NUR 114 Test 4 Compilation
The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
A, B, C, E
A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Proteinuria b. Hypoalbuminemia c. Dehydration d. Lipiduria e. Dysuria f. Costovertebral angle (CVA) tenderness
A, B, D
A client's chart indicates anisocoria. For what should the nurse assess? a. Difference in pupil size b. Draining infection c. Recent eye trauma d. Tumor of the eyelid
A
A client has a foreign body in the eye. What action by the nurse takes priority? a. Administering ordered antibiotics b. Assessing the clients visual acuity c. Obtaining consent for enucleation d. Removing the object immediately
A
A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? a.The treatment reduces testosterone and prevents bone fractures. b.The medications prevent erectile dysfunction and increase libido. c.There is less gynecomastia and osteoporosis with this drug regimen. d.These medications both inhibit tumor progression by blocking androgens
A
A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0 F (37.8 C) c. Loose and bloody stool d. Lower abdominal cramps
A
A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer? a.Alpha-fetoprotein (AFP) b.Prostate-specific antigen (PSA) c.Prostate acid phosphatase (PAP) d.C-reactive protein (CRP)
A
A client does not understand why vision loss due to glaucoma is irreversible. What explanation by the nurse is best? a. Because eye pressure was too high, the tissue died. b. Glaucoma always leads to permanent blindness. c. The traumatic damage to your eye was too great. d. The infection occurs so quickly it cant be treated.
A
A patient is asking advice about which over-the-counter antacid is considered the most safe to use for heartburn. The nurse explains that calcium antacids are not used as frequently as other antacids because a.their use may result in kidney stones. b.they cause decreased gastric acid production. c.they cause severe diarrhea. d.their use may result in fluid retention and edema.
A
A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconis anemia c. Hemolytic anemia d. Vitamin B12 anemia
A
A client has a corneal ulcer. What information provided by the client most indicates a potential barrier to home care? a. Chronic use of sleeping pills b. Impaired near vision c. Slightly shaking hands d. Use of contact lenses
A
A patient will be taking a 2-week course of combination therapy with omeprazole (Prilosec) and another drug for a peptic ulcer caused by Helicobacter pylori. The nurse expects a drug from which class to be ordered with the omeprazole? a.An antibiotic b.A nonsteroidal antiinflammatory drug c.An antacid d.An antiemetic
A
After teaching a client who has a femoral hernia, the nurse assesses the client's understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. "I will put on the truss before I go to bed each night." b. "I'll put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I'll let my health care provider know right away."
A
An elderly patient had gastric surgery due to a gastrointestinal bleed 3 days ago, and he has been stable since the surgery. This evening, his daughter tells the nurse, "He seems to be more confused this afternoon. He's never been like this. What could be the problem?" The nurse reviews the patient's medication record and suspects that which drug could be the cause of the patient's confusion? a.cimetidine (Tagamet) b.pantoprazole (Protonix) c.clarithromycin (Biaxin) d.sucralfate (Carafate)
A
The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a.Cloudy urine b.Urinary hesitancy c.Post-void dribbling d.Weak urinary stream
A
The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? a.There should be no problem with a glass of wine with dinner each night. b.I am so glad that I weaned myself off of coffee about a year ago. c.I need to inform my allergist that I cannot take my normal decongestant. d.My normal routine of drinking a quart of water during exercise needs to change.
A
The nurse reads on a client's chart that the client has exophthalmos. What assessment finding is consistent with this diagnosis? a. Bulging eyes b. Drooping eyelids c. Sunken-in eyes d. Yellow sclera
A
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD) (Select all that apply.) A. Delayed gastric emptying B. Eating large meals C. Hiatal hernia D. Obesity E. Viral infections
A, B, C, D
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer e. Fistula Dilation and colonic ileus caused by paralysis of the colon
A, B, D
A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia
A, B, D
The nursing student learns that age-related changes affect the eyes and vision. Which changes does this include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision
A, B, D, E
A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.
B
A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the clients stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).
B
A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective A. "I can only take this medicine at night." B. "I should take this on a full stomach." C. "This drug decreases stomach acid." D. "This should be taken 1 hour before meals."
B
An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client? a. Check with the pharmacist before taking other medications. b. Increase intake of calcium and vitamin D. c. Report any worsening of symptoms to the provider. d. Take the medication as prescribed by the provider.
B
The nurse is administering eyedrops to a client with an infection in the right eye. The drops go in both eyes, and two different bottles are used to administer the drops. The nurse accidentally uses the left eye bottle for the right eye. What action by the nurse is best? a. Inform the provider of the issue. b. Obtain a new bottle of eyedrops. c. Rinse the client's right eye thoroughly. d. Wipe the left eye bottle with alcohol.
B
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the clients abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.
B
When reviewing the health history of a patient, the nurse will note that a potential contraindication to potassium supplements exists if the patient has which problem?" a Burns b Diarrhea c Renal disease d Cardiac tachydysrhythmias
C
A nurse reviews laboratory results for a client with glomerulonephritis. The client's glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.) a. Excessive GFR b. Normal GFR c. Reduced GFR d. Potential for fluid overload e. Potential for dehydration
C, D
A nurse working with a client who has possible gastritis assesses the clients gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.) a. Anorexia b. Dyspepsia c. Intolerance of fatty foods d. Pernicious anemia e. Nausea and vomiting
C, D
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately? a. Albumin: 2.1 g/dL b. Hematocrit: 28% c. Hemoglobin: 8.1 mg/dL d. International normalized ratio (INR): 4.2
D
After teaching a client with diverticular disease, a nurse assesses the clients understanding. Which menu selection made by the client indicates the client correctly understood the teaching? a. Roasted chicken with rice pilaf and a cup of coffee with cream b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea c. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice
D
During an admission assessment, the patient tells the nurse that he has been self-treating his heartburn for 1 year with over-the-counter Prilosec OTC (omeprazole, a proton pump inhibitor). The nurse is aware that this self-treatment may have which result? a.No serious consequences b.Prevention of more serious problems, such as an ulcer c.Chronic constipation d.Masked symptoms of serious underlying diseases
D
The nurse is teaching a patient who will be taking a proton pump inhibitor as long-term therapy about potential adverse effects. Which statement is correct? a.Proton pump inhibitors can cause diarrhea. b.These drugs can cause nausea and anorexia. c.Proton pump inhibitors cause drowsiness. d.Long-term use of these drugs may contribute to osteoporosis.
D
A patient in the intensive care unit has a nasogastric tube and is also receiving a proton pump inhibitor (PPI). The nurse recognizes that the purpose of the PPI is which effect? a.Prevent stress ulcers b.Reduce bacteria levels in the stomach c.Reduce gastric gas formation (flatulence) d.Promote gastric motility
A
The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)? a. Gastric acid inhibitor b. Histamine receptor blocker c. Mucosal barrier fortifier d. Proton pump inhibitor
C
A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client? a. Metronidazole (Flagyl) b. Ciprofloxacin (Cipro) c. Sulfasalazine (Azulfidine) d. Ceftriaxone (Rocephin)
A
After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best A. "Bacteria can often cause ulcers." B. "This operation often causes ulcers." C. "The medication keeps your blood pH low." D. "It prevents stress-related ulcers."
D
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important? a. Alcohol intake of 1 to 2 drinks per week b. Family history of H. pylori infection c. Former smoker still using nicotine patches d. Willingness to adhere to drug therapy
D
After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice
D
A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.) a. Nocturia b. Flank pain c. Increased abdominal girth d. Dysuria e. Hematuria f. Diarrhea
B, C, E
A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids
B
A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client A. Enteral tube feeding B. Esophageal dilation C. Nissen fundoplication D. Photodynamic therapy
B
A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."
C
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.
D
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first? a. Inspection of oral mucosa b. Recent dietary intake c. Heart rate and rhythm d. Percussion of abdomen
C
A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a.Family history of prostate cancer b.Smoking c.Obesity d.Advanced age e.Eating too much red meat f.Race
A, D, E, F
A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best? a. Slippery elm has no benefit for this problem. b. Slippery elm is often used for this disorder. c. There is no evidence that this will work. d. You should not take any herbal remedies.
B
A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the client's heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the client's abdomen.
B
A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider? a. Flank pain b. Periorbital edema c. Bloody and cloudy urine d. Enlarged abdomen
B
A nurse is seeing clients in the ophthalmology clinic. Which client should the nurse see first? a. Client with intraocular pressure reading of 24 mm Hg b. Client who has had cataract surgery and has worsening vision c. Client whose red reflex is absent on ophthalmologic examination d. Client with a tearing, reddened eye with exudate
B
A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan? a. Risk for falls b. Self-care deficit c. Social isolation d. Impaired physical mobility
C
The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? a. Body image disturbance b. Social isolation c. Risk for falls d. Fear
C
The student learning about vision should remember which facts related to the eyes? (Select all that apply.) a. Aqueous humor controls intraocular pressure. b. Cones work in low light conditions. c. Glaucoma occurs due to increased pressure in the eye. d. Muscles of the iris control light entering the eye. e. Rods work in low light conditions.
A, C, D, E
A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing should the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry
A
A patient is receiving an aluminum-containing antacid. The nurse will inform the patient to watch for which possible adverse effect? a.Diarrhea b.Constipation c.Nausea d.Abdominal cramping
B
After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will avoid large crowds and people who are sick. b. I will take this medication with my breakfast each morning. c. Nausea and vomiting are common side effects of this drug. d. I must wash my hands after I play with my dog.
B
A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a.Complete blood count b.Culture and sensitivity c.Prostate-specific antigen d.Cystoscopy
C
A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating
C
A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers
A
A nurse cares for a client who has obstructive jaundice. The client asks, "Why is my skin so itchy?" How should the nurse respond? a. "Bile salts accumulate in the skin and cause the itching." b. "Toxins released from an inflamed gallbladder lead to itching." c. "Itching is caused by the release of calcium into the skin." d. "Itching is caused by a hypersensitivity reaction."
A
A nurse is working to prevent blindness. Which preventive action is a priority? a. Screen young adults early for visual impairments. b. Include rubella and syphilis screening in the preconception care plan. c. Instruct parents to report reduced eye contact from their child immediately. d. Administer eye prophylactic antibiotics to newborns within 24 hours after birth.
B
After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "Drinking at least 2 liters of water each day is suggested." b. "I will decrease the amount of fatty foods in my diet." c. "Drinking fluids with my meals will increase bloating." d. "I will avoid concentrated sweets and simple carbohydrates."
B
After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition? a. "I must decrease my intake of fat." b. "I will increase my intake of protein." c. "A decreased intake of carbohydrates will be required." d. "An increased intake of vitamin C is necessary."
B
An emergency department nurse assesses a client with kidney trauma and notes that the client's abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation? a. Assessing vital signs every 15 minutes b. Inserting an indwelling urinary catheter c. Administering intravenous fluids at 125 mL/hr d. Typing and crossmatching for blood products
B
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.
B
After teaching a client who is recovering from a colon resection, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "I must change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I might start bicycling and swimming again once my incision has healed." d. "Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I must avoid dairy products to reduce gas and odor in the pouch."
B, C, D
After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the clients understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.) a. Ill have my housekeeper keep my toilet clean. b. I must take a shower or bathe every day. c. I should have my well water tested. d. I will ask my sexual partner to have a stool test. e. I must only eat raw vegetables from my own garden.
B, C, D
After teaching a client who has diverticulitis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. Ill ride my bike or take a long walk at least three times a week. b. I must try to include at least 25 grams of fiber in my diet every day. c. I will take a laxative nightly at bedtime to avoid becoming constipated. d. I should use my legs rather than my back muscles when I lift heavy objects.
C
A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr
B, C, D, E
The nurse is providing patient teaching about antacids. Which statements about antacids are accurate? (Select all that apply.) a.Antacids reduce the production of acid in the stomach. b.Antacids neutralize acid in the stomach. c.Rebound hyperacidity may occur with calcium-based antacids. d.Aluminum-based antacids cause diarrhea. e.Magnesium-based antacids cause diarrhea.
B, C, E
A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client A. Famotidine (Pepcid) B. Magnesium hydroxide (Maalox) C. Omeprazole (Prilosec) D. Ranitidine (Zantac)
C
A clients intraocular pressure (IOP) is 28 mm Hg. What action by the nurse is best? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Plan to teach about drugs for glaucoma. d. Refer the client to local Braille classes.
C
A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia - Results from inadequate healing of an incision e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity
C, D, E
A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently
D
A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes
D
A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."
D
A nurse cares for a client with ulcerative colitis. The client states, I feel like I am tied to the toilet. This disease is controlling my life. How should the nurse respond? a. Lets discuss potential factors that increase your symptoms. b. If you take the prescribed medications, you will no longer have diarrhea. c. To decrease distress, do not eat anything before you go out. d. You must retake control of your life. I will consult a therapist to help.
A
A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this clients teaching? a. Drink plenty of fluids to prevent dehydration. b. You should only drink 1 liter of fluids daily. c. Increase your protein intake by drinking more milk. d. Sips of cola or tea may help to relieve your nausea.
A
After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will take a laxative every night before going to bed." b. "I must increase my intake of dietary fiber and fluids." c. "I shall only use salt when I am cooking my own food." d. "I'll eat white bread to minimize gastrointestinal gas."
B
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk
B
When reviewing the health history of a patient who will be receiving antacids, the nurse recalls that antacids containing magnesium need to be used cautiously in patients with which condition? a.Peptic ulcer disease b.Renal failure c.Hypertension d.Heart failure
B
A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment? a. The client has lost 11 pounds in the past 10 days. b. The client's urine specific gravity is 1.048. c. No blood is observed in the client's urine. d. The client's blood pressure is 152/88 mm Hg.
A
A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment? a. Impaired night vision b. Difficulty hearing low pitch c. Heightened sense of smell d. Increased taste discrimination
A
A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L b. Client ate 20% of breakfast meal c. White blood cell count of 8200/mm3 d. Clients weight decreased by 3 pounds
A
The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.) a. Achlorhydria b. Chronic atrophic gastritis c. Helicobacter pylori infection d. Iron deficiency anemia e. Pernicious anemia
A, B, C, E
A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.) a. Administer vitamin B12 injections. b. Ask the provider about folic acid replacement. c. Educate the client on enteral feedings. d. Obtain consent for total parenteral nutrition. e. Provide iron supplements for the client.
A, B, E
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this client's assessment? (Select all that apply.) a. "Which food types cause an exacerbation of symptoms?" b. "Where is your pain and what does it feel like?" c. "Have you lost a significant amount of weight lately?" d. "Are your stools soft, watery, and black in color?" e. "Do you experience nausea associated with defecation?"
A, B, E
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output
A, B, E
A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching (Select all that apply.) A. Chocolate B. Decaffeinated coffee C. Citrus fruits D. Peppermint E. Tomato sauce
A, C, D, E
A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L
A, C, E
A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this client's teaching? a. "Since you only have one kidney, a salt and fluid restriction is required." b. "Your therapy will include hemodialysis while you recover." c. "Medication will be prescribed to control your high blood pressure." d. "You need to avoid participating in contact sports like football."
D
A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphys sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night
C
A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity
C
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.
C
A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take? a. Contact the clinical pharmacist and request the medication in suspension form. b. Empty the contents of the capsule into applesauce or pudding for administration. c. Ask the health care provider to prescribe the medication as an enema instead. d. Crush the pill carefully and administer it in applesauce or pudding.
C
A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply? a. "Is your stomach rumbling or do you have bowel sounds?" b. "I need to check your gag reflex before you can eat." c. "Have you passed any flatus or moved your bowels?" d. "You will not be able to eat until the pain subsides."
C
A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should Istop driving?" Which response by the nurse is mosttherapeutic? a. "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk." b. "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident." c. "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go." d. "No, instead you should see your ophthalmologist and get some glasses to help you see better."
C
A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate? a. Aspirin must be avoided. b. Do not worry about black stools. c. Report diarrhea to your provider. d. Take 1 hour before meals.
C
A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, "My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How should the nurse respond? a. "Your doctor should not have given you that information prior to the colonoscopy." b. "The colonoscopy is required due to the high percentage of false negatives with the blood test." c. "A negative fecal occult blood test does not rule out the possibility of colon cancer." d. "I will contact your doctor so that you can discuss your concerns about the procedure
C
A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this client's plan of care? a. "You may experience nausea and vomiting for the first few weeks." b. "Carbonated beverages can help decrease acid reflux from anastomosis sites." c. "Take a stool softener to promote softer stools for ease of defecation." d. "You may return to your normal workout schedule, including weight lifting."
C
A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take? a. Document the finding in the client's record. b. Evaluate the tube as working in the hand-off report. c. Clamp the tube in preparation for removing it. d. Assess the client's abdomen and vital signs.
D
A patient is complaining of excessive and painful gas. The nurse checks the patient's medication orders and prepares to administer which drug for this problem? a.famotidine (Pepcid) b.aluminum hydroxide and magnesium hydroxide (Maalox or Mylanta) c.calcium carbonate (Tums) d.simethicone (Mylicon)
D
