NUR450 - Final Exam - Blackboard posted questions and case studies
Musculoskeletal System - Blackboard questions
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ATI Case Management Scenarios with Critical Thinking Exercises, Questions and Answers
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Gastrointestinal System - Blackboard questions
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Gastrointestinal System - Saunders printed book
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Medical Diagnosis: Acute viral hepatitis. • Nursing Problems/Diagnosis: - Risk of injury related to biochemical regulatory Impairment. - Impairment of digestion. - Altered nutrition, less than body requirements. - Self-esteem disturbance - Sensory/perceptual alterations related to chemical alterations. • Chief Complaint: Ms. Bee Is a 25-year-old real estate agent. She complains of fatigue, weakness, dark-yellow urine, and day-colored stools. • History of Present Illness: Two weeks prior to Ms. Bee's hospitalization, she felt very fatigued and weak. She complained of uncomfortable joint pains, frequent headaches, poor appetite, and nausea. On the fourth day of Ms. Bee's hospitalization, she developed jaundice, and strongly insisted that her visitors be restricted to her immediate family. • Past History: Healthy young adult. No previous hospitalizations. • Family History: Father, age 48; mother, age 45; both relatively well. • Physical Exam: Neck: Supple; no pain or stiffness on movement; trachea midline. Chest: Symmetric chest expansion; adequate chest excursion. Lungs: Clear on auscultation. Heart: S1 and distinct; regular rhythm; no S3 or S4 Abdomen: Flat, soft; active bowel sounds; tympanic sound in four quadrants; smooth liver edge with tenderness, palpated 3 cm below right costal margin. Extremities: No rashes or irritation; jaundice of skin noted on fourth hospitalization day; range of motion of all extremities adequate, without pain or discomfort on movement; strong hand grasps bilaterally. • Laboratory and X-ray Data: Chest x-ray: Normal. Blood gases: Normal limits. ECG: Normal sinus rhythm.
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Medical Diagnosis: Bleeding duodenal ulcer • Surgical Treatment: Gastrectomy • Nursing Problems/Diagnosis - Altered bowel elimination. - Altered cardiac output. - Altered comfort (pain). - Effective individual management of therapeutic regimen. - Altered nutrition: less than body requirements. - Self-care deficit: medication administration. • Client Complaint: Mr. Earl Williams, the 46-year-old owner of a small business, is admitted to the hospital complaining of vomiting a large amount of bright red blood. • History or Present Illness: History of gastric disorders for the past 2 years. Current episode consisted of several days of consumption of some alcohol; death of brother (cancer of the lungs); inability to sleep, then epigastric pain, nausea, vomiting gastric contents and then vomiting bright red blood. • Past History: Stomach disorders for several years. Weight loss of 6 pounds. Complainong of gnawing, aching, and burning pain, usually relieved by proper diet and antacids. • Family History: One brother died age 48, heart attack; one brother died, cancer of the lungs one sister, living and well. Wife has multiple sclerosis, early stages. Son Is unemployed and had dropped out of high school. Two daughters: one married (18-years-old) and living at home with husband and 2-month-old daughter; the other daughter is in high school and doing well. • Review of Systems: Weight loss. GI history (see History of Present Illness and Past History). No difficulty in breathing or palpitations. • Physical Exam: Vital signs: BP: 112/60. P: 92. R: 18. Skln pale. Acute pain. Breath sounds clear. Abdomen: complains of burning pain In mid-epigastric area. • Laboratory and X-ray Data: GI series shows abnormality of tissue In the duodenal region. Endoscopy: positive for duodenal ulcer. Stool: positive for occult blood. Hgb: 12g. Hct: 30%
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Medical Diagnosis: Cholelithiasis. • Surgical Treatment: Open cholecystectomy. • Nursing Problems/Diagnosis: - Altered comfort (pain). - Fluid volume deficit. - Health-seeking behaviors: preparation for diagnostic procedures. - Effective individual management of therapeutic regimen. - Risk for injury: postoperative complications. - Altered nutrition: less than body requirements. - Self-care deficit: medication administration. • Chief Complaint: Adele Norfolk, 47-years-old, was admitted to the hospital, complaining of severe pain in her right upper quadrant. • History of Present Illness: Ms. Norfolk has noticed an intolerance to fatty foods over the past few months. She has also noted general indigestion. Prior to this admission, no serious episodes of pain were noted. Her present pain began 6 hours ago; Its onset was sudden and the pain increased in severity. She complained of nausea and vomited twice prior to admission. • Past Health History: Twenty-five pounds overweight. Three normal deliveries; all children living and well. Appendectomy at age 14. Smokes 1 pack of Cigarettes a day. • Family History: No history of gallbladder disease in mother, father, two brothers, or one sister. Diet has been high in fat content throughout lifetime. • Review of Systems: Weight gain gradual over past 5 years. Unsuccessful in own attempts to control Weight. Distress when eating fatty foods; complains of "bloating feeling." Denies cough. • Physical Exam: Vital signs: BP: 140/92, Temperature: 101F. P: 92. R: 26. Head and neck: Tongue dry; face flushed; no jaundice noted. Chest: Some wheezing noted at base of lungs. Difficulty in coughing due to acute distress. Abdomen: Severe pain and tenderness in right upper quadrant. Positive Murphy's sign. Extremities: Some evidence of varicosities In posterior aspect of lower legs. • Laboratory and X-ray Data: X-ray: Absence of opaque materials in the gallbladder-cholecystography. Chest x-ray: Within normal limits. GI series: Negative. WBC: 12,500/microliter. Cholesterol level: 290 mg/dL Urine specific gravity: 1.040
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Medical Diagnosis: Laennec's cirrhosis; hepatic encephalopathy • Nursing Problems/Diagnosis: - Inadequate breathing patterns - Impairment of digestion. - Fluid volume deficit. - Altered nutrition: less than body requirements. - Altered thought processes. • Chief Complaint: Joseph Mesta, Is 55-years-old and married. He complains of vomiting, confusion, restlessness, and increased abdominal size. • History of Present Illness: Six episodes of coffee-ground emesis in past 24 hours. According to wife, he has intermittent disorientation to place and time. Also reports an 18-pound weight gain in past 6 months and a gradual increase in abdominal girth • Past History: Discharged from hospital 6 months ago with diagnosis of Laennec's cirrhosls. Responded well to treatment with diuretics and salt and protein restrictions. • Family History: Mother and father died of "old age" In their 80s. • Review of Symptoms: Admits to difficulty following doctor's prescribed diet. Avoids hard liquor but consumes 4-6 beers each night. • Physical Exam: Lungs: Bilateral, basilar crackles. Abdomen: Marked distention; liver barely palpable; distended veins visible in right and left upper quadrants. Rectal: Black, tarry stools hematest-positive. Extremities: 2 + pitting edema both legs; 1+ arms. Skin: Jaundice; multiple abrasions on forearms which bleed easily. Neurologic: Lethargic; disoriented to time and place; tremor, both upper arms. • Laboratory and X-ray Data: Hgb: 10.1 g. Hct: 31.3%. WBC: 10,200 mcgL. BUN: 62 mg/dL. Creatinine: 3.3 mg/dL. Total bilirubln: 7.3 mg/dL. Albumin: 2.3 g/dL. CK: 460 mU/mL. AST: 180 U/mL. LDH: 451 U/mL. ALT: 488 U/mL. Uric acid: 10.5 mg/dL. UGI: Varices of esophagus and stomach. Paracentesis: 400 mL clear, straw-colored fluid.
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Musculoskeletal - from Saunders printed book
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835. A client is being discharged to home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client states that he or she should: 1. Avoid getting the cast wet. 2. Cover the casted leg with warm blankets. 3. Use the fingertips to lift and move the leg. 4. Use a padded coat hanger end to scratch under the cast.
1 Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; the client may use a hair dryer on the cool setting to relieve an itch.
852. Cyclobenzaprine hydrochloride (Flexeril) is prescribed for a client for muscle spasms. The nurse is reviewing the client's record. Which of the following disorders, if noted in the record, would indicate a need to contact the physician about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus
1 Rationale: Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short term (2 to 3 weeks).
847. Allopurinol (Zyloprim) is prescribed for a client and the nurse provides medication instructions to the client. The nurse instructs the client: 1. To drink 3000 mL of fluid a day 2. To take the medication on an empty stomach 3. That the effect of the medication will occur immediately 4. That if swelling of the lips occurs, this is a normal expected response
1 Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the physician because this may indicate hypersensitivity.
843. A nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be concerned especially with which of the following assessment findings? 1. Temperature of 101.6° F orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises
1 Rationale: The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F should be reported.
845. A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Select all instructions that the nurse would include on the list. 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. 4. Tingling and numbness in the extremity are expected. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft padded object that will fit under the cast to scratch the skin under the cast.
1, 2, 3 Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The physician is notified immediately if circulatory impairment occurs.
854. In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. 1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature on rising in the morning that remains throughout the day
1, 2, 3, 4 Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.
388. A practitioner orders three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound weight loss in 1 month. To ensure valid test results, the nurse should instruct the client to: 1. Avoid eating red meat before testing 2. Test the specimen while it is still warm 3. Discard the day's first stool and use the next three stools 4. Take three specimens from different sections of the fecal sample
1. Red meat can react with reagents used in the test to cause false-positive results.
148. Which area should the nurse examine to look for jaundice in a person with a dark complexion? A. Nailbeds. B. Palms of hands. C. Hard palate. D. Soles of feet.
148. C. Hard palate Jaundice, in persons of various skin colors, can be readily viewed by examining the hard palate of the mouth with the aid of a flashlight. A is incorrect since some persons have naturally yellow, discolored nailbeds or very dark nailbeds, which prevents observation of color change. B and D are incorrect because the do not represent the best site for observing jaundice in dark-skinned persons. Some people have a yellow coloration to their skin because of ethnic background or sun exposure. Others may have such dark skin that jaundice is not clearly visible in these areas.
831. A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage
2 Rationale: A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician.
838. A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Minimal dyspnea 2. Clear mentation 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg
2 Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.
850. A nurse is providing discharge instructions to a client receiving baclofen (Lioresal). Which of the following would be included in the teaching plan? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Notify the physician if fatigue occurs. 4. Stop the medication if diarrhea occurs.
2 Rationale: Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the physician about fatigue.
848. Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which of the following disorders? 1. Myxedema 2. Renal failure 3. Hypothyroidism 4. Diabetes mellitus
2 Rationale: Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, renal, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication.
837. A nurse has given a client instructions about crutch safety. The nurse determines that the client needs reinforcement of information if the client states: 1. That he or she will not use someone else's crutches 2. That crutch tips will not slip even when wet 3. The need to have spare crutches and tips available 4. That crutch tips should be inspected periodically for wear
2 Rationale: Crutch tips should remain dry. Water could cause the client to slip by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.
836. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could most likely result in: 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
2 Rationale: Crutches are measured so that the tops are two to three fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus.
844. A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL 2. Uric acid level of 8.6 mg/dL 3. Potassium level of 4.1 mEq/L 4. Phosphorus level of 3.1 mg/dL
2 Rationale: In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value ranges from 2.5 to 8 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.
846. The client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept (Enbrel), it is most important for the nurse to assess: 1. The injection site for itching and edema 2. The white blood cell counts and platelet counts 3. Whether the client is experiencing fatigue and joint pain 4. A metallic taste in the mouth, with a loss of appetite
2 Rationale: Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste with loss of appetite are not common signs of side effects of this medication.
842. A client is complaining of low back pain that radiates down the left posterior thigh. The nurse further assesses the client to see if the pain is worsened or aggravated by: 1. Bed rest 2. Bending or lifting 3. Ibuprofen (Motrin) 4. Application of heat
2 Rationale: Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test).
828. A nurse has given instructions to a client returning home after knee arthroscopy. The nurse determines that the client understands the instructions if the client states that he or she will: 1. Resume regular exercise the following day. 2. Stay off the leg entirely for the rest of the day. 3. Report fever or site inflammation to the physician. 4. Refrain from eating food for the remainder of the day.
3 Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the physician.
841. A nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. The nurse immediately: 1. Calls the physician 2. Applies ice to the site 3. Rewraps the stump with an elastic compression bandage 4. Applies a dry sterile dressing and elevates it on one pillow
3 Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the stump immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the physician so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the physician were called, the prescription likely would be to reapply the compression dressing anyway.
853. A nurse is administering an intravenous dose of methocarbamol (Robaxin) to a client with multiple sclerosis. For which of the following adverse effects would the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension
3 Rationale: Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these side effects. Options 1, 2, and 4 are not a concern with administration of this medication.
833. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. The nurse interprets that this pain may be caused by: 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture
3 Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the physician because the pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in.
832. A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity
3 Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.
501. After a bilateral herniorrhaphy the nurse should assess a male client for the development of: 1. Hydrocele 2. Paralytic ileus 3. Urinary retention 4. Thrombophlebitis
3. Because of pain and the proximity of the operative site to the lower urinary tract, urinary retention is common after this surgery.
463. The practitioner orders contact precautions for a client with hepatitis A. What specific interventions are required for contact precautions? 1. Private room and the door must be kept closed 2. Persons entering the room must wear a gown, a mask, and gloves 3. Gown and gloves must be worn when handling articles contaminated by urine or feces 4. Gowns and gloves must be worn only when handling the client's soiled linen, dishes, or utensils
3. Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal and! or urine contamination.
834. A nurse is admitting a client with multiple trauma to the nursing unit. The client has a leg fracture and had a plaster cast applied. In positioning the casted leg, the nurse should: 1. Keep the leg in a level position. 2. Elevate the leg for 3 hours and put it flat for 1 hour. 3. Keep the leg level for 3 hours and elevate it for 1 hour. 4. Elevate the leg on pillows continuously for 24 to 48 hours.
4 Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
830. A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse's response is based on the understanding that Buck's (extension) traction primarily: 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization
4 Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin.
840. A client with diabetes mellitus has had a right below-knee amputation. The nurse would assess specifically for which of the following signs because of the history of diabetes? 1. Hemorrhage 2. Edema of the stump 3. Slight redness of the incision 4. Separation of the wound edges
4 Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative stump edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.
851. A nurse is analyzing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which of the following laboratory tests would identify an adverse effect associated with the administration of this medication? 1. Creatinine level determination 2. Platelet count determination 3. Blood urea nitrogen level determination 4. Liver function tests
4 Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered in the lowest effective dosage for the shortest time necessary.
849. Alendronate (Fosamax) is prescribed for a client with osteoporosis. The nurse instructs the client to: 1. Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning.
4 Rationale: Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.
827. A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder? 1. A 25-year-old woman who jogs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes
4 Rationale: Risk factors for osteoporosis include female gender, postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increase the risk.
839. A nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which of the following early symptoms of compartment syndrome? 1. Cold, bluish-colored fingers 2. Pain that is out of proportion to the type of injury or condition 3. Pain that increases when the arm is dependent 4. Numbness and tingling in the fingers
4 Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.
829. A nurse is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. The nurse would plan to: 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage the person to remain still.
4 Rationale: With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.
467. When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in: 1. The left side-lying position with the head of the bed elevated 2. A high Fowler's position with both arms supported on several pillows 3. The right side-lying position with pillows placed under the costal margin 4. Any comfortable recumbent position as long as the client remains immobile
467. 3 In this position the liver capsule at the entry site is compressed against the chest wall and escape of blood and/or bile is impeded.
468. A client who has had right upper quadrant pain for several months now experiences clay-colored stools and visits the local clinic. Based on the reported history and elevated liver enzymes, a needle biopsy of the liver is scheduled. The nurse explains that: 1. The procedure is painless because general anesthesia is used 2. Disfiguring scars are minimal because a small incisionis made 3. Lying on the right side after the procedure is required because it will decrease the risk of hemorrhage 4. A light meal should be eaten 2 hours before the procedure because it stimulates gastrointestinal secretions
468. 3 Because of the vascularity of the liver, compression of the needle insertion site limits the risk of hemorrhage; also it decreases the risk of bile leakage.
469. The nurse identifies a small amount of bile-colored drainage on the dressing of a client who has had a liver biopsy. The nurse concludes that: 1. Fluid is lealdng into the intestine 2. The pancreas has been lacerated 3. This is a typical, expected response 4. A biliary vessel has been penetrated
469. 4 The flow of bile through the puncture site indicates that a biliary vessel was punctured; this is a common complication after a liver biopsy.
470. The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. The priority nursing intervention is to: 1. Weigh the client daily 2. Restrict the client's oral fluid intake 3. Measure the client's urine specific gravity 4. Observe the client for increasing confusion
470. 4 An increased serum ammonia level impairs the CNS, causing an altered level of consciousness.
471. A client with a long history of alcohol abuse is admitted to the hospital with ascites, jaundice, and confusion. A diagnosis of hepatic cirrhosis is made. A nursing priority is to: 1. Institute safety measures 2. Monitor respiratory status 3. Measure abdominal girth daily, 4. Test stool specimens for blood
471. 1 The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coina; safety is the priority.
472. A client with a history of gastrointestinal varices develops severe hematemesis, and the practitioner inserts a Sengstaken-Blakemore tube. The nurse understands that this tube is a: 1. Single-lumen tube for gastric lavage 2. Double-lumen tube for intestinal decompression 3. Triple-lumen tube used to compress the esophagus 4. Multi-lumen tube for gastric and intestinal decompression
472. 3 One lumen inflates the esophageal balloon, the second inflates the gastric balloon, and the third decompresses the stomach.
473. A client with Laennec's cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority? 1. Apply a safety jacket 2. Give the pm sedative as ordered 3. Notify the practitioner immediately 4. Provide oxygen via a nasal catheter
473. 1 Measures must be taken immediately to ensure client safety.
474. A client with cirrhosis of the liver and malnutrition begins to develop slurred speech, confusion, drowsiness, and tremors. With these signs and symptoms, the diet should be limited to: 1. 20 grams of protein, 2000 calories 2. 80 grams of protein, 1000 calories 3. 100 grams of protein, 2500 calories 4. 150 grams of protein, 1200 calories
474. 1 The signs and symptoms indicate hepatic coma; protein is reduced according to tolerance, and calories are increased to prevent tissue catabolism.
475. A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply. 1. Fever 2. Tachypnea 3. Hypertension 4. Abdominal rigidity 5. Increased bowel sounds
475. Answer: 1,2,4 1 The metabolic rate will be increased and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. 2 Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. 4 With increased intraabdominal pressure, the abdominal wall will become rigid and tender.
476. When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client first: 1. Passes flatus 2. Has bowel sounds 3. Tolerates clear liquids 4. Has a bowel movement
476. 2 Bowel sounds are the result of peristaltic movements that propel intestinal contents through the alimentary tract, causing characteristic sounds.
477. One month after abdominal surgery a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse should maintain the client in the: 1. Supine position 2. Right Sims position 3. Semi-Fowler's position 4. Most comfortable position
477. 3 This position promotes localization of purulent material and inflammation and prevents an ascending infection.
478. A nurse is performing a physical assessment of a client with ulcerative colitis. The finding most often associated with a serious complication of this disorder is: 1. Decreased bowel sounds 2. Loose, blood-tinged stools 3. Distention of the abdomen 4. Intense abdominal discomfort
478. 1 Decreased intestinal motility is associated with serious problems, such as perforation or toxic megacolon.
479. A client with colitis inquires as to whether surgery will eventually be necessary. When teaching about the disease and its treatment, the nurse should emphasize that: 1. Medical treatment for colitis is curative; surgery is not required 2. Surgery for colitis is considered only as a last resort for most clients 3. Surgery for colitis is done early in the course of the disorder for most clients 4. Medical treatment is all that will be needed if the client can acquire some emotional stability
479. 2 Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations.
480. When caring for a client who had abdominal intestinal surgery, it is important for the nurse to consider that: 1. Rectal intubation will relieve vomiting 2. Air swallowing causes gastric distention 3. Preoperative enemas prevent a postoperative ileus 4. Clear liquids a day after surgery stimulate peristalsis
480. 2 When anxious, in pain, or performing deep breathing exercises, it is common for air to be swallowed, which can cause gastric distention.
481. When discussing nutrition with a client who has inflammatory bowel disease of the ascending colon, the most appropriate suggestion by the nurse concerning food to include in the diet is: 1. Scrambled eggs and applesauce 2. Barbecued chicken and French fries 3. Fresh fruit salad with cheddar cheese 4. Chunky peanut butter on whole wheat bread
481. 1 Low-residue foods produce less fecal waste, decreasing bowel contents and irritation; protein promotes healing and calories provide energy.
482. A client with colitis has a hemicolectomy performed. After surgery the nurse identifies that, in addition to having vomited 300 mL of dark green viscous fluid, the client has increasing abdominal distention and absent bowel sounds. Immediate care should be directed toward: 1. Replacing fluid losses 2. Decreasing the vomiting 3. Decompressing the bowel 4. Restoring electrolyte balance
482. 3 Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing.
483. After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, the primmy nursing intervention is to: 1. Coax the client into caring for the ileostomy alone 2. Evaluate the client's ability to care for the ileostomy 3. Ensure the client understands the dietary limitations that must be followed 4. Have the client change the dry sterile dressing on the incision without assistance
483. 2 The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge.
484. After the surgical creation of an ileostomy, a client is transferred to a rehabilitation unit. The client asks for help in selecting breakfast. What should the nurse encourage the client to eat or drink? 1. Hot coffee and oranges 2. Shredded wheat and mille 3. Toast and a western omelet 4. Cream of wheat and bananas
484. 4 Low-residue foods will not increase motility.
485. When teaching a' community health class about the signs of colorectal cancer, the nurse stresses that the most common complaint of persons with colorectal cancer is: 1. Rectal bleeding 2. Abdominal pain 3. Change in bowel habits 4. Decrease in diameter of stools
485. 3 Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common signs of colorectal cancer.
486. A client with the diagnosis of cancer of the transverse colon is transferred from the postanesthesia care unit to a room on a surgical unit after a colon resection with an anastomosis. The nurse on the unit receives the client from the transporting nurse and observes that an IV is in progress and the client has a nasogastric tube and an indwelling urinary catheter. Place the nursing actions in order of priority when receiving this client on the unit. 1. Assess the airway 2. Take the vital signs 3. Check the abdominal dressing 4. Receive the report from the nurse
486. Answer: 4, 1, 3, 2 The first step is for the nurse to receive report from the transporting nurse. The receiving nurse should be informed about the type of surgery performed, important events that occurred during surgery, and the client's response and current status. Once the report is completed, the next step is for the receiving nurse to ensure that the client has a patent airway. Vital signs are then taken to assess the client's current cardiopulmonary status and to assess for signs of hemorrhage or other postoperative complications. This assessment follows the ABCs (airway, breathing, circulation) of assessment. After the client's vital signs are determined to be stable, the nurse should assess and monitor the dressing, IV, and the indwelling urinary catheter.
487. A 50-rear-old executive reports a loss of 20 pounds in 3 months. The stools are black and tarry, and a colonoscopy is scheduled. The nurse prepares the client for this test by: 1. Administering an oil-retention enema just before the test 2. Instructing that a bland diet be eaten the night before the test 3. Explaining that the pretest cathartic will cause diarrhea after the test 4. Telling the client not to eat or drink anything the morning of the test
487. 4 The initiation of the gastrocolic reflex can cause intestinal contents to reach the lower GI tract and interfere with visualization of the colon.
488. A middle-aged male client has an adenocarcinoma of the colon. The practitioner suspects that this has metastasized and orders a CT scan of the liver. When preparing the client for the CT scan the nurse explains that: 1. After the procedure he must rest in bed for about six hours to prevent complications 2. There will be some discomfort during the procedure but the practitioner will administer an analgesic 3. He will be in tWilight sleep during the procedure and may be able to hear people talking in the same room 4. He will be given an IV infusion containing a contrast medium before the procedure and must lie as still as possible for a period of time
488. 4 This is an accurate explanation of what the client can expect during the CT scan.
489. A client who has cancer of the sigmoid colon is to have an abdominoperineal resection with a permanent colostomy. Before surgery a low-residue diet is ordered. The nurse explains that this is necessary to: 1. Limit production of flatus in the intestine 2. Prevent irritation of the intestinal mucosa 3. Reduce the amount of stool in the large bowel 4. Lower the bacterial count in the gastrointestinal tract
489. 3. 3. This diet is low in fiber; after digestion and absorption there is only a small amount of residue to be eliminated.
490. A client with carcinoma of the colon is scheduled for an abdominoperineal resection. Preparation of this client several days before surgery should include: 1. Medications to promote diuresis 2. Restriction of fluids to one L daily 3. Antibiotics to reduce intestinal bacteria 4. Abdominal exercises to facilitate recovery
490. 3. 3. Except in an emergency, the client received an intestinal antibiotic for several days preoperatively to reduce the amount of intestinal bacteria
492. On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear: 1. Dry, pale pink, and flush with the skin 2. Moist, red, and raised above the skin surface 3. Dry, purple, and depressed below the skin surface 4. Moist, pink, flush with the skin, and painful when touched
492. 2. 2. The surface of a stoma is mucous membrane and should be dark pink to red, moist and shiny; the stoma is usually raised beyond the skin surface.
493. The nurse teaches a client to irrigate a new sigmoid colostomy when the: 1. Stool starts to become formed 2. Client can lie on the side comfortably 3. Abdominal incision is closed and contamination is no longer a danger 4. Perineal wound heals and the client can sit comfortably on the commode
493. 1. 1. Once stool is formed, peristalsis needs to be stimlated to promote the passage of stool.
494. A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response? 1. Intestinal edema after surgery 2. Presurgical decrease in fluid intake 3. Absence of gastrointestinal motility 4. Effective functioning of nasogastric suction
494. 3. 3. This is caused by intestinal manipulation and the depressive effects of anesthesia and analgesics.
495. A Client has a surgical creation of a colostomy for cancer of the rectum. When comparing the procedures of a colostomy irrigation and an enema, the nursing intervention that is unique to a colostomy irrigation is: 1. Positioning the client for evacuation of the bowel 2. Lubricating the catheter tip with a water-soluble jelly 3. Instilling the irrigating solution using a cone-shaped tip catheter 4. Clearing the tubing of air before insertion of the irrigating solution
495. 3. 3. A cone-shaped tip controls the depth of insertion of the catheter; which prevents perforation of the bowl and limits leakage of water from the stoma during fluid insertion
496. A client has a colostomy after surgery for cancer of the colon. What is the nurse's most therapeutic intervention during the postoperative period? 1. Empty the colostomy bag when it is three fourths full 2. Allow one half inch between the stoma and the appliance 3. Help the client to remove the appliance on the first postoperative day 4. Apply stoma adhesive around the stoma and then attach the appliance
496. 4. 4. Stoma adhesive protects the skin and helps to keep the appliance attached to the skin
497. The nurse evaluates that dietary teaching for a client with a colostomy is effective when the client states, "It is important that I eat: 1. food low in fiber so that there is less stool." 2. bland foods so that my intestines do not become irritated." 3. everything I ate before the operation and avoid foods that cause gas." 4. soft foods that are more easily digested and absorbed by my large intestine."
497. 3. 3. Clients with a colostomy can eat a regular diet; only gas-forming foods that cause distention and discomfort should be avoided.
498. Part of discharge teaching for a client with a sigmoid colostomy includes how to protect clothing from colostomy leakage. What is the nurse's most appropriate response when the client asks about the use of appliances and dressings? 1. "Appliances are used to avoid soiling your clothing." 2. "Special appliances are expensive but they provide for better bowel control." 3. "I will give you enough appliances to last until your next visit to the physician." 4. "Many people do not need appliances once they regulate their bowels with routine irrigations."
498. 4. 4. Regular irrigation and effective evacuation prevent unexpected bowl movement; generally a drainage pouch is needed only immediately after an irrigation.
499. A client is admitted for repair of bilateral inguinal hernias. Before surgery the nurse assesses the client for signs that strangulation of the intestine may have occurred. What is an early sign of strangulation? 1. Increased flatus 2. Projectile vomiting 3. Sharp abdominal pain 4. Decreased bowel sounds
499. 3. Pain is wavelike, colicky, and sharp because of obstruction and localized bowel ischemia
500. An 80-year-old male client had surgery for a strangulated hernia. One hour after surgery his blood pressure drops from 134/80 to 114/76. Assessment reveals that he does not have postoperative bleeding. The nurse should: 1. Turn him onto his left side 2. Encourage him to move his legs 3. Call the practitioner immediately 4. Administer his prescribed pain medication
500. 2. 2. The lowered blood pressure may be caused by pooling of blood in peripheral vessels; moving the legs will aid venous return.
502. A client receiving a 1500-calorie diet eats these foods for breakfast: 1 cup of milk (12 grams of carbohydrate, 8 grams of protein, 10 grams of fat); 3/4 cup corn flakes (15 grams of carbohydrate, 2 grams of protein)j and half of an orange (5 grams of carbohydrate). How many calories has this client ingested? 1. 208 2. 258 3. 416 4.456
502. 2. 2. The client has ingested 258 calories. Carbohydrates and proteins each yield 4 calories per gram, and fat yields 9 calories per gram. The total carbohydrate calories are 32 x 4 = 128. The total protein calories are 10 x 4 = 40. The total fat calories are 10 x 9 = 90; 128 + 40 + 90 = 258 calories.
614. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention? 1. Notify the physician. 2. Administer the prescribed pain medication. 3. Call and ask the operating room team to perform the surgery as soon as possible. 4. Reposition the client and apply a heating pad on warm setting to the client's abdomen.
614. 1 Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
615. The client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin
615. 2 Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.
616. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? 1. Right lower quadrant, radiating to the back 2. Right lower quadrant, radiating to the umbilicus 3. Right upper quadrant, radiating to the left scapula and shoulder 4. Right upper quadrant, radiating to the right scapula and shoulder
616. 4 Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect.
617. The client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only three large meals daily.
617. 2 Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet because fat may be tolerated poorly because of decreased bile production. Small frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.
618. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort
618. 1 Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
619. A client has just had a hemorrhoidectomy. What nursing intervention is appropriate for this client? 1. Instruct the client to limit fluid intake to avoid urinary retention. 2. Instruct the client to eat low-fiber foods to decrease the bulk of the stool. 3. Apply and maintain ice packs over the dressing until the packing is removed. 4. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
619. 3 Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding. An ice pack will increase comfort and decrease bleeding. Options 1, 2, and 4 are incorrect interventions.
620. The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which item should the nurse include on this list? 1. Coffee 2. Chocolate 3. Fatty foods 4. Nonfat milk
620. 4 Rationale: Foods that increase lower esophageal sphincter (LES) pressure will decrease reflux and lessen the symptoms of gastroesophageal reflux disease (GERD). The food that will increase LES pressure is nonfat milk. The other substances listed decrease LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol.
621. The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex
621. 4 Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority.
622. The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? 1. "I know I must sign the consent form." 2. "I hope the throat spray keeps me from gagging." 3. "I'm glad I don't have to lie still for this procedure." 4. "I'm glad some IV medication will be given to relax me."
622. 3 Rationale: The client does have to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.
623. The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D
623. 1 Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
624. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E
624. 2 Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.
625. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate? 1. Clamp the T-tube. 2. Irrigate the T-tube. 3. Notify the physician. 4. Document the findings.
625. 4 Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.
626. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, board-like abdomen
626. 4 Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.
627. The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises
627. 3 Rationale: In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the physician. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.
628. The nurse is providing discharge instructions to a client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal. 2. Eat high carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high Fowler's position during meals.
628. 3 Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
629. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain
629. 1 Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
630. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? 1. Diarrhea 2. Chronic constipation 3. Constipation alternating with diarrhea 4. Stool constantly oozing from the rectum
630. 1 Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.
631. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.
631. 3 Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.
632. The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet
632. 1 Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed.
633. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm
633. 3 Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
634. The client with hiatal hernia chronically experiences heartburn following meals. The nurse plans to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2. Taking in small, frequent, bland meals 3. Raising the head of bed on 6-inch blocks 4. Taking H2-receptor antagonist medication
634. 1 Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2-receptor antagonists and antacids, and elevation of the thorax following meals and during sleep.
635. The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? 1. Protruding stoma 2. Sunken and hidden stoma 3. Narrowed and flattened stoma 4. Dark- and bluish-colored stoma
635. 1 Rationale: A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with a dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed.
636. The client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.
636. 1 Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect.
637. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance
637. 4 Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
638. The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement? 1. "I will be able to pass stool by the rectum eventually." 2. "The drainage from this type of ostomy will be formed." 3. "I will need to drain the pouch regularly with a catheter." 4. "I will need to wear a drainage bag for the rest of my life."
638. 3 Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.
639. A nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which of the following interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Administer antacids as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics as prescribed. 4. Give small, frequent high-calorie feedings. 5. Maintain the client in a supine and flat position. 6. Give Meperidine (Demerol) as prescribed for pain.
639. 1, 2, 3, 6 Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.
640. A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed
640. 2 Rationale: The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.
641. The client has a PRN prescription for loperamide hydrochloride (Imodium). For which condition should the nurse plan to administer this medication? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage
641. 3 Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.
642. The client has a PRN prescription for ondansetron (Zofran). For which condition should the nurse administer this medication to the postoperative client? 1. Paralytic ileus 2. Incisional pain 3. Urinary retention 4. Nausea and vomiting
642. 4 Rationale: Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect.
643. The client has begun medication therapy with pancrelipase (Pancrease). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain
643. 3 Rationale: Pancrelipase (Pancrease) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.
644. An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations
644. 3 Rationale: Cimetidine is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.
645. The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime
645. 4 Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.
646. The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count
646. 2 Rationale: The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Options 3 and 4 are incorrect.
647. The client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving optimal intended effect of the medication if the client reports the absence of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation
647. 2 Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.
648. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." 3. "The medications will kill the bacteria and stop the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach."
648. 3 Rationale: Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.
649. The client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition? 1. Intestinal obstruction 2. Peptic ulcer with melena 3. Diverticulitis with perforation 4. Vomiting following cancer chemotherapy
649. 4 Rationale: Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of emesis after surgery, chemotherapy, and radiation.
650. The nurse has given instructions to a client who has just been prescribed cholestyramine (Questran). Which statement by the client indicates a need for further instructions? 1. I will continue taking vitamin supplements. 2. This medication will help lower my cholesterol. 3. This medication should only be taken with water. 4. A high-fiber diet is important while taking this medication.
650. 3 Rationale: Cholestyramine (Questran) is a bile acid sequestrant used to lower the cholesterol level and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption.
651. A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply. 1. Nizatidine (Axid) 2. Ranitidine (Zantac) 3. Famotidine (Pepcid) 4. Cimetidine (Tagamet) 5. Esomeprazole (Nexium) 6. Lansoprazole (Prevacid)
651. 1, 2, 3, 4 Rationale: H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.
851. A client returns from surgery with a hip prosthesis. An abductor splint is in place. The nurse should remove the splint: 1. When the client gets up in a chair 2. If the client needs a change of position 3. Once the client's edema and pain have ceased 4. During the client's skin care and physical therapy
851. Ans: 4 4. Until the order is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; adduction to or beyond the midline is not permitted until allowed by the practitioner.
852. When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, the nurse should instruct the client to: 1. Turn toward the operative side 2. Flex both knees while slowly lifting the pelvis 3. Extend both legs and pull on the trapeze to lift the pelvis 4. Flex the unaffected knee and pull on the trapeze to raise the pelvis
852. Ans: 4 4. The pelvis is elevated by actions involving the unaffected upper extremities and unaffected leg.
155. As Mr. Mesta's condition improves, he mentions his dislike for the low-sodium, low-protein diet ordered by his doctor. He states, "That food is not fit for a man to eat!" The best response that the nurse could make at this time is: A. "It must be difficult for you to accept these changes In your diet, Mr. Mesta." B. "Well, you've got to make the best of it, Mr. Mesta. You've really no choice but to follow the doctor's orders." C. "It could be worse, Mr. Mesta. That poor person In the next bed isn't allowed to eat anything at all" D. "Maybe we could talk to your doctor, Mr. Mesta. We could ask him. to put you on a regular diet since you will be going home soon."
A. ''It must be difficult for you to accept these changes in your diet, Mr. Mesta." This response is the most supportive of the four choices given. It shows concern and understanding for Mr. Mesta's situation in a nonjudgmental way. B is a less desirable response since it focuses on telling the client what to do and suggest he is powerless in the situation. C is also an undesirable response if the nurse hopes to achieve long-term compliance with the prescribed diet. The fact that another client cannot eat may be true, but it is unlikely to motivate Mr. Mesta to change his dietary habits. D is incorrect and suggests that the nurse does not understand the need for long-term changes in dietary habits.
124. The first IV infusion began at 8 AM. At 11 A.M., given a correct flow rate and no interference, the nurse expects the first 1000-mL container to contain: A. 625 mL. B. 736 mL. C. 840 mL. D. 437 mL.
A. 625 mL. 3000 mL in 24 hours = 125 mL per hour. 125 mL x 3 hours = 375 mL. 1000 - 375 = 625 mL.
38. If the client with severe liver damage is retaining nitrogen waste products, the nurse will note in the lab reports an increase in serum: A. Ammonia. B. Leukocytes. C. Creatinine. D. Urea nitrogen.
A. Ammonia. Ammonia Is formed by the decomposition of nitrogen containing substances, such as proteins and amino acid. It is markedly elevated in clients with a severely damaged liver-specifically, hepatocellular necrosis. The damaged liver is unable to convert ammonia to urea thus, an increased ammonia level is seen. B Is a general Indication of infection, and Is not specific to liver damage. C and D are incorrect. They indicate dysfunction of the kidneys.
37. The nurse needs to know that lactulose and neomycin are given to clients with hepatic encephaiopathy to: A. Decrease fecal pH and ammonia absorption. B. Induce peristalsis and promote bowel movement. C. Reduce antibacterial activity in the intestines. D. Remove potassium and magnesium in the intestines.
A. Decrease fecal pH and ammonia absorption. Lactulose, a synthetic disaccharide that contains galactose and fructose, reduces the ammonia level by expeliing the ammonia Into the bowel through its laxative action. Neomycin reduces the ammonia-forming bacteria in the intestinal tract. Thus, lactulose and neomycin are effective drugs used in clients with hepatic encephalopathy because they reduce the ammonia level in the body. The pharmacologic actions of lactulose and neomycin are not Included in B, C, and D they are incorrect responses.
112. Mr. Williams enters the hospital reporting that he has vomited a very large amount of blood. The nurse should expect which sign to be present? A. Decreased blood pressure. B. Decreased pulse. C. Decreased respirations. D. Increased urinary output.
A. Decreased blood pressure. The decreased blood pressure is due to a fall in cardiac output because of loss of volume. Band C are Incorrect because both pulse and respirations are increased. D is incorrect because urinary output is decreased.
152. Which nursing observation Is an Inappropriate indicator of GI bleeding? A. Elevated BUN. B. Coffee-ground emesis. C. Black, tarry stools. D. Lowered hemoglobin.
A. Elevated BUN. BUN levels reflect the kidney's ability to excrete urea, an end product of protein metabolism. B, C, and D are classic signs of GI bleeding.
36. An Ineffective nursing measure to prevent the progress of hepatic coma is: A. Giving diuretics. B. Making certain that a low-protein diet is served. C. Assessing if there Is adequate renal perfusion. D. Assessing for a patent airway and oxygenation.
A. Giving diuretics. A is the incorrect nursing measure and therefore the correct answer. Diuretics stimulate the excretion of urine. They are not used in clients who are in hepatic coma because they precipitate the occurrence of hypovolemia. Hypovolemia decreases the perfusion of the liver, causing further injury to the already damaged liver cells and potentiating hepatic coma. B, C, and D are appropriate nursing measures, but they are incorrect responses to the question asked. Any source of increase in blood ammonia, such as a high-protein diet and a markedly decreased urine output, should be prevented. Poor tissue oxygenation to the liver cells should also be prevented.
115. The nurse is observing for the possible complication of postoperative peritonitis. Which sign or symptom is feast indicative of peritonitis? A. Hyperactive bowel sounds. B. Pain, local or general. C. Abdominal rigidity. D. Shallow respirations.
A. Hyperactive bowel sounds. Absence of bowel sounds is indicative of peritonitis, as in B, C, and D.
128. As she Is preparing for discharge, Ms. Norfolk reports to the nurse that she has pain In the calf of her left leg. The nurse assesses the situation and finds a positive Romans' sign. The nurse's decision Is to: A Put Ms. Norfolk on bedrest. B. Measure her left calf and reassess in 4 hours. C. Assist Ms. Norfolk In ambulation. D. Massage the cramp In her calf.
A. Put Ms. Norfolk on bedrest. Thrombophlebitis is a very serious complication and the client must be immobilized to prevent further life threatening problems. B Is incorrect because problems should be reported immediately. C and D are incorrect because they could assist a clot in traveling from the calf to a vital organ. The nurse should not ambulate and should never massage the client when thrombophlebitis is suspected.
111. Cllents with duodenal ulcers are sometimes given drugs such as propanthellne bromide (Pro-Banthine). The nurse knows that the desired effect of these drugs is to: A. Decrease gastric motility. B. Tranquilize the cIient C. Increase gastric secretions. D. Directly stimulate mucosal cell growth.
A. To decrease gastric motility. These drugs decrease gastric secretions by decreasing gastric motility. B, C, and D are incorrect because the drugs have no tranquilizing effect; decrease, rather than increase, secretions; and do not influence cell growth.
390. Because of chronic crampy pain, diarrhea, and cachexia, a young adult is to receive total parenteral nutrition (TPN) via a central line. Before preparing a client for the insertion of the catheter, the nurse is aware that a: 1. Parenteral solution may be administered intermittently 2. Fluoroscopy must be done before the catheter is inserted 3. Jugular vein is the most commonly used catheter insertion site 4. Client will experience a moderate amount of pain during the procedure
Ans: 1 1 Although the central venous catheter remains in situ, total parenteral nutrition does not have to infuse continuously. Continuous versus intermittent administration depends on the practitioner's order.
859. As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints because this may precipitate: 1. Pain 2. Swelling 3. Nodule formation 4. Tophaceous deposits
Ans: 1 1 Palpation will elicit tenderness because pressure stimulates nerve endings and causes pain.
865. After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is: 1. Addressing the pain 2. Reversing feelings of hopelessness 3. Promoting mobility in the residual limb 4. Acknowledging the grieving for the lost limb
Ans: 1 1 Phantom limb sensation is a real experience with no known cause or cure. The pain must acknowledged and interventions to relieve the discomfort explored.
416. A client with gastric cancer asks whether this cancer will spread. The nurse identifies that the client is looking for reassurance. When preparing a response to the client's question, the nurse recalls that gastric cancers are most likely to metastasize to the: 1. Liver and lung 2. Bone and brain 3. Pancreas and brain 4. Lymph nodes and blood
Ans: 1 1. 1 Statistics demonstrate that these are the most likely sites for metastasis of this tumor.
456. A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: 1. Monitor the client's vital signs 2. Increase the client's fluid intake 3. Improve the client's nutritional status 4. Determine the client's reasons for drinking
Ans: 1 1. A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol.
401. During a health symposium a nurse teaches the group how to prevent food poisoning. The nurse evaluates that the teaching is understood when one of the participants states: 1. "Meats and cream-based foods need to be refrigerated." 2. "Once most food is cooked it does not need to be refrigerated." 3. "Poultry should be stuffed and then refrigerated before cooking." 4. "Cooked food should be cooled before being put into the refrigerator."
Ans: 1 1. A cold environment limits growth of microorganisms.
430. Three hours after a subtotal gastrectomy, a client who has a nasogastric tube to continuous low suction and IV fluids complains of nausea and abdominal pain. The client's abdomen appears distended and there are no bowel sounds. The nurse should first: 1. Instill air into the tube 2. Give the prn pain medication 3. Check bowel movements for blood 4. Notify the surgeon of absent bowel sounds
Ans: 1 1. Abdominal distention, nausea, and abdominal pain can be signs of nasogatric tube blockage. Instilling 30 ml of air may reestablish patency.
862. A client with rheumatoid arthritis is in the convalescent stage of an exacerbation. What should the nurse encourage the client to do when the client says, "The only time I am without pain is when I lie perfectly still." 1. Active joint flexion and extension 2. Flexion exercises three times a day 3. Range-of-motion exercises once a day 4. Continued immobility until remission occurs
Ans: 1 1. Active exercises (e.g., alternating extension, flexion, abduction, and adduction) mobilize exudate in the joints and relieve stiffness and pain.
415. A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Preoperative preparation for this client should include an explanation about the postoperative: 1. Gastric suction 2. Oxygen therapy 3. Fluid restriction 4. Urinary catheter
Ans: 1 1. After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions.
405. A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for esophageal perforation, which is indicated by: 1. Tachycardia and abdominal pain 2. Faintness and feelings of fullness 3. Diaphoresis and cardiac palpitations 4. Increased blood pressure and urinary output
Ans: 1 1. An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux.
438. A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment is conducted to determine whether the client: 1. Is deficient in vitamins A, D, and K 2. Eats adequate amounts of dietary fiber 3. Consumes excessive amounts of protein 4. Has excessive levels of potassium and folic acid
Ans: 1 1. Bile promotes the absorption of the fat-soluble vitamins. An obstruction of the common bile duct limits the flow of bile to the duodenum and thus the absorption of these fat-soluble vitamins.
425. To determine when a client who had a subtotal gastrectomy can begin oral feedings after surgery, the nurse must assess for the: 1. Presence of flatulence 2. Extent of incisional pain 3. Stabilization of hematocrit levels 4. Occurrence of dumping syndrome
Ans: 1 1. Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the GI tract.
410. When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as: 1. Gnawing epigastric pain or boring pain in the back 2. Located in the right shoulder and preceded by nausea 3. Sudden, sharp abdominal pain, increasing in intensity 4. Heartburn and substernal discomfort when lying down
Ans: 1 1. Classic symptoms of peptic ulcer include gnawing, boring, or dull pain located in the midepigastrium or back; pain is caused by irritability and erosion of the mucosal lining.
826. After a long leg cast is removed, the client should be instructed to: 1. Elevate the leg when sitting 2. Report stiffness of the ankle 3. Perform full range of motion once a day 4. Cleanse the leg by scrubbing with a washcloth
Ans: 1 1. Elevation will help control the edema that usually occurs after an injury or if the injured part is left in a dependent position.
819. A client with multiple injuries from an automobile collision is now permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse: 1. Fold the client's arms across, the chest 2. Place the sling so that the top is below the client's scapulae 3. Call the practitioner to secure an order to use a mechanical lift 4. Raise the lift so that the sling is at least twelve inches above the mattress
Ans: 1 1. Folding the arms across the chest maintains both arms in a safe position during the transfer.
459. A client is diagnosed as having hepatitis A. The information from the admitting data that most likely is linked to hepatitis A is the client's history of working: 1. For a local plumber 2. In a hemodialysis unit of a hospital 3. As a dishwasher at a local restaurant 4. With occupational arsenic compounds
Ans: 1 1. Hepatitis A is primarily spread via a fecal-oral route; sewage-polluted water may harbor the virus.
419. After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for: 1. Monthly injections of vitamin B12 2. Regular daily use of a stool softener 3. Weekly injections of iron dextran (Imferon) 4. Daily replacement therapy of pancreatic enzymes
Ans: 1 1. Intrinsic factor is lost with removal of the stomach, and vitamin B12 is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life.
864. A nurse is providing health teaching to a client with rheumatoid arthritis. The statement by the nurse that best describes a technique to reduce joint stress is: 1. "Respond to pain in your joints." 2. "Use your smaller muscles most frequently." 3. "Do your heavy tasks at one time to reduce muscle strain." 4. "Increase exercise to reduce swelling when your joints are swollen."
Ans: 1 1. Not neglecting joint pain protects the joints, especially if the pain lasts more than 1 or 2 hours after a particular activity.
832. An older female client is experiencing frequency and uses the bathroom often during the night. One night while attempting to go to the bathroom without assistance, she develops severe back pain and is found to have a vertebral compression fracture. The nurse understands that this is a: 1. Collapse of vertebral bodies 2. Demineralization of the spinal cord 3. Wear and tear of the spinous processes 4. Bulging of the spinal cord from the vertebra
Ans: 1 1. Osteoporotic vertebrae collapse under the weight of the upper body or by improper or rapid turning, reaching, or lifting.
435. A client with a tentative diagnosis of cholecystitis is discharged from the emergency department with instructions to make an appointment for a definitive diagnostic workup. The recommendation that will produce the most valuable diagnostic information is: 1. "Keep a journal related to your pain." 2. "Save all stool and urine for inspection." 3. "Follow the physician's orders exactly without question." 4. "Keep a record of the amount and type of fluid you are drinking daily."
Ans: 1 1. Pain is a cardinal symptom; it is helpful to have as much specific information about it as possible, particularly its description and its relationship to foods ingested.
445. A client with cholelithiasis is scheduled for a lithotripsy. Preoperative teaching should include the information that: 1. Opioids will be available for postoperative pain 2. Fever is a common response to this intervention 3. Heart palpitations often occur after the procedure 4. Anesthetics are not necessary during the procedure
Ans: 1 1. Painful biliary colic may occur in the postoperative period as a result of the passage of pulverized fragments of the calculi; this may occur 3 or more days after the lithotripsy.
839. A male client has a diskectomy and fusion for a herniated nucleus pulposis. When two nurses are assisting the client to get out of bed for the first time he complains of feeling faint and lightheaded. The nurses should have the client: 1. Sit on the edge of the bed so they can hold him upright 2. Slide to the floor so he will not hurt himself when falling 3. Bend fonvard so that blood flow to his brain is increased 4. Lie down immediately so they can take his blood pressure
Ans: 1 1. Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides.
384. A practitioner tells a client that an increase in vitamin E and beta-carotene is important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are: 1. Spinach and mangoes 2. Fish and peanut butter 3. Oranges and grapefruits 4. Carrots and sweet potatoes
Ans: 1 1. The antioxidants vitamin E and beta-carotene, which help inhibit oxidation and therefore tissue breakdown, are found in these foods.
380. The most effective method for the nurse to evaluate a client's response to ongoing serum albumin therapy for biliary cirrhosis is to monitor the client's: 1. Weight daily 2. Vital signs frequently 3. Urine output every half hour 4. Urine albumin level evety shift
Ans: 1 1. The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss.
398. A client has a body mass index (BMI) of 35 and verbalize the need to lose weight. The nurse encourages the client to lose weight safely by: 1. Decreasing portion size and fat intake 2. Increasing protein and vegetable intake 3. Decreasing carbohydrate and fat intake 4. Increasing fruits and limiting fluid intake
Ans: 1 1. The most effective and safest method for achieving weight loss is to decrease caloric intake. This is best accomplished by maintaining a balance of nutrients while decreasing portion size and fat intake. A gram of fat is 9 calories, whereas a gram of protein and a gram of carbohydrate are each 4 calories.
393. After surgical implantation of radon seeds for oral cancer, the nurse observes the client for the side effects of the radiation including: 1. Nausea and/or vomiting 2. Hematuria and/or occult blood 3. Hypotension and/or bradycardia 4. Abdominal cramping and/or diarrhea
Ans: 1 1. The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting.
421. A client with extensive gastric carcinoma is admitted to the hospital for an esophagojejunostomy. What information should the nurse include in the teaching plan when preparing this client for surgery? 1. Chest tube will be in place immediately after surgery 2. Liquids by mouth may be permitted the evening after surgery 3. Complete bed rest may be necessary for two days after surgery 4. Trendelenburg's position will be used on the first day after surgery
Ans: 1 1. The thoracic cavity usually is entered for a complete resection, necessitating a chest tube.
434. The characteristics that alert the nurse that a client is at increased risk of developing gallbladder disease is a female: 1. Older than the age of 40, obese 2. Younger than the age of 40, history of high fat intake 3. Older than the age of 40, low serum cholesterol level 4. Younger than the age of 40, family history of gallstones
Ans: 1 1. These characteristics are well-established risk factors for gallbladder disease (3 Fs - female, fat, and forty).
816. A client is scheduled for arthroscopic knee surgery and asks the nurse about the procedure. The statement by the nurse that best describes the procedure is: 1. "It is surgical repair of a joint under direct visualization using an arthroscope." 2. "It is a radiological procedure that will help diagnose the extent of the knee injury." 3. "The procedure will determine the type of treatments the surgeon will prescribe." 4. "You will be anesthetized so that you do not remember anything about the procedure."
Ans: 1 1. This describes the procedure in which the surgeon uses a scope to visualize and operate on the knee.
841. A back brace is prescribed for a client who has had a laminectomy. What instruction should the nurse include in the teaching plan? 1. Apply the brace before getting out of bed 2. Put the brace on while in the sitting position 3. Use the brace when the back begins to feel tired 4. Wear the brace when performing twisting exercises
Ans: 1 1. This is done while in the supine position before the body is subjected to the force of gravity in a vertical position. Anatomical landmarks are easier to located for correct application of the braace, and intra-abdominal organs have not shifted toward the pelvic floor by gravity.
466. When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed: 1. In the supine position, with the right arm raised behind the head 2. On the right side, with the left arm stretched up and over the head 3. On the left side, with the right arm extended out in front across the bed 4. In the prone position, with both elbows flexed and the hands resting on the pillow
Ans: 1 1. This position exposes the right intercostal space, making the large right lobe of the liver accessible.
382. A client is cautioned to avoid vitamin D toxicity while increasing protein intake. The nurse evaluates that dietary teaching is understood when the client states, "I must increase my intake of: 1. tofu products." 2. eggnog with fruit." 3. powdered whole milk." 4. cottage cheese custard."
Ans: 1 1. Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D.
427. A client who is diagnosed with a duodenal ulcer asks, "Now that I have an ulcer, what comes next?" The nurse's best response is: 1. "Most peptic ulcers heal with medical treatment." 2. "Clients with peptic ulcers have pain while eating." 3. "Early surgery is advisable, especially after the first attack." 4. "If ulcers are untreated, cancer of the stomach can develop."
Ans: 1 1. Treatment with medications, rest, diet, and stress reduction relieves symptoms, heals the ulcer, and prevents complications and recurrence.
491. An abdominoperineal resection with the creation of a colostomy is scheduled for a client with cancer of the rectum. The nurse anticipates that the client must sign a consent for a: 1. Permanent sigmoid colostomy 2. Permanent ascending colostomy 3. Temporary double-barrel colostomy 4. Temporary transverse loop colostomy
Ans: 1 1. When intestinal continuity cannot be resorted after removal of the anus, rectum, and adjacent colon, a permanent colostomy is formed.
429. After abdominal surgery a client returns to the unit with a nasogastric tube to decompression. The practitioner orders an antiemetic every 6 hours pm for nausea. When the client complains of nausea, the first action by the nurse is to: 1. Check for placement of the tube 2. Administer the ordered antiemetic 3. Irrigate the tube with normal saline 4. Notify the practitioner of the problem
Ans: 1 1. With a nasogatric tube for decompression in place, nausea may indicate tube displacement or obstruction. Checking placement can determine whether it is in the stomach; once placement is verified, then fluid can be instilled to ensure patency.
449. A 50-year-old man is admitted to the hospital with severe back and abdominal pain, nausea and occasional vomiting, and an oral temperature of 101°F. He reports drinking six to eight beers a day. A diagnosis of acute pancreatitis is made. Based on the data presented, the primary nursing concern for this client is: 1. Acute pain 2. Inadequate nutrition 3. Electrolyte imbalance 4. Disturbed self-concept
Ans: 1. 1. Pain with pancreatitis usually is severe and is the major symptom; it occurs because of the auto-digestive process in the pancrease and peritoneal irritation.
869. A nurse is teaching a client who is to have an above-the-knee amputation about postoperative activities. Which activity is designed to aid in the use of crutches? 1. Lifting weights 2. Changing bed positions 3. Caring for the residual limb 4. Performing phantom limb exercises
Ans: 1. 1. Preparation for crutch walking includes exercises to strengthen arm and shoulder muscles.
444. Because of prolonged bile drainage from aT-tube after a cholecystectomy, the nurse must monitor the client for responses related to a lack of fat -soluble vitamins such as: 1. Easy bruising 2. Muscle twitching 3. Excessive jaundice 4. Tingling of the fingers
Ans: 1. 1. Vitamin K, a precursor for prothrombin, cannot be absorbed without bile.
845. A client sustains a fracture of the femur after jumping from the second story of a building during a fire. The client is placed in Buck's traction until an open reduction and internal fixation is performed. The client keeps slipping down in bed. To alleviate this problem the nurse should: 1. Elevate the foot of the bed 2. Shorten the rope on the weights 3. Release the traction so the client can be repositioned 4. Move the client toward the head of the bed every couple of hours
Ans: 1. 1. This provides slight contertraction, which will prevent sliding down the bed.
856. A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to: 1. Cleanse the pin sites with alcohol several times a day 2. Perform a neurovascular assessment of both lower extremities 3. Ambulate the client with partial weight bearing on the affected leg 4. Maintain placement of an abduction pillow between the client's legs
Ans: 2 2 A neurovascular assessment identifies early signs and symptoms of compartment syndrome. Compartment syndrome is increased pressure within a closed fascial space caused by a fracture and/or soft tissue damage that compresses circulatory vessels, nerves, and tissues compromising viability of the limb. The nurse should monitor for the 6 P's: unrelenting pain, pallor, paresthesia, pressure, pulselessness, and paralysis. In addition, the circumference of the extremity will increase and the leg, will feel hard and In-m on palpation. Both legs are assessed for symmetry.
448. A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis? 1. Blood glucose 2. Serum amylase 3. Serum bilirubin level 4. White blood cell count
Ans: 2 2 Amylase concentration is increased in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed; this distinguishes pancreatitis from other acute abdominal problems.
858. When assessing a client experiencing an acute episode of rheumatoid arthritis, the nurse observes that the client's finger joints are swollen. The nurse concludes that this swelling most likely is related to: 1. Urate crystals in the synovial tissue 2. Inflammation in the joint's synovial lining 3. Formation of bony spurs on the joint surfaces 4. Escaped fluid from the capillaries that increases interstitial fluids
Ans: 2 2 The pathological process involved with rheumatoid arthritis is accompanied by vascular congestion, fibrin exudate) and cellular infiltrate) causing inflammation of the synovium.
860. A practitioner orders bed rest for a client with acute arthritis who has bilateral, painful, swollen knee and wrist joints. To prevent flexion deformities during the acute phase, the client's positioning schedule should include placement in the: 1. Sims position 2. Prone position 3. Contour position 4. Trendelenburg position
Ans: 2 2 The prone position provides for extension of the hip and knee joints.
373. When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. This area is known as the: 1. Iliac area 2. Epigastric area 3. Hypogastric area 4. Suprasternal area
Ans: 2 2 The stomach is located within the sternal angle, known as the epigastric area.
823. A nurse is providing teaching about self-care to a client who had a cast applied for a fracture of the right ulna and radius. For which occurrence should the nurse instruct the client to immediately notify the practitioner? 1. Slight stiffness of the fingers 2. Increasing pain at the injury site 3. Small amount of bloody drainage on the cast 4. Bounding radial pulse in the affected extremity
Ans: 2 2 This may indicate cast pressure on a nerve and should be investigated further.
850. The most appropriate action by the nurse when assisting a client who has had a hip replacement to get out of bed 4 hours after surgery is to: 1. Tell the client that weight bearing must be on both legs equally 2. Advise the client that the legs must be kept wide apart continually 3. Sit the client in a straight-back chair so that the hips are kept flexed 4. Transfer the client using a mechanical lift because weight bearing on the leg is not allowed
Ans: 2 2. Abduction keeps the prosthesis firmly in place; adduction of the extremity may cause the prosthesis to dislocate.
407. When discussing future meal plans with a client who has a hiatal hernia, the nurse asks what beverages the client usually enjoys. The beverage that should be included in the diet when the client is discharged is: 1. Ginger ale 2. Apple juice 3. Orange juice 4. Cola beverages
Ans: 2 2. Apple juice is not irritating to the gastric mucosa.
423. Immediately after a subtotal gastrectomy a client is brought to the postanesthesia care unit. The nurse identifies small blood clots in the gastric drainage. The nurse should: 1. Clamp the tube 2. Consider this an expected event 3. Instill the tube with iced normal saline 4. Notify the client's surgeon of this finding
Ans: 2 2. As a result of the trauma of surgery, some bleeding can be expected for 4 to 5 hours.
818. A client with impaired balance is using a walker to provide support when ambulating. While observing the client transferring from a sitting to a standing position and using the walker, the nurse evaluates that further teaching is required when the client: 1. Slides toward the edge of the seat before standing 2. Holds both handles of the walker while rising to the standing position 3. Moves forward into the walker after transferring from sitting to standing 4. Stands in place holding on to the walker for at least 30 seconds before walking
Ans: 2 2. Because of the angle of force applied to a walker when a person uses it to move from a sitting to a standing position, the walker can become unstable and tip over. The arms of the chair should be used for support when rising from a sitting position.
404. Immediately after esophageal surgery the priority nursing assessment concerns the client's: 1. Incision 2. Respirations 3. Level of pain 4. Nasogastric tube
Ans: 2 2. Because of the trauma of surgery and the proximity of the esophagus to the trachea, respiratory assessments become the priority.
849. A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, the nurse expects the surgeon's order to state: 1. "Turn from side to side periodically." 2. "Apply sequential compression stockings." 3. "Encourage isometric exercises to the extremities." 4. "Perform passive range of motion to the affected extremity:
Ans: 2 2. Compressed air inflates the padded plastic stockings systematically from ankle to calf to thigh and then deflates; this prmotes venous return and prevents venous stasis and thromboembolism.
461. A client with jaundice associated with hepatitis expresses concern over the change in skin color. The nurse explains that this color change is a result of: 1. Stimulation of the liver to produce an excess quantity of bile pigments 2. Inability of the liver to remove normal amounts of bilirubin fi'om the blood 3. Increased destruction of red blood cells during the acute phase of the disease 4. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
Ans: 2 2. Damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, with resulting deposition in the skin and sclera.
821. An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. The nurse expects that with a comminuted fracture: 1. Bone protrudes through a break in the skin 2. The bone has broken into several fragments and the skin is intact 3. The bone is broken into two parts and the skin mayor may not be broken 4. Splintering has occurred on one side of the bone and bending on the other
Ans: 2 2. In a comminuted fracture, the bone is splintered or crushed.
417. Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric tube. The nurse should: 1. Clamp the tube and call the surgeon immediately 2. Report the characteristics of drainage to the surgeon 3. Instill 30 mL of iced normal saline into the nasogastric tube 4. Continue to monitor the drainage and record the observations
Ans: 2 2. Large amounts of blood or excessive bloody drainage 12 hours postoperatively must be reported immediately because the client is hemorrhaging.
866. A client has an above-the-knee amputation because of a gangrenous leg ulcer. To prevent deformities after the second postoperative day the nurse should: 1. Place an abduction pillow between the legs 2. Encourage lying in the supine or prone position 3. Keep the client's residual limb elevated on a pillow 4. Teach the client to press the residual limb against a hard surface several times a day
Ans: 2 2. Lying in the horizontal position stretches the flexor muscles and prevents a flexion contraction of the hip.
840. When preparing a client for discharge after a laminectomy, the nurse evaluates that further health teaching is necessary when the client says, "I should: 1. sleep on a firm mattress to support my back." 3. spend most of day sitting in a straight-back chair." 3. put a pillow under my legs when sleeping on my back." 4. avoid lifting heavy objects until the physician tells me I can."
Ans: 2 2. Maintaining the sitting position for a prolonged period places excessive stress on the surgical area.
822. Clients who have casts applied to an extremity must be monitored for complications. The most significant complication for which the nurse should assess the client's extremity is: 1. Warmth 2. Numbness 3. Skin desquamation 4. Generalized discomfort
Ans: 2 2. Numbness is a neurological sign because it indicates pressure on the nerves and blood vessels and should be reported immediately. 1. Warmth is a sign of adequate circulation. 3. Skin desquamation results from inadequate skin care and can be managed with lotion or oil. 4. Some degree of discomfort is expected after cast application.
440. A 40-year-old client is admitted with biliary cancer. The associated jaundice gets progressively worse. The nurse is most concerned about the potential complication of: 1. Pruritus 2. Bleeding 3. Flatulence 4. Hypokalemia
Ans: 2 2. Obstruction of bile flow impairs absorption of vitamin K, a fat-soluble vitamin; prothrombin is not produces and the clotting process is prolonged.
411. A client is suspected of having a gastric peptic ulcer. When obtaining a history from this client, the nurse expects the reported pain to: 1. Intensify when the client vomits 2. Occur one to three hours after meals 3. Increase when the client eats fatty foods 4. Begin in the epigastrium, radiating across the abdomen
Ans: 2 2. Pain occurs after the stomach empties with a gastric peptic ulcer; ingesting food stimulates gastric secretions, which later act on the gastric mucosa of the empty stomach, causing the gnawing pain.
838. The nurse teaches a male client who developed degenerative joint disease of the vertebral column to turn himself from his back to his side, keeping his spine straight. The nurse explains that the least effort will be exerted if he crosses his arm over his chest and: 1. Uses his overbed table to pull himself to one side 2. Bends his top kuee to the side to which he is turning 3. Crosses his ankles while turning with both his legs straight 4. Flexes his bottom knee to the side to which he wishes to turn
Ans: 2 2. Putting the upper arm and leg toward the side to which the client is turning uses body weight to facilitate turning; the spine is kept straight.
454. After revision of the pancreas because of cancer, total parenteral nutrition is instituted via a central venous infusion route. During the fourth hour of the infusion the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. The nurse should call the practitioner and: 1. Stop the infusion while covering the insertion site 2. Slow the infusion and check the serum glucose level 3. Prepare the client for immediate surgery for possible bowel obstruction 4. Increase fluids via a peripheral intravenous route and give analgesics for the headache
Ans: 2 2. Rapid administration can cause glucose overload, leading to osmotic diuresis and dehydration; slowing the infusion decreases the possibility of glucose overload.
831. When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating: 1. eggs." 2. shellfish." 3. fried poultry." 4. cottage cheese."
Ans: 2 2. Shellfish contains more than 100 mg of purine per 100 grams.
842. After a cervical neck injury, a male client is placed in a halo fixation device with a body cast. A statement that indicates that the client's concern about body image has been successfully resolved is: 1. "I hate having everyone else do things for me." 2. ''I've gotten used to the brace. 1 may even miss it when it's gone." 3. ''I've been keeping my daily calories low in an attempt to lose weight." 4. "I can't get to sleep. However, I make up for it in the morning by sleeping later."
Ans: 2 2. The client is demonstrating acceptance and is looking toward the future.
827. While a woman with a fractured femur is being prepared for surgery, she exhibits cyanosis, tachycardia, dyspnea, and restlessness. What should the nurse do first? 1. Call the practitioner 2. Administer oxygen by mask 3. Place her in the high Fowler's position 4. Lower her to the Trendelenburg position
Ans: 2 2. The client probably has a fat embolus; oxygen reduces surface tension of the fat globules and reduces hypoxia.
814. A nurse is performing range-of-motion exercises with a client who had a brain attack. The nurse places the client's hand in the position exhibited in the picture (open hand with fingers fully extended). This position is known as: 1. Flexion 2. Extension 3. Adduction 4. Circumduction
Ans: 2 2. The fingers are flared out in the extended, abducted position.
399. A client has symptoms associated with salmonellosis. Relevant data to gather from this client include a history of: 1. Any rectal cancer in the family 2. All foods eaten in the past 24 hours 3. Any recent extreme emotional stress 4. An upper respiratory infection in the past 10 days
Ans: 2 2. The salmonella organism thrives in warm, most environments; washing, cooking, and refrigeration of food limits the growth of or eliminates the organism
378. The diet ordered for a client permits 190 grams of carbohydrates, 90 grams of fat, and 100 grams of protein. The nurse calculates that this diet contains approximately how many calories? 1. 920 calories 2. 1970 calories 3. 2470 calories 4. 2970 calories
Ans: 2 2. This diet contains approximately 1970 calories. There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate and protein.
825. Three days after a cast is applied to a client's fractured tibia, the client reports that there is a burning pain over the ankle. The cast over the ankle feels warm to the touch, and the pain is not relieved when the client changes position. The nurse's priority action is to: 1. Obtain an order for an antibiotic 2. Report the client's concern to the practitioner 3. Administer the prescribed medication for pain 4. Explain that this is typical after a cast is applied
Ans: 2 2. This indicates tissue hypoxia or breakdown and should be reported to the practitioner.
379. A client's serum albumin value is 2.8 g/dL. The nurse evaluates that teaching is successful when the client says, "For lunch I am going to have: 1. fruit salad." 2. sliced turkey." 3. spinach salad." 4. clear beef broth."
Ans: 2 2. This serum albumin value indicates severe depletion of visceral protein stores; the expected range for serum albumin is 3.5 to 5.5 g/dL; white meat turkey (two slices 4 x 2 x 1/4 inch) contains approximately 28 grams of protein.
813. A nurse explains to a client that stimulation of calcium deposition in the bone after a distal femoral fracture is best achieved by: 1. Resting the extremity 2. Weight-bearing activity 3. Normal aging processes 4. Ingesting foods high in ca
Ans: 2 2. Weight bearing and the use of antigravity muscles stimulate bone formatiqn or osteoblastic function.
870. A client has a below-the-knee amputation. The nurse concludes that a major advantage of a postoperative prosthesis applied immediately is that it: 1. Decreases phantom limb sensations 2. Encourages a normal walking pattern 3. Reduces the incidence of wound infection 4. Allows for the fitting of the prosthesis before discharge
Ans: 2 2. Without the prosthesis, a walker or crutches will be necessary and require the readjustment of weight bearing on one leg.
376. Routine postoperative intravenous fluids are designed to supply hydration and electrolytes and only limited energy. Because 1 L of a 5% dextrose solution contains 50 grams of sugar, 3 L/day will supply approximately: 1. 400 kilocalories 2. 600 kilocalories 3. 800 kilocalories 4. 1000 kilocalories
Ans: 2 Ans: 2 2. Carbohydrates provide 4 kcal/g; therefore, 3 L x 50 g/L x 4 kcal/g = 600 kcal, only about a third of the basal energy need.
414. After an acute episode of upper GI bleeding, a client vomits undigested antacids and complains of severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the practitioner, the nurse should: 1. Start oxygen via nasal cannula 2. Keep the client NPO in preparation for surgery 3. Inquire whether any red or black stools have been noted 4. Place the client in the supine position with the legs elevated
Ans: 2 These are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated.
422. A client has just undergone a subtotal gastrectomy. Part of discharge teaching includes information about dumping syndrome. What instructions by the nurse will best minimize dumping syndrome? Select all that apply. 1. Drink fluids with meals 2. Eat small frequent meals 3. Lie down for 1 hour after eating 4. Chew food five times before swallowing 5. Increase the carbohydrate component of the diet
Ans: 2,3 2. Small, frequent meals keep the volume within the stomach to a minimum at anyone time, limiting dumping syndrome. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. 3. Lying down delays emptying of the stomach contents, which will limit dumping syndrome.
863. A client who has passed the acute phase of rheumatoid arthritis is now allowed out of bed as tolerated. After assisting the client out of bed, the nurse should place the client in a: 1. Low, soft lounge chair 2. Straight-back armchair 3. Wheelchair with footrests 4. Recliner chair with both legs elevated
Ans: 2. 2. This chair allows the hips and shoulders to be against the back of the chair while fully supporting the thighs.
844. A 67-year-old woman fen while washing windows in her apartment. X-ray films indicate an intertrochanteric fracture of the left femur. She is to be placed in Buck's traction until surgery is performed the next morning. Nursing care is based on the fact that the primary purpose of Buck's traction is to: 1. Reduce the fracture 2. Immobilize the fracture 3. Maintain abduction of the leg 4. Eliminate rotation of the femur
Ans: 2. A continuous pull on the lower extremity keeps bone fragments from moving and causing further trauma, pain and edema.
424. On the third postoperative day after a subtotal gastrectomy, a client complains of severe abdominal pain. The nurse palpates the client's abdomen and identifies rigidity. The nurse should first: 1. Assist the client to ambulate 2. Obtain the client's vital signs 3. Administer the prescribed analgesic 4. Encourage the use of the spirometer
Ans: 2. Rigidity and pain are hallmarks of bleeding from the suture line and/or peritonitis; vital signs provide supportive data.
374. A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8 o'clock the next morning. The nurse advises the client to: 1. Have dinner and then nothing by mouth after 6 PM 2. Drink full liquids tonight and clear liquids in the morning 3. Consume a light evening meal and no food or fluid after midnight 4. Eat lunch the day before surgery and then not drink or eat anything until after surgery
Ans: 3 3 Eating a light meal and eliminating food and fluids after midnight limit complications during and after surgery, which include aspiration, nausea, dehydration, and possible ileus.
855. When planning discharge teaching for a client who had a total hip replacement, the nurse should include encouraging the client to avoid: 1. Climbing stairs 2. Stretching exercises 3. Sitting in a low chair 4. Lying prone for half an hour
Ans: 3 3 Excessive flexion of the hip can cause dislocation of the femoral head.
817. The practitioner orders non-weight bearing with crutches for a client with a leg injury. Before arnbulation is begun, the most important activity the nurse should teach the client to facilitate walking with crutches is: 1. Sitting up in a chair to help strengthen back muscles 2. Keeping the unaffected leg in extension and abduction 3. Exercising the triceps, finger flexors, and elbow extensors 4. Using a trapeze frequently to strengthen the bicep muscles
Ans: 3 3 These sets of muscles are used in crutch walking and therefore need strengthening.
847. A client has an open reduction and internal fixation for a fractured hip. Postoperatively the nurse should position the client's affected extremity in: 1. External rotation 2. Slight hip flexion 3. Moderate abduction 4. Anatomical body alignment
Ans: 3 3. Abduction reduces stress on anatomical structures and maintains the head of the femur in the acetabulum.
450. A client is diagnosed with chronic pancreatitis. When providing dietary teaching it is most important that the nurse instruct the client to: 1. Eat a low-fat, low-protein diet 2. Avoid foods high in carbohydrates 3. Avoid ingesting alcoholic beverages 4. Eat a bland diet of six small meals a day
Ans: 3 3. Alcohol increases pancreatic secretions, which cause pancreatic cell destruction.
837. After a client has spinal surgery, it is essential that the nurse: 1. Encourage the client to drink fluids 2. Log-roll the client to the prone position 3. Assess the client's feet for circulation and sensation 4. Observe the client's bowel movements and voiding patterns
Ans: 3 3. Alteration in circulation and sensation indicates damage to the spinal cord; if this occurs, the surgeon must be notified immediately.
854. A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is: 1. Oliguria 2. Dyspnea 3. Petechiae 4. Confusion
Ans: 3 3. At the time of a fracture or orthopedic surgery, fat globules may move from the bone marrow into the bloodstream. Also elevated catecholamines cause mobilization of fatty acids and the development of fat globules. In addition to obstructing vessels in the lung, brain, and kidneys with systemic embolization of small vessels from fat globules, petechiae are noted in the buccal membranes, conjunctival sacs, hard palate, chest, and anterior axillary folds; these adaptations only occur with a fat embolism.
372. A 79-year-old client is admitted to the hospital with painful abdominal spasms and severe diarrhea of 2 days' duration. The order of physical skills the nurse should follow when performing an admitting examination of this client should be "inspection" followed by: 1. Percussion, palpation, auscultation 2. Percussion, palpation, auscultation 3. Auscultation, palpation, percussion 4. Auscultation, percussion, palpation
Ans: 3 3. Auscultation must be performed bedore palpation and percussion because they may influence intestinal peristalsis resulting in inaccurate results. Palpation is performed before percussion because percussion will have a greater impact on peristalsis.
403. The laboratory values of a client with cancer of the esophagus show a hemoglobin of 7 g/dL, hematocrit of 25%, and RBC count of 2.5 million/mm3. The outcome that takes priority at this time is, "The client will: 1. be free of in injury." 2. remain pain free." 3. demonstrate improved nutrition." 4. maintain an effective airway clearance."
Ans: 3 3. Based on the presented data, improving nutritional status is the priority at this time. The decreased hemoglobin and hematocrit levels and RBC count may be a result of malnutrition; also cancer of the esophagus can cause dysphagia and anorexia.
409. A male client is diagnosed with acute gastritis, secondary to alcoholism and cirrhosis. When obtaining this client's history, the nurse gives priority to the client's statement that: 1. His pain increases after meals 2. He experiences nausea frequently 3. His stools have a black appearance 4. He recently joined Alcoholics Anonymous
Ans: 3 3. Black (tarry) stools indicate upper GI bleeding; digestive enzymes act on the blood resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels.
396. A client has decided to become a vegan and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse instructs this client to: 1. Add mille to grains to provide complete proteins 2. Use eggs and plant foods to provide essential amino acids 3. Plan a careful mixture of plant proteins to provide a balance of amino acids 4. Add cheese to grains and beans to increase the quality of the protein consumed
Ans: 3 3. Complementary mixtures of essential amino acids in plan proteins provide complete dietary protein equivalents.
828. A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the crutch walking? 1. Pulse of 100 and deep respirations 2. Flushed skin and slowed respirations 3. Profuse diaphoresis and rapid respirations 4. Blood pressure of 150/88 mm Hg and shallow respirations
Ans: 3 3. Diaphoresis and tachypnea indicate that the client has exceeded tolerance for the activity.
872. A 48-year-old farmer is admitted for the repair and revision of a residual limb immediately after the traumatic amputation of the left hand in a corn picker accident. A week after surgery the client complains of constant throbbing in the affected limb. Which is the most appropriate nursing intervention? 1. Applying cool compresses to the limb 2. Securing an order for pain medication 3. Elevating the extremity on two pillows 4. Loosening the bandage around the limb
Ans: 3 3. Elevation of the extremity promotes venous return, which limits edema and the related pressure on nerve endings that cause pain
400. A client is admitted to the hospital with the diagnosis of acute salmonellosis. The nurse expects that the client will receive: 1. Opioids 2. Antacids 3. Electrolytes 4. Antidiarrheals
Ans: 3 3. Fluids of dextrose and normal saline and electrolytes are administered to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output.
843. A 30-year-old runner sustains multiple fractures of the left femur when hit by an automobile. At the scene ofthe accident, an immediate life-threatening systemic complication of injury to the long bones can be minimized by: 1. Elevating the affected limb 2. Encouraging deep breathing and coughing 3. Handling and transporting the client gently 4. Maintaining anatomic alignment of the client's limb
Ans: 3 3. Gentle intervention reduces pain and shock and inhibits the release of bone marrow into the system, which can cause a fat embolism.
394. A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. This plan can best be implemented by: 1. Offering a firm-bristled toothbrush 2. Providing an antiseptic mouthwash 3. Using a gentle spray of normal saline 4. Swabbing the mouth with a moistened gauze square
Ans: 3 3. Gentle sprays are effective in cleaning the mouth and teeth without disturbing the sensitive tissues or radon seeds.
386. A client is instructed to avoid straining on defecation postoperatively. The nurse evaluates that the related teaching is understood when the client states, "I must increase my intake of: 1. ripe bananas." 2. milk products." 3. green vegetables." 4. creamed potatoes."
Ans: 3 3. Green vegetables contain fiber, which promotes defecation.
432. A client progresses to a regular diet after a gastrectomy for gastric cancer. After eating lunch the client becomes diaphoretic and has palpitations. What probably has caused these responses? 1. Intolerance to fatty foods 2. Dehiscence of the surgical incision 3. Extracellular fluid shift into the bowel 4. Diminished peristalsis in the small intestine
Ans: 3 3. Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (dumping syndrome).
442. During a laparoscopic cholecystectomy on an obese client, the surgeon encounters difficulty because of the presence of adhesions as a result of the client's having had a previous surgery. An abdominal cholecystectomy is performed. After surgery the nurse plans to alleviate tension on the surgical wound by: 1. Limiting deep breathing 2. Maintaining T-tube patency 3. Maintaining nasogastric tube patency 4. Encouraging the right side-lying position
Ans: 3 3. Maintaining nasogastric tube patency ensure gastric decompression, thus preventing abdominal distension, which places tension on the incision.
834. A client who is diagnosed as having a herniated nucleus pulposus complains of pain. The nurse concludes that the pain is caused by the: 1. Inflammation of the lamina of the involved vertebra 2. Shifting of two adjacent vertebral bodies out of alignment 3. Compression of the spinal cord by the extruded nucleus pulposus 4. Increased pressure of cerebrospinal fluid within the vertebral column
Ans: 3 3. Pain results because herniation of the nucleus pulposus into the spinal column irritates the spinal cord or the roots of spinal nerves.
439. A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the nursing action that is the priority for this client is: 1. Irrigating the T-tube frequently 2. Changing the dressing at least twice a day 3. Encouraging coughing and deep breathing 4. Promoting an adequate fluid and food intake
Ans: 3 3. Self-splinting results in shallow breathing, which does not aerate the lungs adequately, particularly the lower right lobe.
413. A traveling salesman develops gastric bleeding and is hospitalized. An important etiologic clue for the nurse to explore while taking this client's history is: 1. Any recent foreign travel 2. The client's usual dietary pattern 3. The medications that the client is taking 4. Any change in the status of family relationships
Ans: 3 3. Some medications, such as aspirin, NSAIDs, and prednisone, irritate the stomach lining and may cause bleeding with prolonged use.
385. Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling's). Stress ulcers usually are evidenced by: 1. Unexplained shock 2. Melena for several days 3. Sudden massive hemorrhage 4. Gradual drop in the hematocrit value
Ans: 3 3. Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding.
381. A practitioner orders a high-calorie, high-protein diet for a client who is a heavy smoker. In light of the history of smoking, the nurse encourages the client to eat foods high in: 1. Niacin 2. Thiamine 3. Vitamin C 4. Vitamin B-12
Ans: 3 3. The RDA requirement of vitam in C for an adult male is 90 mg; smoking accelerates oxidation of tissue vitamin C, so smokers need an additional 35mg/day.
833. A dock worker is admitted to the hospital with lower back pain and a tentative diagnosis of a herniated nucleus pulposus. When assessing the client's back pain, the nurse should ask: 1."Is there any tenderness in the calf of your leg?" 2. "Have you had any burning sensation on urination?" 3. "Do you have any increase in pain during bowel movements?" 4. "Does the pain progress from your flank around to your groin?"
Ans: 3 3. The Valsalva maneuver raises cerebrospinal fluid pressure, thereby causing pain.
871. A 70-year-old client is scheduled for a below-the-knee amputation because of a 10-year history of impaired arterial circulation to the lower extremities. The skill that the nurse teaches the client preoperatively that can be most helpful during the first several postoperative days is to: 1. Log-roll when turning in bed 2. Toughen the distal residual limb 3. Transfer from the bed to a wheelchair 4. Stand on one leg for five minutes several times a day
Ans: 3 3. The ability to transfer ensures mobility and a degree of independence postoperatively.
815. A male college basketball player comes to the infirmary complaining of a "click" in his knee when walking. He states that it occasionally gives way when he is running and sometimes locks. He does not recall any specific injury. Which condition should the nurse anticipate that the practitioner primarily will consider when determining the diagnostic tests to order? 1. Cracked patella 2. Ruptured Achilles tendon 3. Injured cartilage in the knee 4. Stress fracture of the tibial plateau
Ans: 3 3. These adaptations are consistent with a torn cartilage; this injury is common among basketball players.
389. When a client develops steatorrhea, the nurse documents this stool as: 1. Dry and rock-hard 2. Clay colored and pasty 3. Bulky and foul smelling 4. Black and blood-streaked
Ans: 3 3. These characteristics describe steatorrhea, which results from impaired fat digestion.
465. A 64-year-old client is suspected of having carcinoma of the liver, and a liver biopsy is scheduled. A liver biopsy may be contraindicated in certain situations. Therefore, for what should the nurse assess the client? 1. Confusion and disorientation 2. Presence of any infectious disease 3. Prothrombin time of less than 40% of normal 4. Inclusion of foods high in vitamins E and K in the client's diet
Ans: 3 3. This indicates that the client has a deficiency in clotting, which should be corrected before the biopsy to prevent hemorrhage.
408. A client who has a hiatal hernia is 5 feet 3 inches tall and weighs 140 pounds, asks the nurse how to prevent esophageal reflux. The nurse's best response is: 1. "Increase your intake of fat with each meal" 2. "Lie down after eating to help your digestion." 3. "Reduce your caloric intake to foster weight reduction." 4. "Drink several glasses of fluid during each of your meals."
Ans: 3 3. Weight reduction decreases intra-abdominal pressure, thereby decreasing the tendency to reflux: into the esophagus.
377. After abdominal surgery a client is to receive a progressive postsurgical diet. This diet is characterized by progressive alterations in the: 1. Caloric content of food 2. Nutritional value of food 3. Texture and digestibility of food 4. Variety of food and fluids included
Ans: 3. 3. This diet progresses from the one that makes the least metabolic demand on the client (clear liquid) to a regular diet that requires the capability of unimpaired digestion.
853. A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment reflects this complication? 1. Fever and chest pain 2. Positive Homans' sign 3. Loss of sensation in the operative leg 4. Tachycardia and petechiae over the chest
Ans: 4 4 Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin.
812. A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client states that: 1. "X-rays will be taken to identify where I may have lost calcium from my bones." 2. "Portions of my bone marrow will be removed and examined for cell composition." 3. "A radioactive chemical will be injected into my vein that will destroy cancer cells present in my bones." 4. "A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."
Ans: 4 4. A bone scan maps the uptake of a bone-seeking radioactive isotope; an increased uptake is seen in metastatic bone disease, osteosarcoma, osteomyelitis, and certain fractures.
412. The response after a gastroscopy that indicates a major complication is: 1. Difficulty swallowing 2. Increased GI motility 3. Nausea with vomiting 4. Abdominal distention with pain
Ans: 4 4. Abdominal distention, which may be associated with pain, can indicate perforation, a complication that can lead to peritonitis.
375. What should the nurse do when a client is scheduled for a barium swallow? 1. Give clear fluids on the day of the test 2. Ask the client about allergies to iodine 3. Administer cleansing enemas before the test 4. Ensure a laxative is ordered after the procedure
Ans: 4 4. Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium.
436. A nurse asks a client to make a list of the foods that cause dyspepsia. If the client has cholecystitis, the foods that are most likely to be included on this list are: 1. Nuts and popcorn 2. Meatloaf and baked potato 3. Chocolate and boiled shrimp 4. Fried chicken and buttered corn
Ans: 4 4. Cholecystitis is often accompanied by intolerance to fatty foods, including fried foods and butter.
460. The nurse instructs a client diagnosed with hepatitis A about untoward signs and symptoms related to hepatitis that may develop. The one that should be reported to the practitioner is: 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools
Ans: 4 4. Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines.
835. A client is awaiting surgery for a herniated lumbar nucleus pulposus. The nurse's teaching should include that the pain will most likely increase if the client: 1. Breathes deeply 2. Lies on the side 3. Flexes the knees 4. Coughs excessively
Ans: 4 4. Coughing raises intervertebral pressure and places strain on the lumbar area, increasing the herniation of the nucleus pulposis.
824. A client's right tibia is fractured in an automobile collision, and a cast is applied. For which manifestation related to damage to major blood vessels by the fractured tibia should the nurse assess? 1. Increased blood pressure 2. Prolonged edema in the thigh 3. Increased skin temperature of the foot 4. Prolonged reperfusion of the toes after blanching
Ans: 4 4. Damage to the blood vessels may decrease circulatory perfusion of the toes.
428. A client is diagnosed as having a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report any stools that appear: 1. Frothy 2. Ribbon shaped 3. Pale or clay colored 4. Dark brown or black
Ans: 4 4. Dark brown or black stools (melena) indicate gastrointestinal bleeding.
431. A client who had a gastric resection for cancer of the stomach is admitted to the postanesthesia care unit with a nasogastric tube. The nurse expects to observe: 1. Periodic vomiting 2. Intermittent bouts of diarrhea 3. Gastric distention after 6 hours 4. Bloody drainage for the first 12 hours
Ans: 4 4. Drainage is bright red initially and gradually becomes darker red during the first 24 hours.
437. A client develops a gallstone that becomes lodged in the common bile duct. The practitioner schedules an endoscopic sphincterotomy. Preoperative teaching includes information that for the procedure the client will: 1. Have a spinal anesthetic 2. Receive an epidural block 3. Have a general anesthetic 4. Receive an intravenous sedative
Ans: 4 4. During the procedure a sedative is administered intravenously as needed to help the client stay calm.
458. A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis the nurse should: 1. Shave the client's abdomen 2. Medicate the client for pain 3. Encourage the client to drink fluids 4. Instruct the client to empty the bladder
Ans: 4 4. Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered.
397. To motivate an obese client to eventually include aerobic exercises in a weight-reduction program, the nurse discusses exercise and its relationship to weight loss. The nurse evaluates that this teaching is effective when the client states, "I know that exercise will: 1. decrease my appetite." 2. lower my metabolic rate." 3. raise my resting heart rate." 4. increase my lean body mass."
Ans: 4 4. Exercise builds skeletal muscle mass and reduces excess fatty tissues.
402. The nurse teaches the client with gastroesophageal reflux disease that after meals the client should: 1. Drink 8 ounces of water 2. Take a walk for 30 minutes 3. Lie down for at least 20 minutes 4. Rest in a sitting position for 1 hour
Ans: 4 4. Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus
836. A young adult with a herniated nucleus pulposus is scheduled for a diskectomy with fusion. Preoperatively, the nurse should demonstrate the: 1. Use of a trapeze 2. Contour position 3. Traction apparatus 4. Log-rolling technique
Ans: 4 4. Log-rolling to the prone position supports vertebral alignment, decreasing trauma to the operative site.
446. A client is to be discharged after a laser laparoscopic cholecystectomy. The nurse evaluates that the discharge instructions are understood when the client states: 1. "I can change the bandages every day." 2. "I should stay on a full liquid diet for 3 days." 3. "I should not clean the surgical sites for a week." 4. "I may have mild shoulder pain for about a week."
Ans: 4 4. Mild shoulder pain is common up to 1 week after surgery because of diaphragmatic irritation secondary to abdominal stretching or residual carbon dioxide that was used to inflate the abdominal cavity during surgery.
857. A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. The nurse should suggest: 1. Wearing loose but warm clothing 2. Planning a short rest break periodically 3. Avoiding excessive physical stress and fatigue 4. Taking a hot tub bath or shower in the morning
Ans: 4 4. Moist heat increases circulation and decreases muscle tension, which help relieve chronic stiffness.
457. A male client with liver dysfunction reports that his gums bleed spontaneously. In addition, the nurse identifies small hemorrhagic lesions on his face. The nurse concludes that the client needs additional vitamin: 1. D 2. E 3. A 4. K
Ans: 4 4. Petechiae are evidence of capillary bleeding; the diseased liver is no longer able to metabolize vitamin K, which is necessary to activate blood clotting factors.
453. A long-term complication that a client must be made aware of after a pancreaticoduodenectomy for cancer of the pancreas is hypoinsulinism. The nurse evaluates that the teaching about hypoinsulinism is understood when the client states, "I should seek medical supervision if I experience: 1. oliguria." 2. anorexia." 3. weight gain." 4. increased thirst."
Ans: 4 4. Polydipsia is characteristic of hypoinsulinism (diabetes mellitus) because excessive urine is excreted related to glycosuria.
418. A nurse assesses for the development of pernicious anemia when a client has a history of: 1. Hemorrhage 2. Diabetes mellitus 3. Unhealthy dietary habits 4. Having had a gastrectomy
Ans: 4 4. Removal of the fundus of the stomach destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum).
395. When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1. Froot Loops 2. Corn Flakes 3. Cap'n Crunch 4. Shredded Wheat
Ans: 4 4. Shredded Wheat contains 5.5 grams of fiber per serving, which is more that the other choices.
861. The physiotherapist in a nursing home develops an exercise program for an 82-year-old resident with rheumatoid arthritis. The nurse evaluates that the client understands the purpose of this program when the client states: 1. "I know the exercises are important, so I do them whenever I can." 2. "I do my exercises when I go to physical therapy in the morning and afternoon." 3. "Since I'm stiff in the morning, I do most of my exercises then, so I'm done for the day." 4. "After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day."
Ans: 4 4. Spacing activity protects joints from overuse, misuse, and stress, limiting inflammation; it provides a balance between rest and activity.
441. After a cholecystectomy to remove a cancerous gallbladder, the client has aT-tube in place that has drained 300 mL of bile-colored fluid during the first 24 hours. The nurse should: 1. Clamp the tube intermittently to slow drainage 2. Increase the rate of intravenous fluids to compensate for this loss 3. Empty the portable drainage system and reestablish negative pressure 4. Consider this an expected response after surgery and record the results
Ans: 4 4. The T-tube provides an outlet for bile produced by the liver and is expected to drain 300-500 mL in the first day.
829. A client with chronic osteomyelitis in a leg is to have a debridement of the infected bone. When planning for postoperative care the nurse expects that: 1. Frequent range-of-motion exercises are needed 2. Septicemia is a common postoperative complication 3. The client will be allowed out of bed after the first day 4. The client's leg may be immobilized in a cast or splint
Ans: 4 4. The infected bone is placed at rest and may be in a cast or splint to reduce pain and limit motion that promotes spread of the infection.
433. After a subtotal gastrectomy a client experiences an episode reflective of dumping syndrome. About 1.5 hours after the initial attack, the client experiences a second period of feeling "shaky." The nurse determines that this latter effect is caused by: 1. A second more extensive rise in glucose 2. An overwhelmed insulin-adjusting mechanism 3. A distention of the duodenum from an excessive amount of chyme 4. An overproduction of insulin that occurs in response to the rise in blood glucose
Ans: 4 4. The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome.
447. After a cholecystectomy a client asks whether there are any dietary restrictions that must be followed. The nurse evaluates that the dietary teaching is understood when the client tells a family member: 1. "I should avoid fatty foods for the rest of my life." 2. "I should not eat those foods that upset me before I had surgery." 3. "I need to eat a high-protein diet for several months after surgery." 4. "I probably will be able to tolerate a regular diet after this type of surgery."
Ans: 4 4. The response is individual, but ultimately most people can eat anything they want.
820. A nurse performs full range of motion on a client's extremities. When putting an ankle through range of motion, the nurse must perform: 1. Flexion, extension, and rotation 2. Abduction, flexion, adduction, and extension 3. Pronation, supination, rotation, and extension 4. Dorsiflexion, plantar flexion, eversion, and inversion
Ans: 4 4. These movements include all possible range of motion for the ankle joint.
420. After 2 months of self-management for symptoms of gastritis is unsuccessful, a client goes to the practitioner, and extensive carcinoma of the stomach is diagnosed. The client asks the nurse how the disease got so advanced. The nurse's explanation is based on the knowledge that carcinoma of the stomach is: 1. Painful in the early stages of the disease process 2. Difficult to accurately diagnose until late in the disease process 3. Usually diagnosed after the discovery of enlarged lymph nodes in the epigastric area 4. Rarely diagnosed early because the symptoms usually are nonspecific until late in the disease
Ans: 4 4. This cancer is usually asymptomatic in the early stages; the stomach accommodates the mass.
387. A client with Parkinson's disease complains about a problem with elimination. The nurse should encourage the client to: 1. Eat a banana daily 2. Decrease fluid intake 3. Take cathartics regularly' 4. Increase residue in the diet
Ans: 4 4. This produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson's disease.
451. A client who was diagnosed with cancer of the head of the pancreas 2 months ago is admitted to the hospital with weight loss, severe epigastric pain, and jaundice. When performing the admission history and physical assessment, the nurse expects the client's stool to be: 1. Green 2. Brown 3. Red-tinged 4. Clay-colored
Ans: 4 4. Tumors of the head of the pancreas usually obstruct the common bile duct where it passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The feces will be clay-colored when bile is prevented from entering the duodenum.
464. A nurse is performing the physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. What skin conditions should the nurse expect to observe? Select all that apply. 1. Vitiligo 2. Hirsutism 3. Melanosis 4. Ecchymoses 5. Telangiectasis
Ans: 4, 5 4 Ecchymoses are small areas of bleeding into the skin or mucous membrane forming a blue or purple patch. With cirrhosis there is decreased synthesis of prothombin in the liver. 5. Telangiectasis is a vascular lesion formed by dilation of a group of small blood vessels. When cirrhosis causes an increase in pressure in the portal circulation that results in a dilation of cutaneous blood vessels around the umbilicus, it is specifically called caput medusae.
848. After surgery for a fractured hip, a client complains of pain. The nurse should: 1. Notify the surgeon 2. Use distraction techniques 3. Medicate the client as ordered 4. Perform a complete pain assessment
Ans: 4. 4. A complete assessment must be performed to determine the location, characteristics, intensity, and duration of the pain. The pain may be incisional, result from a pulmonary embolus, or be cause by neurovascular trauma to the affected leg, and the intervention for each is different.
452. When teaching a client about the diet after a pancreaticoduodenectomy (Whipple procedure) performed for cancer of the pancreas, the statement the nurse should include is: 1. "There are no dietary restrictions; you may eat what you desire." 2. "Your diet should be low in calories to prevent taxing your pancreas." 3. "Meals should be restricted in protein because of your compromised liver function." 4. "Low-fat meals should be eaten because of interference with your fat digestion mechanism."
Ans: 4. 4. A pancreaticoduodenectomy leads to malabsorption because of impaired delivery of bile to the intestine; fat metabolism is interfered with, causing dyspepsia.
846. A 72-year-old male client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: 1. Pneumonia 2. Hemorrhage 3. Wound infection 4. Pulmonary embolism
Ans: 4. 4. A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow.
455. After surgery for cancer of the pancreas, the client's nutrition and fluid regimen will be influenced by the remaining amount of functioning pancreatic tissue. Considering both the exocrine and the endocrine functions of the pancreas, the client's postoperative regimen will primarily include managing the intake of: 1. Alcohol and caffeine 2. Fluids and electrolytes 3. Vitamins and minerals 4. Fats and carbohydrates
Ans: 4. 4. Formation of lipase necessary for diegstion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism.
462. A mother whose son has hepatitis A states that there is only one bathroom in their home and she is worried that other members of the family may get hepatitis. The nurse's best reply is: 1. "I suggest that you buy a commode exclusively for your son's use." 2. "There is no problem with your son sharing the same bathroom with everyone." 3. "Your son may use the bathroom, but you need to use disposable toilet covers." 4. "It is important that family members, including your son, wash their hands after using the bathroom."
Ans: 4. 4. Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing.
426. A client who has a gastric ulcer asks what to do if epigastric pain occurs. The nurse evaluates that teaching is effective when the client states, "I will: 1. increase my food intake." 2. take an aspirin with milk." 3. eliminate fluids with meals." 4. take an antacid preparation."
Ans: 4. 4. Over-the-counter antacid preparations neutralize gastric acid and relieve pain.
868. A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains that it: 1. Limits the formation of blood clots 2. Decreases the phantom limb sensation 3. Caring for the residual limb. 4. Performing phantom limb exercises
Ans: 4. 4. Pressure supports tissue, promotes venous return, and limits edema, thus promoting shrinkage of the distal part of the residual limb.
443. A client with cholelithiasis has a laser laparoscopic cholecystectomy. Postoperatively it is most appropriate for the nurse to: 1. Wait about 24 hours to begin clear liquids 2. Monitor the abdominal incision for bleeding 3. Offer clear carbonated beverages to the client 4. Instruct the client to resume moderate activity in 2 to 3 days
Ans: 4. 4. Recovery will be rapid because there is no large abdominal incision.
867. A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse evaluates the client's response to the prosthesis. Which indicates that the prosthesis fits the residual limb correctly? 1. Absence of phantom limb sensation 2. Uneven wearing down of the heels of the shoes 3. Shrinkage of the end portion of the residual limb 4. Darkened skin areas surrounding the end of the residual limb
Ans: 4. 4. The even distribution of hemosiderin (iron-rich pigment) in the tissue in response to pressure of the prosthesis indicates a correct fit.
392. When preparing a client to go home with total parenteral nutrition (TPN), the nurse helps the client plan: 1. The days to be used for administration 2. For daily insertion of the circulatory access 3. For professional help to administer the TPN 4. A schedule of administration around regular activity
Ans: 4. 4. The less disruptive the procedure, the greater the acceptance by the client.
391. A practitioner orders total parenteral nutrition 1 L every 12 hours. The primary nursing responsibility is to monitor the client's: 1. Electrolytes 2. Urinary output 3. Blood pressure 4. Serum glucose levels
Ans: 4. 4. This is essential because the solution is hyperosmolar, and a concentrated source of glucose can result in hyperglycemia.
830. A nurse is performing a physical assessment of a client with gout. What parts of the client's body should the nurse assess for the presence of tophi (urate deposits)? Select all that apply. 1. Feet 2. Ears 3. Chin 4. Buttocks 5. Abdomen
Answer: 1, 2 1. Clients with gout may develop deposits of monosodium urate in their tissues (tophi); these consist of a core of monosodium urate with a surrounding inflammatory reaction. Also, urate crystals form in the synovial tissue, typically the metatarsophalangeal joint of the great toe of a foot.
406. A 76-year-old obese client arrives at the clinic complaining of epigastric distress and esophageal burning. During the health history the client admits to binge drinking and frequent episodes of bronchitis. After diagnostic studies, a diagnosis of hiatal hernia is made. Which health problems most likely contributed to the development of the hiatal hernia? Select all that apply. 1. Aging 2. Obesity 3. Bronchitis 4. Alcoholism 5. Esophagitis
Answer: 1,2 1. Muscle weakness consistent with the aging process is associated with the development of a hiatal hernia. 2. Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity.
383. A nurse is assisting a client to plan a therapeutic diet that is high in vitamin C. What excellent sources of vitamin C should be included in the plan? Select all that apply. 1. Lettuce 2. Oranges 3. Broccoli 4. Apricots 5. Strawberries
Answer: 2, 3, 5 2. One cup of fresh orange sections contains 96 mg of vitamin C. 3. Vitamin C (ascorbic acid), an antioxidant, is found in vegetables such as broccoli, tomatoes, and potatoes; 1 cup of broccoli contains 140 mg of vitamin C.
123. Ms. Norfolk Is to receive 3000 mL of solution Intravenously in each 24-hour period. If there Is a drop factor of 15 drops/mL, at approximately how many drops per minute should the nurse regulate the IV? A. 22 drops. B. 31 drops. C. 42 drops. D. 51 drops.
B. 31 drops. To determine the number of drops per minute, the nurse uses the following calculation: (total amount of solution x drop factor) + (total time x minutes) (3000 x 15) + (24 x 60) = 31 drops.
125. Because of Ms. Norfolk's weight and the location of her incision, the nurse' can anticipate that the most likely complication will be: A. Fluid and electrolyte imbalance. B. Atelectasis. C. Infection. D. Nausea and vomiting.
B. Atelectasis. Respiratory complications are the most probable due to the unwillingness of the client to cough and deep breathe because of the high incision. This inhibits ventilatory movement, and the incidence of postoperative pneumonia is very high. A, C, and D are all possible complications, but respiratory complications are the most common.
35. Which neurologic assessment parameter(s) would least likely indicate to the nurse the occurrence of impending hepatic coma? A. Flapping tremors. B. Decorticate rigidity. C. Hyperactive reflexes. D. Irritability and drowsiness.
B. Decorticate rigidity. B is correct because decorticate rigidity is a neurologic manifestation Indicative of lesions In the cerebral white matter, internal capsules, and thalamus - not impending hepaticcoma. Flexion of the fingers, wrists, and arms is seen in the client with this neurologic dysfunction. A, C, and D are incorrect answers because In the presence of advanced hepatocellular disease, these parameters do indicate impending hepatic coma.
151. Which is irrelevant In the nursing evaluation of the effectiveness of the treatment for hepatic encephalopathy? A. lessening of flapping tremors of the hands. B. Decreases in pedal edema. C. Improved levels of consciousness. D. Increased cooperativeness.
B. Decreases in pedal edema. Pedal edema suggests circulatory disturbances rather than the cerebral disturbances that are characteristic of hepatic encephalopathy. A, C, and D are examples of improved cerebral functioning.
127. Ms. Norfolk develops a paralytic ileus postoperatlvely. The nurse should question which medical order before carrying it out? A Begin intermittent nasogastric suction. B. Encourage the client to take carbonated beverages. C. Neostigmine (Prostigmin), 500mcg IM. D. Continuous IV therapy, 3000 mL in 24 hours; alternate 5% dextrose in water with Ringer's lactate.
B. Encourage the client to take carbonated beverages. B Is the order that should be questioned because nothing should be given by mouth when nonfunctioning bowel is suspected. A, C, and D are all appropriate actions for such a client and are therefore not the answers.
113. The nurse needs to teach Mr. Williams that if he is having bleeding from his stomach ulcer, his stools will be: A. Claylike in color. B. Tarry. C. Bright red. D. Light brown.
B. Tarry The tarry color indicates digested blood. Stools that are the color of clay, A, indicate a diet with excess fat. Bright red stools, C, indicate bleeding low in the large intestine or rectum. Light brown stools, D, indicate a diet too high in milk and low in meat.
153. A Sengstaken-Blakemore (S-B) tube was Inserted in Mr. Mesta to control bleeding of esophageal varices. On entering the room, the nurse notices that he is gasping for breath. His color has become cyanotic and his respirations are rapid and shallow. What should the nurse first suspect? A. A pulmonary embolus has probably developed. B. The S-B tube has dislodged and one of its balloons is obstructing the airway. C. The client Is air hungry due to anemia. D. The client is anxious and this can cause changes in respiratory status.
B. The S-B tube has dislodged and one of its balloons is obstructing the airway. Each of the answers given could conceivably cause respiratory distress in a client like Mr. Mesta. A and B are the most likely to cause a sudden respiratory crisis. B should first be considered since Mr. Mesta has a S-B tube in place. Displacement of the tube constitutes a medical emergency. A is a less correct response since the case study makes no reference to chest pain or hemoptysis, classic signs of a pulmonary embolus. Also, the client's history does not suggest prolonged immobility or long bone fractures, conditions that often precipitate an embolus. C is incorrect because Mr. Mesta's anemia is unlikely to cause such a sudden respiratory change. D is incorrect because the case situation states that the client is lethargic and disoriented-not especially anxious.
149. Which goal of care is inappropriate when a lowered blood ammonia level Is the desired outcome? A. Prevention of GI bleeding. B. Reduction of dietary protein Intake. C. Avoidance of enemas and cathartics. D. Decrease in bacterial flora in the intestine.
C. Avoidance of enemas and cathartics. C is not indicated if a lowering of blood ammonia is desired, so it is the correct answer. Enemas and cathartics may be given to hasten the removal of protein materials from the intestine, thereby lowering blood ammonia. A and B lower ammonia levels by decreasing Intestinal protein. D lowers ammonia levels by reducing the bacterial production of this substance.
30. Based on the data given, the most common nursing problem is: A. Depression related to feelings of guilt. B. Anxiety related to a fear of impending doom. C. Body Image change related to altered skin appearance. D. Anger and hostility related to restriction of physical activity.
C. Body Image change related to altered skin appearance. C is cqriect because the appearance of Ms. Bee's jaundice and her insistence on visitor restrictions occurred concurrently. Because of the jaundice, she became more self-conscious of her appearance, suggesting a change in her perception of her body image. A, B, and D are Incorrect. The data do not reflect the presence of depression, A; anxiety, B; or anger and hostility, D. It is possible, however, that the nurse may encounter these nursing problems during the hospitalization of a client with hepatitis.
120. Ms. Norfolk Is discharged from the hospital. She must follow a low-fat diet until her readmission for surgery. The nurse knows that the client is demonstrating her dietary knowledge when she eliminates: A. fruit juices. B. Broiled chicken. C. Chocolate pudding. D. Carrots and spinach.
C. Chocolate pudding. Chocolate and milk are eliminated from the diet because of their fat content. A, B, and D are allowed in a fat-free diet.
31. Which laboratory result may the nurse expect to find during the initial phases of hepatitis? A. Increased LDH and CK B. Normal prothrombin time. C. Elevated serum transaminases. D. Decreased alkaline phosphatase.
C. Elevated serum transaminases. C is correct because the serum transaminases, ALT and AST, increase during the initial stage of the disease process, reflecting the liver cell injury present. A is incorrect because although moderate elevation of LDH levels is common in acute viral hepatitis, the CK level remains unchanged. CK is elevated in myocardial infarction, not in liver disease. B is also incorrect. Prothrombin is synthesized in the liver and variations in the prothrombin time can be expected because the liver cells are injured. D is incorrect because there is an increased release of, not a decrease in, alkaline phosphatase. Because of an Impaired hepatic excretory function, enzyme synthesis is increased-subsequently, an increased release of alkaline phosphatase.
114. Mr. Williams begins to hemorrhage from his ulcer and will have surgery. The nurse considers that the urgency of this surgery is: A. Planned. B. Imperative. C. Emergency. D. Optional.
C. Emergency This Is a life-threatening situation because of the blood loss. The client's surgery is an emergency and must take priority over other surgeries scheduled. Surgery can be described as planned, A, when conditions necessitate it but it can be scheduled at a convenient time. Imperative surgery, B, must be done within 24 hours. Optional surgery, D, is done at the client's request. The client can survive without having this surgery performed.
118. Which drug may Increase biliary colic pain if given to a client with cholecystitis? A. Meperidine (Demerol). B. Nitroglycerin. C. Morphine. D. Ibuprofen.
C. Morphtne. Morphine is thought to stimulate the sphincter of Oddi, causing biliary pain; therefore, it is usually avoided. A, meperidine, is the drug of choice for pain. B, nitroglycerin, is given to relax smooth muscle and decrease colic pain. D, ibuprofen, an NSAID, most likely will have no significant effect on biliary colic.
116. Mr. Williams complains of postoperative pain. The nurse administers the analgesic as ordered. What nursing actions will help reduce the pain while the analgesic is taking its effect? A. Move the client quickly; administer stimulating backrub. B. Encourage the client to discuss his feelings. C. Position comfortably; subdue the lighting. D. Give the client a bath; change bed linens.
C. Position comfortably; subdue the lighting. These actions encourage relaxation and provide a quiet environment, which should help reduce pain until the analgesic takes effect. A, B, and D produce a stimulating effect and are unlikely to help alleviate the client's pain.
126. Ms. Norfolk has a T-tube Inserted in the surgical wound. The most important nursing function In caring for this tube is: A. Recording quantity and color of drainage. B. Changing the dressing every shift. C. Preventing the tube from kinking. D. Teaching the client about the reason for the tube.
C. Preventing the tube from kinking. For any tube to function properly, the opening must remain patent for drainage of fluid. A and D are important functions but do not have the highest priority. B is incorrect because dressings should be changed only when necessary due to wetness.
119. Ms. Norfolk Is having an oral cholecystogram. She asks the nurse If there are any special preparations for this type of x-ray. The nurse tells her that she will: A. Have a regular diet the evening before the test. B. Eat a full meal the morning of the test. C. Take Iodine dye capsules by mouth the evening before the test. D. Have this test done after her scheduled GI series.
C. Take iodine dye capsules by mouth the evening before the test. Telepaque capsules, usually six, are administered the evening prior to the test. It takes about 13 hours for the dye to reach the liver and be excreted into the bile, where it is stored in the gallbladder. A is incorrect; the diet should be fat free, since fat is the principal cause of contraction of the diseased organ and should be avoided. B is incorrect; the client is given no food after the evening meal, to prevent contraction of the gallbladder and expulsion of the dye. D is incorrect; barium studies should be performed after, not before, the gallbladder series because the barium may shadow normal structures if it Is not excreted completely.
121. In preparing Ms. Norfolk for the surgical experience, the nurse Is least likely to Initiate teaching about: A. The reason for being NPO after midnight prior to surgery. B. Deep breathing, coughing, and turning techniques. C. The expected results of the surgical procedure. D. The availability of pain medication pm.
C. The expected results of the surgical procedure. The surgeon usually initiates this information; the nurse reinforces the Information as needed by the client. A, B, and D are all Included by the nurse in routine preoperative teaching, and are therefore not the correct answers.
33. The greatest risk of the spread of hepatitis B Is from contaminated: A. Urine and feces. B. Nasogastrlc secretions. C. Used needles and syringes. D. Feces and oral secretions.
C. Used needles and syringes. Ms. Bee has acute viral hepatitis, type B. Her disease Is spread mainly through contaminated needles and blood products, choice C. Some theorize, however, that it is possible that the disease also spreads through body excretions such as saliva, tears, intestinal fluids, and gastric juice. Hepatitis A Is transmitted by the oral-fecal route. Based on this explanation, A, B, and D are Incorrect.
154. Mr. Mesta Is restless and uncooperative in the early days of his treatment. His wife asks the nurse If he could be medicated to "calm him down." Which statement should guide the nurse's response? A. Sedatives are never given to clients with liver disease because damaged liver cells cannot metabolize the drug. B. Sedatives are usually metabolized by the kidneys, so this request Is feasible. C. Sedatives have an excitant, rather than a calming, effect on clients with liver disease. D. A few sedatives that are not metabolized in the liver exist, but they should be used cautiously.
D. A few sedatives that are not metabolized in the liver exist, but they should be used cautiously. Clients with liver disease respond adversely to sedation. The inability of damaged liver cells to metabolize drugs Is generally given as a reason for this. A is incorrect in that a few drugs - namely, phenobarbital and paraldehyde - are given to clients if absolutely necessary. B is incorrect since most opiates, short-acting barbiturates, and major tranquilizers are metabolized primarily in the liver. C is incorrect because "excitant" effects with sedatives are rarely, if ever, reported.
34. Pruritus, caused by the accumulation of bile salts In the skin, can be relieved by administering prescribed: A. Valium to help the client relax. B. Benadryl to promote sleep during the night. C. Questran to stimulate the reabsorption of bile salts. D. Cholestyramine to bind bile salts in the intestines.
D. Cholestyramine to bind bile salts in the intestines. Cholestyramine, a bile add-sequestering resin, Increases fecal bile excretion, resulting In the reduction of excess bile salt deposits in the skin. Questran, C, Is another bile add sequestrant, but It stimulates the excretion, not the reabsorption, of bile salts, so C is incorrect. A and B are incorrect. As stated, they do not relieve the pruritus of the client with hepatitis.
117. Mr. Williams demonstrates that he is aware of dietary influences in the prevention of the dumping syndrome when he adjusts his intake by: A. Decreasing fats. B. Decreasing proteins. C. Increasing fluids at mealtimes. D. Decreasing carbohydrates.
D. Decreasing carbohydrates. The food mass is a concentrated hyperosmolar solution in relation to surrounding extracellular fluid. Water is drawn from the blood into the intestines, and symptoms of distress occur. A and B are incorrect; fats should be increased because they slow passage of food into the intestines, and protein should be increased. C is incorrect, as fluids with meals should be decreased or eliminated so that food will stay in the stomach longer.
32. The nurse observes that Ms. Bee has clay-colored stools. The reason is that: A. Hepatic uptake of bilirubin is impaired. B. Excretion of fecal urobilinogen is increased. C. Conjugated bilirubin reenters the bloodstream. D. Excretion of conjugated bilirubin into the intestines Is decreased.
D. Excretion of conjugated bilirubin into the intestines Is decreased. D is correct because decreased excretion of conjugated bilirubin Into the Intestines is a common occurrence in viral hepatitis. It causes lack of bile pigments in the stools-thus, the clay-colored stools seen. A and C are incorrect. Although both can also occur In hepatitis, they do not have any effect on the color of the stools. The life span of the RBCs In clients with liver diseases is shortened, causing an Jmpaired hepatic uptake of bilirubin, A. The reentry of conjugated bilirubin into the bloodstream, C, results in jaundice. B Is also incorrect. Increased excretion of fecal urobilinogen occurs in hemolytic anemia, not in hepatitis.
29. Which client problem is the nurse least likely to encounter? A. Bleeding. B. Pruritus. C. Weight loss. D. Hyperglycemia.
D. Hyperglycemia. D Is the best answer because hypoglycemia, not hyperglycemia, occurs in acute hepatitis. This is due to an inadequate hepatic glycogen reserve. In addition, inadequate carbphydrate intake, prolonged nausea, and vomiting are also contrlbutory factors. A, B, and C do occur. These are problems that are encountered because of A, prolonged prothrombin time; B, jaundice; and C, anorexia.
150. Which drug might the nurse be asked to give to decrease ammonia levels in a client with liver disease? A. Diazepam (Valium). B. Diphenoxylate hydrochloride and atropine sulfate (Lomotil). C. Furosemide (Lasix). D. Lactulose.
D. Lactulose. Lactulose is a drug that lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, reducing blood ammonia levels. A, B, and C do not have the desired effect on ammonia levels. Diazepam is a sedative and skeletal-muscle relaxant that should be used with much caution in a person with liver disease. Lomotil is an antidiarrheal drug that will slow the removal of protein materials from the ntestine and thereby increase ammonia levels. Furosemide is a diuretic drug that Inhibits reabsorption of sodium and water in renal tubules.
110. Mr. Williams goes to the drugstore to buy an antacid. The nurse should teach him of the laxative effect of: A. Calcium carbonate (Tltralac). B. Aluminum hydroxide gel (Amphojel). C. Magaldrate (Rlopan). D. Magnesium hydroxide (magnesium magma).
D. Magnesium hydroxide (magnesium magma). Milk of magnesia (magnesium hydroxide) has a laxative effect. A, B, and C all have a constipating effect.
122. Ms. Norfolk returns from surgery. Which nursing action has the highest priority during the recovery room period? A. Checking vital signs every 15 minutes. B. Recording Intake and output. C. Explaining procedures to her family. D. Maintaining a patent airway.
D. Maintaining a patent airway. D is correct because life-threatening factors always have priority. A, B, and C are all important functions, but the airway has priority.
