client's spouse complains about having frequent loose stools, and the physician diagnosed viral gastroenteritis. The nurse is MOST concerned if which of the following is observed? A. The spouse washes hands frequently. B. The spouse drinks Gatorade. C. The spouse uses a separate tube of toothpaste. D. The spouse prepares lunch for the client.

D. The spouse prepares lunch for the client. Due to diarrhea, should not prepare foods that will be eaten by others.

A sexual contact of a patient with hepatitis B is given HBIg. The nurse explains to the contact the purpose of medication is to A. prevent other STDs. B. stimulate his immune system, to develop antibodies to hepatits. C. assure that he doesn't contract hepatitis. D. temporarily increase the person's resistance to hepatitis.

D. temporarily increase the person's resistance to hepatitis. An injection of pooled human gamma globulin is an example of passive immunity.