NUR 2 Exam 3 nclex

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76. When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: ■ 1. While inhaling through an open mouth. ■ 2. While exhaling through pursed lips. ■ 3. After exhaling but before inhaling. ■ 4. While taking a deep breath and holding it.

2. Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.

13. A 36-year-old female client has been diagnosed with hemorrhoids. Which of the following factors in the client's history would most likely be a primary cause of her hemorrhoids? ■ 1. Her age. ■ 2. Three vaginal delivery pregnancies. ■ 3. Her job as a schoolteacher. ■ 4. Varicosities in her legs

2. Hemorrhoids are associated with prolonged sitting or standing, portal hypertension, chronic constipation, and prolonged increased intra-abdominal pressure, as associated with pregnancy and the strain of vaginal delivery. Her job as a schoolteacher does not require prolonged sitting or standing. Age and leg varicosities are not related to the development of hemorrhoids.

59. A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to: ■ 1. Adhere to a low-cholesterol diet. ■ 2. Supplement the diet with pyridoxine (vitamin B6). ■ 3. Get extra rest. ■ 4. Avoid excessive sun exposure.

2. INH competes for the available vitamin B6 in the body and leaves the client at risk for development of neuropathies related to vitamin deﬁ ciency. Supplemental vitamin B6 is routinely prescribed. Following a low-cholesterol diet, getting extra rest, and avoiding excessive sun exposure will not prevent the development of peripheral neuropathies.

26. Pancreatic enzyme replacements are ordered for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? ■ 1. Three times daily between meals. ■ 2. With each meal and snack. ■ 3. In the morning and at bedtime. ■ 4. Every 4 hours, at speciﬁ ed times

2. In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Speciﬁ ed hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.

17. A client has been placed on long-term sulfasalazine (Azulﬁ dine) therapy for treatment of his ulcerative colitis. The nurse should encourage the client to eat which of the following foods to help avoid the nutrient deﬁ ciencies that may develop as a result of this medication? ■ 1. Citrus fruits. ■ 2. Green, leafy vegetables. ■ 3. Eggs. ■ 4. Milk products.

2. In long-term sulfasalazine therapy, the client may develop folic acid deﬁ ciency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in his diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.

34. A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following ﬁ rst? ■ 1. Encourage the client to drink at least 1,000 mL per day. ■ 2. Provide parenteral rehydration therapy ordered by the physician. ■ 3. Turn and reposition every 2 hours. ■ 4. Monitor vital signs every shift.

2. Initially, the extracellular ﬂ uid (ECF) volume with isotonic I.V. ﬂ uids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral ﬂ uid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is ﬁ rst necessary to rehydrate this client.

102. Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client? ■ 1. Repositioning the client immediately after administering pain medication. ■ 2. Reassessing the client 30 minutes after administering pain medication. ■ 3. Verbally reassuring the client after administering pain medication. ■ 4. Readjusting the pain medication dosage as needed according to the client's condition.

2. It is essential that the nurse evaluate the effects of pain medication after the medication has had time to act; reassessment is necessary to determine the effectiveness of the pain management plan. Although it is prudent to check for discomfort related to positioning when assessing the client's pain, repositioning the client immediately after administering pain medication is not necessary. Verbally reassuring the client after administering pain medication may be useful to help instill conﬁ dence in the treatment plan; however, it is not as important as evaluating the effectiveness of the medication. Readjusting the pain medication dosage as needed according to the client's condition is essential, but the effectiveness of the medication must be evaluated ﬁ rst.

17. The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difﬁ cult to manage shock in pancreatitis? ■ 1. Severity of intestinal hemorrhage. ■ 2. Vasodilating effects of kinin peptides. ■ 3. Tendency toward heart failure. ■ 4. Frequent incidence of acute tubular necrosis.

2. Life-threatening shock is a potential complication of pancreatitis. Kinin peptides activated by the trapped trypsin cause vasodilation and increased capillary permeability. These effects exacerbate shock and are not easily reversed with pharmacologic agents such as vasopressors. Hemorrhage may occur into the pancreas, but not in the intestines. Systemic complications include pulmonary complications, but not heart failure or

61. The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate? ■ 1. "Surgery is usually required, although medical treatment is attempted ﬁ rst." ■ 2. "Hiatal hernia symptoms can usually be successfully managed with diet modiﬁ cations, medications, and lifestyle changes." ■ 3. "Surgery is not performed for this type of hernia." ■ 4. "A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned."

2. Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modiﬁ cations. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms

74. Postoperative nursing care for a client after an appendectomy should include which of the following? ■ 1. Administering sitz baths four times a day. ■ 2. Noting the ﬁ rst bowel movement after surgery. ■ 3. Limiting the client's activity to bathroom privileges. ■ 4. Measuring abdominal girth every 2 hours.

2. Noting the client's ﬁ rst bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not conﬁ ned to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours

55. Which of the following lifestyle modiﬁ cations should the nurse encourage the client with a hiatal hernia to include in activities of daily living? ■ 1. Daily aerobic exercise. ■ 2. Eliminating smoking and alcohol use. ■ 3. Balancing activity and rest. ■ 4. Avoiding high-stress situations.

2. Smoking and alcohol use both reduce esophageal sphincter tone and can result in reﬂ ux. They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing activity and rest, and avoiding high-stress situations may increase the client's general health and well- being, but they are not directly associated with hiatal hernia.

62. In which areas of the United States is the incidence of tuberculosis highest? ■ 1. Rural farming areas. ■ 2. Inner-city areas. ■ 3. Areas where clean water standards are low. ■ 4. Suburban areas with signiﬁ cant industrial pollution.

2. Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence

26. A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse shuld tell the client? ■ 1. "Ulcerative colitis can be cured by the use of steroids." ■ 2. "Steroids are used in severe ﬂ are-ups because they can decrease the incidence of bleeding." ■ 3. "Long-term use of steroids will prolong periods of remission." ■ 4. "The side effects of steroids outweigh their beneﬁ ts to clients with ulcerative colitis."

2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the beneﬁ ts of short-term steroid therapy usually outweigh the potential adverse effects.

40. After insertion of a nasoenteric tube, the nurse should place the client in which position? ■ 1. Supine. ■ 2. Right side-lying. ■ 3. Semi-Fowler's. ■ 4. Upright in a bedside chair.

2. The client is placed in a right side-lying position to facilitate movement of the mercuryweighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops. Placing the client in the supine or semi-Fowler's position

42. The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate? ■ 1. Reassure the client that the nasoenteric tube is functioning. ■ 2. Assess the client for a rigid abdomen. ■ 3. Administer an opioid as ordered. ■ 4. Reposition the client on the left side.

2. The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.

93. The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? ■ 1. Occupational exposure to toxins. ■ 2. Viral respiratory infections. ■ 3. Exposure to cigarette smoke. ■ 4. Exercising in cold temperatures.

2. The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the ﬂ u or a cold and should get yearly ﬂ u vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic attacks are triggered by exercising in cold weather.

44. Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reﬂ ux disease (GERD)? ■ 1. Limit caffeine intake to two cups of coffee per day. ■ 2. Do not lie down for 2 hours after eating. ■ 3. Follow a low-protein diet. ■ 4. Take medications with milk to decrease irritation

2. The nurse should instruct the client to not lie down for about 2 hours after eating to prevent reﬂ ux. Caffeinated beverages decrease pressure in the lower esophageal sphincter and milk increases gastric acid secretion, so these beverages should be avoided. The client is encouraged to follow a high-protein, low-fat diet, and avoid foods that are irritating.

75. When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract? ■ 1. Friction between the cilia. ■ 2. Force of gravity. ■ 3. Sweeping motion of cilia. ■ 4. Involuntary muscle contractions.

2. The principle behind using postural drainage is that gravity will help move secretions from smaller to larger airways. Postural drainage is best used after percussion has loosened secretions. Coughing or suctioning is then used to remove secretions. Movement of cilia is not sufﬁ cient to move secretions. Muscle contractions do not move secretions within the lungs.

108. The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. This observation should prompt the nurse to do which of the following? ■ 1. Continue monitoring as usual; this is expected. ■ 2. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle. ■ 3. Decrease the suction to -15 cm H2O and continue observing the system for changes in bubbling during the next several hours. ■ 4. Drain half of the water from the water-seal chamber.

2. There should never be constant bubbling in the water-seal bottle; normally the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction or draining part of the water in the water-seal chamber will not reduce the leak.

51. The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated: ■ 1. Dust particles. ■ 2. Droplet nuclei. ■ 3. Water. ■ 4. Eating utensils.

2. Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air. Dust particles and water do not spread tubercle bacilli. Tuberculosis is not spread by eating utensils, dishes, or other fomites.

7. The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician? ■ 1. The stoma is slightly edematous. ■ 2. The stoma is dark red to purple. ■ 3. The stoma oozes a small amount of blood. ■ 4. The stoma does not expel stool

2.A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.

68. After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. ■ 1. "With careful attention to my diet, my diverticulosis can be cured." ■ 2. "Using a cathartic laxative weekly is okay to control bowel movements." ■ 3. "I should follow a diet that's high in ﬁ ber." ■ 4. "It is important for me to drink at least 2,000 mL of ﬂ uid every day." ■ 5. "I should exercise regularly."

3, 4, 5. Clients who have diverticulosis should be instructed to maintain a diet high in ﬁ ber and, unless contraindicated, should increase their ﬂ uid intake to a minimum of 2,000 mL/day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.

124. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. ■ 1. The family is coming in to visit. ■ 2. The client has increased secretions requiring frequent suctioning. ■ 3. The SpO2 and PO2 have decreased. ■ 4. The client is tachycardic with drop in blood pressure. ■ 5. The face has increased skin breakdown and edema.

3, 4, 5. The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.

16. When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply. ■ 1. Epigastric pain at night. ■ 2. Relief of epigastric pain after eating. ■ 3. Vomiting. ■ 4. Weight loss. ■ 5. Melena.

3, 4, 5. Vomiting and weight loss are common with gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs during the night and is frequently relieved by eating.

6. A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T-tube. To evaluate the effectiveness of the T-tube, the nurse should: ■ 1. Irrigate the tube with 20 mL of normal saline every 4 hours. ■ 2. Unclamp the T-tube and empty the contents every day. ■ 3. Assess the color and amount of drainage every shift. ■ 4. Monitor the multiple incision sites for bile drainage.

3. A T-tube is inserted in the common bile duct to maintain patency until edema from the duct exploration subsides. The bile color should be gold to dark green and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless ordered using a smaller volume of ﬂ uid. The T-tube is not clamped in the early post-op period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions.

111. Which of the following should be readily available at the bedside of a client with a chest tube in place? ■ 1. A tracheostomy tray. ■ 2. Another sterile chest tube. ■ 3. A bottle of sterile water. ■ 4. A spirometer

3. A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be re-established. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use.

36. Following a gastrectomy, the nurse should postion the client in which of the following positions? ■ 1. Prone. ■ 2. Supine. ■ 3. Low Fowler's. ■ 4. Right or left Sims.

3. A client who has had abdominal surgery is best placed in a low Fowler's position postoperatively. This positioning relaxes abdominal muscles and provides for maximum respiratory and cardiovascular function. The prone, supine, or Sims position would not be tolerated by a client who has had abdominal surgery, nor do those positions support respiratory or cardiovascular functioning.

105. Which of the following rehabilitative measures should the nurse teach the client who has undergone chest surgery to prevent shoulder ankylosis? ■ 1. Turn from side to side. ■ 2. Raise and lower the head. ■ 3. Raise the arm on the affected side over the head. ■ 4. Flex and extend the elbow on the affected side.

3. A client who has undergone chest surgery should be taught to raise the arm on the affected side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power. Turning from side to side, raising and lowering the head, and ﬂ exing and extending the elbow on the affected side do not exercise the shoulder joint.

16. The nurse teaches the client who has had rectal surgery the proper timing for sitz baths. The nurse knows that the client has understood the teaching when the client states that it is most important to take a sitz bath: ■ 1. First thing each morning. ■ 2. As needed for discomfort. ■ 3. After a bowel movement. ■ 4. At bedtime.

3. Adequate cleaning of the anal area is difﬁ cult but essential. After rectal surgery, sitz baths assist in this process, so the client should take a sitz bath after a bowel movement. Other times are dictated by client comfort

29. The physician prescribes sulfasalazine (Azulﬁ dine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication? ■ 1. Avoid taking it with food. ■ 2. Take the total dose at bedtime. ■ 3. Take it with a full glass (240 mL) of water. ■ 4. Stop taking it if urine turns orange-yellow

3. Adequate ﬂ uid intake of at least 8 glasses a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs

13. Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy? ■ 1. Avoid showering for 48 hours after surgery. ■ 2. Return to work within 1 week. ■ 3. Leave dressings in place until you see the surgeon at the postoperative visit. ■ 4. Use acetaminophen (Tylenol) to control any fever.

3. After a laparoscopic cholecystectomy, the client should not remove dressings from the puncture sites but should wait until visiting the surgeon. The client may shower the day after surgery. A client can return to work within 1 week, but only if approved by the surgeon and no strenuous activity is involved. The client should report any fever, which could be an indication of a complication

65. Which of the following laboratory ﬁ ndings would the nurse expect to ﬁ nd in a client with diverticulitis? ■ 1. Elevated red blood cell count. ■ 2. Decreased platelet count. ■ 3. Elevated white blood cell count. ■ 4. Elevated serum blood urea nitrogen concentration.

3. Because of the inﬂ ammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory ﬁ ndings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or ﬂ uid volume deﬁ cit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.

138. A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do ﬁ rst? ■ 1. Initiate gastric lavage. ■ 2. Maintain body temperature. ■ 3. Administer 100% oxygen by mask. ■ 4. Obtain a psychiatric referral.

3. Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature, thus steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate.

44. Which of the following mental status changes may occur when a client with pneumonia is ﬁ rst experiencing hypoxia? ■ 1. Coma. ■ 2. Apathy. ■ 3. Irritability. ■ 4. Depression.

3. Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.

19. A client is admitted with acute necrotizing pancreatitis. Lab results have been obtained and a peripheral I.V. has been inserted. Which of the following orders from a health care provider should the nurse question? ■ 1. Infuse a 500 mL normal saline bolus. ■ 2. Calcium gluconate 90 mg in 100 mL NS. ■ 3. Total parenteral nutrition (TPN) at 72 mL/ hour. ■ 4. Placement of a Foley catheter.

3. Clients with acute necrotizing pancreatitis should remain NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is considered if enteral feedings are contraindicated. Access is also needed for TPN, preferably via a central line. Hemodynamic instability can result from ﬂ uid volume loss and bleeding and requires ﬂ uid and electrolyte replacement. Fat necrosis occurring with acute pancreatitis can cause hypocalcemia requiring calcium replacement. A Foley catheter provides accurate output assessment to monitor for prerenal acute renal failure that can occur from hypovolemia

86. A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? ■ 1. Promote bronchodilation. ■ 2. Act as an expectorant. ■ 3. Have an anti-inﬂ ammatory effect. ■ 4. Prevent development of respiratory infections

3. Corticosteroids have an anti-inﬂ ammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

133. Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? ■ 1. Tracheostomy. ■ 2. Use of a nasal cannula. ■ 3. Mechanical ventilation. ■ 4. Insertion of a chest tube

3. Endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or ﬂ uid from intrapleural spaces.

24. A client's ulcerative colitis signs and symptoms have been present for longer than 1 week. The nurse should assess the client for signs and symptoms of which of the following complications? ■ 1. Heart failure. ■ 2. Deep vein thrombosis. ■ 3. Hypokalemia. ■ 4. Hypocalcemia.

3. Excessive diarrhea causes signiﬁ cant depletion of the body's stores of sodium and potassium as well as ﬂ uid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia

115. A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the ﬂ uid in the water-seal column is ﬂ uctuating with each breath that the client takes. What is the signiﬁ cance of this ﬂ uctuation? ■ 1. An obstruction is present in the chest tube. ■ 2. The client is developing subcutaneous emphysema. ■ 3. The chest tube system is functioning properly. ■ 4. There is a leak in the chest tube system

3. Fluctuation of ﬂ uid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, ﬂ uid ﬂuctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.

27. A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 lb since the exacerbation of his ulcerative colitis. Which of the following will be most effective in helping the client meet his nutritional needs? ■ 1. Continuous enteral feedings. ■ 2. Following a high-calorie, high-protein diet. ■ 3. Total parenteral nutrition (TPN). ■ 4. Eating six small meals a day.

3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client's nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, highprotein diet will worsen the client's symptoms.

38. A client with pneumonia has a temperature of 102° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? ■ 1. Position changes every 4 hours. ■ 2. Nasotracheal suctioning to clear secretions. ■ 3. Frequent linen changes. ■ 4. Frequent offering of a bedpan.

3. Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

60. The nurse should caution sexually active female clients taking isoniazid (INH) that the drug has which of the following effects? ■ 1. Increases the risk of vaginal infection. ■ 2. Has mutagenic effects on ova. ■ 3. Decreases the effectiveness of hormonal contraceptives. ■ 4. Inhibits ovulation.

3. INH interferes with the effectiveness of hormonal contraceptives, and female clients of childbearing age should be counseled to use an alternative form of birth control while taking the drug. INH does not increase the risk of vaginal infection, nor does it affect the ova or ovulation.

12. A client undergoes a laparoscopic cholecystectomy. Which of the following dietary instructions should the nurse give the client immediately after surgery? ■ 1. "You cannot eat or drink anything for 24 hours." ■ 2. "You may resume your normal diet the day after your surgery." ■ 3. "Drink liquids today and eat lightly for a few days." ■ 4. "You can progress from a liquid to a bland diet as tolerated."

3. Immediately after surgery, the client will drink liquids. A light diet can be resumed the day after surgery. There is no need for the client to remain on nothing-by-mouth status after surgery because peristaltic bowel activity should not be affected. The client will probably not be able to tolerate a full meal comfortably the day after surgery. There is no need for the client to stay on a bland diet after a laparoscopic cholecystectomy. The client should, however, avoid excessive fats.

144. Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal inﬂ uenza vaccination? ■ 1. A 60-year-old man with a hiatal hernia. ■ 2. A 36-year-old woman with three children. ■ 3. A 50-year-old woman caring for a spouse with cancer. ■ 4. A 60-year-old woman with osteoarthritis.

3. Individuals who are household members or home care providers for high-risk individuals are high-priority targeted groups for immunization against inﬂ uenza to prevent transmission to those who have a decreased capacity to deal with the disease. The wife who is caring for a husband with cancer has the highest priority of the clients described because her husband is likely to be immunocompromised and particularly susceptible to the ﬂ u. A healthy 60-year-old man or a healthy 36-year-old woman is not in a high-priority category for inﬂ uenza vaccination. A 60-year-old woman with osteoarthritis does not have a higher priority for inﬂ uenza vaccination than a home care provider.

11. When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which of the following dietary instructions? ■ 1. Foods containing roughage should not be eaten. ■ 2. Liquids are best limited to prevent diarrhea. ■ 3. Clients should experiment to ﬁ nd the diet that is best for them. ■ 4. A high-ﬁ ber diet will produce a regular passage of stool.

3. It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of ﬂ uid per day. A high-ﬁ ber diet may produce loose stools.

37. When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values? ■ 1. Serum sodium. ■ 2. Serum potassium. ■ 3. Serum creatinine. ■ 4. Serum calcium.

3. It is essential to monitor serum creatinine in the client receiving an aminoglycoside antibiotic because of the potential of this type of drug to cause acute tubular necrosis. Aminoglycoside antibiotics do not affect serum sodium, potassium, or calcium levels.

34. After a subtotal gastrectomy, care of the client's nasogastric (NG) tube and drainage system should include which of the following nursing interventions? ■ 1. Irrigate the tube with 30 mL of sterile water every hour, if needed. ■ 2. Reposition the tube if it is not draining well. ■ 3. Monitor the client for nausea, vomiting, and abdominal distention. ■ 4. Turn the machine to high suction if the drainage is sluggish on low suction.

3. Nausea, vomiting, or abdominal distention indicates that gas and secretions are accumulating within the gastric pouch due to impaired peristalsis or edema at the operative site and may indicate that the drainage system is not working properly. Saline solution is used to irrigate NG tubes. Hypotonic solutions such as water increase electrolyte loss. In addition, a physician's order is needed to irrigate the NG tube because this procedure could disrupt the suture line. After gastric surgery, only the surgeon repositions the NG tube because of the danger of rupturing or dislodging the suture line. The amount of suction varies with the type of tube used and is ordered by the physician. High suction may create too much tension on the gastric suture line.

25. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? ■ 1. Before meals. ■ 2. With meals. ■ 3. At bedtime. ■ 4. When pain occurs

3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.

112. A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? ■ 1. Diminished bilateral breath sounds. ■ 2. Mufﬂ ed heart sounds. ■ 3. Respiratory distress. ■ 4. Tracheal deviation.

3. Respiratory distress or arrest is a universal ﬁ nding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common ﬁ nding. Tracheal deviation is an inconsistent and late ﬁ nding. Mufﬂ ed heart sounds are suggestive of pericardial tamponade.

77. The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan? ■ 1. Clubbing of nail beds. ■ 2. Hypertension. ■ 3. Peripheral edema. ■ 4. Increased appetite.

3. Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased ﬂ uid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

53. Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia? ■ 1. Introduce the client to other people who are successfully managing their care. ■ 2. Include the client's daughter in the teaching so that she can help implement the plan. ■ 3. Ask the client to identify other situations in which he demonstrated responsibility for himself. ■ 4. Reassure the client that he will be able to implement all aspects of the plan successfully.

3. Self-responsibility is the key to individual health maintenance. Using examples of situations in which the client has demonstrated self responsibility can be reinforcing and supporting. The client has ultimate responsibility for his personal health habits. Meeting other people who are managing their care and involving family members can be helpful, but individual motivation is more important. Reassurance can be helpful but is less important than individualization of care

49. A client is receiving streptomycin in the treatment regimen of tuberculosis. The nurse should assess for: ■ 1. Decreased serum creatinine. ■ 2. Difﬁ culty swallowing. ■ 3. Hearing loss. ■ 4. I.V. inﬁ ltration.

3. Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin is given via intramuscular injection

54. The client has been taking magnesium hydroxide (milk of magnesia) at home in an attempt to control hiatal hernia symptoms. The nurse should assess the client for which of the following conditions most commonly associated with the ongoing use of magnesium-based antacids? ■ 1. Anorexia. ■ 2. Weight gain. ■ 3. Diarrhea. ■ 4. Constipation.

3. The magnesium salts in magnesium hydroxide are related to those found in laxatives and may cause diarrhea. Aluminum salt products can cause constipation. Many clients ﬁ nd that a combination product is required to maintain normal bowel elimination. The use of magnesium hydroxide does not cause anorexia or weight gain.

30. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication? ■ 1. The client complains of a sore throat. ■ 2. The client displays signs of sedation. ■ 3. The client experiences a sudden increase in temperature. ■ 4. The client demonstrates a lack of appetite.

3. The most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the physician. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process.

81. The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next: ■ 1. Administer the medication to maintain blood levels of the drug. ■ 2. Ask another registered nurse to verify that the capsule is ampicillin. ■ 3. Contact the pharmacy to bring a properly labeled medication. ■ 4. Notify the unit manager to report the problem

3. The nurse should contact the pharmacy directly and request that a properly labeled medication be provided. The nurse should not administer any drug that is not properly labeled, even if the nurse or another nurse recognizes the medication. It is not necessary to notify the unit manager at this point because the client needs to receive the antibiotic as soon as possible.

72. The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: ■ 1. Contact the surgeon to request an order for a narcotic for the pain. ■ 2. Maintain the client in a recumbent position. ■ 3. Place the client on nothing-by-mouth (NPO) status. ■ 4. Apply heat to the abdomen in the area of the pain.

3. The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.

3. A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain, nausea, and has vomited several times. Based on these data, which nursing diagnosis would have the highest priority for intervention at this time? ■ 1. Anxiety related to severe abdominal discomfort. ■ 2. Deﬁ cient ﬂ uid volume related to vomiting. ■ 3. Pain related to gallbladder inﬂ ammation. ■ 4. Imbalanced nutrition: Less than body requirements related to vomiting.

3. The priority for nursing care at this time is to decrease the client's severe abdominal pain. The pain, which is frequently accompanied by nausea and vomiting, is caused by biliary spasm. Opioid analgesics are given to relieve the severe pain and spasm of cholecystitis. Relief of pain may decrease nausea and vomiting and thereby decrease the client's likelihood of developing further complications, such as deﬁ cient ﬂ uid volume and imbalanced nutrition. There are no data to suggest that the client is anxious.

76. A client who has a history of an inguinal hernia is admitted to the hospital with sudden, severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further for which of the following complications? ■ 1. Peritonitis. ■ 2. Incarcerated hernia. ■ 3. Strangulated hernia. ■ 4. Intestinal perforation.

3. The symptoms are indicative of a strangulated hernia. In a strangulated hernia, the hernia cannot be reduced back into the abdominal cavity. The intestinal lumen and the blood supply to the intestine are obstructed, causing an acute intestinal obstruction. Without immediate intervention, necrosis and gangrene may develop. Surgery is required to release the strangulation. Although many of these signs and symptoms are present with peritonitis or perforated bowel, abdominal rigidity, a cardinal sign of peritonitis and perforated bowel, is not mentioned. Therefore, the nurse would not immediately suspect these conditions. An incarcerated hernia refers to a hernia that is irreducible but has not necessarily resulted in an obstruction.

81. The nurse administers theophylline (TheoDur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate? ■ 1. Suppression of the client's respiratory infection. ■ 2. Decrease in bronchial secretions. ■ 3. Relaxation of bronchial smooth muscle. ■ 4. Thinning of tenacious, purulent sputum.

3. Theophylline (Theo-Dur) is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions

61. Clients who have had active tuberculosis are at risk for recurrence. Which of the following conditions increases that risk? ■ 1. Cool and damp weather. ■ 2. Active exercise and exertion. ■ 3. Physical and emotional stress. ■ 4. Rest and inactivity.

3. Tuberculosis can be controlled but never completely eradicated from the body. Periods of intense physical or emotional stress increase the likelihood of recurrence. Clients should be taught to recognize the signs and symptoms of a potential recurrence. Weather and activity levels are not related to recurrences of tuberculosis.

89. A client who has been taking ﬂ unisolide (AeroBid), two inhalations a day, for treatment of asthma. has painful, white patches in his mouth. Which response by the nurse would be most appropriate? ■ 1. "This is an anticipated adverse effect of your medication. It should go away in a couple of weeks." ■ 2. "You are using your inhaler too much and it has irritated your mouth." ■ 3. "You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent." ■ 4. "Be sure to brush your teeth and ﬂ oss daily. Good oral hygiene will treat this problem."

3. Use of oral inhalant corticosteroids such as ﬂ unisolide (AeroBid) can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem.

46. A client who has been diagnosed with gastroesophageal reﬂ ux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? ■ 1. Lean beef. ■ 2. Air-popped popcorn. ■ 3. Hot chocolate. ■ 4. Raw vegetables.

3. With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reﬂ ux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.

79. The nurse is taking care of a client with Clostridium difﬁ cile (C. difﬁ cile). The nurse should do which of the following to prevent the spread of infection? Select all that apply. ■ 1. Wear a particulate respirator. ■ 2. Wear sterile gloves when providing care. ■ 3. Cleanse hands with alcohol-based hand sanitizer. ■ 4. Wash hands with soap and water. ■ 5. Wear a protective gown when in the client's room.

4, 5. Clostridium difﬁ cile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly hand washing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C difﬁ cile is not spread via the respiratory tract, therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difﬁ cile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.

123. The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: ■ 1. For administration of oxygen. ■ 2. To promote formation of lung scar tissue. ■ 3. To insert antibiotics into the pleural space. ■ 4. To remove air and ﬂ uid.

4. A chest tube is inserted to re-expand the lung and remove air and ﬂ uid. Oxygen is not administered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiotics are not used to treat a pneumothorax.

40. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? ■ 1. Decreased cardiac output. ■ 2. Pleural effusion. ■ 3. Inadequate peripheral circulation. ■ 4. Decreased oxygenation of the blood.

4. A client with pneumonia has less lung surface available for the diffusion of gases because of the inﬂ ammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. Decreased cardiac output may be a comorbid condition in some clients with pneumonia; however, it is not the cause of cyanosis. Pleural effusions are a potential complication of pneumonia but are not the primary cause of decreased oxygenation. Inadequate peripheral circulation is also not the cause of the cyanosis that develops with bacterial pneumonia.

3. Which of the following has been identiﬁ ed as a potential risk factor for the development of colon cancer? ■ 1. Chronic constipation. ■ 2. Long-term use of laxatives. ■ 3. History of smoking. ■ 4. History of inﬂ ammatory bowel disease.

4. A history of inﬂ ammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-ﬁ ber diet

Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible adverse effect of this drug? ■ 1. Constipation. ■ 2. Bradycardia. ■ 3. Diplopia. ■ 4. Restlessness.

4. Adverse effects of pseudoephedrine (Sudafed) are experienced primarily in the cardiovascular system and through sympathetic effects on the central nervous system (CNS). The most common CNS adverse effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular adverse effects include tachycardia, hypertension, palpitations, and arrhythmias. Constipation and diplopia are not adverse effects of pseudoephedrine. Tachycardia, not bradycardia, is a adverse effect of pseudoephedrine

43. One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. Which of the following indicates that the client has attained the goal? The client has: ■ 1. Regained weight loss. ■ 2. Resumed normal dietary intake of three meals a day. ■ 3. Controlled nausea and vomiting through regular use of antiemetics. ■ 4. Achieved optimal nutritional status through oral or parenteral feedings

4. An appropriate expected outcome is for the client to achieve optimal nutritional status through the use of oral feedings or total parenteral nutrition (TPN). TPN may be used to supplement oral intake, or it may be used alone if the client cannot tolerate oral feedings. The client would not be expected to regain lost weight within 1 month after surgery or to tolerate a normal dietary intake of three meals a day. Nausea and vomiting would not be considered an expected outcome of gastric surgery, and regular use of antiemetics would not be anticipated

27. A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? ■ 1. "I should take my antacid before I take my other medications." ■ 2. "I need to decrease my intake of ﬂ uids so that I don't dilute the effects of my antacid." ■ 3. "My antacid will be most effective if I take it whenever I experience stomach pains." ■ 4. "It is best for me to take my antacid 1 to 3 hours after meals."

4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease ﬂ uid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.

135. Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? ■ 1. Assessing the client's skin color. ■ 2. Monitoring the respiratory rate. ■ 3. Verifying the amount of cuff inﬂ ation. ■ 4. Auscultating breath sounds bilaterally.

4. Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inﬂ ation cannot validate the placement of the endotracheal tube.

91. Which of the following is an appropriate expected outcome for an adult client with well controlled asthma? ■ 1. Chest X-ray demonstrates minimal hyperinﬂ ation. ■ 2. Temperature remains lower than 100° F (37.8° C). ■ 3. Arterial blood gas analysis demonstrates a decrease in PaO2. ■ 4. Breath sounds are clear.

4. Between attacks, breath sounds should be clear on auscultation with good air ﬂ ow present throughout lung ﬁ elds. Chest X-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.

71. When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following? ■ 1. Participate regularly in aerobic exercises. ■ 2. Maintain a high-protein diet. ■ 3. Avoid exposure to people with known respiratory infections. ■ 4. Abstain from cigarette smoking.

4. Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although beneﬁ cial, will not decrease the risk of COPD. Insufﬁ cient protein intake and exposure to people with respiratory infections do not increase the risk of COPD.

28. The client with chronic pacreatitis should be monitored closely for the development of which of the following disorders? ■ 1. Cholelithiasis. ■ 2. Hepatitis. ■ 3. Irritable bowel syndrome. ■ 4. Diabetes mellitus.

4. Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic ﬁ brosis that occurs. The pancreas becomes unable to secrete insulin. Cholelithiasis, hepatitis, and irritable bowel syndrome are not caused by chronic pancreatitis

67. The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home? ■ 1. Using enemas to relieve constipation. ■ 2. Decreasing ﬂ uid intake to increase the formed consistency of the stool. ■ 3. Eating a high-ﬁ ber diet when symptomatic with diverticulitis. ■ 4. Refraining from straining and lifting activities.

4. Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-ﬁ ber diet is used when inﬂ ammation is present.

73. A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment ﬁ ndings, the nurse should further assess the client for which of the following complications? ■ 1. Deﬁ cient ﬂ uid volume. ■ 2. Intestinal obstruction. ■ 3. Bowel ischemia. ■ 4. Peritonitis.

4. Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deﬁ cient ﬂ uid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

139. A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: ■ 1. Put all four side rails up on the bed. ■ 2. Ask the unlicensed personnel to place restraints on the client's upper extremities. ■ 3. Request that the client's roommate put the call light on when the client is attempting to get out of bed. ■ 4. Check on the client at regular intervals to ascertain the need to use the bathroom.

4. Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or unlicensed personnel should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written order from a physician before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety

43. Before abdominal surgery for an intestinal obstruction, the nurse monitors the client's urine output and ﬁ nds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client's total intake and output over the last 24 hours and notes that he had 2,000 mL of I.V. ﬂ uid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. This would indicate which of the following? ■ 1. Decreased renal function. ■ 2. Inadequate pain relief. ■ 3. Extension of the obstruction. ■ 4. Inadequate ﬂ uid replacement.

4. Considering that there is usually 1 L of insensible ﬂ uid loss, this client's output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating deﬁ cient ﬂ uid volume. The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of less than 30 mL/hour. This indicates that increased ﬂ uid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.

56. Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease? ■ 1. 45-year-old mother. ■ 2. 17-year-old daughter. ■ 3. 8-year-old son. ■ 4. 76-year-old grandmother.

4. Elderly persons are believed to be at higher risk for contracting tuberculosis because of decreased immunocompetence. Other high-risk populations in the United States include the urban poor, clients with acquired immunodeﬁ ciency syndrome, and minority groups.

19. A client with peptic ulcer disease is taking ranitidine (Zantac). What is the expected outcome of this drug? ■ 1. Heal the ulcer. ■ 2. Protect the ulcer surface from acids. ■ 3. Reduce acid concentration. ■ 4. Limit gastric acid secretion.

4. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretory, or proton-pump inhibitors, such as omeprazole (Prilosec), help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate (Carafate), protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

84. A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal ﬂ aring, and use of accessory muscles. Auscultation of the lung ﬁ elds reveals greatly diminished breath sounds. Based on these ﬁ ndings, which action should the nurse take to initiate care of the client? ■ 1. Initiate oxygen therapy and reassess the client in 10 minutes. ■ 2. Draw blood for an arterial blood gas analysis and send the client for a chest X-ray. ■ 3. Encourage the client to relax and breathe slowly through the mouth. ■ 4. Administer bronchodilators

4. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur). Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis and obtaining a chest X-ray. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

69. Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan? ■ 1. The client promises to do pursed-lip breathing at home. ■ 2. The client states actions to reduce pain. ■ 3. The client says that he will use oxygen via a nasal cannula at 5 L/minute. ■ 4. The client agrees to call the physician if dyspnea on exertion increases.

4. Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-ﬂ ow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

63. The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis? ■ 1. Take the medication with antacids. ■ 2. Double the dosage if a drug dose is missed. ■ 3. Increase intake of dairy products. ■ 4. Limit alcohol intake.

4. Isoniazid and rifampin (Rifamate) is a hepatotoxic drug. The client should be warned to limit intake of alcohol during drug therapy. The drug should be taken on an empty stomach. If antacids are needed for gastrointestinal distress, they should be taken 1 hour before or 2 hours after the drug is administered. The client should not double the dose of the drug because of potential toxicity. The client taking the drug should avoid foods that are rich in tyramine, such as cheese and dairy products, or he may develop hypertension.

2. A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate? ■ 1. "It has been 4 days since your surgery and you will soon be discharged. You have to learn to care for your colostomy before you leave the hospital." ■ 2. "I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it." ■ 3. "I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness." ■ 4. "I can see that you are upset. Would you like to share your concerns with me?"

4. It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling

25. A client who has ulcerative colitis says to the nurse, "I can't take this anymore! I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, an appropriate nursing diagnosis for this client would be: ■ 1. Impaired physical mobility related to fatigue. ■ 2. Disturbed thought processes related to pain. ■ 3. Social isolation related to chronic fatigue. ■ 4. Ineffective coping related to chronic abdominal pain.

4. It is not uncommon for clients with ulcerative colitis to become apprehensive and upset about the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes

24. A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? ■ 1. Conduct physical activity in the morning so that he can rest in the afternoon. ■ 2. Have the family agree to perform the necessary yard work at home. ■ 3. Give up jogging and substitute a less demanding hobby. ■ 4. Incorporate periods of physical and mental rest in his daily schedule.

4. It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identiﬁ ed to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful.

9. After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet? ■ 1. Cheese omelet. ■ 2. Peanut butter. ■ 3. Ham salad sandwich. ■ 4. Roast beef.

4. Lean meats, such as beef, lamb, veal, and well-trimmed lean ham and pork, are low in fat. Rice, pasta, and vegetables are low in fat when not served with butter, cream, or sauces. Fruits are low in fat. The amount of fat allowed in a client's diet after a cholecystectomy will depend on the client's ability to tolerate fat. Typically, the client does not require a special diet but is encouraged to avoid excessive fat intake. A cheese omelet and peanut butter have high fat content. Ham salad is high in fat from the fat in salad dressing.

125. The nurse has calculated a low PaO2/FIO2 (P/F) ratio < 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? ■ 1. Supine. ■ 2. Semi-fowlers. ■ 3. Lateral side. ■ 4. Prone.

4. Prone positioning is used to improve oxygenation in clients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.

72. Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? ■ 1. To promote oxygen intake. ■ 2. To strengthen the diaphragm. ■ 3. To strengthen the intercostal muscles. ■ 4. To promote carbon dioxide elimination.

4. Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursedlip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

98. A client who underwent a left lower lobectomy has been out of surgery for 48 hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA) system. She tells the nurse that she has some pain in her left thorax that worsens when she coughs. The nurse should: ■ 1. Let the client rest, so that she is not stimulated to cough. ■ 2. Encourage the client to take deep breaths to help control the pain. ■ 3. Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve her pain. ■ 4. Obtain a more detailed assessment of the client's pain using a pain scale.

4. Systematic pain assessment is necessary for adequate pain management in the postoperative client. Guidelines from a variety of health care agencies and nursing groups recommend that institutions adopt a pain assessment scale to assist in facilitating pain management. Even though the client is receiving morphine sulfate by PCA, assessment is needed if she is experiencing pain. The concern is not to eliminate coughing but to control pain adequately. Coughing is necessary to prevent postoperative atelectasis and pneumonia. Breathing exercises may help control pain in some circumstances; however, most clients with thoracic surgery require parenteral opioid analgesics in the early postoperative period. Although it is necessary that the PCA device be checked periodically to ensure that it is functioning properly, if the machine is functional and the client's pain is not relieved, further intervention, beginning with a pain assessment, is indicated.

15. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? ■ 1. An intestinal obstruction has developed. ■ 2. Additional ulcers have developed. ■ 3. The esophagus has become inﬂ amed. ■ 4. The ulcer has perforated.

4. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause midepigastric pain. The development of additional ulcers or esophageal inﬂ ammation would not cause a rigid, boardlike abdomen.

80. Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? ■ 1. Low-fat, low-cholesterol diet. ■ 2. Bland, soft diet. ■ 3. Low-sodium diet. ■ 4. High-calorie, high-protein diet.

4. The client should eat high-calorie, highprotein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low- cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods.

21. The nurse should monitor the client with acute pancreatitis for which of the following complications? ■ 1. Heart failure. ■ 2. Duodenal ulcer. ■ 3. Cirrhosis. ■ 4. Pneumonia.

4. The client with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis

106. When caring for a client with a chest tube and water-seal drainage system, the nurse should: ■ 1. Verify that the air vent on the water-seal drainage system is capped when the suction is off. ■ 2. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. ■ 3. Ensure that the chest tube is clamped when moving the client out of the bed. ■ 4. Make sure that the drainage apparatus is always below the client's chest level.

4. The drainage apparatus is always kept below the client's chest level to prevent back ﬂ ow of ﬂ uid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.

78. After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications? ■ 1. Hypostatic pneumonia. ■ 2. Deep vein thrombosis. ■ 3. Paralytic ileus. ■ 4. Urine retention.

4. The most common complication after an inguinal hernia repair is the inability to void, especially in men. The nurse should evaluate the client carefully for urine retention. Hypostatic pneumonia, deep vein thrombosis, and paralytic ileus are potential postoperative problems with any surgical client but are not as likely to occur after an inguinal hernia repair as is urine retention

136. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? ■ 1. Administering oxygen every 2 hours. ■ 2. Turning the client every 4 hours. ■ 3. Administering sedatives to promote rest. ■ 4. Suctioning if cough is ineffective.

4. The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindicated in acute respiratory distress because sedatives can depress respirations.

42. Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia? ■ 1. Encourage the client to breathe shallowly. ■ 2. Have the client practice abdominal breathing. ■ 3. Offer the client incentive spirometry. ■ 4. Teach the client to splint the rib cage when coughing.

4. The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain.

40. A client who is recovering from a subtotal gastrectomy experiences dumping syndrome. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which of the following responses by the nurse is most appropriate? ■ 1. "Eating six meals a day is time-consuming, isn't it?" ■ 2. "You will have to eat six small meals a day for the rest of your life." ■ 3. "You will be able to tolerate three meals a day before you are discharged." ■ 4. "Most clients can resume their normal meal patterns in about 6 to 12 months."

4. The symptoms related to dumping syndrome that occur after a gastrectomy usually disappear by 6 to 12 months after surgery. Most clients can begin to resume normal meal patterns after signs of the dumping syndrome have stopped. Acknowledging that eating six meals a day is time-consuming does not address the client's question and makes an assumption about the client's concerns. It is not necessarily true that a six-meal-a-day dietary pattern will be required for the rest of the client's life. Clients will not be able to eat three meals a day before hospital discharge.

1. A client has undergone a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the discharge teaching? ■ 1. Empty the bile bag daily. ■ 2. If you become nauseated, breathe deeply into a paper bag. ■ 3. Keep adhesive dressings in place for 6 weeks. ■ 4. Report bile-colored drainage from any incision

4. There should be no bile-colored drainage coming from any of the incisions postoperatively. A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will prevent a person from passing out due to hyperventilation; it does not alleviate nausea. If the adhesive dressings have not already fallen off, they are removed by the surgeon in 7 to 10 days, not 6 weeks.

52. What is the rationale that supports multidrug treatment for clients with tuberculosis? ■ 1. Multiple drugs potentiate the drugs' actions. ■ 2. Multiple drugs reduce undesirable drug adverse effects. ■ 3. Multiple drugs allow reduced drug dosages to be given. ■ 4. Multiple drugs reduce development of resistant strains of the bacteria.

4. Use of a combination of antituberculosis drugs slows the rate at which organisms develop drug resistance. Combination therapy also appears to be more effective than single-drug therapy. Many drugs potentiate (or inhibit) the actions of other drugs; however, this is not the rationale for using multiple drugs to treat tuberculosis. Treatment with multiple drugs does not reduce adverse effects and may expose the client to more adverse effects. Combination therapy may allow some medications (e.g., antihypertensives) to be given in reduced dosages; however, reduced dosages are not prescribed for antibiotics and antituberculosis drugs.

80. The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem? ■ 1. Readjust the solution to infuse the desired amount. ■ 2. Continue the infusion at the current rate, but run the next bottle at an increased rate. ■ 3. Double the infusion rate for 2 hours. ■ 4. Notify the physician.

4. When TPN ﬂ uids are infused too rapidly or too slowly, the physician should be notiﬁ ed. TPN solutions must be carefully and accurately infused. Rate adjustments should not be made without a written order from the physician. Signiﬁ cant alterations in rate (10% increase or decrease) can result in ﬂ uctuations of blood glucose levels. Speeding up the solution can result in too much glucose entering the system.

82. The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included? ■ 1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. ■ 2. Lie ﬂ at on the back, splint the thorax, take two deep breaths, and cough. ■ 3. Take several rapid, shallow breaths and then cough forcefully. ■ 4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

. 1. The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the ﬂ oor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough). Lying ﬂ at does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.

95. The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should: ■ 1. Assess breath sounds. ■ 2. Remove the catheter. ■ 3. Insert a peripheral I.V. ■ 4. Reposition the client.

. 1. The nurse should ﬁ rst assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral I.V. access was not available or adequate for the client. Repositioning may be considered after assessments are done.

104. When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following? ■ 1. Contract the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale. ■ 2. Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle. ■ 3. Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds. ■ 4. Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.

. 1. The recommended procedure for teaching clients postoperatively to deep breathe includes contracting (pulling in) the abdominal muscles and taking a slow, deep breath through the nose. This breath is held 3 to 5 seconds, which facilitates alveolar ventilation by improving the inspiratory phase of ventilation. Exhaling slowly as if trying to blow out a candle is a technique used in pursedlip breathing to facilitate exhalation in clients with chronic obstructive pulmonary disease. It is recommended that the abdominal muscles be contracted, not relaxed, to promote deep breathing. The client should breathe through the nose.

21. A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these ﬁ ndings, which nursing actions would be most appropriate for the nurse to take? Select all that apply. ■ 1. Administering an antacid hourly until nausea subsides. ■ 2. Monitoring the client's vital signs. ■ 3. Notifying the physician of the client's symptoms. ■ 4. Initiating oxygen therapy. ■ 5. Reassessing the client in an hour.

. 2, 3. The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client's vital signs and notify the physician of the client's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment ﬁ ndings and then initiate oxygen therapy if ordered by the physician.

35. The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply. ■ 1. Monitoring vital signs once a shift. ■ 2. Weighing the client daily. ■ 3. Changing the central venous line dressing daily. ■ 4. Monitoring the I.V. infusion rate hourly. ■ 5. Taping all I.V. tubing connections securely

. 2, 4, 5. When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the I.V. ﬂ uid infusion rate hourly (even when using an I.V. ﬂ uid pump), and securely tape all I.V. tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the I.V. dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

2. A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis. The nurse should contact the physician to question which of the following orders? ■ 1. I.V. ﬂ uid therapy of normal saline solution to be infused at 100 mL/hour until further orders. ■ 2. Administer morphine sulfate 10 mg I.M. every 4 hours as needed for severe abdominal pain. ■ 3. Nothing by mouth (NPO) until further orders. ■ 4. Insert a nasogastric tube and connect to low intermittent suction.

. 2. A nurse should question the order for morphine sulfate because it is believed to cause biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is meperidine (Demerol). Elderly clients should not be given meperidine because of the risk of acute confusion and seizures in this population. An alternative pain medication will be necessary. I.V. ﬂ uid therapy is used to maintain ﬂ uid and electrolyte balance that may result from NPO status and gastric suctioning. NPO status and gastric decompression prevent further gallbladder stimulation.

36. Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease? ■ 1. Encouraging regular ambulation. ■ 2. Promoting bowel rest. ■ 3. Maintaining current weight. ■ 4. Decreasing episodes of rectal bleeding

. 2. A priority goal of care during an acute exacerbation of Crohn's disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn's disease, and episodes of rectal bleeding are not expected.

52. Which of the following factors would most likely contribute to the development of a client's hiatal hernia? ■ 1. Having a sedentary desk job. ■ 2. Being 5 feet, 3 inches tall and weighing 190 lb. ■ 3. Using laxatives frequently. ■ 4. Being 40 years old.

. 2. Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than in men. Having a sedentary desk job, using laxatives frequently, or being 40 years old is not likely to be a contributing factor in development of a hiatal hernia

48. Bethanechol (Urecholine) has been ordered for a client with gastroesophageal reﬂ ux disease (GERD). The nurse should assess the client for which of the following adverse effects? ■ 1. Constipation. ■ 2. Urinary urgency. ■ 3. Hypertension. ■ 4. Dry oral mucosa.

. 2. Bethanechol (Urecholine), a cholinergic drug, may be used in GERD to increase lower esophageal sphincter pressure and facilitate gastric emptying. Cholinergic adverse effects may include urinary urgency, diarrhea, abdominal cramping, hypotension, and increased salivation. To avoid these adverse effects, the client should be closely monitored to establish the minimum effective dose

75. A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: ■ 1. Provide access for wound irrigation. ■ 2. Promote drainage of wound exudates. ■ 3. Minimize development of scar tissue. ■ 4. Decrease postoperative discomfort

. 2. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

18. A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 beats per minute, respirations of 28 per minute, and Grey Turner's sign. What action should the nurse perform ﬁ rst? ■ 1. Assess the urine output. ■ 2. Place an intravenous line. ■ 3. Position on the left side. ■ 4. Insert a nasogastric tube.

. 2. Grey Turner's sign is a bluish discoloration in the ﬂ ank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. I.V. access should be obtained to provide immediate volume replacement. The urine output will provide information on the ﬂ uid status. A nasogastric tube is indicated for clients with uncontrolled nausea and vomiting or gastric distension. Repositioning the client may be considered for pain management once the client's vital signs are stable

8. The nurse measures the amount of bile drainage from a T-tube and records it by which one of the following methods? ■ 1. Adding it to the client's urine output. ■ 2. Charting it separately on the output record. ■ 3. Adding it to the amount of wound drainage. ■ 4. Subtracting it from the total intake for each day.

. 2. T-tube bile drainage is recorded separately on the output record. Adding the T-tube drainage to the urine output or wound drainage makes it difﬁ cult to accurately determine the amounts of bile, urine, or drainage. The client's total intake will be incorrect if drainage is subtracted from it.

41. A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for: ■ 1. A mild but constant aching in the chest. ■ 2. Severe midsternal pain. ■ 3. Moderate pain that worsens on inspiration. ■ 4. Muscle spasm pain that accompanies coughing.

. 3. Chest pain in pneumonia is generally caused by friction between the pleural layers. It is more severe on inspiration than on expiration, secondary to chest wall movement. Pleuritic chest pain is usually described as sharp, not mild or aching. Pleuritic chest pain is not localized to the sternum, and it is not the result of a muscle spasm.

22. The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? ■ 1. Bland foods. ■ 2. High-protein foods. ■ 3. Any foods that are tolerated. ■ 4. Large amounts of milk.

. 3. Diet therapy for ulcer disease is a controversial issue. There is no scientiﬁ c evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.

33. A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: ■ 1. Hyperalbuminemia. ■ 2. Thrombocytopenia. ■ 3. Hypokalemia. ■ 4. Hypercalcemia.

. 3. Hypokalemia is the most expected laboratory ﬁ nding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

27. The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by doing which of the following? ■ 1. Monitoring ﬂ uid intake. ■ 2. Performing regular glucose ﬁ ngerstick tests. ■ 3. Observing stools for steatorrhea. ■ 4. Testing urine for ketones.

. 3. If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.

26. A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? ■ 1. The client has not been including enough ﬁ ber in his diet. ■ 2. The client needs to increase his daily exercise. ■ 3. The client is experiencing an adverse effect of the aluminum hydroxide. ■ 4. The client has developed a gastrointestinal obstruction.

. 3. It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary ﬁ ber intake or daily exercise may be a beneﬁ cial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.

14. Which position would be best for the client in the early postoperative period after a hemorrhoidectomy? ■ 1. High Fowler's. ■ 2. Supine. ■ 3. Side-lying. ■ 4. Trendelenburg's.

. 3. Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective. A high Fowler's or supine position will place pressure on the operative site and is not recommended. There is no need for Trendelenburg's position.

32. The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, "I wish my life could stay the same." Based on this information, which one of the following nursing diagnoses would be appropriate at this time? ■ 1. Ineffective coping related to the diagnosis of cancer. ■ 2. Insomnia related to fear of the unknown. ■ 3. Grieving related to the diagnosis of cancer. ■ 4. Anxiety related to the need for gastric surgery

. 3. The information presented most clearly supports a nursing diagnosis of Grieving. The feelings expressed in this situation are more related to grieving about the changes that will occur in the client's life as a result of the diagnosis of gastric cancer than to fear of the unknown or anxiety about the surgery. There is no evidence of ineffective coping at this time.

103. While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the ﬁ ngertips along the entire incision. Which of the following should be the nurse's ﬁ rst action? ■ 1. Lower the head of the bed and call the physician. ■ 2. Prepare an aspiration tray. ■ 3. Mark the area with a skin pencil at the outer periphery of the crackling. ■ 4. Turn off the suction of the chest drainage system.

. 3. This crackling sensation is subcutaneous emphysema. Subcutaneous emphysema is not an unusual ﬁ nding, and it is not dangerous if conﬁ ned. But progression can be serious, especially if the neck is involved; a tracheotomy may be needed. If emphysema progresses noticeably in 1 hour, the physician should be notiﬁ ed. Lowering the head of the bed will not arrest the progress or provide any further information. A tracheotomy tray would be useful if subcutaneous emphysema progresses to the neck. Subcutaneous emphysema may progress if the chest drainage system does not adequately remove air and ﬂ uid; therefore, the system should not be turned off.

82. On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half the incision has torn apart. The nurse should immediately take what action? ■ 1. Flush the wound with sterile water. ■ 2. Apply an abdominal binder. ■ 3. Cover the wound with a sterile dressing moistened with normal saline. ■ 4. Apply strips of tape.

. 3. When dehiscence occurs, the nurse should immediately cover the wound with a sterile dressing moistened with normal saline. If the dehiscence is extensive, the incision must be resutured in surgery. Later, after the sutures are removed, additional support may be provided to the incision by applying strips of tape as directed by institutional policy or by the surgeon. An abdominal binder may also be utilized for additional support

39. To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following? ■ 1. Sit upright for 30 minutes after meals. ■ 2. Drink liquids with meals, avoiding caffeine. ■ 3. Avoid milk and other dairy products. ■ 4. Decrease the carbohydrate content of meals

. 4. Carbohydrates are restricted, but protein, including meat and dairy products, is recommended because it is digested more slowly. Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine.

47. The client with gastroesophageal reﬂ ux disease (GERD) complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions? ■ 1. Development of laryngeal cancer. ■ 2. Irritation of the esophagus. ■ 3. Esophageal scar tissue formation. ■ 4. Aspiration of gastric contents.

. 4. Clients with GERD can develop pulmonary symptoms, such as coughing, wheezing, and dyspnea, that are caused by the aspiration of gastric contents. GERD does not predispose the client to the development of laryngeal cancer. Irritation of the esophagus and esophageal scar tissue formation can develop as a result of GERD. However, GERD is more likely to cause painful and difﬁ cult swallowing.

101. After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises? ■ 1. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange. ■ 2. Deep breathing increases blood ﬂ ow to the lungs to allow them to recover from the trauma of surgery. ■ 3. Deep breathing controls the rate of air ﬂ ow to the remaining lobe so that it will not become hyperinﬂ ated. ■ 4. Deep breathing expands the alveoli and increases the lung surface available for ventilation.

. 4. Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and ﬂ uid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood ﬂ ow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinﬂ ates to ﬁ ll the space created by the resected lobe. This is an expected phenomenon.

78. The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following ﬁ ndings would be expected? ■ 1. Normal breath sounds. ■ 2. Prolonged inspiration. ■ 3. Normal chest movement. ■ 4. Coarse crackles and rhonchi.

. 4. Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.

71. A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? ■ 1. Remove the dressing and leave the incision open to air. ■ 2. Remove the drain if wound drainage is minimal. ■ 3. Gently irrigate the drain to remove exudate. ■ 4. Clean the area around the drain moving away from the drain.

. 4. The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

4. The nurse is conducting a community presentation on the early detection of colon cancer. Which of the following should the nurse encourage members of the audience to report to their health care providers? Select all that apply. ■ 1. Fatigue. ■ 2. Unexplained weight loss with adequate nutritional intake. ■ 3. Rectal bleeding. ■ 4. Bowel changes. ■ 5. Positive fecal occult blood testing

1, 2, 3, 4, 5. Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deﬁ ciency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer. Fecal occult blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic

83. A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply. ■ 1. Activation of the MDI is not coordinated with inspiration. ■ 2. The client inspires rapidly when using the MDI. ■ 3. The client holds his breath for 3 seconds after inhaling with the MDI. ■ 4. The client shakes the MDI after use. ■ 5. The client performs puffs in rapid succession.

1, 2, 3, 4, 5. Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a sufﬁ cient amount of time between puffs to provide an adequate amount of inhalation medication.

20. A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply. ■ 1. Obtain adequate rest to reduce stimulation. ■ 2. Eat small, frequent meals throughout the day. ■ 3. Take all medications on time as ordered. ■ 4. Sit up for one hour when awakened at night. ■ 5. Stay away from crowded areas

1, 2, 3, 4. The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.

4. A client's stools are light gray in color. The nurse should assess the client further for which of the following? Select all that apply. ■ 1. Intolerance to fatty foods. ■ 2. Fever. ■ 3. Jaundice. ■ 4. Respiratory distress. ■ 5. Pain at McBurney's point. ■ 6. Peptic ulcer disease

1, 2, 3. Bile is created in the liver, stored in the gallbladder, and released into the duodenum giving stool its brown color. A bile duct obstruction can cause pale colored stools. Other symptoms associated with cholelithiasis are right upper quadrant tenderness, fever from inﬂ ammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis.

145. The nurse is a member of a team that is planning a client-centered approach to care of clients with chronic obstructive pulmonary disease (COPD) using the Chronic Care Model (CCM). The team should focus on improving quality of care and delivery in which of the following areas? Select all that apply. ■ 1. The community. ■ 2. Clinical information systems. ■ 3. Delivery system design. 4. Administrative leadership. ■ 5. Emphasis on the acute care setting.

1, 2, 3. The process of changing a health care system from an acute care model to a Chronic Care Model (CCM) uses continuous quality improvement (CQI) methods. The goal of the CCM is to improve the health of chronically ill clients. The CCM identiﬁ es six basic areas upon which health care organizations need to focus to improve quality of care and delivery: health systems, delivery system design, decision support, clinical information systems, self-management support, and the community. This system requires health care services that are client-centered and coordinated among members of the health care staff and the client and family. CCM does not focus on the administrative leadership or the care in the acute care setting alone.

64. Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply. ■ 1. Bran cereal. ■ 2. Broccoli. ■ 3. Tomato juice. ■ 4. Navy beans. ■ 5. Cheese.

1, 2, 4. Clients with diverticulosis are encouraged to follow a high-ﬁ ber diet. Bran, broccoli, and navy beans are foods high in ﬁ ber. Tomato juice and cheese are low-residue foods.

28. A client with ulcerative colitis is to take sulfasalazine (Azulﬁ dine). Which of the following instructions should the nurse provide for the client about taking this medication at home? Select all that apply. ■ 1. Drink enough ﬂ uids to maintain a urine output of at least 1,200-1,500 mL per day. ■ 2. Discontinue therapy if symptoms of acute intolerance develop and notify the health care provider. ■ 3. Stop taking the medication if the urine turns orange-yellow. ■ 4. Avoid activities that require alertness. ■ 5. If dose is missed, skip and continue with the next dose.

1, 2, 4. Sulfasalazine may cause dizziness and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the health care provider immediately. Fluid intake should be sufﬁ cient to maintain a urine output of at least 1,200-1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not signiﬁ cant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

70. A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply. ■ 1. Percuss the abdomen to note resonance and tympany. ■ 2. Percuss the liver to note lack of dullness. ■ 3. Monitor the vital signs for fever, tachypnea, and bradycardia. ■ 4. Assess presence of polyphagia and polydipsia. ■ 5. Auscultate bowel sounds to note frequency

1, 2, 5. Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.

Which of the following is signiﬁ cant data to gather from a client who has been diagnosed with pneumonia? Select all that apply. ■ 1. Quality of breath sounds. ■ 2. Presence of bowel sounds. ■ 3. Occurence of chest pain. ■ 4. Amount of peripheral edema. ■ 5. Color of nail beds.

1, 3, 5. A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the client with pneumonia.

14. After a client who has had a laparoscopic cholecystectomy receives discharge instructions, which of the following client statements would indicate that the teaching has been successful? Select all that apply. ■ 1. "I can resume my normal diet when I want." ■ 2. "I need to avoid driving for about 4 weeks." ■ 3. "I may experience some pain in my right shoulder." ■ 4. "I should spend 2 to 3 days in bed before resuming activity." ■ 5. "I can wash the puncture site with mild soap and water."

1, 3, 5. Following a laparoscopic cholecystectomy, the client can resume a normal diet as tolerated. The client may experience right shoulder pain from the gas that was used to inﬂ ate the abdomen during surgery. The puncture site should be cleansed daily with mild soap and water. Driving can usually be resumed in 3 to 4 days following surgery and there is no need for the client to maintain bed rest in the days following surgery. Light exercise such as walking can be resumed immediately.

43. The nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing which of the following? Select all that apply. ■ 1. Decreased pain when breathing. ■ 2. Prolonged clotting time. ■ 3. Decreased temperature. ■ 4. Decreased respiratory rate. ■ 5. Increased ability to expectorate secretions.

1, 3. Aspirin is administered to clients with pneumonia because it is an analgesic that helps control chest discomfort and an antipyretic that helps reduce fever. Aspirin has an anticoagulant effect, but that is not the reason for prescribing it for a client with pneumonia, and the use of the drug will be short term. Aspirin does not affect the respiratory rate, and does not facilitate expectoration of secretions

126. A client with acute respiratory distress syndrome (ARDS) has ﬁ ne crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. ■ 1. Monitor serum creatinine and blood urea nitrogen levels. ■ 2. Administer a sedative. ■ 3. Keep the head of the bed ﬂ at. ■ 4. Administer humidiﬁ ed oxygen. ■ 5. Auscultate the lungs.

1, 4, 5. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidiﬁ ed oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.

37. A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply. ■ 1. Projectile vomiting. ■ 2. Signiﬁ cant abdominal distention. ■ 3. Copious diarrhea. ■ 4. Rapid onset of dehydration. ■ 5. Increased bowel sounds

1, 4, 5. Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and signiﬁ cant abdominal distention.

22. When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which of the following nursing interventions would be most appropriate for this client? Select all that apply. ■ 1. Placing the client in a side-lying position. ■ 2. Administering morphine sulfate for pain as needed. ■ 3. Maintaining the client on a high-calorie, highprotein diet. ■ 4. Monitoring the client's respiratory status. ■ 5. Obtaining daily weights.

1, 4, 5. The client with acute pancreatitis usually experiences acute abdominal pain. Placing the client in a side-lying position relieves the tension on the abdominal area and promotes comfort. A semi-Fowler's position is also appropriate. The nurse should also monitor the client's respiratory status because clients with pancreatitis are prone to develop respiratory complications. Daily weights are obtained to monitor the client's nutritional and ﬂ uid volume status. While the client will likely need opioid analgesics to treat the pain, morphine sulfate is not appropriate as it stimulates spasm of the sphincter of Oddi, thus increasing the client's discomfort. During the acute phase of the illness while the client is experiencing pain, the pancreas is rested by withholding food and drink. When the diet is reintroduced, it is a high-carbohydrate, low-fat, bland diet.

87. The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. ■ 1. The inhaler is held upright. ■ 2. The head is tilted down while inhaling the medicine. ■ 3. The client waits 5 minutes between puffs. ■ 4. The mouth is rinsed with water following administration. ■ 5. The client lies supine for 15 minutes following administration.

1, 4. The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright.

68. When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to: ■ 1. Develop respiratory infections easily. ■ 2. Maintain current status. ■ 3. Require less supplemental oxygen. ■ 4. Show permanent improvement.

1. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

57. The nurse instructs the client on health maintenance activities to help control symptoms from her hiatal hernia. Which of the following statements would indicate that the client has understood the instructions? ■ 1. "I'll avoid lying down after a meal." ■ 2. "I can still enjoy my potato chips and cola at bedtime." ■ 3. "I wish I didn't have to give up swimming." ■ 4. "If I wear a girdle, I'll have more support for my stomach."

1. A client with a hiatal hernia should avoid the recumbent position immediately after meals to minimize gastric reﬂ ux. Bedtime snacks, as well as high-fat foods and carbonated beverages, should be avoided. Excessive vigorous exercise also should be avoided, especially after meals, but there is no reason why the client must give up swimming. Wearing tight, constrictive clothing such as a girdle can increase intra-abdominal pressure and thus lead to reﬂ ux of gastric juices.

94. Which of the following ﬁ ndings would most likely indicate the presence of a respiratory infection in a client with asthma? ■ 1. Cough productive of yellow sputum. ■ 2. Bilateral expiratory wheezing. ■ 3. Chest tightness. ■ 4. Respiratory rate of 30 breaths/minute

1. A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms-wheezing, chest tightness, and increased respiratory rate-are all ﬁndings associated with an asthma attack and do not necessarily mean an infection is present.

60. Cimetidine (Tagamet) may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following? ■ 1. Esophageal reﬂ ux. ■ 2. Dysphagia. ■ 3. Esophagitis. ■ 4. Ulcer formation.

Cimetidine (Tagamet) is a histamine receptor antagonist that decreases the quantity of gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophagitis and heartburn associated with reﬂ ux. Cimetidine is not used to prevent reﬂ ux, dysphagia, or ulcer development

73. Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? ■ 1. Maintaining functional ability. ■ 2. Minimizing chest pain. ■ 3. Increasing carbon dioxide levels in the blood. ■ 4. Treating infectious agents.

1. A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

33. After a subtotal gastrectomy, the nasogastric tube drainage will be what color for about 12 to 24 hours after surgery? ■ 1. Dark brown. ■ 2. Bile green. ■ 3. Bright red. ■ 4. Cloudy white

1. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally brown, which indicates digested blood. Bile green or cloudy white drainage is not expected during the ﬁ rst 12 to 24 hours after a subtotal gastrectomy. Drainage during the ﬁ rst 6 to 12 hours contains some bright red blood, but large amounts of blood or excessive bloody drainage should be reported to the physician promptly.

97. The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, "I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client? ■ 1. "It's okay to be scared. What is it about cancer that you're afraid of?" ■ 2. "It's normal to be scared. I would be, too. We'll help you through it." ■ 3. "Don't be so hard on yourself. You don't know if your smoking caused the cancer." ■ 4. "Do you feel guilty because you smoked?"

1. Acknowledging the basic feeling the client expresses-fear-and asking an open-ended question allows the client to explain any fears. The other options dismiss the client's feelings and may give false reassurance or label the client's feelings. The client should be encouraged to explore feelings about a cancer diagnosis.

5. A client with colon cancer is having a barium enema. The nurse should instruct the client to take which of the following after the procedure is completed? ■ 1. Laxative. ■ 2. Anticholinergic. ■ 3. Antacid. ■ 4. Demulcent

1. After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea

16. The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: ■ 1. There is a strong link between alcohol use and acute pancreatitis. ■ 2. Alcohol intake can interfere with the tests used to diagnose pancreatitis. ■ 3. Alcoholism is a major health problem, and all clients are questioned about alcohol intake. ■ 4. The physician must obtain the pertinent facts, regardless of religious beliefs.

1. Alcoholism is a major cause of acute pancreatitis in the United States. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. Physicians do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

12. Which of the following would be an expected outcome for a client who is recovering from an abdominal-perineal resection with a colostomy? The client will: ■ 1. Maintain a ﬂ uid intake of 3,000 mL/day. ■ 2. Eliminate ﬁ ber from the diet. ■ 3. Limit physical activity to light exercise. ■ 4. Accept that sexual activity will be diminished.

1. An expected outcome is that the client will maintain a ﬂ uid intake of 3,000 mL/day unless contraindicated. There is no need to eliminate ﬁ ber from the diet; the client can eat whatever foods are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The client's sexual activity may be affected, but it does not need to be diminished

15. The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which of the following complications? ■ 1. Hemorrhage. ■ 2. Rectal spasm. ■ 3. Urine retention. ■ 4. Constipation

1. Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reﬂ ex spasm may also be relieved by moist heat. Increasing ﬁ ber and ﬂ uid in the diet can help prevent constipation

66. The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema: ■ 1. Can perforate an intestinal abscess. ■ 2. Would greatly increase the client's pain. ■ 3. Is of minimal diagnostic value in diverticulitis. ■ 4. Is too lengthy a procedure for the client to tolerate.

1. Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be ordered after the client has been treated with antibiotic therapy and the inﬂ ammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client's pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure but the concern is the potential for perforation of the intestine.

99. Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer? ■ 1. The support available to assist the client at home. ■ 2. The distance the client lives from the hospital. ■ 3. The client's ability to do home blood pressure monitoring. ■ 4. The client's knowledge of the causes of lung cancer

1. Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support they have to assist them with self-care at home. The distance the client lives from the hospital is not a critical factor in discharge planning. There are no data indicating that home blood pressure monitoring is needed. Knowledge of the causes of lung cancer, although important, is not the most essential area to evaluate given the client's postoperative status.

107. A client has a chest tube attached to a waterseal drainage system and the nurse notes that the ﬂ uid in the chest tube and in the water-seal column has stopped ﬂ uctuating. The nurse should determine that: ■ 1. The lung has fully expanded. ■ 2. The lung has collapsed. ■ 3. The chest tube is in the pleural space. ■ 4. The mediastinal space has decreased

1. Cessation of ﬂ uid ﬂ uctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been re-established; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid ﬂ uctuation occurs because, during inspiration, intrapleural pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and ﬂ uid moves away from the client. When the lung is collapsed or the chest tube is in the pleural space, ﬂ uid ﬂ uctuation is likely to be noted. The chest tube is not inserted in the mediastinal space.

42. After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan? ■ 1. Nutritional intake. ■ 2. Management of alopecia. ■ 3. Exercise and activity levels. ■ 4. Access to community resources.

1. Clients who have had gastric surgery are prone to postoperative complications, such as dumping syndrome and postprandial hypoglycemia, that can affect nutritional intake. Vitamin absorption can also be an issue, depending on the extent of the gastric surgery. Radiation therapy to the upper gastrointestinal area also can affect nutritional intake by causing anorexia, nausea, and esophagitis. The client would not be expected to develop alopecia. Exercise and activity levels as well as access to

25. Which of the following dietary instructions would be appropriate for the nurse to give a client who is recovering from acute pancreatitis? ■ 1. Avoid crash dieting. ■ 2. Restrict carbohydrate intake. ■ 3. Eat six small meals a day. ■ 4. Decrease sodium in the diet

1. Crash dieting or bingeing may cause an acute attack of pancreatitis and should be avoided. Carbohydrate intake should be increased because carbohydrates are less stimulating to the pancreas. There is no need to maintain a dietary pattern of six meals a day; the client can eat whenever desired. There is no need to place the client on a sodium restricted diet because pancreatitis does not promote ﬂ uid retention.

10. A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4° C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive: ■ 1. Hydromorphone (Dilaudid) I.V. ■ 2. Diltiazem (Cardizem) PO. ■ 3. Meperidine (Demerol) I.M. ■ 4. Promethazine (Phenergan).

1. Dilaudid should be considered for pain management. It should be administered intravenously for rapid action to address the severe pain the client is experiencing. Intramuscular injections are painful and slower acting. Since meperidine's toxic metabolite can cause seizures, it is no longer the treatment choice for pain. Diltiazem, a calcium channel blocker, is not indicated. Elevation of heart rate and blood pressure are likely due to pain and fever. Phenergan is used to treat nausea.

65. The nurse is providing follow-up care to a client with tuberculosis who does not regularly take his medication. Which nursing action would be most appropriate for this client? ■ 1. Ask the client's spouse to supervise the daily administration of the medications. ■ 2. Visit the client weekly to ask him whether he is taking his medications regularly. ■ 3. Notify the physician of the client's noncompliance and request a different prescription. ■ 4. Remind the client that tuberculosis can be fatal if it is not treated promptly.

1. Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes the client taking the medication. Visiting the client, changing the prescription, or threatening the client will not ensure compliance if the client will not or cannot follow the prescribed treatment.

69. A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he: ■ 1. Passes stool without cramping. ■ 2. Does not have diarrhea any longer. ■ 3. Is not as anxious as he was. ■ 4. Does not expel gas like he used to.

1. Diverticular disease is treated with a highﬁ ber diet and bulk laxatives such as psyllium hydrophilic mucilloid (Metamucil). Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety or relieve gas formation.

45. The client with pneumonia develops mild constipation, and the nurse administers docusate sodium (Colace) as ordered. This drug works by: ■ 1. Softening the stool. ■ 2. Lubricating the stool. ■ 3. Increasing stool bulk. ■ 4. Stimulating peristalsis.

1. Docusate sodium (Colace) is a stool softener that allows ﬂ uid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis.

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do ﬁrst? ■ 1. Elevate the head of the bed 30 to 45 degrees. ■ 2. Encourage the client to cough and deep breathe. ■ 3. Auscultate the lungs to detect abnormal breath sounds. ■ 4. Contact the physician.

1. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

50. Which of the following dietary measures would be useful in preventing esophageal reﬂ ux? ■ 1. Eating small, frequent meals. ■ 2. Increasing ﬂ uid intake. ■ 3. Avoiding air swallowing with meals. ■ 4. Adding a bedtime snack to the dietary plan.

1. Esophageal reﬂ ux worsens when the stomach is overdistended with food. Therefore, an important measure is to eat small, frequent meals. Fluid intake should be decreased during meals to reduce abdominal distention. Avoiding air swallowing does not prevent esophageal reﬂ ux. Food intake in the evening should be strictly limited to reduce the incidence of nighttime reﬂ ux, so bedtime snacks are not recommended.

39. Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's: ■ 1. Decreased cellular demand for oxygen. ■ 2. Reduced episodes of coughing. ■ 3. Diminished pain when breathing deeply. ■ 4. Ability to expectorate secretions more easily

1. Exudate in the alveoli interferes with ventilation and the diffusion of gases in clients with pneumonia. During the acute phase of the illness, it is essential to reduce the body's need for oxygen at the cellular level; bed rest is the most effective method for doing so. Bed rest does not decrease coughing or promote clearance of secretions, and it does not reduce pain when taking deep breaths.

49. The client attends two sessions with the dietitian to learn about diet modiﬁ cations to minimize gastroesophageal reﬂ ux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods? ■ 1. Fats. ■ 2. High-sodium foods. ■ 3. Carbohydrates. ■ 4. High-calcium foods

1. Fats are associated with decreased esophageal sphincter tone, which increases reﬂ ux. Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss. Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reﬂ ux.

20. Which of the following medications would the nurse question for a client with acute pancreatitis? ■ 1. Furosemide (Lasix) 20 mg I.V. push. ■ 2. Imipenem (Primaxin) 500 mg I.V. ■ 3. Morphine Sulfate 2 mg I.V. push. ■ 4. Famotidine (Pepcid) 20 mg I.V. push.

1. Furosemide (Lasix) can cause pancreatitis. Additionally, hypovolemia can develop with acute pancreatitis and Lasix will further delete ﬂ uid volume. Imipenem is indicated in the treatment of acute pancreatitis with necrosis and infection. Research no longer supports Meperidine (Demerol) over other opiates. Morphine and Dilaudid are opiates of choice in acute pancreatitis to get pain under control. Famotidine is a Histamine 2 receptor antagonist used to decrease acid secretion and prevent stress or peptic ulcers.

137. Which of the following complications is associated with mechanical ventilation? ■ 1. Gastrointestinal hemorrhage. ■ 2. Immunosuppression. ■ 3. Increased cardiac output. ■ 4. Pulmonary emboli.

1. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, ﬂ uid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

51. The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reﬂ ux. The nurse should ask the client about the presence of which of the following symptoms? ■ 1. Heartburn. ■ 2. Jaundice. ■ 3. Anorexia. ■ 4. Stomatitis.

1. Heartburn, the most common symptom of a sliding hiatal hernia, results from reﬂ ux of gastric secretions into the esophagus. Regurgitation of gastric contents and dysphagia are other common symptoms. Jaundice, which results from a high concentration of bilirubin in the blood, is not associated with hiatal hernia. Anorexia is not a typical symptom of hiatal hernia. Stomatitis is inﬂ ammation of the mouth

23. The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the signiﬁ cance of these symptoms? ■ 1. The client may be developing hypocalcemia. ■ 2. The client is experiencing a reaction to meperidine (Demerol). ■ 3. The client has a nutritional imbalance. ■ 4. The client needs a muscle relaxant to help him rest.

1. Hypocalcemia develops in severe cases of acute pancreatitis. The exact cause is unknown. Signs and symptoms of hypocalcemia include jerking and muscle twitching, numbness of ﬁ ngers and lips, and irritability. Meperidine (Demerol) may cause tremors or seizures as an adverse effect, but not muscle twitching. Muscle twitching is not caused by a nutritional deﬁ cit, nor does it indicate that the client needs a muscle relaxant.

70. Which of the following physical assessment ﬁ ndings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)? ■ 1. Increased anteroposterior chest diameter. ■ 2. Underdeveloped neck muscles. ■ 3. Collapsed neck veins. ■ 4. Increased chest excursions with respiration.

1. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are ﬁ xed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood

39. The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if: ■ 1. Fluid and gas have been removed from the intestine. ■ 2. The client has had a bowel movement. ■ 3. The client's urinary output is adequate. ■ 4. The client can sit up without pain.

1. Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10-foot tubes are passed into the small intestine to the obstruction. They remove accumulated ﬂ uid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression

88. A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? ■ 1. Irregular heartbeat. ■ 2. Constipation. ■ 3. Pedal edema. ■ 4. Decreased pulse rate.

1. Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

9. Which of the following skin preparations would be best to apply around the client's colostomy? ■ 1. Karaya. ■ 2. Petroleum jelly. ■ 3. Cornstarch. ■ 4. Antiseptic cream.

1. Karaya and Stomahesive are both effective agents for protecting the skin around a colostomy. They keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag

92. Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? ■ 1. Incorporate physical exercise as tolerated into the daily routine. ■ 2. Monitor peak ﬂ ow numbers after meals and at bedtime. ■ 3. Eliminate stressors in the work and home environment. ■ 4. Use sedatives to ensure uninterrupted sleep at night.

1. Physical exercise is beneﬁ cial and should be incorporated as tolerated into the client's schedule. Peak ﬂ ow numbers should be monitored daily, usually in the morning (before taking medication). Peak ﬂ ow does not need to be monitored after each meal. Stressors in the client's life should be modiﬁ ed but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep.

24. A client is receiving Propantheline bromide (Pro-Banthine) in the management of acute pancreatitis. Which of the following would indicate that the nurse should withhold the medication? ■ 1. Absent bowel sounds. ■ 2. Increased urine output. ■ 3. Diarrhea. ■ 4. Decreased heart rate.

1. Propantheline is an anticholinergic, antispasmodic medication that decreases vagal stimulation and pancreatic secretions. It is contraindicated in paralytic ileus, therefore the nurse should be concerned with the absent bowel sounds. Side effects are urinary retention, constipation, and tachycardia

5. A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction? ■ 1. Providing the client with information about what to expect postoperatively. ■ 2. Telling the client it is normal to be afraid. ■ 3. Reassuring the client by telling her that surgery is a common procedure. ■ 4. Stressing the importance of following the physician's instructions after surgery.

1. Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow her physician's orders will not necessarily decrease anxiety.

96. A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increase the client's risk of developing postoperative pulmonary complications? ■ 1. Height is 5 feet, 7 inches and weight is 110 lb. ■ 2. The client tends to keep her real feelings to herself . ■ 3. She ambulates and can climb one ﬂ ight of stairs without dyspnea. ■ 4. The client is 58 years of age.

1. Risk factors for postoperative pulmonary complications include malnourishment, which is indicated by this client's height and weight. It is thought that emotional responses can affect overall health; however, not verbalizing one's feelings is not a contributing factor in postoperative pulmonary complications. The client's current activity level and age do not place her at increased risk for complications.

10. A client is recovering from an abdominalperineal resection. Which of the following measures would most effectively promote wound healing after the perineal drains have been removed? ■ 1. Taking sitz baths. ■ 2. Taking daily showers. ■ 3. Applying warm, moist dressings to the area. ■ 4. Applying a protected heating pad to the area

1. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients ﬁ nd them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may promote wound contamination and delay healing. A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort

19. A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest signiﬁ cance in causing an exacerbation of ulcerative colitis? ■ 1. A demanding and stressful job. ■ 2. Changing to a modiﬁ ed vegetarian diet. ■ 3. Beginning a weight-training program. ■ 4. Walking 2 miles every day.

1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modiﬁ ed vegetarian diet or an exercise program is an unlikely cause of the exacerbation

55. Which of the following techniques for administering the Mantoux test is correct? ■ 1. Hold the needle and syringe almost parallel to the client's skin. ■ 2. Pinch the skin when inserting the needle. ■ 3. Aspirate before injecting the medication. ■ 4. Massage the site after injecting the medication.

1. The Mantoux test is administered via intradermal injection. The appropriate technique for an intradermal injection includes holding the needle and syringe almost parallel to the client's skin, keeping the skin slightly taut when the needle is inserted, and inserting the needle with the bevel side up. There is no need to aspirate, a technique that assesses for incorrect placement in a blood vessel, when giving an intradermal injection. The injection site is not massaged.

130. A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-AssessmentRecommendation) technique for communication, the nurse calls the physician with the recommendation for: ■ 1. Initiating I.V. sedation. ■ 2. Starting a high-protein diet. ■ 3. Providing pain medication. ■ 4. Increasing the ventilator rate

1. The client may be ﬁ ghting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.

45. The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to: ■ 1. Take a laxative. ■ 2. Follow a clear liquid diet. ■ 3. Administer an enema. ■ 4. Take an antiemetic

1. The client should take a laxative after an upper gastrointestinal series to stimulate a bowel movement. This examination involves the administration of barium, which must be promptly eliminated from the body because it may harden and cause an obstruction. A clear liquid diet would have no effect on stimulating removal of the barium. The client should not have nausea and an antiemetic would not be necessary; additionally, the antiemetic will decrease peristalsis and increase the likelihood of eliminating the barium. An enema would be ineffective because the barium is too high in the gastrointestinal tract.

50. A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: ■ 1. Vertigo. ■ 2. Facial paralysis. ■ 3. Impaired vision. ■ 4. Difﬁ culty swallowing.

1. The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difﬁ culty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve.

15. A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition? ■ 1. Ranson's criteria. ■ 2. Vital signs. ■ 3. Urine output. ■ 4. Glasgow Coma Scale.

1. The elevated amylase and lipase and symptoms suggest acute pancreatitis. Ranson's criteria is a clinical predictor scale used to assess the severity of acute pancreatitis and prognosis. Vital signs are used to evaluate hemodynamic stability Urine output is monitored for assessment of ﬂ uid volume status. Glasgow Coma Scale (GCS) is a neurological scale to assess the level of consciousness.

134. Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? ■ 1. Septic shock. ■ 2. Chronic obstructive pulmonary disease. ■ 3. Asthma. ■ 4. Heart failure.

1. The two risk factors most commonly associated with the development of ARDS are gramnegative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inﬂ ammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inﬂ ammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

48. Which of the following symptoms is common in clients with active tuberculosis? ■ 1. Weight loss. ■ 2. Increased appetite. ■ 3. Dyspnea on exertion. ■ 4. Mental status changes.

1. Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis

100. Which of the following would be a signiﬁ cant intervention to help prevent lung cancer? ■ 1. Encourage cigarette smokers to have yearly chest radiographs. ■ 2. Instruct people about techniques for smoking cessation. ■ 3. Recommend that people have their houses and apartments checked for asbestos leakage. ■ 4. Encourage people to install central air cleaners in their homes.

100. 2. Epidermoid cancer involving the larger bronchi is almost entirely associated with heavy cigarette smoking. The American Cancer Society reports that smoking is responsible for more than 80% of lung cancers in men and women. The prevalence of lung cancer is related to the duration and intensity of the smoking, so nurses can best prevent lung cancer by persuading clients to stop smoking. Chest radiographs aid in detection of lung cancer; they do not prevent it. Exposure to asbestos has been implicated as a risk factor for lung cancer, but cigarette smoking is the major risk factor. There are no data to support the use of home air cleaners in the prevention of lung cancer.

66. The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client? ■ 1. "Breathe in normally through your nose for 2 counts (while counting to yourself, one, two)." ■ 2. "Relax your neck and shoulder muscles." ■ 3. "Pucker your lips as if you were going to whistle." ■ 4. "Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four)."

2, 1, 3, 4. The nurse should instruct the client to ﬁ rst relax the neck and shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and ﬁ nally breathe out through pursed lips.

142. A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin (Keﬂ ex) 500 mg, the nurse notices that the pharmacy sent cefazolin (Kefzol). What should the nurse do? Select all that apply. ■ 1. Administer the cefazolin (Kefzol). ■ 2. Verify the medication order as written by the physician. ■ 3. Contact the pharmacy and speak to a pharmacist. ■ 4. Request that cephalexin (Keﬂ ex) be sent promptly. ■ 5. Return the cefazolin (Kefzol) to the pharmacy.

2, 3, 4, 5. One of the "ﬁ ve rights" of drug administration is "right medication." Kefzol was not the medication ordered. The pharmacist is the professional resource and serves as a check to ensure that clients receive the right medication. Returning unwanted medications to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse.

29. A nurse is admitting a client who has been admitted with a diagnosis of upper GI bleeding to the hosptial. The nurse should assess the client for which of the following? Select all that apply. ■ 1. Dry, ﬂ ushed skin. ■ 2. Decreased urine output. ■ 3. Tachycardia. ■ 4. Widening pulse pressure. ■ 5. Rapid respirations. ■ 6. Thirst.

2, 3, 5, 6. The client who is experiencing upper GI bleeding is at risk for developing hypovolemic shock from blood loss. Therefore, the signs and symptoms the nurse should expect to ﬁ nd are those related to hypovolemia, including decreased urine output, tachycardia, rapid respirations, and thirst. The client's skin would be cool and clammy, not dry and ﬂ ushed. The client would also be likely to develop hypotension, which would lead to a narrowing pulse pressure, not a widening pulse pressure.

64. A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply. ■ 1. Having eye examinations every 6 months. ■ 2. Maintaining follow-up monitoring of liver enzymes. ■ 3. Decreasing protein intake in the diet. ■ 4. Avoiding alcohol intake. ■ 5. The urine may have an orange color.

2, 4, 5. A potential adverse effect of rifampin (Rifadin) is hepatotoxicity. Clients should be instructed to avoid alcohol intake while taking rifampin and keep follow-up appointments for periodic monitoring of liver enzyme levels to detect liver toxicity. Rifampin causes the urine to turn an orange color and the client should understand that this is normal. It is not necessary to restrict protein intake in the diet or have the eyes examined due to rifampin therapy.

17. The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply. ■ 1. The client has a sore throat. ■ 2. The client has a temperature of 100° F (37.8° C). ■ 3. The client appears drowsy following the procedure. ■ 4. The client has epigastric pain. ■ 5. The client experiences hematemesis.

2, 4, 5. Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the procedure.

21. When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistant? Select all that apply. ■ 1. Assessing the client's bowel sounds. ■ 2. Providing skin care following bowel movements. ■ 3. Evaluating the client's response to antidiarrheal medications. ■ 4. Maintaining intake and output records. ■ 5. Obtaining the client's weight

2, 4, 5. The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements, maintaining intake and output records, and obtaining the client's weight. Assessing the client's bowel sounds and evaluating the client's response to medication are registered nurse activities that cannot be delegated.

57. The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply. ■ 1. "I will need to dispose of my old clothing when I return home." ■ 2. "I should always cover my mouth and nose when sneezing." ■ 3. "It is important that I isolate myself from family when possible." ■ 4. "I should use paper tissues to cough in and dispose of them promptly." ■ 5. "I can use regular plates and utensils whenever I eat."

2, 4, 5. When teaching the client how to avoid the transmission of tubercle bacilli, it is important for the client to understand that the organism is transmitted by droplet infection. Therefore, covering the mouth and nose when sneezing, using paper tissues to cough in with prompt disposal, and using regular plates and utensils indicate that the client has understood the nurse's instructions about preventing the spread of airborne droplets. It is not essential to discard clothing, nor does the client need to isolate himself from family members.

18. The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply. ■ 1. A client with Crohn's disease who is receiving total parenteral nutrition (TPN). ■ 2. A client who underwent inguinal hernia repair surgery 3 hours ago. ■ 3. A client with an intestinal obstruction who needs a Cantor tube inserted. ■ 4. A client with diverticulitis who needs teaching about his take-home medications. ■ 5. A client who is experiencing an exacerbation of his ulcerative colitis.

2, 5. The nurse should consider client needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of his ulcerative colitis are appropriate clients to assign to a licensed practical nurse as the care they require fall within the scope of practice for a licensed practical nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.

31. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate? ■ 1. The procedure will result in enlargement of the pyloric sphincter. ■ 2. The procedure will result in anastomosis of the gastric stump to the jejunum. ■ 3. The procedure will result in removal of the duodenum. ■ 4. The procedure will result in repositioning of the vagus nerve.

2. A Billroth II procedure bypasses the duodenum and connects the gastric stump directly to the jejunum. The pyloric sphincter is removed, along with some of the stomach fundus.

8. While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following? ■ 1. The client asks what time the doctor will visit that day. ■ 2. The client asks about the supplies used during the dressing change. ■ 3. The client talks about something she read in the morning newspaper. ■ 4. The client complains about the way the night nurse changed the dressing.

2. A client who displays interest in the procedure and asks about supplies used for dressings may be ready to participate in self-care. Inquiring about the physician's visit, discussing news events, and complaining about a dressing change are behaviors that avoid the subject of the colostomy.

128. The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? ■ 1. Elevated carbon dioxide level. ■ 2. Hypoxia not responsive to oxygen therapy. ■ 3. Metabolic acidosis. ■ 4. Severe, unexplained electrolyte imbalance.

2. A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS

41. Which of the following statements about nasoenteric tubes is correct? ■ 1. The tube cannot be attached to suction. ■ 2. The tube contains a soft rubber bag ﬁ lled with mercury. ■ 3. The tube is taped securely to the client's cheek after insertion. ■ 4. The tube can have its placement determined only by auscultation.

2. A nasoenteric tube has a small balloon at its tip that is weighted with mercury. The weight of the mercury helps advance the tube by gravity through the intestine. Nasoenteric tubes are attached to suction. A nasoenteric tube is not taped in position until it has reached the obstruction. Because the tube has a radiopaque strip, its progress through the intestinal tract can be followed by ﬂ uoroscopy

58. A client has a positive reaction to the Mantoux test. The nurse correctly interprets this reaction to mean that the client has: ■ 1. Active tuberculosis. ■ 2. Had contact with Mycobacterium tuberculosis. ■ 3. Developed a resistance to tubercle bacilli. ■ 4. Developed passive immunity to tuberculosis.

2. A positive Mantoux skin test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. A positive Mantoux test does not mean that the client has developed resistance. Unless involved in treatment, the client may still develop active disease at any time. Immunity to tuberculosis is not possible.

23. The nurse ﬁ nds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: ■ 1. Involvement with his job will keep the client from becoming bored. ■ 2. A relaxed environment will promote ulcer healing. ■ 3. Not keeping up with his job will increase the client's stress level. ■ 4. Setting limits on the client's behavior is an important nursing responsibility

2. A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Being involved with his work may prevent boredom; however, this client is upset and argumentative. Not keeping up with his job will probably increase the client's stress level, but the nurse's response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client's behavior; clients must make the decision to make lifestyle changes.

38. As a result of a gastric resection, the client is at risk for development of dumping syndrome. The nurse should prepare a plan of care for this client based on knowledge that this problem stems primarily from which of the following gastrointestinal changes? ■ 1. Excess secretion of digestive enzymes in the intestines. ■ 2. Rapid emptying of stomach contents into the small intestine. ■ 3. Excess glycogen production by the liver. ■ 4. Loss of gastric enzymes

2. After a gastric resection, ingested food moves rapidly from the remaining stomach into the duodenum or jejunum. The food has not undergone adequate preliminary digestion in the stomach. It is concentrated (hypertonic), distends the intestine, and stimulates signiﬁ cant secretion of insulin by the pancreas, as well as a shift of ﬂ uid into the bowel. The dumping syndrome results from these factors, which are initiated by the rapid movement of food out of the stomach. After gastric resection, excess digestive enzymes are not secreted and the liver does not produce glycogen. Dumping syndrome is not caused by loss of gastric secretions.

77. A client has just had an inguinal herniorrhaphy. Which of the following instructions would be most appropriate to include in his discharge plan? ■ 1. Turning, coughing, and deep breathing every 2 hours. ■ 2. Applying an ice bag to the scrotum. ■ 3. Applying a truss before the client ambulates. ■ 4. Maintaining a high Fowler's position while resting.

2. After inguinal herniorrhaphy, an ice bag to the scrotum will help decrease pain and edema. The client is encouraged to turn and deep-breathe, but coughing is not encouraged, to decrease straining on the surgical area. A truss is not needed for support after surgery. While resting, the client may be most comfortable in a semi-Fowler's position, but there is no need to maintain a high Fowler's position.

28. Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: ■ 1. Demonstrate appropriate use of analgesics to control pain. ■ 2. Explain the rationale for eliminating alcohol from the diet. ■ 3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months. ■ 4. Eliminate contact sports from his or her lifestyle.

2. Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client's hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

23. The client with ulcerative colitis is following orders for bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: ■ 1. Conserved energy. ■ 2. Reduced intestinal peristalsis. ■ 3. Obtained needed rest. ■ 4. Minimized stress

2. Although modiﬁ ed bed rest does help conserve energy and promotes comfort, its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress

47. Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? ■ 1. A respiratory rate of 25 to 30 breaths/minute. ■ 2. The ability to perform activities of daily living without dyspnea. ■ 3. A maximum loss of 5 to 10 lb of body weight. ■ 4. Chest pain that is minimized by splinting the rib cage.

2. An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/ minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain.

1. Which of the following guidelines reﬂ ects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk? ■ 1. Annual digital rectal examination should begin at age 40. ■ 2. Annual fecal testing for occult blood should begin at age 50. ■ 3. Individuals should obtain a baseline barium enema at age 40. ■ 4. Individuals should obtain a baseline colonoscopy at age 45.

2. Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they experience signs or symptoms that indicate the need for such diagnostic testing, or are considered to be at high risk

6. The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period? ■ 1. Maintain the client in a semi-Fowler's position. ■ 2. Assist the client with warm sitz baths. ■ 3. Administer 30 mL of milk of magnesia to stimulate colostomy activity. ■ 4. Remove the ostomy pouch as needed so the stoma can be assessed.

2. Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage.

37. As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identiﬁ ed Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions? ■ 1. Instruct the client to increase the amount eaten at each meal. ■ 2. Encourage the client to eat smaller amounts more frequently. ■ 3. Explain that if vomiting occurs after a meal, nothing more should be eaten that day. ■ 4. Inform the client that bland foods are typically less nutritional and should be used minimally.

2. Because of the client's reduced stomach capacity, frequent small feedings are recommended. Early satiety can result, and large quantities of food are not well tolerated. Each client should progress at his or her own pace, gradually increasing the amount of food eaten. The goal is three meals daily if possible, but this can take 6 months or longer to achieve. Nausea can be episodic and can result from eating too fast or eating too much at one time. Eating less and eating more slowly, rather than not eating at all, can be a solution. Bland foods are recommended as starting foods because they are easily digested and are less irritating to the healing mucosa. Bland foods are not less nutritional.

56. In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful? ■ 1. Number and length of breaks. ■ 2. Body mechanics used in lifting. ■ 3. Temperature in the work area. ■ 4. Cleaning solvents used

2. Bending, especially after eating, can cause gastroesophageal reﬂ ux. Lifting heavy objects increases intra-abdominal pressure. Assessing the client's lifting techniques enables the nurse to evaluate the client's knowledge of factors contributing to hiatal hernia and how to prevent complications. Number and length of breaks, temperature in the work area, and cleaning solvents used are not directly related to treatment of hiatal hernia

18. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? ■ 1. Ineffective coping related to fear of diagnosis of chronic illness. ■ 2. Deﬁ cient knowledge related to unfamiliarity with signiﬁ cant signs and symptoms. ■ 3. Constipation related to decreased gastric motility. ■ 4. Imbalanced nutrition: Less than body requirements related to gastric bleeding

2. Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. The data do not support the other diagnoses

114. A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time? ■ 1. Reduce the client's anxiety. ■ 2. Maintain adequate oxygenation. ■ 3. Decrease chest pain. ■ 4. Maintain adequate circulating volume

2. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

79. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD? ■ 1. High oxygen concentrations will cause coughing and dyspnea. ■ 2. High oxygen concentrations may inhibit the hypoxic stimulus to breathe. ■ 3. Increased oxygen use will cause the client to become dependent on the oxygen. ■ 4. Administration of oxygen is contraindicated in clients who are using bronchodilators.

2. Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidiﬁ ed, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.

32. Which of the following diets would be most appropriate for the client with ulcerative colitis? ■ 1. High-calorie, low-protein. ■ 2. High-protein, low-residue. ■ 3. Low-fat, high-ﬁ ber. ■ 4. Low-sodium, high-carbohydrate.

2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

116. A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? ■ 1. Respiratory rate greater than 16 breaths/ minute. ■ 2. Continuous bubbling in the water-seal chamber. ■ 3. Fluid in the chest tube. ■ 4. Fluctuation of ﬂ uid in the water-seal chamber

2. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is ﬂ uctuation of the ﬂ uid in the waterseal chamber.

22. Which goal for the client's care should take priority during the ﬁ rst days of hospitalization for an exacerbation of ulcerative colitis? ■ 1. Promoting self-care and independence. ■ 2. Managing diarrhea. ■ 3. Maintaining adequate nutrition. ■ 4. Promoting rest and comfort.

2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the ﬁ rst goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inﬂ ammatory drugs.

53. The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority? ■ 1. Offering the client emotional support. ■ 2. Teaching the client about the disease and its treatment. ■ 3. Coordinating various agency services. ■ 4. Assessing the client's environment for sanitation.

2. Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatment

127. Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? ■ 1. Teaching cigarette smoking cessation. ■ 2. Maintaining adequate serum potassium levels. ■ 3. Monitoring clients for signs of hypercapnia. ■ 4. Replacing ﬂ uids adequately during hypovolemic states.

4. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate ﬂ uid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.

36. A client with bacterial pneumonia is to be started on I.V. antibiotics. Which of the following diagnostic tests must be completed before antibiotic therapy begins? ■ 1. Urinalysis. ■ 2. Sputum culture. ■ 3. Chest radiograph. ■ 4. Red blood cell count.

2. A sputum specimen is obtained for culture to determine the causative organism. After the organism is identiﬁ ed, an appropriate antibiotic can be prescribed. Beginning antibiotic therapy before obtaining the sputum specimen may alter the results of the test. Neither a urinalysis, a chest radiograph, nor a red blood cell count needs to be obtained before initiation of antibiotic therapy for pneumonia.

117. Which of the following ﬁ ndings would suggest pneumothorax in a trauma victim? ■ 1. Pronounced crackles. ■ 2. Inspiratory wheezing. ■ 3. Dullness on percussion. ■ 4. Absent breath sounds.

4. Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of ﬂ uid.

109. A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should: ■ 1. Check the tubing to ensure that the client is not lying on it or kinking it. ■ 2. Increase the suction. ■ 3. Lower the drainage bottles 2 to 3 feet below the level of the client's chest. ■ 4. Ensure that the chest tube has two clamps on it to prevent air leaks.

. 1. In this case, there may be some obstruction to the ﬂ ow of air and ﬂ uid out of the pleural space, causing air and ﬂ uid to collect and build up pressure. This prevents the remaining lung from reexpanding and can cause a mediastinal shift to the opposite side. The nurse's ﬁ rst response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a physician's order. The normal position of the drainage bottles is 2 to 3 feet below chest level. Clamping the tubes obstructs the ﬂ ow of air and ﬂ uid out of the pleural space and should not be done.

122. A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: ■ 1. Sudden, sharp chest pain. ■ 2. Wheezing breath sounds over affected side. ■ 3. Hemoptysis. ■ 4. Cyanosis.

. 1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycardia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax.

NUR 2 Exam 3 nclex

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