NUR 102 Exam 1
A client is ordered to receive 1 g of neomycin sulfate orally every hour × 4 doses followed by 1 g orally every 4 hours for the remaining balance of the 24 days. Neomycin sulfate tablets are available in 500 mg per tablet. How many tablets should the nurse administer for each dose? Record your answer using a whole number.
2 tablets
A client is scheduled for a cholecystectomy. Prior to the procedure, the client asks the nurse, "what will happen without my gallbladder?" Which response by the nurse is the best? A. "Another structure such as the liver will take over its function." B. "When you have a bowel movement, you will not have solid stools." C. "Since you have an inability to process glucose you will have to take insulin." D. "You will have to take medication to help your blood clot."
A. "Another structure such as the liver will take over its function."
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. Before administration of the medication, the nurse explains that the drug is given because of what reason? A. "Atropine decreases salivation and gastric secretions." B. "Atropine controls the heart rate and blood pressure." C. "Atropine improves ventilation by increasing the respiratory rate." D. "Atropine enhances the effect of anesthetic agents."
A. "Atropine decreases salivation and gastric secretions."
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. The nurse includes which instruction in the discharge teaching? A. "Continue to take antacids, even if your symptoms subside." B. "You may take antacids with other medications." C. "Avoid taking antacids containing magnesium if you develop a heart problem." D. "Take antacids with meals."
A. "Continue to take antacids, even if your symptoms subside."
Which breakfast has the least amount of carbohydrates? A. Bacon and eggs B. A banana and toast with butter C. Waffles and an orange D. Oatmeal and blueberries
A. Bacon and eggs
A client with severe abdominal pain is being evaluated for appendicitis. The client asks what is the most common cause of appendicitis. How would the nurse best respond? A. "Appendicitis is caused by the appendix rupturing." B. "Appendicitis is caused by an obstruction of the appendix." C. "Appendicitis is caused by a client consuming a high-fat diet." D. "Appendicitis is caused by a client developing a duodenal ulcer."
B. "Appendicitis is caused by an obstruction of the appendix."
Which nursing intervention is the best way to help reduce the occurrence of poisoning in children? A. Place the number for poison control in the home. B. Provide education to those who care for children. C. Identify children who are at risk of poisoning. D. Teach parents to read toy labels.
B. Provide education to those who care for children.
The nurse is discussing a client's concern regarding recent weight gain. About which type of diet should the nurse educate the client? A. Bland diet B. Reduced-calorie diet C. Mechanical soft diet D. Low-fiber diet
B. Reduced-calorie diet
The nurse prepares to administer morning medications to a client with hepatitis. The client's medications are listed below. Which medication should the nurse withhold? A. lamivudine 150 mg orally twice daily B. acetaminophen 650 mg orally every day C. vitamin B12 one capsule twice daily D. phytonadione 5 mg IM once daily
B. acetaminophen 650 mg orally every day
Following a liver transplant a client develops ascites. The nurse should teach the client to: A. increase water intake. B. brace the abdomen with a pillow during coughing. C. perform 10 leg raises every waking hour. D. reduce requests for pain medicine.
B. brace the abdomen with a pillow during coughing.
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas. The nurse anticipates administration of neomycin to this client to: A. control postoperative nausea and vomiting. B. decrease the intestinal bacteria count. C. increase the intestinal bacteria count. D. prevent the development of megacolon.
B. decrease the intestinal bacteria count.
The nurse is performing an assessment on a client who has developed a paralytic ileus. The nurse expects the client's bowel sounds will be: A. hyperactive. B. hypoactive. C. high-pitched. D. blowing.
B. hypoactive.
A nurse is verifying orders from a health care provider. Which diet will the nurse discuss with child and family related to a new diagnosis of celiac disease? A. low-fat diet B. no-gluten diet C. high-protein diet D. no-phenylalanine diet
B. no-gluten diet
Oral lactulose is prescribed for the client with a hepatic disorder, and the nurse reinforces instructions to the client regarding this medication. Which statement by the client indicates an understanding of the instructions? A. "Increasing my fluid intake will make the medication work better." B. "I should remain close to the restroom when I take the medication." C. "I need to include more high-fiber foods in my diet." D. "I should call the health care provider immediately if I start having nausea."
C. "I need to include more high-fiber foods in my diet."
A client was hospitalized and treated for acute diverticulitis. The nurse has reinforced discharge education. Which statement by the client indicates that the client understands the discharge instructions? A. I'll reduce my fluid intake." B. "I'll decrease the fiber in my diet." C. "I'll take all of my antibiotics." D. "I'll exercise to increase my intra-abdominal pressure."
C. "I'll take all of my antibiotics."
A nurse is caring for a client with chronic pancreatitis. Which response by the client indicates that discharge education has been effective? A. "I'll eat a low-carbohydrate diet." B. "I can have an occasional glass of wine." C. "I'll take pancreatic enzymes with each meal." D. "I'll take pancreatic enzymes before breakfast and at bedtime."
C. "I'll take pancreatic enzymes with each meal."
The nurse is providing ileostomy care for a client and observes redness and a yeast-like growth around the site. After notifying the healthcare provider and receiving an order, which intervention will the nurse most likely provide? A. Application of Neosporin ointment B. Application of alcohol to the area C. Application of nystatin (Mycostatin) powder D. Washing the area with soap and water
C. Application of nystatin (Mycostatin) powder
A client who practices Orthodox Judaism and follows a kosher diet receives a tray for supper and requests that it be taken away. Which item on the tray would the nurse recognize that the client is unable to consume? A. Green salad with oil and vinegar dressing B. Cookies and a carton of milk C. Baked pork chop with gravy D. A cheese sandwich
C. Baked pork chop with gravy
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse instructs the nursing student to observe this client's stools for which finding? A. Coffee-ground-like B. Clay-colored C. Black and tarry D. Bright red
C. Black and tarry
A client is experiencing indigestion, bloating, excess gas, and constipation due to delayed gastric emptying. Which suggestion offered by the nurse may help alleviate these symptoms? A. Limit the amount of fluid intake B. Increase the amount of dairy in the diet C. Limit spicy and gas forming foods D. Decrease the amount of fiber ingested
C. Limit spicy and gas forming foods
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention would the nurse use to determine if TPN is providing adequate nutrition? A. Accelerating the infusion if it falls behind schedule B. Ensuring that the TPN tubing has an in-line filter C. Monitoring the client's weight every day D. Recording fluid intake and output
C. Monitoring the client's weight every day
A client with abdominal pain secondary to a malignant mass in the colon is receiving fentanyl by transdermal patch. His current patch expires in 48 hours and he reports a pain level of 8 on a 1-to-10 scale. What should a nurse do? A. Replace the patch with a new patch. B. Massage the patch. C. Notify the client's physician. D. Apply a warm compress to the patch.
C. Notify the client's physician.
A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task? A. Keep the side rails up. B. Position the overbed table away from the bed. C. Raise the bed to approximately waist level. D. Position the client on the far side of the bed.
C. Raise the bed to approximately waist level.
A nurse reinforces education that has been provided to an older adult about good bowel habits. Which statement indicates that the client understands the information? A. "I should eat a diet that is low in fiber-rich foods." B. "Using a laxative each day will help to prevent constipation." C. "I need to drink two to three glasses of fluid every day." D. "Fifteen minutes of exercise three times a week improves bowel habits."
D. "Fifteen minutes of exercise three times a week improves bowel habits."
Which symptoms may the nurse observe in a client who has a low-protein intake? A. Nosebleeds B. Diminished peripheral pulses C. Dry, scaly skin D. Edema in the lower extremities
D. Edema in the lower extremities
A nurse is caring for a client with active upper gastrointestinal (GI) bleed. Which diet is appropriate for this client during the first 24 hours after admission? A. bland B. full liquids C. nothing by mouth D. clear liquids
C. nothing by mouth
The client states an intake of high amounts of salt and fats. The nurse is aware that this predisposes the client to what possible medical diagnoses? Select all that apply. A. Hypertension B. Atherosclerosis C. Gallbladder disease D. Obesity E. Acne
A. Hypertension B. Atherosclerosis C. Gallbladder disease D. Obesity
Which enzymes are responsible for facilitating the formation of proteins into amino acids? Select all that apply. A. Pepsin B. Trypsin C. Maltase D. Lactose E. Chymotrypsin
A. Pepsin B. Trypsin E. Chymotrypsin
Which information should the nurse provide to a client regarding the ketogenic diet? A. Very low in carbohydrates and high in fat B. Allows for unlimited fruits and vegetables C. Low in protein and high in carbohydrates D. Reduced in calories
A. Very low in carbohydrates and high in fat
A client has a diagnosis of pernicious anemia due to a loss of intrinsic factor. An order has been issued. Which treatment will the nurse most likely need to prepare to administer to the client? A. Vitamin B12 injection B. A blood transfusion C. A dose of heparin subcutaneously D. Intravenous fluids
A. Vitamin B12 injection
A client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after the birth of her second child. Diagnostic tests reveal gluten-induced enteropathy. Which foods would the nurse instruct the client to eliminate from her diet permanently? A. milk and dairy products B. protein-containing foods C. cereal grains (except rice and corn) D. carbohydrates
C. cereal grains (except rice and corn)
The nurse is caring for a client who is on a regular diet but has not eaten any food from the tray for 2 days. Which nursing action would be appropriate at this time? A. Tell the client "You have to eat this or you will become even more ill." B. Obtain a dietary consult and permission to have food brought in by the family. C. Inform the client "If you don't eat, you will not be able to take your medication." D. Place a nasogastric tube in and feed the client through there.
B. Obtain a dietary consult and permission to have food brought in by the family.
A client with colon cancer asks the nurse why radiation therapy is being received before surgery. Which response would be most appropriate? A. "It helps reduce the size of the tumor." B. "It eliminates the malignant cells." C. "The chances of curing the cancer are improved." D. "The therapy helps to heal the bowel after surgery."
A. "It helps reduce the size of the tumor."
A nurse is collecting data on a client with a history of constipation. Which data, obtained by the nurse, would indicate a risk factor for constipation? A. a 66-year-old white male B. daily fluid intake of 72 ounces (2.1 L) C. diet high in cheese, lean meats, and pasta D. engages in walking 20 minutes every other day
C. diet high in cheese, lean meats, and pasta
A client has a new colostomy created during surgery to remove a mass in the sigmoid colon. The client is very upset and states, "I can't look at that!" Which is the best response by the nurse? A. "Would you like to talk about it? I can answer questions you may have." B. "You will have to look at it sometime. You are going to care for it." C. "You should be thankful this procedure removed your tumor and saved your life." D. "You don't have to look at it. Let's get a family member to learn the care."
A. "Would you like to talk about it? I can answer questions you may have."
The nurse is caring for a group of clients at an extended-care facility. Which clients would require documentation and reporting to the team leader? Select all that apply. A. A client who is eating only 25% of the meal trays for 3 days. B. A client who states, "I feel nauseated and don't want to eat." C. A client who states, "I am having a hard time swallowing your food." D. A client who states, "Your food doesn't taste very good." E. A client who states, "I'm eating better here than I was at home."
A. A client who is eating only 25% of the meal trays for 3 days. B. A client who states, "I feel nauseated and don't want to eat." C. A client who states, "I am having a hard time swallowing your food."
Which statements illustrate the process of acculturation? Select all that apply. A. Adopting the predominant religious beliefs of the country where an individual resides B. Maintaining the values and attitudes from an individual's country of origin C. Eating bagels and cream cheese regularly in New York City D. Eating tacos and salsa regularly in Maine E. Learning about the cultures around you
A. Adopting the predominant religious beliefs of the country where an individual resides C. Eating bagels and cream cheese regularly in New York City
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method? A. Aspiration of gastric contents and testing for a pH less than 6 B. Instillation of 30 ml of water while listening with a stethoscope C. Cessation of reflex gagging D. Ensuring proper measurement of the tube before insertion
A. Aspiration of gastric contents and testing for a pH less than 6
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia? A. Atrophy of the gastric mucosa B. Decrease in intestinal flora C. Increase in bile secretion D. Dulling of nerve impulses
A. Atrophy of the gastric mucosa
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's dusky-appearing stoma is related to which factor? A. Blood supply to the stoma has been interrupted. B. This is a normal finding 1 day after surgery. C. The ostomy bag should be adjusted. D. An intestinal obstruction has occurred.
A. Blood supply to the stoma has been interrupted.
What information should the nurse include in a discussion with a client about calorie intake? Select all that apply. A. Consume foods and drinks to meet, not exceed, caloric needs. B. Plan ahead to make better food choices. C. Pay attention to feeling hunger and eat until full, not satisfied. D. Limit calorie intake from solid fats. E. Limit intake of added sugars.
A. Consume foods and drinks to meet, not exceed, caloric needs. B. Plan ahead to make better food choices. D. Limit calorie intake from solid fats. E. Limit intake of added sugars.
A client says, "I have been using home remedies to thin my blood." Which food items should the nurse caution the client about ingesting while taking warfarin (Coumadin)? A. Dark, green, leafy vegetables B. Milk and milk products C. Berries D. Whole grains
A. Dark, green, leafy vegetables
A client with colorectal cancer being prepared for colostomy placement tells the nurse, "I am very nervous and unsure about this surgery." What should the nurse's initial action be when caring for this client? A. Determine what the client already knows about colostomies. B. Show the client pictures of colostomies to prepare for the surgery. C. Arrange for someone who has a colostomy to visit the client. D. Provide the client with written materials about colostomy care.
A. Determine what the client already knows about colostomies.
The nurse is preparing a client for an abdominal paracentesis. Which priority action by the nurse will help prevent complications? A. Have the client void before the procedure. B. Ensure the client has had a bowel movement within 24 hr. C. Have the client lie in the supine position. D. Insert an indwelling catheter.
A. Have the client void before the procedure.
What key points should the nurse plan to include in a presentation of the MyPlate dietary guidelines? Select all that apply. A. Increase the intake of vitamins, minerals, dietary fiber, and other essential nutrients. B. Lower the intake of trans fats, saturate fats, and cholesterol. C. Increase the intake of fruits, vegetables, and whole grains. D. Adjust portions to meet individual energy needs. E. Success is more likely if the menu varies the preparation of a few basic foods.
A. Increase the intake of vitamins, minerals, dietary fiber, and other essential nutrients. B. Lower the intake of trans fats, saturate fats, and cholesterol. C. Increase the intake of fruits, vegetables, and whole grains. D. Adjust portions to meet individual energy needs.
A client is scheduled to have a cholecystectomy. Which education should the nurse reinforce regarding the use of incentive spirometry? Select all that apply. A. It increases alveolar inflation. B. It will eliminate the need for nasogastric intubation. C. It will promote lung expansion. D. It will improve nutritional status during recovery. E. It will promote deep breathing. F. decrease the amount of postoperative analgesia needed
A. It increases alveolar inflation. C. It will promote lung expansion. E. It will promote deep breathing.
Which foods can be included in a lacto-vegetarian diet? Select all that apply. A. Lettuces B. Eggs C. Oatmeal D. Yogurt E. Cottage cheese
A. Lettuces C. Oatmeal D. Yogurt E. Cottage cheese
The nurse is caring for a client who is edentulous and has difficulty chewing. Which therapeutic diet should the nurse suggest that would be helpful and nutritious? A. Mechanical soft diet B. Low-fiber diet C. Bland diet D. High-calorie diet
A. Mechanical soft diet
What suggestions should the nurse make about foods that are compatible with a vegan diet? Select all that apply. A. Oatmeal B. Quinoa C. Cottage cheese D. Tofu E. Eggplant
A. Oatmeal B. Quinoa D. Tofu E. Eggplant
What information about the process of digestion is important for the nurse to provide about gastrin? Select all that apply. A. Stimulates the secretion of hydrochloric acid and pepsinogen B. Stimulates the pancreas to secrete enzymes and the gallbladder to release bile C. Produced by the parietal cells in the gastric mucosa D. Secreted by the jejunum in response to the presence of fat in the duodenum E. It is required for the effective absorption of vitamin B12
A. Stimulates the secretion of hydrochloric acid and pepsinogen B. Stimulates the pancreas to secrete enzymes and the gallbladder to release bile
A nurse is gathering data on a client receiving an enteral feeding who suddenly states, "I feel very faint and sweaty." What is the nurse's immediate action? A. Stop the feeding. B. Notify the charge nurse. C. Lower the head of the bed. D. Check the blood sugar level.
A. Stop the feeding.
Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease? A. To keep gastric pH at 3.0 to 3.5 B. To promote client compliance C. To maintain a regular bowel pattern D. To increase pepsin activity
A. To keep gastric pH at 3.0 to 3.5
The nurse is caring for a client with anal sphincter insufficiency who is bed confined and requires ADL (activities of daily living) assistance. Which nursing actions should be included when caring for this client? Select all that apply. A. Turn the client every 2 hours B. Insert a rectal tube C. Provide pads on the bed D. Ensure a bedside commode is readily accessible for the client E. Use barrier cream to protect the skin
A. Turn the client every 2 hours C. Provide pads on the bed D. Ensure a bedside commode is readily accessible for the client
A client reports right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. The health care provider documents rebound tenderness, an elevated white blood cell count (WBC), and positive psoas sign. Based on these findings, what would the nurse suspect? A. appendicitis B. pancreatitis C. cholecystitis D. constipation
A. appendicitis
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: A. auscultate bowel sounds. B. palpate the abdomen. C. change the client's position. D. insert a rectal tube.
A. auscultate bowel sounds.
A preschooler is brought to the emergency department after ingesting a large amount of liquid acetaminophen. Which finding should the nurse anticipate in this child? A. bradycardia B. hypertension C. tachypnea D. tinnitus
A. bradycardia
The ingestion of substances containing lead is mostly influenced by which risk factor? A. child's age B. child's gender C. child's nationality D. a parent with the same habit
A. child's age
Which food items selected by a child with celiac disease would cause the nurse to intervene? Select all that apply. A. corn flakes cereal, skim milk, and a banana B. a bologna, lettuce, and tomato sandwich C. slice of cheese, sausage, and vegetable pizza D. a wheat tortilla with southwestern chicken and rice E. steamed broccoli florets with a grilled pork chop F. sliced strawberries with a tossed green salad
A. corn flakes cereal, skim milk, and a banana B. a bologna, lettuce, and tomato sandwich C. slice of cheese, sausage, and vegetable pizza D. a wheat tortilla with southwestern chicken and rice
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must stay alert for: A. diaphoresis, vomiting, and diarrhea. B. manifestations of electrolyte disturbances. C. manifestations of hypoglycemia. D. constipation, dehydration, and hypercapnia.
A. diaphoresis, vomiting, and diarrhea.
A nurse is planning care for a client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A? A. fecal contamination and oral ingestion B. exposure to contaminated blood C. sexual activity with an infected partner D. sharing a contaminated needle or syringe
A. fecal contamination and oral ingestion
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? A. metabolic acidosis B. respiratory acidosis C. metabolic alkalosis D. respiratory alkalosis
A. metabolic acidosis
A client is being discharged after the creation of an ileostomy. Which dietary information would the nurse reinforce? Select all that apply. A. Maintain a clear liquid diet for 1 month. B. Chew food very well. C. Avoid meat that is in a casing such as hot dogs. D. Eliminate gas-forming food. E. Blend all foods.
B. Chew food very well. C. Avoid meat that is in a casing such as hot dogs. D. Eliminate gas-forming food.
The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? A. "Maintain a high-fat diet and drink at least 3 L of fluid a day." B. "Maintain a high-sodium, high-calorie diet." C. "Maintain a high-carbohydrate, low-fat diet." D. "Maintain a high-fat, high-carbohydrate diet."
B. "Maintain a high-sodium, high-calorie diet." C. "Maintain a high-carbohydrate, low-fat diet."
A client is recovering from a small-bowel resection. To relieve pain, the physician prescribes meperidine, 75 mg I.M. every 4 hours. When will the nurse evaluate the client, after administration of meperidine, to determine if the onset of action has occurred? A. 5 to 10 minutes B. 15 to 30 minutes C. 30 to 60 minutes D. 2 to 4 hours
B. 15 to 30 minutes
The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation? A. Antiarrhythmic drugs B. Anticholinergic drugs C. Anticoagulant drugs D. Antihypertensive drugs
B. Anticholinergic drugs
A client informs the nurse that due to a busy work schedule, the need to defecate is often ignored and he then often feels constipated. Which action should the nurse take first? A. Give the client a soapsuds enema B. Auscultate for bowel sounds C. Administer a laxative D. Instruct the client to defecate when the urge is present
B. Auscultate for bowel sounds
Which symptoms would be anticipated if a client with lactose intolerance consumes dairy products? Select all that apply. A. Vomiting B. Bloating C. Gas D. Diarrhea E. Severe right lower quadrant pain
B. Bloating C. Gas D. Diarrhea
The nurse is caring for a client who does not speak English. The family member present with the client informs the nurse that foods must be Yin since the client has a Yang condition. Which type of food would adhere to this request? A. High in calories B. Cooked at low temperatures C. Spicy D. Red-orange in color
B. Cooked at low temperatures
When considering nutrition, which conditions are less likely to occur in vegetarian clients? Select all that apply. A. Insulin-dependent diabetes B. Coronary artery disease C. Hypertension D. Obesity D. Type 2 diabetes
B. Coronary artery disease C. Hypertension D. Obesity D. Type 2 diabetes
The nurse is assessing a client who complains of abdominal pain, nausea, and diarrhea. When examining the client's abdomen, which sequence should the nurse use? A. Inspection, palpation, percussion, and auscultation B. Inspection, auscultation, percussion, and palpation C. Auscultation, inspection, percussion, and palpation D. Palpation, auscultation, percussion, and inspection
B. Inspection, auscultation, percussion, and palpation
While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse would be correct to implement which intervention(s)? Select all that apply. A. Administer a preparation to cleanse the GI tract, such as Golytely or Fleets Phospho-Soda. B. Instruct not to eat or drink for 6 to 12 hours before the procedure. C. Teach the client to ingest only a clear liquid diet for 24 hours before the procedure. D. Inform the client of receiving a sedative before the procedure. E. Encourage the client to eat and drink immediately after the procedure.
B. Instruct not to eat or drink for 6 to 12 hours before the procedure. D. Inform the client of receiving a sedative before the procedure.
A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently? A. It has a slow onset of action. B. It has a short duration of action. C. It has a prolonged half-life. D. It's highly metabolized.
B. It has a short duration of action.
When discussing present physical activity, the client tells the nurse "I do casual walking 3 to 5 times per week and light housework." Which description fits the activity level of this client? A. Sedentary lifestyle B. Light intensity C. Moderate physical activity D. Vigorous physical activity
B. Light intensity
The nurse is assisting with the care of an infant following surgical repair of esophageal atresia and tracheoesophageal fistula. Which nursing intervention takes the highest priority during the first 24 hours following the surgical repair? A. Perform daily weights. B. Monitor for excessive secretions. C. Encourage maternal-infant bonding. D. Provide gastrostomy feedings.VA
B. Monitor for excessive secretions.
When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation perforation, and surgery. Based on which evidence, why is the nurse selecting this nursing diagnosis? A. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. C. The appendix may develop gangrene and rupture, especially in a middle-aged client. D. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.
B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
The nurse inserts a nasogastric tube (NGT) for a client. Which is the most reliable action that the nurse should take to ensure correct placement? A. Aspirate stomach contents. B. Obtain a chest x-ray. C. Instill 14-20 mL of air and auscultate. D. Test the pH of gastric contents.
B. Obtain a chest x-ray.
A client is suspected of having gastric cancer. The nurse expects to prepare the client for which diagnostic test that will aid in confirming the diagnosis of gastric cancer? A. barium enema B. colonoscopy C. gastroscopy D. serum chemistry levels
C. gastroscopy
When assisting with development of a postoperative care plan for a client after gastric resection, which would be the priority? A. body image B. nutritional needs C. skin care D. spiritual needs
B. nutritional needs
A client who has just arrived on the medical-surgical unit after an appendectomy appears to be malnourished. Which nutritional deficiency can delay wound healing? A. thiamine B. vitamin C C. folate D. glucose
B. vitamin C
A nurse is supervising a new nurse who is preparing to perform wound care for a client whose abdominal wound is infected with vancomycin-resistant enterococci. The supervising nurse should make sure that the new nurse: A. confirms proper fit of protective eyewear before entering the client's room. B. wears a gown and gloves while caring for the client. C. assembles all wound care supplies after donning protective equipment but before entering the client's room. D. remembers to remove the gown before the gloves after completing client care.
B. wears a gown and gloves while caring for the client.
The nurse is assisting a client, who is visually impaired, with the meal tray. Which nursing action can promote independence in self-feeding? A. Feed the client if the client begins spilling items. B. Place the food on the utensil and give it to the client. C. Describe the location of the foods as if they are on the face of a clock. D. Only give finger food such as sandwiches.
C. Describe the location of the foods as if they are on the face of a clock.
The nurse is caring for an infant after a cleft lip and cleft palate repair. Which nursing intervention is a priority to prevent tissue infection after the repair? A. Keep the suture line moist at all times. B. Allow the infant to suck on a pacifier. C. Rinse the infant's mouth after each feeding. D. Feed the infant with a catheter-tipped syringe.
C. Rinse the infant's mouth after each feeding.
The nurse is caring for a client that has taken an overdose of acetaminophen. For which initial complication should the nurse closely monitor the client? A. brain damage B. heart failure C. hepatic damage D. kidney stones
C. hepatic damage
A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client A. to the bathroom. B. to the bedside commode. C. onto the bedpan. D. to a standing position so they can urinate.
C. onto the bedpan.
Which client requires immediate nursing intervention? The client who A. complains of epigastric pain after eating. B. complains of anorexia and periumbilical pain. C. presents with a rigid, boardlike abdomen. D. presents with ribbonlike stools.
C. presents with a rigid, boardlike abdomen.
A client diagnosed with glossitis is prescribed a diet high in folic acid. When assisting with the development of a teaching plan for this client, which food products will the nurse reinforce to fulfill the need for increased folic acid? A. poultry B. strawberries C. spinach D. yogurt
C. spinach
A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate? A. "You have stones in your gallbladder and the treatment is to remove the gallbladder." B. "This is a common procedure performed using a scope and will relieve your symptoms." C. "The surgeon feels this is the best option for you at this time based on your symptoms." D. "I will ask the surgeon to come speak to you about the procedure."
D. "I will ask the surgeon to come speak to you about the procedure."
The nurse reinforces home care instructions given to a client with a diagnosis of hiatal hernia. Which statement made by the client indicates an understanding of the instructions? A. "I'll drink carbonated cola beverages with my meals." B. "I'll be sure to lie down immediately after eating." C. "I should eat three large, high-carbohydrate meals each day." D. "I'll sleep with my head elevated about 3 to 4 inches."
D. "I'll sleep with my head elevated about 3 to 4 inches."
A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response? A. "You could have gotten it by using I.V. drugs." B. "You must have received an infected blood transfusion." C. "You probably got it by engaging in unprotected sex." D. "You may have eaten contaminated restaurant food."
D. "You may have eaten contaminated restaurant food."
The nurse is caring for a client who is Muslim in the acute care facility during the month of Ramadan. How will the client's eating patterns alter during this time period? A. "Hot" foods will be given for "hot" illness and "cold" foods given for "cold" illness. B. Yin foods will be given for Yang illness. C. No meat products will be consumed. D. A breakfast tray will be brought prior to dawn and a supper tray after dark.
D. A breakfast tray will be brought prior to dawn and a supper tray after dark.
A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant? A. A newly admitted client with signs of a stroke B. A client with an order for enteral feeding C. A client with nausea and abdominal pain D. A client with bilateral blindness
D. A client with bilateral blindness
A parent brings a child to the emergency department after the child ingested a poisonous hydrocarbon. What is a priority nursing action? A. Induce vomiting. B. Keep the child calm and relaxed. C. Scold the child for the wrongdoing. D. Keep the parents away from the child.
D. Keep the parents away from the child.
A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do? A. Tell the physician that only registered nurses can witness consents. B. Explain the procedure to the client before signing the consent. C. Sign the consent if the physician says that the client has already signed it in front of him. D. Sign the consent only if she sees the client sign it.
D. Sign the consent only if she sees the client sign it.
The client with a peptic ulcer is prescribed an antacid. After administering the medication, the nurse assesses the pH of which organ contents to determine effectiveness? A. Large intestine B. Esophagus C. Small intestine D. Stomach
D. Stomach
Which substance is typically added to the diet of a client diagnosed with alcoholism? A. Potassium B. Riboflavin C. Folic acid D. Thiamine
D. Thiamine
The nurse is reviewing macronutrients and micronutrients with a client. Which items should the nurse include in the list of micronutrients? Select all that apply. A. Carbohydrates B. Fat C. Protein D. Vitamins E. Minerals
D. Vitamins E. Minerals
A nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the health care provider? A. blood pressure 140/84 mm Hg B. abdominal pain C. loss of appetite D. heart rate 126 bpm
D. heart rate 126 bpm
A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task? A. weighing the client B. teaching the client coughing and deep breathing exercises C. teaching the client how to collect a urine specimen D. initiating I.V. therapy, as ordered
D. initiating I.V. therapy, as ordered
A nurse is caring for a client after a hemorrhoidectomy. Which order would the nurse question on the medical record? A. warm sitz baths as needed B. fluid encouragement C. stool softener daily D. low-fiber diet
D. low-fiber diet
The nurse receives a client at the clinic for follow-up after being treated in the hospital for pancreatitis. When gathering data from the client, which finding should immediately be reported to the health care provider? A. dry, itchy, and scaly skin B. abdomen bloated but non-tender C. greenish-yellow bruise over the IV site D. shortness of breath with minimal exertion
D. shortness of breath with minimal exertion
