***NP2 ENDO/GI EXAM
Order: ranitidine (Zantac) 50 mg, IV, q6h. Set: infusion pump. Drug available: premixed drug in bag (Zantac 50 mg in 0.45% NaCl [½ NSS]). Instructions: Infuse over 15 minutes. a. .Infusion pump rate: b. how many mg of ranitidine the patient will receive in 24 hours
Evaluation Method Correct Answer Exact Match a.infuse 50 mg of Zantac in 50 mL of .45 % NSS via a pump at 200 mL/ hour b. 200 mg in 24 hours Response Feedback: 15 minutes is .25 of an hour. 50mg divided by .25 of an hour every 6 hours is 4X's a day or 50 mg X4= 200 mg in 24 hours
The MD has ordered Protonix 40 mg IVPB in 100 mL of D5W to infuse over 20 minutes. This is administered via pump. What would you set the pump rate at to deliver this medication.
Evaluation Method Correct Answer Pattern Match 20/60=.33 of an hour Infuse protonix 40 mg via IV pump at 300 or 303 mL / in 100 mL of D5W hour Response Feedback: 300 or 303 mL / hour is accepted what part of an hour is 20 minutes
Analyze the following diagnostic findings for your patient with type 2 diabetes. Which result will need further assessment? a. BP 126/80 b. FBG 130mg/d c. LDL cholesterol 136mg/dL d. A1C 9 %
Response Feedback: "B) A1C 9% Rationale: Lowering hemoglobin A1C (to average of 7%) reduces microvascular and neuropathic complications. Tighter glycemic control(normal A1C < 6%) may further reduce complications but increases hypoglycemia risk."
A 56-year-old female client is being discharged after undergoing a thyroidectomy. Which discharge instructions would be appropriate for this client? Select all that apply a. "Watch for lethargy, restlessness, sensitivity to cold and report to healthcare provider." b. "Carry injectable dexamethasone at all times." c. "Take thyroid replacement medication as ordered." d. "Recognize the signs of dehydration." e. "Report signs and symptoms of hypoglycemia."
Selected Answers: A,C a. "Watch for lethargy, restlessness, sensitivity to cold and report to healthcare provider." c. "Take thyroid replacement medication as ordered." Response Feedback: After the removal of the thyroid gland, the client needs to take thyroid replacement medication. The client also needs to report such changes as lethargy, restlessness, cold sensitivity, and dry skin, which may indicate the need for a higher dosage of medication. The thyroid gland doesn't regulate blood glucose levels; therefore, signs and symptoms of hypoglycemia aren't relevant for this client. Dehydration is seen in diabetes insipidus. Injectable dexamethasone isn't needed for this client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application
When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says, a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." b. "If I become ill, I may have to take insulin to control my blood sugar." c. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels." d. "If I overeat at a meal, I will still take just the usual dose of medication."
a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." Response Feedback: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glypizide.
A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that the medication is effective? a. The patient is alert and oriented. b. The patient's bilirubin level decreases. c. The patient has at least one stool daily. d. The patient denies nausea or anorexia.
a. The patient is alert and oriented. Response Feedback: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
Which change in clinical manifestations in a client with long-standing diabetes mellitus alerts the nurse to the possibility of renal dysfunction? a. The presence of glucose in the urine b. A sustained increase in blood pressure from 130/84 to 150/100 c. The presence of ketone bodies in the urine d. Loss of tactile perception (loss of touch)
b. A sustained increase in blood pressure from 130/84 to 150/100 Response Feedback: Hypertension is both a cause of renal dysfunction and a result of renal dysfunction. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment/Analysis MSC: Client Needs Category: Physiological Integrity
Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with hyperosmolar, hyperglycemic nonketotic syndrome (HHNS). Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which she receives 8 units of regular insulin. The nurse should expect which of the following? a. Onset to be at 4 p.m. and its peak to be at 6 p.m b. Onset to be at 2:30 p.m. and its peak to be at 4 p.m c. Onset to be at 2:15 p.m. and its peak to be at 3 p.m d. Onset to be at 2 p.m. and its peak to be at 3 p.m
b. Onset to be at 2:30 p.m. and its peak to be at 4 p.m Response Feedback: Answer C. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m. comprehension application of medications
A few months after bariatric surgery, a 62-year-old patient tells the nurse, "My skin is hanging in folds. I think I need cosmetic surgery." Which response by the nurse is most appropriate? a. "The skinfolds will gradually disappear once most of the weight is lost." b. "Perhaps you would like to talk to a counselor about your body image." c. "Cosmetic surgery is certainly a possibility once your weight has stabilized." d. "The important thing is that your weight loss is improving your health."
c. "Cosmetic surgery is certainly a possibility once your weight has stabilized." Response Feedback: Reconstructive surgery may be used to eliminate excess skinfolds after at least a year has passed since the surgery. Skinfolds may not disappear over time, especially in older patients. The response, "The important thing is that your weight loss is improving your health" ignores the patient's concerns about appearance and implies that the nurse knows what is important. Whereas it may be helpful for the patient to talk to a counselor, it is more likely to be helpful to know that cosmetic surgery is available.
The health care provider orders IV ranitidine (Zantac) for a patient with an acute exacerbation of chronic peptic ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include? Ranitidine a. "neutralizes the acid in the stomach." b. "constricts the blood vessels in the stomach and decreases bleeding." c. "covers the ulcer with a protective material which promotes healing." d. "decreases secretion of gastric acid."
d. "decreases secretion of gastric acid." Response Feedback: Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response beginning "Ranitidine neutralizes the acid" describes the effect of antacids. And the response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).
Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate to nursing assistive personnel? a. Palpating the abdomen for distention b. Assessing the patient for jaundice c. Assisting the patient in choosing the diet d. Providing oral hygiene before meals
d. Providing oral hygiene before meals Response Feedback: Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs.
A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. When teaching the patient about foot care the nurse should include which of the following a. the feet should be soaked in warm water on a daily basis b. heating pads should always be set at a very low temperature c. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure. d. flat-soled leather shoes are the best choice to protect the feet from injury
d. flat-soled leather shoes are the best choice to protect the feet from injury Response Feedback: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems.
20-year-old client comes to the clinic because she has experienced a weight loss of 20 lb over the last month, even though her appetite has been "ravenous" and she hasn't changed her activity level. She's diagnosed with Graves' disease. Which other signs and symptoms support the diagnosis of Graves' disease? Select all that apply a. Nervousness b. Constipation c. Heat intolerance d. Bradycardia e. Rapid, bounding pulse
Answer: A,C,E A. Nervousness, C. Heat intolerance E. Rapid, bounding pulse Response Feedback: RATIONALES: Graves' disease, or hyperthyroidism, is a hypermetabolic state that's associated with rapid, bounding pulses; heat intolerance; tremors; and nervousness. Bradycardia and constipation are signs and symptoms of hypothyroidism. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: comprehension
During change-of-shift report, the nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient refused to drink the ordered polyethylene glycol (GoLYTELY). b. The patient has a permanent pacemaker to prevent bradycardia. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient is worried about discomfort during the examination.
Selected Answer: a. The patient refused to drink the ordered polyethylene glycol (GoLYTELY). Response Feedback: If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.
Which information will the nurse plan to include in discharge teaching for a patient after gastric bypass surgery? a. Choose high-fat foods for at least 30% of intake. b. Avoid drinking fluids with meals. c. Choose foods that are high in fiber to promote bowel function. d. Development of flabby skin can be prevented by daily exercise.
Selected Answer: b. Avoid drinking fluids with meals. Response Feedback: Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.
The nurse is providing instructions for a client being discharged with Cushings syndrome. Which of the following responses by the patient indicate further teaching is needed? a. I should immediately stop taking my steriods for my asthma. b. I need to remove clutter in my home so I don't trip and fall, hurting myself. c. I should try to avoid eating to many potato chips. d. I should report any slow wound healing or infections to my doctor.
Selected Answer: a. I should immediately stop taking my steriods for my asthma. Response Feedback: They need to continue to take medications for Asthma
The 48-year-old client with diabetes mellitus type II is being treated for her third episode of acute pyelonephritis in the past year. She asks what she could do to help prevent these infections. What is the nurse's best response? a. "Drink more water and try to empty your bladder at least every 2 to 3 hours while you are awake." b. "Test your urine daily for the presence of ketone bodies and proteins." c. "Use tampons rather than sanitary napkins during your menstrual period." d. "Inject your insulin in larger doses or more frequently to keep your blood sugar lower so the microorganisms have fewer nutrients for growth."
Selected Answer: a. "Drink more water and try to empty your bladder at least every 2 to 3 hours while you are awake." Response Feedback: Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the client's sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Physiological Integrity
The nurse is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?Answers: a. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." b. "I'll take all of my hydrocortisone in the morning, right after I wake up." c. "I'll take my hydrocortisone in the late afternoon, before dinner." d. "I'll take the entire dose at bedtime."
Selected Answer: a. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." Response Feedback: RATIONALES: Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application
A patient with Cushing disease is admitted to the hospital to have laparoscopic adrenalectomy for an adrenal tumor. During the admission assessment, the patient tells the nurse, "The worst thing about this disease is how terrible I look. I feel awful about it." The best response by the nurse is a. "Most of the physical and mental changes caused by the disease will gradually improve after surgery." b. "I do not think you look bad. Your appearance is just altered by your disease." c. "Let me show you how to dress so that the changes are not so noticeable." d. "You really should not worry about how you look in the hospital. We see many worse things."
Selected Answer: a. "Most of the physical and mental changes caused by the disease will gradually improve after surgery." Response Feedback: The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing disease will resolve after hormone levels return to normal postoperatively. The response beginning "Let me show you how to dress" indicates that the changes are permanent and that the patient's appearance needs disguising. The response beginning, "I do not think you look bad" does not acknowledge the patient's feelings and also fails to communicate that the changes will be resolved after surgery. And the response beginning "You really should not worry about how you look in the hospital" implies that the patient's appearance is not good.
The client had undergone ileostomy for ulcerative colitis. He has nasogastric tube connected to intermittent suction, with IV fluid and Foley catheter. Which of the following physician's instructions requires intervention (be questioned) by the nurse? a. remove the NGT on the third day postop b. remove foley catheter after 24 hours c. clear liquid diet once peristalsis returns d. irrigate ileostomy at bed time with 100 mL of NS
Selected Answer: d. irrigate ileostomy at bed time with 100 mL of NS Response Feedback: ileostomy does not require irrigation because it continuously drains watery fecal drainage
A client is scheduled for a paracentesis for the ascites. Which statement by the client would indicate to the nurse that the preprocedure teaching has been successful? a. "The doctor will slowly remove fluid from my abdomen to relieve the swelling." b. "I need to drink two glasses of water right before the procedure to maintain a full bladder." c. "I will need to lie flat in bed during the procedure." d. "I believe this is an overnight surgical procedure."
Selected Answer: a. "The doctor will slowly remove fluid from my abdomen to relieve the swelling." Response Feedback: Rationale: After signing an informed consent form for the procedure, the client will need to sit upright at the side of the bed with feet propped on a stool, while fluid is removed to relieve acute symptoms of ascites. The procedure is performed at the bedside or in an ambulatory care setting. It is not an "overnight surgical" procedure. The fluid is drawn out slowly and checked for amount, color, and characteristics of drainage. Rapid removal can lead to decreased abdominal pressure, which can contribute to shock and vasodilation. The puncture site will need a compression bandage, and the site must be monitored. (Ignatavicius, Workman, 7 ed., p. 1300.)
A female client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurses best response? a. "You may have eaten contaminated restaurant food." b. "How often do you shoot up with heroin ?" c. "Could you have engaged in unprotected sex? d. "When was or have you ever had a blood transfusion?"
Selected Answer: a. "You may have eaten contaminated restaurant food." Response Feedback: hep a is transmitted thru oral fecal route primarily from contaminated restaurants Hep B is IV or blood transfusion and hep c unprotected sex. comprehensions assessment
After a 3-month trial of dietary therapy, a client with type 2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take the glyburide: a. 30 minutes before breakfast b. 30 minutes after dinner c. at bedtime d. in the midmorning
Selected Answer: a. 30 minutes before breakfast Response Feedback: RATIONALES: Like other oral antidiabetic agents prescribed in a single daily dose, glyburide should be taken with breakfast or 30 minutes before breakfast. If the client takes glyburide later, such as in the midmorning, after dinner, or at bedtime, the drug won't provide adequate coverage for all meals consumed during the day. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension
A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dL (3.5 mmol/L) and a phosphorus of 1.7 mg/dL (0.55 mmol/L). Which nursing action should be included in the plan of care? a. Encourage 3000 to 4000 mL of oral fluids daily b. Encourage the patient to remain on complete bed rest c. Monitor for positive Chvostek's sign d. Institute routine seizure precautions
Selected Answer: a. Encourage 3000 to 4000 mL of oral fluids daily Response Feedback: The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone. application medical management and nusring assessment
What statement best describes the action of a proton pump inhibitor? a. It suppresses the secretion of hydrochloric acid into the stomach b. It coats the stomach to protect the mucosa c. It stimulates receptors in the stomach that release protons into the stomach d. It enhances the secretion of hydrochloric acid into the stomach
Selected Answer: a. It suppresses the secretion of hydrochloric acid into the stomach Response Feedback: Proton pump inhibitors share the same suffix "prazole." PPIs essentially shut off the proton pump so only about 3% of normal acid secretion takes place during treatment and up to 5 days following the last dose. While the drug half-life is only 1 hour, the effects last until new Na+ K+ ATPase is synthesized. Full recovery of gastric acid secretion takes several weeks following discontinuation of a PPI. Gastric acid secretion is suppressed, regardless of the stimulus (acetylcholine comprehension health maintenence
A client with Grave's Disease arrives in the ED following an accidental overdose of propylthiouracil (PTU). The client has a heart rate 54/min, respirations 12/min, and reports feeling "very cold." The nurse should anticipate the administration of which of the following medications? a. Levothyroxine (Synthroid) b. Methimazole (Tapazole) c. Potassium Iodide (SSKI) d. Atropine sulfate
Selected Answer: a. Levothyroxine (Synthroid) Response Feedback: RATIONALE: A. Grave's disease is the most common form of hyperthyroidism and is often treated with propylthiouracil (PTU) by preventing the formation of new thyroid hormones. An overdose of PTU can produce manifestations of hypothyroidism, such as bradycardia, hypothermia, and respiratory depression. This client needs levothyroxine (Synthroid) to increase the thyroid levels. If the bradycardia were severe enough to cause hemodynamic instability (e.g., hypotension, decreasing level of consciousness, chest pain) atropine may be considered in addition to Synthroid to increase the client's heart rate. There is no indication of hemodynamic instability in this client. Although this client has Grave's disease, which is a type of hyperthyroidism, he/she is currently showing signs of hypothyroidism (e.g., bradycardia, feeling cold). Atropine would not be indicated because this client's bradycardia is due to the overdose of PTU which has suppressed thyroid hormone levels. d. Methimazole (Tapazole) is an antithyroid drug that is administered to prevent thyroid hormone production. This client is showing signs of hypothyroidism as a result of decreased thyroid hormone levels due to an overdose of PTU. Administering additional antithyroid medication would further suppress thyroid levels. This client needs levothyroxine (Synthroid), which is a thyroid replacement hormone, to increase thyroid levels. C. Potassium iodide (SSKI) is another antithyroid medication that inhibits thyroid hormone release. This client is showing signs of hypothyroidism as a result of decreased thyroid hormone levels due to an overdose of PTU. Administering potassium iodide (SSKI) would further suppress thyroid levels and worsen the manifestations of hypothyroidism. This client needs levothyroxine (Synthroid) to increase thyroid levels. b. CORRECT: Levothyroxine (Synthroid) is a thyroid replacement hormone used to treat hypothyroidism, whether it is primary or secondary in origin. This client is exhibiting manifestations of hypothyroidism secondary to an overdose of the antithyroid medication, PTU. A client who has taken an excessive amount of PTU and showing signs of hypothyroidism may temporarily require Synthroid to reestablish thyroid hormone levels. This is the correct answer. NCLEX Category: Pharmacological and Parenteral Therapies
A client returns from a liver biopsy and the nurse is monitoring for complications after the procedure. Which of the following would reflect these complications? a. Pulse of 110 beats/min, blood pressure of 90/60 mm Hg, and rapid breathing b. Pulse of 68 beats/min, respiration of 18 breaths/min, redness, and pain at the biopsy site c. Jaundice, vomiting, and weakness d. Nausea, chest, and side pains
Selected Answer: a. Pulse of 110 beats/min, blood pressure of 90/60 mm Hg, and rapid breathing Response Feedback: Rationale: The liver is very vascular and manufactures clotting factors. After a liver biopsy, the major complication is the possibility of hemorrhage, which would be reflected in a drop in the blood pressure, a compensatory rise in the pulse, and rapid respirations caused by hypoxia. Nausea, chest and side pains, jaundice, vomiting, and weakness are not the priority complications. Coagulation problems result from the liver's inability to produce prothrombin and other factors essential for clotting. Clotting problems are manifested by hemorrhage or bleeding tendencies. (Ignatavicius, Workman, 7 ed., p. 1299.)
The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease? a. Purpura and petechiae b. Dyspnea and fatigue c. Ascites and orthopnea d. Gynecomastia and testicular atrophy
Selected Answer: a. Purpura and petechiae Response Feedback: Answer C. A hepatic disorder, such as cirrhosis may disrupt the use of vitamin K to produce prothrombin the nurse should monitor the client for signs of bleeding, including purpura and petechiae Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver
The nurse explains to a client with thyroid disease that the thyroid gland normally produces: a. T3, T4, and calcitonin. b. Thyrotropin-releasing hormone (TRH) and TSH. c. TSH, T3, and calcitonin. d. Iodine and thyroid-stimulating hormone (TSH).
Selected Answer: a. T3, T4, and calcitonin. Response Feedback: RATIONALES: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. TSH is produced by the pituitary gland to regulate the thyroid gland. TRH is produced by the hypothalamus gland to regulate the pituitary gland. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Knowledge
What is the main focus of the Bogalusa health /heart study and who is the target population? a. cardiovascular diseases in children b. gastrointestinal disorders in the elderly c. renal disease in young adults d. carcinomas in adults
Selected Answer: a. cardiovascular diseases in children Response Feedback: data provided in assigned weight of the nation video
The nurse is preparing to initiate bolus enteral feedings via Gatrostomy (PEG) tube to a client. Which of the following actions represents safe practice by the nurse? a. checks the volume of the residual before administering the bolus feeding b. measures the length of the tube from where it protrudes from the nose to the end and compares to previously documented measurements c. aspirates gastric contents prior to initiating the feeding and assures that pH is >9 d. elevates the head of the bed to 25 degrees and maintains for 30 minutes after instillation of feeding
Selected Answer: a. checks the volume of the residual before administering the bolus feeding Response Feedback: injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen; and aspirating the secretions and checking to see if the pH is between 1 and 5. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation. Residual should be assessed before administration of the next feeding. PEG tube is inserted into the stomach and only has a small section protruding. it is NOT in the nose
The nurse is providing dietary teaching to a patient who is recovering from an acute episode of diverticulitis. The nurse determines that the patient understood his teaching by which statement? a. "I will need to increase my intake of Proteins and complex carbohydrates to increase healing." b. "Peanuts, fruits and vegetables with seeds can cause problems, so I should avoid them." c. " I will make sure I decrease my soluble fiber in my diet to prevent a relapse." d. "Milk and milk products can cause lactose intolerance. If this occurs, I need to decrease my intake of these products."
Selected Answer: b. "Peanuts, fruits and vegetables with seeds can cause problems, so I should avoid them." Response Feedback: diverticulitis is a problem w small food particles as this can get caught in the "pouches and cause an infection. need to increase fiber post acute phase application nursing education and assessment
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of: a. chloride and magnesium abnormalities. b. sodium and potassium abnormalities. c. sodium and chloride abnormalities. d. calcium and phosphorus abnormalities.
Selected Answer: b. sodium and potassium abnormalities. Response Feedback: RATIONALES: In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis
In addition to controlling pain and healing lesions, the therapeutic goals for treating peptic ulcers include: a. weight loss. b. reducing transmission to family members. c. preventing recurrences. d. increased consumption of dairy products.
Selected Answer: c. preventing recurrences. Response Feedback: the other choices are not goals for treating PUD stated in your text, preventing recurrences decreases the chances of serious complications
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. "I will need lab tests to be sure that I can still fight infections." b. "I will take the Sulfasalazine as an enema or suppository." c. "The medication suppresses the inflammation in my large intestine." d. "The medication will prevent infections that cause the diarrhea."
Selected Answer: c. "The medication suppresses the inflammation in my large intestine." Response Feedback: 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.
Which action by unlicensed assistive personnel (UAP) when caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the RN intervene? a. Swabbing the patient's mouth with cold water b. Checking the vital signs every 30 minutes c. Positioning the patient on the right side d. Offering the patient a glass of water
Selected Answer: d. Offering the patient a glass of water Response Feedback: Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the NAP are appropriate.
In the initial postoperative phase following bariatric surgery, the RN recognizes the significance of monitoring obese patients for respiratory insufficiency based on what knowledge? a. The patient's head must remain flat for a minimum of two hours post-procedure. b. Postoperative pain may cause a decreased respiratory rate. c. The body stores anesthetics in adipose tissue d. Intubation may be difficult because of extra chin skin folds.
Selected Answer: c. The body stores anesthetics in adipose tissue Response Feedback: Rationale: Pg. 958 The body stores anesthetics in adipose tissue, placing patients with excess adipose tissue at risk for resedation. As adipose cells release anesthetics back into the bloodstream, the patient may become sedated after surgery, increasing the risk of hypoventilation and resultant respiratory insufficiency. Pain usually increases respiratory rate. Difficult intubation does not cause respiratory insufficiency. The patient's head should be elevated after bariatric surgery to decrease abdominal pressure and facilitate respirations.
A total proctocolectomy with a permanent ileostomy is performed for a patient with ulcerative colitis. The patient is very upset and tells the nurse, "I can not bear to even look at the stoma. I do not think I can manage all these changes." The nurse's best approach to the patient's remarks is to a. wait to intervene until the patient adjusts to the body image change b. reassure the patient that care for the ileostomy will become easier c. ask the patient if a member of an ostomy support group may visit. d. develop a detailed written plan for ostomy care for the patient
Selected Answer: c. ask the patient if a member of an ostomy support group may visit. Response Feedback: A visitor from an ostomy support group who has had similar experiences may be helpful to the patient. In the response beginning, "reassure the patient," the nurse does not acknowledge the patient's feelings. The response beginning "develop a detailed written plan" also fails to acknowledge the patient's emotional response to the ostomy. The nurse should act to assist the patient with body image changes, not just wait for the patient to adjust as in the remaining response.
An adult onset diabetic patient (type II DM) has informed the nurse she is worried that she will loose her job due to more frequent hypoglycemic events daily. Her boss thinks she is drunk and has been drinking on the job with the symptoms she is having. Which action by the nurse would BEST assist the patient in meeting her needs with this situation a. confront the patient to determine if she is indeed drinking b. discuss with her boss that the patient is a diabetic and she is not drinking c. assess the factors with the patient that may be causing the hypoglycemia d. contact the AA office to schedule an assessment
Selected Answer: c. assess the factors with the patient that may be causing the hypoglycemia Response Feedback: always go with the 1st phase of the nursing process. you are not allowed to speak with the boss as this is a violation of HIPPA she is not drinking as the symptoms of hyoglycemia can mimic alcohol symptoms analyis: psychological assessement
A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations, with an urge to defecate about 20 minutes after eating. To prevent recurrence of these symptoms, the nurse teaches the patient to a. choose foods that are high in carbohydrates b. increase the amount of fluid intake with meals c. lie down for at least 30 minutes after eating d. drink sugared fluids or eat candy after each meal.
Selected Answer: c. lie down for at least 30 minutes after eating Response Feedback: The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome. application assessment nursing process
Your client is diagnosed with hyperthyroidism . Which of the following comments by the client indicates that she understands information you've provided regarding side effects and complications of Inderal (propranolol) which is recently prescribed for her? a. "I'll have my blood tested daily." b. "I'll be sure to take the drug with meals." c. "I'll take the drug whenever I feel my heart pounding." d. "I'll be sure to report any dizziness."
Selected Answer: d. "I'll be sure to report any dizziness." Response Feedback: Inderal is a beta blocker Inderal is a beta blocker and will reduce the symptoms of the tachycardia and hypertension.
Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?A a. Maintain the client on bed rest during the feedings. b. Maintain the head of the bed at a 15-degree elevation continuously. c. Check the gastrostomy tube for position every 2 days. d. Change the tube feeding administration set at least every 24 hours.
Selected Answer: d. Change the tube feeding administration set at least every 24 hours. Response Feedback: Correct Answer: 1 Your Answer: 1 RATIONALES: Tube feeding administration sets should be changed every 24 hours. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
The nurse is caring for a client who has been diagnosed with a bleeding duodenal ulcer. What data identified on a nursing assessment would indicate an intestinal perforation and require immediate nursing action? a. Diarrhea with increased bowel sounds and hypovolemia b. Decreasing hemoglobin and hematocrit with bloody stools c. Increasing blood pressure with tachycardia and disorientation d. Increasing abdominal distention, with increased pain and vomiting
Selected Answer: d. Increasing abdominal distention, with increased pain and vomiting Response Feedback: Rationale: Perforation is characterized by increasing distention and boardlike abdomen. There is frequently increasing pain with fever and guarding of the abdomen. Peritonitis occurs rapidly. The nurse should maintain the client NPO, keep the client on bed rest, and immediately notify the physician. Decreasing hemoglobin and hematocrit and decreasing blood pressure are associated with hemorrhage rather than perforation. Remember to select an answer that reflects what the question is specifically asking. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 995.)
While hospitalized and recovering from an episode of hyperosmolar, nonketotoc syndrome (HHNS), the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. have the patient drink 4 ounces of orange juice b. administer 10 units if regular insulin subcutaneously c. have the patient eat a candy bar d. obtain a glucose reading using a finger stick
Selected Answer: d. obtain a glucose reading using a finger stick Response Feedback: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment.. insulin is contraindicated as the clinet is already too low
The nurse is preparing discharge teaching for a client with a diagnosis of gastroesophageal reflux disease (GERD). What would be important for the nurse to include in this teaching plan? Select all that apply a. Elevate the head of the bed b. Decrease intake of caffeine products c. Take ranitidine (Zantac) at bedtime d. Discuss strategies for weight loss if overweight e. Increase fluid intake with meals
Selected Answers: A,B,C,D a. Elevate the head of the bed b. Decrease intake of caffeine products c. Take ranitidine (Zantac) at bedtime d. Discuss strategies for weight loss if overweight Response Feedback: Rationale: Each of these actions will help either neutralize the acid in the stomach or decrease the physiologic reflux. Increased fluids with meals will exacerbate the problem, as will eating before going to bed. (Lewis, Dirksen, Heitkemper, et al, 8 ed., p. 975.)
Common signs and symptoms for a client diagnosed with Cushings are: Select All that apply a. moon face b. buffalo hump c. bronze skin pigmentation d. weight loss e. abdominal straie
Selected Answers: A,B,E a. moon face b. buffalo hump e. abdominal straie Response Feedback: in text and lecture, these are classic symptoms of Cushings
Before discharge, what should a client with Addison's disease be instructed to do when exposed to periods of stress? a. Drink 8 oz of fluids b. Perform capillary blood glucose monitoring four times daily c. Administer hydrocortisone I.M. d. Continue to take his usual dose of prednisone
c. Administer hydrocortisone I.M. Response Feedback: RATIONALES: Clients with Addison's disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. It's important to keep well hydrated during stress, but the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn't indicated in this situation because the client doesn't have diabetes mellitus. Hydrocortisone replacement doesn't cause insulin resistance. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application
Your client has alcoholic cirrhosis and ascites. Albumin is expected to alleviate his/her ascites by which of the following mechanisms? a. Albumin will decrease the bacterial count of ascitic fluid, facilitating its excretion b. Albumin will increase the kidney's ability to excrete sodium and water c. Albumin will make the vascular compartment hypertonic, causing a fluid shift from the peritoneal cavity into the bloodstream d. Albumin will make the vascular compartment hypotonic, causing a fluid shift from the peritoneal cavity into the bloodstream
c. Albumin will make the vascular compartment hypertonic, causing a fluid shift from the peritoneal cavity into the bloodstream Response Feedback: albumin is given to ehaance the absortpion of fluid back into the "normal space where the fluid is third spacing. becomes hypertonic and draws fluid into the vasculat space. this allows the abd to decrease in size as well as increasing the BP application and assessment theraputic responses
A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient goal has the highest priority when the nurse is developing the plan of care? a. Identify the source of exposure to hepatitis. b. Increase activity level. c. Maintain adequate nutrition. d. Establish a stable home environment.
c. Maintain adequate nutrition. Response Feedback: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis. application level assessment and nursing management
Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done? a. The patient eats frequent meals in fast-food restaurants. b. The patient had a blood transfusion after surgery in 1998. c. The patient reports a one-time use of IV drugs 20 years ago. d. The patient recently traveled to an undeveloped country.
c. The patient reports a one-time use of IV drugs 20 years ago. Response Feedback: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.
