nclex questions 4100 exam 1

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet? 1.Protein 2.Calories 3.Minerals 4.Carbohydrates

1 Rationale:Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

1 Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1.Elevated lipase level 2.Elevated lactase level 3.Elevated trypsin level 4.Elevated amylase level 5.Elevated sucrase level

1, 3, 4 Rationale:Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1.Diarrhea 2.Black, tarry stools 3.Hyperactive bowel sounds 4.Gray-blue color at the flank 5.Abdominal guarding and tenderness 6.Left upper quadrant pain with radiation to the back

4, 5, 6 Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

1 Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? 1.Encourage the client to ambulate. 2.Position the client on the left side. 3.Frequently irrigate the nasogastric tube (NG) with 30 mL saline. 4.Discourage the use of the patient-controlled analgesia (PCA) machine.

1 Rationale:Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated and positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain and it is important for their pain to be controlled so that they are able to do the activities required, such as coughing and deep breathing and ambulation, to prevent complications.

Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies? 1.Serum potassium, serum calcium 2.Urinalysis, hematocrit, hemoglobin 3.Culture and sensitivity testing, serum sodium 4.Urine specific gravity, intravenous pyelogram

1 Rationale:Because of the potentially life-threatening outcomes associated with hyperkalemia and hypocalcemia, they are the most relevant to nursing management of the client with CKD. The diagnostic tests in the remaining options may be helpful in diagnosing CKD or in monitoring treatment but are not the most relevant. Additionally, decreased hematocrit and hemoglobin occur in CKD because of the decreased level of erythropoietin. However, a decrease in hematocrit and hemoglobin may be reflective of various health alterations.

The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor? 1.Alcohol intake 2.Duodenal ulcer 3.Crohn's disease 4.Diabetes mellitus

1 Rationale:Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not specifically associated with pancreatitis.

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 1.Age younger than 50 years 2.History of colorectal polyps 3.Family history of colorectal cancer 4.Chronic inflammatory bowel disease

1 Rationale:Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.

The nurse has provided teaching for an adult client about screening for a colon cancer. Which statement by the client indicates that education was effective? 1."I should have an annual fecal occult blood test." 2."I should have an annual colonoscopy when I become 60." 3."I will have a colonoscopy before the fecal occult blood test." 4."I will not need to have further fecal occult blood tests after a colonoscopy."

1 Rationale:Fecal occult blood testing for colorectal cancer should be done annually for both men and women. Less invasive diagnostic testing such as a fecal occult blood test will be performed first. Colonoscopy is done at age 50 and then every 10 years.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? 1.Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish-brown drainage

1 Rationale:For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

The nurse is reviewing the laboratory test results for a client with bladder cancer with bone metastasis. The nurse should contact the health care provider (HCP) if which finding is noted? 1.Calcium level of 15 mg/dL (3.75 mmol/L) 2.Potassium level of 3.8 mEq/L (3.8 mmol/L) 3.Platelet count of 200,000 mm3 (200 × 109/L) 4.White blood cell (WBC) count of 6000 mm3 (6 × 109/L)

1 Rationale:Hypercalcemia is a serum calcium level greater than 10.5 mg/dL (2.6 mmol/L). It most often occurs in clients who have bone metastasis and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream. Hypercalcemia is an oncological emergency, and the HCP needs to be notified. Options 2, 3, and 4 indicate normal laboratory values.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask? 1."Do you abuse alcohol?" 2."Do you have any known cardiac disease?" 3."Does your type of employment cause you to have exposure to chemicals?" 4."Have you ever been told that you have had obstruction to your biliary ducts?"

1 Rationale:Laënnec's cirrhosis results from long-term alcohol abuse; therefore, the question inquiring about alcohol abuse is most appropriate. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

The nurse is completing an admission assessment for a client with suspected esophageal cancer. Which statement made by the client indicates the presence of a risk factor for esophageal cancer? 1."I've been smoking for 20 years now." 2."I eat plenty of fresh fruits and vegetables." 3."I'm 5 feet, 8 inches tall and weigh 160 pounds." 4."My alcohol consumption is about 2 beers per month."

1 Rationale:Primary risk factors associated with the development of esophageal cancer are smoking and obesity. The compounds in tobacco smoke may be responsible for the genetic mutations seen in many squamous cell carcinomas of the esophagus. Malnutrition, untreated gastroesophageal reflux disease (GERD), and excessive alcohol intake are also associated with esophageal cancer. Diets that are chronically deficient in fresh fruits and vegetables have also been implicated in the development of squamous cell carcinoma of the esophagus.

A client with renal cancer is being treated preoperatively with radiation therapy. What statement by the client demonstrates understanding of proper care of the skin over the treatment field? 1."I need to avoid skin exposure to direct sunlight and chlorinated water." 2."I need to use lanolin-based cream on the affected skin on a daily basis." 3."I need to use the hottest water possible to wash the treatment site twice daily." 4."I need to remove the lines or ink marks using a gentle soap after each treatment."

1 Rationale:The client undergoing radiation therapy should avoid washing the site until instructed to do so. The client should then wash, using mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools).

The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? 1.Full liquid diet 2.Morphine sulfate for pain 3.Nasogastric tube insertion 4.An anticholinergic medication

1 Rationale:The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1.Chili 2.Bagel 3.Lentil soup 4.Watermelon

1 Rationale:The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1.Elevated creatinine level 2.Decreased hemoglobin level 3.Decreased red blood cell count 4.Increased number of white blood cells in the urine

1 Rationale:The creatinine level is the most specific laboratory test to determine renal function. The creatinine level increases when at least 50% of renal function is lost. A decreased hemoglobin level and red blood cell count are associated with anemia or blood loss and not specifically with decreased renal function. Increased white blood cells in the urine are noted with urinary tract infection.

The oncology nurse is providing a teaching session for a group of nursing students regarding the risks and causes of bladder cancer. Which statement by a student would indicate a need for further teaching? 1."Bladder cancer most often occurs in women." 2."Using cigarettes and drinking coffee can increase the risk." 3."Bladder cancer generally is seen in clients older than age 40." 4."Environmental health hazards have been implicated as a cause."

1 Rationale:The incidence of bladder cancer is greater in men than in women and affects white people twice as often as black people. The remaining options describe risks associated with bladder cancer.

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis? 1."Does the pain in your stomach radiate to your back?" 2."Does the pain in your lower abdomen radiate to your hip?" 3."Does the pain in your lower abdomen radiate to your groin?" 4."Does the pain in your stomach radiate to your lower middle abdomen?"

1 Rationale:The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. In planning care, which nursing action should be the priority for this client? 1.Assessment of vital signs 2.Complete abdominal examination 3.Thorough investigation of precipitating events 4.Insertion of a nasogastric tube and Hematest of emesis

1 Rationale:The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube 4.Thorough investigation of precipitating events

1 Rationale:The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a health care provider's prescription; in addition, the vital signs should be checked before performing this procedure.

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? 1.Elevated serum lipase level 2.Elevated serum bilirubin level 3.Decreased serum trypsin level 4.Decreased serum amylase level

1 Rationale:The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Monitor daily weight. 2.Measure abdominal girth. 3.Monitor respiratory status. 4.Place the client in a supine position. 5.Assist the client with care as needed.

1, 2, 3, 5 Rationale:Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

A client with end-stage renal disease (ESRD) has the problem of ineffective coping. Which nursing interventions are appropriate in working with this client? Select all that apply. 1.Acknowledge the client's feelings. 2.Assess the client and family's coping patterns. 3.Explore the meaning of the illness with the client. 4.Set limits on mood swings and expressions of hostility. 5.Give the client information when the client is ready to listen

1, 2, 3, 5 Rationale:Clients with ESRD are likely to experience mood swings or express hostility, anger, and depression, among other responses. The nurse should acknowledge the client's feelings, allow the client to express those feelings, and be supportive. Options 1, 2, 3, and 5 are helpful and appropriate interventions for the client. Setting limits for this client is not client focused, does not allow the client to express concerns, and is nontherapeutic in this situation.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1.Orthopnea and dyspnea 2.Petechiae and ecchymosis 3.Inguinal or umbilical hernia 4.Poor body posture and balance 5.Abdominal distention and tenderness

1, 2, 3, 5 Rationale:Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

The nurse is providing discharge instructions for a client following a Roux-en-Y gastric bypass surgery 3 days ago. What will the nurse include in the instructions? Select all that apply. 1.Do not drink fluids with meals. 2.Avoid foods high in carbohydrates. 3.Take an extended-release multivitamin daily. 4.Maintain a clear liquid diet for about 6 weeks. 5.Eat 6 small meals a day that are high in protein.

1, 2, 5 Rationale:A Roux-en-Y gastric bypass is a combination of restrictive and malabsorptive surgery in which the size of the stomach is made much smaller and a large part of the small intestine (which absorbs food) is bypassed. Because the stomach is so small, clients are instructed to not drink fluids with meals because providers do not want them to fill up on less nutritional liquids before having food; to avoid foods high in carbohydrates because they are not as nutritional and tend to promote diarrhea and dumping syndrome; and to eat frequent, small meals that are high in protein. An extended-release vitamin will not be absorbed by the client since much of the small intestine is bypassed and food moves through quickly, and 6 weeks is too long a period to be on clear liquids. The typical bariatric surgery client is only on clear liquids for a few days and should then be on a high-protein diet.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1.Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hour to keep the vein open

1, 2, 5 Rationale:The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In creating a discharge teaching plan for the client, the nurse should include which instruction in the plan? 1.Dietary restrictions 2.Technique of catheterization 3.External pouch and application care 4.Proper administration of prophylactic antibiotics

2 Rationale:A Kock pouch is a continent internal ileal reservoir. The nurse instructs the client about the technique of catheterization. Dietary restrictions are not required. There is no external pouch. Antibiotics are not required unless an infection is present; also, antibiotics are prescribed by the health care provider.

A female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which problem? 1.Rupture of the bladder 2.The development of a vesicovaginal fistula 3.Extreme stress because of the diagnosis of cancer 4.Altered perineal sensation as a side effect of radiation therapy

2 Rationale:A complication of radiation therapy for bladder cancer is fistula formation. In women, this frequently is manifested as a vesicovaginal fistula, which is an opening between the bladder and the vagina. With this complication the client senses that urine is flowing out of the vagina. In men, a colovesical fistula may develop, which is an opening between the bladder and the colon. This is manifested as voiding urine that contains fecal material. The remaining options are incorrect interpretations.

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? 1.Rupture of the bladder 2.The development of a vesicovaginal fistula 3.Extreme stress caused by the diagnosis of cancer 4.Altered perineal sensation as a side effect of radiation therapy

2 Rationale:A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina. The client's complaint is not associated with options 1, 3, or 4.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1."I will obtain adequate rest." 2."I will take acetaminophen if I get a headache." 3."I should monitor my weight on a regular basis." 4."I need to include sufficient amounts of carbohydrates in my diet."

2 Rationale:Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1.Restlessness 2.Presence of asterixis 3.Complaints of fatigue 4.Decreased serum ammonia levels

2 Rationale:Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder? 1.Weight gain 2.Use of alcohol 3.Exposure to occupational chemicals 4.Abdominal pain relieved with food or antacids

2 Rationale:Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1.Clamp the surgical drain. 2.Change the dressing as prescribed. 3.Notify the health care provider (HCP). 4.Remove and replace the perineal packing.

2 Rationale:Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the HCP at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include? 1.Alcohol should be consumed in moderation. 2.Avoid caffeine because it may aggravate symptoms. 3.Diet should be high in carbohydrates, fats, and proteins. 4.Frothy, fatty stools indicate that enzyme replacement is working.

2 Rationale:Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy, fatty stools indicate that the replacement enzyme dose needs to be increased.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1.Vomiting occurs. 2.The fecal pH is acidic. 3.The client experiences diarrhea. 4.The client is able to tolerate a full diet.

2 Rationale:Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1.Eating helps to decrease the pain. 2.The pain usually increases after vomiting. 3.The pain is mostly around the umbilicus and comes and goes. 4.The pain increases when the client sits up and bends forward.

2 Rationale:Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

A client is admitted to the hospital with suspected bladder cancer. The nurse assesses the client for which early signs and symptoms of the disease? 1.Proteinuria and dysuria 2.Hematuria and absence of pain 3.Painful urination and hematuria 4.Pyuria and palpable abdominal mass

2 Rationale:The most common earliest manifestation of bladder cancer is hematuria that is not accompanied by pain. The hematuria is intermittent at first. Later signs and symptoms include hematuria with dysuria and frequency because of bladder irritation. Pyuria and proteinuria are not part of the clinical picture. A mass usually is not palpable.

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer? 1.Dysuria 2.Hematuria 3.Urgency on urination 4.Frequency of urination

2 Rationale:The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1.Sitting up 2.Lying flat 3.Leaning forward 4.Drawing the legs to the chest

2 Rationale:The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.

The nurse is reviewing the preoperative prescriptions for a client with a colon tumor who is scheduled for abdominal perineal resection and notes that the health care provider has prescribed neomycin for the client. After discussing a prescription for neomycin with the nursing student who is caring for the client, the nurse determines that the student understands the rationale for administration if which statement is made? 1."The client is allergic to penicillin." 2."It will help to decrease the bacteria in the bowel." 3."It is given to prevent an immune dysfunction postoperatively." 4."It is given because the client has an infection that must be treated prior to surgery."

2 Rationale:To reduce the risk of contamination at the time of surgery, the surgeon may prescribe that the bowel is emptied and cleansed. Laxatives and enemas may be prescribed to empty the bowel. An intestinal anti-infective such as neomycin may also be prescribed to decrease the bacteria in the bowel. There are no data in the question that indicate that the client has an infection or is allergic to penicillin. The medication does not prevent immune dysfunction.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1.Flat neck veins 2.Abdominal distention 3.Hemoglobin of 14.2 g/dL (142 mmol/L) 4.Platelet count of 600,000 mm3 (600 × 109/L)

2 Rationale:With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1.Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.

3 Rationale:After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.

The nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is most likely to be a result of which factor? 1.A stress response to the ordeal of surgery 2.A latent fear of needing dialysis if the surgery is unsuccessful 3.Pain that is intensified because of the location of the incision near the diaphragm 4.Effects of circulating metabolites that have not been excreted by the remaining kidney

3 Rationale:After nephrectomy, the client may be in considerable pain. This is because of the size of the incision and its location near the diaphragm, which make coughing and deep breathing very uncomfortable. For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. The items in the other options are not likely factors for the client's statement.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1.Dorsiflex the client's foot. 2.Measure the abdominal girth. 3.Ask the client to extend the arms. 4.Instruct the client to lean forward.

3 Rationale:Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams are evaluating donor and recipient. What is the most appropriate response by the nurse? 1.Helps reduce the cost of the preoperative workup 2.Saves the client and the recipient valuable preoperative time 3.Avoids a conflict of interest between the team evaluating the recipient and the team evaluating the donor 4.Provides for a sufficient number of persons reviewing the case so that no information is overlooked

3 Rationale:Both the kidney donor and the kidney recipient need thorough medical and psychological evaluation before transplant surgery. Separate teams evaluate the donor and the recipient to avoid a conflict of interest in providing care for the 2 clients. Options 1, 2, and 4 are not related to the purpose of this approach.

In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate? 1.Glycosuria 2.Polyphagia 3.Crackles auscultated in the lungs 4.Blood pressure of 98/58 mm Hg

3 Rationale:CKD is a condition in which the kidneys have progressive problems in clearing nitrogenous waste products and controlling fluid and electrolyte balance within the body. Cardiovascular symptoms of heart failure and hypertension are caused by the fluid volume overload resulting from the kidneys' inability to excrete water. Signs and symptoms of heart failure include jugular venous distention, S3 heart sound, pedal edema, increased weight, shortness of breath, and crackles auscultated in the lungs. The typical signs and symptoms of CKD include proteinuria or hematuria, not glycosuria. The nurse would observe anorexia and nausea in this client, not polyphagia.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? 1.Roast pork 2.Cheese omelet 3.Pasta with sauce 4.Tuna fish sandwich

3 Rationale:Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection.

A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse should plan to use which information in discussions with the client to alleviate anxiety? 1.There is a strong likelihood that the client will need dialysis within 5 to 10 years. 2.There is absolutely no chance of needing dialysis because of the nature of the surgery. 3.One kidney is adequate to meet the needs of the body as long as it has normal function. 4.Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.

3 Rationale:Fears about having only 1 functioning kidney are common in clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs, as long as it has normal function. Therefore, the remaining options are incorrect.

The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? 1.Anxiety 2.Memory deficits 3.Presence of family 4.Short attention span

3 Rationale:The client with CKD may have several barriers to learning. The presence of family members is helpful because they need to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. Anxiety about the disease and its ramifications frequently interferes with learning. Physiological effects of the disease process also impair the client's mental functioning. Specifically, the client may exhibit a short attention span and have memory deficits. Mental functioning usually improves once hemodialysis has begun.

The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1.Elevated level of pepsin 2.Decreased level of lactase 3.Elevated level of amylase 4.Decreased level of enterokinase

3 Rationale:The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

The nurse is caring for a client after intravesical instillation of an alkylating chemotherapeutic agent for the treatment of bladder cancer. What should the nurse instruct the client to do after the instillation? 1.Urinate immediately. 2.Maintain strict bed rest. 3.Change position every 15 minutes. 4.Retain the instillation fluid for 30 minutes.

3 Rationale:With intravesical instillation, normally the medication is injected into the bladder through a urethral catheter, the catheter is clamped or removed, and the client is asked to retain the fluid for 2 hours. The client changes position every 15 to 30 minutes, usually from side to side and from supine to prone. The client then voids and is instructed to drink water to flush the bladder.

A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1.Antibiotic therapy 2.Peritoneal dialysis 3.Removal of the transplanted kidney 4.Increased immunosuppression therapy

4 Rationale:Acute rejection most often occurs within 1 week after transplantation but can occur any time posttransplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Treatment consists of increasing immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis cannot be used with a newly transplanted kidney due to the recent surgery. Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours of the transplant surgery.

A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition? 1.Advancing uremia 2.Phosphate overdose 3.Folic acid deficiency 4.Aluminum intoxication

4 Rationale:Aluminum hydroxide may be prescribed as a phosphate-binding agent. Aluminum intoxication can occur when there is an accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It can be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. The data in the question are not specifically associated with the other conditions noted in the options.

A client experiencing end-stage kidney disease has an arteriovenous (AV) fistula placed surgically for hemodialysis. Which action is most appropriate for the nurse to document in the plan for care of the AV fistula? 1.Palpate the bruit of the AV fistula weekly to assess for thrombosis. 2.Use the AV fistula site for blood draws to prevent increased pain of multiple blood draws. 3.Take the blood pressure readings in the extremity with the AV fistula to get a more accurate reading. 4.Teach the client to avoid carrying heavy objects that would compress the AV fistula and cause thrombosis.

4 Rationale:An AV fistula is a vascular access system that is required for hemodialysis. It is a device established for clients who need long-term hemodialysis. It is created by connecting an artery to a vein inside the body to create a vessel that can handle the amount of blood flow necessary for effective dialysis. Bleeding, clotting, and infection are risks with all vascular devices. It also is very important to avoid any activity that would promote the status of blood or increase the risk for infection. Taking the blood pressure in the affected arm, carrying heavy objects in the arm, and lying on the arm at night could increase the risk for clotting in the fistula. To check circulation of the fistula, the nurse should palpate or feel for the thrill or auscultate (listen with a stethoscope) for the bruit. It is important to do this at least daily to ascertain the patency of the fistula. To avoid infection, that extremity is never used for peripheral intravenous access (placement of an intravenous line) or for blood draws. Strict aseptic technique is used in accessing the fistula for dialysis.

The nurse is performing an admission assessment of a client with a possible right colon tumor. Which sign or symptom should the nurse anticipate the client may report? 1.Frequent diarrhea 2.Crampy gas pains 3.Flat, ribbon-like stools 4.Dull abdominal pain exacerbated by walking

4 Rationale:Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors.

The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? 1.High-fiber, low-fat diet 2.Age older than 30 years 3.Distant relative with colorectal cancer 4.Personal history of ulcerative colitis or gastrointestinal polyps

4 Rationale:Common risk factors for colorectal cancer include age older than 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems, such as ulcerative colitis or familial polyposis.

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1.Hypertension, tachycardia, and fever 2.Hypotension, bradycardia, and hypothermia 3.Restlessness, irritability, and generalized weakness 4.Headache, deteriorating level of consciousness, and twitching

4 Rationale:Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing increased intracranial pressure and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates. Tachycardia and fever are associated with infection. Generalized weakness is associated with low blood pressure and anemia. Restlessness and irritability are not associated with disequilibrium syndrome.

The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? 1.Potassium 2.Creatinine 3.Phosphorus 4.Red blood cell (RBC) count

4 Rationale:Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia because RBCs are lost during dialysis from blood sampling and anticoagulation and from residual blood left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process.

The nurse is caring for a client immediately after nephrectomy and renal transplantation. What is the most appropriate datum to use in planning administration of intravenous fluids to this client? 1.A strict hourly rate of 100 mL 2.A strict hourly rate of 150 mL 3.One half of the previous hour's urine output 4.The number of milliliters in the previous hour's urine output

4 Rationale:Intravenous fluids are managed very carefully after nephrectomy and renal transplantation. Fluids are usually given according to a formula that takes into account the previous hour's urine output. The desired urine output is generally high; therefore, options 1, 2, and 3 are incorrect.

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1."I have epigastric pain radiating to my neck." 2."I have severe abdominal pain that is relieved after vomiting." 3."My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)." 4."I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

4 Rationale:Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign. Epigastric pain radiating to the neck area is not a characteristic symptom.

The nurse is teaching a client with renal cancer who is scheduled for a renal artery embolization about the procedure. Which statement by the client indicates that the educational session was effective? 1."This will reduce the time needed for surgery by at least half because it provides hemostasis." 2."This will cause the tumor to become tougher and easier to resect in surgery with the scalpel." 3."This will prevent the risk of pulmonary embolism by occluding the renal artery and its branches." 4."This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge."

4 Rationale:Renal artery embolization may be done instead of radiation therapy to shrink the kidney tumor by cutting off its blood supply and impairing its overall vascularity. A secondary benefit is that it reduces the risk of hemorrhage during surgery. This procedure can be accomplished in a number of ways, including placement of an absorbable gelatin sponge, a balloon, a metal coil, or any of various other substances.

A client being discharged home after renal transplantation has a risk for infection related to immunosuppressive medication therapy. The nurse determines that the client needs further teaching on measures to prevent and control infection if the client states that it is necessary to take which action? 1.Take an oral temperature daily. 2.Use good hand-washing technique. 3.Take all scheduled medications exactly as prescribed. 4.Monitor urine character and output at least 1 day each week.

4 Rationale:The client receiving immunosuppressive medication therapy must learn and use infection control methods for use at home. The client self-monitors urine output and its characteristics on a daily basis. The client must learn proper hand-washing technique and should take the temperature daily to detect early infection. This is especially important because the client also takes corticosteroids, which mask signs and symptoms of infection. All medications should be taken exactly as prescribed.

A client is having difficulty coughing and deep-breathing because of pain after a nephrectomy. Which action by the nurse is helpful in promoting optimal respiratory function? 1.Administering pain medication just before ambulation 2.Administering pain medication when the client asks for it 3.Encouraging the use of the incentive spirometer every 8 hours 4.Assisting the client to splint the incision during respiratory exercise

4 Rationale:The client who has had a nephrectomy may have pain with coughing and deep breathing and other respiratory exercises because the location of the incision is so close to the diaphragm. The nurse assists the client by offering opioid analgesics when due, encouraging incentive spirometer use hourly, and assisting the client to splint the incision during coughing. If the client takes pain medication only before ambulation, control of pain may be insufficient, which will not promote optimal respiratory function (pain medication should be offered 30 to 45 minutes before the client ambulates). Laparoscopic nephrectomy can also be performed. Compared to conventional nephrectomy, the laparoscopic approach is less painful and requires no sutures or staples, involves a shorter hospital stay, and has a much faster recovery.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1.Difficulty with sleeping 2.Risk for skin breakdown 3.Difficulty with breathing 4.Excessive body fluid volume

4 Rationale:The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There are no data in the question that indicate that the client is having difficulty with sleep.