Nursing 2- Exam 1 read thru

The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Presence of fatigue with a headache c. Presence of slight nausea and no appetite d. Two diarrhea stools yesterday

A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range, 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

The nurse notes a bulge in a client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. Reducible inguinal hernia b. Indirect umbilical hernia c. Strangulated ventral hernia d. Incarcerated femoral hernia

A In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down.

The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurse's best response? a. "You are at risk for developing more polyps in the future." b. "You may have other cancerous lesions that could not be seen right now." c. "The doctor can remove only a few of the polyps during each colonoscopy." d. "This test will ensure that you have healed where the polyp was removed."

A Once a person has developed a polyp, risk for occurrence of multiple polyps is present. The physician usually can remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed, or to check for cancerous lesions that were not visible during the first procedure.

The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis? a. Severe, steady right lower quadrant (RLQ) pain b. Abdominal pain that started a day after vomiting began c. Abdominal pain that increases with knee flexion d. Marked peristalsis and hyperactive bowel sounds

A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has a gastroenteritis. Abdominal pain due to appendicitis decreases with knee flexion. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis.

The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel? a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L b. Losing 15 pounds over the last month without dieting c. Reports of crampy abdominal pain across the lower quadrants d. High-pitched, hyperactive bowel sounds in all quadrants

A Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction.

The nurse is teaching a client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching? a. "I will put on the truss before I go to bed each night." b. "I will put some powder under the truss to avoid skin irritation." c. "The truss will help my hernia because I can't have surgery." d. "If I have abdominal pain, I will let my health care provider know right away."

A The client is instructed to apply the truss before arising, not before going to bed at night. The other statements show accurate knowledge in using a truss.

The nurse is caring for a client with an umbilical hernia who reports increased abdominal pain, nausea, and vomiting. The nurse notes high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings? a. Bowel obstruction; client should be placed on NPO status. b. Perforation of the bowel; client needs emergency surgery. c. Adhesions in the hernia; client needs elective surgery. d. Hernia is dangerously enlarged; client needs a nasogastric (NG) tube.

A The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The client should be placed on NPO status, and the health care provider should be notified. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.

A client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurse's best response? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity."

A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband.

A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse's best response? a. "This is normal for your type of colostomy." b. "I will let the health care provider know, so that it can be assessed." c. "You should add extra fiber to your diet to stop the diarrhea." d. "Your stool will become firmer over the next few weeks."

A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.

The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client's abdomen for the presence of an acquired umbilical hernia? a. Body mass index (BMI) of 41.9 b. Cholecystectomy last year c. History of irritable bowel syndrome d. Daily dose of lansoprazole (Prevacid) 30 mg orally

A This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.

The client scheduled for intravenous urography informs the nurse of the following allergies. Which one should the nurse report to the physician immediately?

A - Seafood - Clients with seafood allergies often have severe allergic reactions to the standard dyes used during intravenous urography.

The client scheduled to have intravenous urography is a diabetic and taking the antidiabetic agent metformin. What should the nurse tell this client?

A -"Call your diabetes doctor and tell him or her that you are having an intravenous urogram performed using dye." -Metformin can cause lactic acidosis and renal impairment because of an interaction with the dye. This drug must be discontinued for 48 hours before the procedure and not started again after the procedure until urine output is well established.

The client is being admitted with a suspected diagnosis of bladder cancer. Which question will assist in determining risk factors?

A -"Do you smoke cigarettes?" -Smoking is known to be a factor that greatly increase the risk of bladder cancer. Neither alcohol use, prescription drug use (except medications that contain phenacetin), nor recreational drug use are known to increase the risk of developing bladder cancer.

Which prevention strategy will the nurse teach the client with a risk for renal calculi?

A -"Drink at least 3 to 4 L of fluid every day." -Dehydration contributes to the precipitation of minerals to form a stone. Ingestion of calcium or aspirin does not cause a stone. Antibiotics neither prevent nor treat a stone.

Which statement made by the client with stress incontinence indicates a need for clarification of nutrition therapy?

A -"I will limit my total intake of fluids." -Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

The client is beginning to undergo urinary habit training. Which is an effective instruction to give this client's caregiver?

A -"Keep a continence record for at least 3 days." -The caregiver should keep a continence record to determine patterns in the client's voiding and incontinence episodes. The caregiver should use the power of suggestion, establish a toileting interval of not less than 2 hours, and avoid leaving the client on the toilet for more than 5 minutes.

The client is a young woman who is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give the client?

A -"Use a second form of birth control while on the drug." -The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

Which drug will the nurse administer to the client diagnosed with renal calculi from hyperuricemia?

A -Allopurinol (Zyloprim) -Allopurinol inhibits the enzyme that converts purine metabolites into uric acid, thereby reducing the amount of uric acid present for precipitation into stones. The other drugs listed would not be effective.

Which client will not be able to adhere to bladder training for incontinence?

A -An older man who is confused -For a bladder training program to succeed in urge incontinence, the client must be alert, aware, and able to resist the urge to urinate.

Which would be the response if a person's nephrons were not able to filter normally caused by scarring of the proximal convoluted tubule leading to inhibition of reabsorption?

A -Increased urine output, fluid volume deficit -The nephrons filter about 120 mL/min. Most of this filtrate is reabsorbed in the proximal convoluted tubule. If the tubule were not able to reabsorb the fluid that has been filtered, urine output would greatly increase, leading to rapid and severe dehydration.

The nurse is assessing the laboratory findings of a client with a urinary tract infection. Which finding requires immediate intervention?

A -Left shift in the white blood cell (WBC) differential -A left shift most commonly occurs with urosepsis, a condition that has a 15% mortality rate. Left shifts rarely occur with uncomplicated cystitis. This is the most life-threatening change in values of the laboratory findings listed.

Which client is at greatest risk for development of a bacterial cystitis?

A -Older female client not taking estrogen replacement -Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at an increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged female client who has never been pregnant would not have a risk potential as high as the older female client who is using hormone replacement therapy.

The hospitalized client with a urethral retention catheter has cystitis. Which is the priority nursing diagnosis for this client?

A -Risk for Infection -The most common cause of sepsis in hospitalized clients is a urinary tract infection. Ascending infections from cystitis with an indwelling catheter is a major source of such infections. Although the other diagnoses are important, they would not have life-threatening implications for the client.

Which type of incontinence is most common after a difficult vaginal delivery

A -Stress incontinence -Childbirth is most likely to result in stress incontinence. There is no evidence that childbirth is likely to result in the development of urge, reflex, or overflow incontinence.

The nurse is helping a student prepare to insert a nasogastric tube for an adult client with a bowel obstruction. Which actions by the student indicate to the nurse that a review of the procedure is needed? (Select all that apply.) a. Gathering supplies, including an 8 Fr Levin tube, sterile gloves, tape, and water-soluble lubricant b. Performing hand hygiene and positioning the client in high Fowler's position, with pillows behind the head and shoulders c. Attaching a 60-mL irrigation syringe to the end of the nasogastric tube before inserting it into the nose d. Instructing the client to extend the neck against the pillow once the nasogastric tube has reached the oropharynx e. Checking for correct placement by checking the pH of the fluid aspirated from the tube f. Securing the nasogastric tube by taping it to the client's nose and pinning the end to the pillowcase g. Connecting the nasogastric tube to intermittent medium suction with an anti-reflux valve on the air vent

A, D, F

The nurse is performing a physical assessment for a client who underwent a hemorrhoidectomy the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse's priority action? a. Assess the client's vital signs. b. Determine the last time the client voided. c. Insert a rectal tube to facilitate passage of flatus. d. Document the findings in the client's chart.

B Assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding owing to urinary retention. A rectal tube should not be inserted for a client who had a hemorrhoidectomy the previous day. The client's vital signs may be checked after the nurse determines the client's last void. The nurse should document all findings and actions in the client's medical record.

A client has irritable bowel syndrome. Which menu selections by this client indicate good understanding of dietary teaching? a. Tuna salad on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed green beans, glass of apple juice c. Grilled cheese sandwich, small ripe banana, cup of hot tea with lemon d. Grilled steak, green beans, dinner roll with butter, cup of coffee with cream

B Clients with irritable bowel syndrome are advised to eat a high-fiber diet (30 to 40 grams a day), with 8 to 10 cups of liquid daily. This selection has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

A middle-aged male client has irritable bowel syndrome that has not responded well to diet changes and bulk-forming laxatives. He asks the nurse about the new drug lubiprostone (Amitiza). What information does the nurse provide him? a. "This drug is investigational right now for irritable bowel syndrome." b. "Unfortunately, this drug is approved only for use in women." c. "Lubiprostone works well only in a small fraction of irritable bowel cases." d. "Let's talk to your health care provider about getting you a trial prescription."

B Lubiprostone (Amitiza) is approved only for use in women. The other statements are not accurate.

The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone who had a similar experience. Which is the nurse's best response? a. "Most people who have had a colostomy are reluctant to talk about it." b. "I will make a referral to the United Ostomy Associations of America." c. "You can get all the information you need from the enterostomal therapist." d. "I do not think that we have any other clients with colostomies on the unit right now."

B Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the client's request by saying that no colostomy clients are present on the unit at the time.

The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Ask whether the client was riding in the front or back seat of the car.

B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present; this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or asking about seating in the car is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

The nurse is providing preoperative teaching for a client who will undergo herniorrhaphy surgery. Which instruction does the nurse give to the client? a. "Eat a low-residue diet for the first week after surgery." b. "Change the dressing every day until the staples are removed." c. "Take acetaminophen (Tylenol) 1000 mg every 4 hours for pain." d. "Cough and deep breathe every 2 hours for the first week after surgery."

B The dressing should be changed every day until the staples are removed, so the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours means that intake is 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion but should avoid coughing, which can place stress on the incision line.

A client post-hemorrhoidectomy feels the need to have a bowel movement. Which action by the nurse is best? a. Have the client use the bedside commode. b. Stay with the client, providing privacy. c. Make sure toilet paper and the call light are in reach. d. Plan to send a stool sample to the laboratory.

B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure needed items are within reach is an important nursing action too, but it does not take priority over client safety. The other two actions are not needed in this situation.

The nurse conducts a physical assessment for a client with severe right lower quadrant (RLQ) abdominal pain. The nurse notes that the abdomen is rigid and the client's temperature is 101.1° F (38.4° C). Which laboratory value does the nurse bring to the attention of the health care provider as a priority? a. A "left shift" in the white blood cell count b. White blood cell count, 22,000/mm3 c. Serum sodium, 149 mEq/L d. Serum creatinine, 0.7 mg/dL

B This client may have appendicitis based on RLQ pain. A white blood cell count of 22,000/mm3 is severely elevated and could indicate a perforated appendix, as could the fever. The nurse should bring these findings to the provider's attention as soon as possible. A left shift would be expected in uncomplicated appendicitis. The sodium reading is only slightly high; this could be due to hemoconcentration from vomiting or from decreased intake. The creatinine level is normal.

Which client statement indicates understanding regarding antibiotic therapy for recurrent urinary tract infections?

B -"Even if I feel completely well, I should take the medication until it is gone." -Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course and not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client.

Which statement made by the client who has kidney stones from secondary hyperoxaluria indicates correct understanding of the role of dietary therapy for this condition?

B -"I will avoid dark green leafy vegetables, chocolate, and nuts." -Secondary hyperoxaluria is caused by an excessive ingestion of foods containing large amounts of oxalate, such as spinach, rhubarb, Swiss chard, collard greens, cocoa, beets, wheat germ, pecans, peanuts, okra, chocolate, and lime peel.

The postmenopausal female client has had two episodes of bacterial urethritis in the last 6 months. She asks her nurse why this is happening to her now. Which is the nurse's best response?

B -"Low estrogen levels can make the tissue more susceptible to infection." -Low estrogen levels decrease moisture and the type of secretions in the perineal area, predisposing it to the development of infection. The client's immune system, personal hygiene, and sexual practices do not place her at risk for developing urethritis.

Which personal factor places the client at risk for bladder cancer?

B -A 50 pack-year cigarette smoking history -The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

Which assessment maneuver should the nurse perform first when assessing the renal system at the same time as the abdomen?

B -Abdominal auscultation -Auscultation precedes percussion and palpation because the nurse needs to auscultate for abdominal bruits before palpation or percussion of the abdominal and renal components of a physical assessment.

The client with a renal calculus has just returned from an extracorporeal shock wave lithotripsy procedure and the nurse finds an ecchymotic area on the client's right lower back. Which is the nurse's priority intervention?

B -Applying ice to the site -The shock waves can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising.

The client is taking a medication for an endocrine problem that inhibits aldosterone secretion and release. For which complications of this therapy should the nurse be alert?

B -Dehydration, hyperkalemia -Aldosterone is a mineralocorticoid that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and potassium reabsorption.

Which of the following muscle actions results in voluntary urination?

B -Detrusor contraction, external sphincter relaxation -Voiding becomes a voluntary act as a result of learned responses controlled by the cerebral cortex. This causes contraction of the bladder detrusor muscle and simultaneous relaxation of the external urethral sphincter muscle.

The client's urine specific gravity is 1.018. Which is the nurse's best action?

B -Documenting the finding as the only action -This specific gravity is within the normal range for urine

A client presents with senile dementia, Alzheimer's type (SDAT) and incontinence. Which therapy will best help this client?

B -Habit training -Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can only be used with a client who is alert, aware, and able to resist the urge to urinate. Exercise therapy may be too difficult for the cognitively impaired client to grasp, and electrical stimulation will be traumatic for this client.

The client is an older woman who is receiving treatment with levofloxacin (Levaquin). Which is the highest priority instruction that the nurse can provide to this client?

B -How to assess her own radial pulse -The client should assess her own radial pulse at least twice daily because this class of drugs can induce serious cardiac dysrhythmias. Assessment of blood pressure and respirations will not allow the client to detect if she is experiencing cardiac side effects of the medication. She should not attempt to assess her carotid pulse because a syncopal episode could result.

Which of the following conditions is associated with oversecretion of renin?

B -Hypertension -Renin is secreted when special cells in the distal convoluted tubule (DCT), called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume is low, blood pressure is low, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause the secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension.

The female client's urinalysis shows all the following results. Which should the nurse document as abnormal?

B -Ketone bodies present -Ketone bodies are byproducts of incomplete metabolism of fatty acids. Normally, there are no ketones in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy.

Which condition would trigger the release of antidiuretic hormone (ADH)?

B -Plasma osmolarity increased secondary to dehydration -Antidiuretic hormone is triggered by a rising extracellular fluid (ECF) osmolarity, especially hypernatremia.

The nurse is providing discharge teaching for a client who has undergone colon resection surgery with a colostomy. Which statements by the client indicate that the instruction was understood? (Select all that apply.) a. "I will change the ostomy appliance daily and as needed." b. "I will use warm water and a soft washcloth to clean around the stoma." c. "I will start bicycling and swimming again once my incision has healed." d. "I will notify the doctor right away if any bleeding from the stoma occurs." e. "I will check the stoma regularly to make sure that it stays a deep red color." f. "I will avoid dairy products to reduce gas and odor in the pouch." g. "I will cut the flange so it fits snugly around the stoma to avoid skin breakdown."

B, C, G

The client is beginning to undergo urinary bladder training. Which is an effective instruction to give this client?

B-"Try to consciously hold your urine until the scheduled toileting time." -The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client has been continent for 3 days

A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurse's best response? a. "I will call and cancel the test for tomorrow." b. "You need two negative fecal occult blood tests." c. "This does not rule out the possibility of colon cancer." d. "You should wait at least a week to have the colonoscopy."

C A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed, so the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer (CRC).

The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective does the nurse include in the client's plan of care? a. Understanding colostomy care and lifestyle implications b. Learning how to change the appliance independently c. Demonstrating the correct way to change the appliance by discharge d. Not being afraid to handle the ostomy appliance tomorrow

C Client learning goals must be measurable and objective with a time frame, so the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The specific time frame of "by discharge" is easily measurable also. The other goals are all subjective and cannot be measured objectively. The first two options do not have time frames. "Tomorrow" is a vague time frame.

The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions does the nurse give to the client? a. "You must fast for 12 hours before the test." b. "You will be given a cleansing enema the morning of the test." c. "You must avoid eating meat for 48 hours before the test." d. "You will be sedated and will require someone to accompany you home."

C The client is instructed to avoid meat, aspirin, vitamin C, and anti-inflammatory drugs for 48 hours before the test. The other directions are not accurate for this test.

The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy does the nurse use to assist the client at this time? a. Ask the health care provider for a psychiatric consult for the client. b. Explain the improved prognosis for colon cancer with new treatment. c. Encourage the client to verbalize feelings about the diagnosis. d. Allow the client to remain withdrawn as long as he or she wishes.

C The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the client's withdrawal behavior.

The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings? a. The tumor has metastasized to the liver and biliary tract. b. The tumor has caused an intussusception of the intestine. c. The growing tumor has caused a partial bowel obstruction. d. The client has developed toxic megacolon from the growing tumor.

C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. Assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon.

The client is going home after urography. Which instruction or precaution should the nurse teach this client?

C -"Be sure to drink at least 3 L of fluids today to help eliminate the dye faster." -Dyes used in urography are potentially nephrotoxic.

The client with severe bacterial cystitis is prescribed to take cefadroxil (Duricef) and phenazopyridine (Pyridium). What will the nurse teach this client regarding the drug regimen?

C -"Do not be alarmed by the discoloration of your urine." -Phenazopyridine discolors urine most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing.

The client with bladder cancer is scheduled to have intravesical chemotherapy. Which statement made by the client indicates correct understanding of this therapy?

C -"I will have few, if any, side effects from this type of chemotherapy." -Intravesical chemotherapy involves instilling the chemotherapy agents directly into the bladder. The side effects are local, not systemic.

The client is receiving treatment with nitrofurantoin (Furadantin). Which is the highest priority instruction that the nurse can provide to this client regarding accurate administration of the medication?

C -"You should shake the medication well before measuring it out." -The medication is available in a suspension that must be shaken before being measured out. The medication does not have to be mixed before taking, and it will not discolor the urine. The drug is not available in granules that are dissolved.

With a renal threshold for glucose of 220 mg/dL, what is the expected response when a client has a blood glucose level of 400 mg/dL?

C -180 mg/dL of glucose is excreted in the urine -Blood glucose is freely filtered at the glomerulus. Therefore, if a client has a blood sugar level of 400 mg/dL, the filtrate in the proximal convoluted tubule will have a glucose concentration of 400 mg/dL. With a renal threshold of 220 mg/ dL, a total of 220 mg/dL of the 400 mg/dL will be reabsorbed back into the systemic circulation, and the final urine will have a glucose concentration of 180 mg/dL.

Two hours after a closed percutaneous kidney biopsy, the client reports a dramatic increase in pain. Which is the nurse's best first action?

C -Assessing pulse rate and blood pressure -An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal hemorrhage.

To obtain a sterile urine specimen from a client with a Foley catheter, the nurse begins by applying a clamp to the drainage tubing distal to the injection port. What should the nurse do next?

C -Clean the injection port cap of the catheter drainage tubing with povidone-iodine solution. -It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination prior to injecting the syringe.

Which is the result of stimulation of erythropoietin production in the kidney tissue?

C -Increased bone marrow production of red blood cells -Erythropoietin is produced in the kidney and released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell (RBC) production in the bone marrow.

Which is an appropriate dietary choice for the client with uric acid renal calculi?

C -Mixed green salad, melba toast -The only diet selection that does not contain any type of meat is the mixed green salad and melba toast. To reduce the client's level of uric acid, he or she must avoid any food that contains purine. This is found primarily in organ meats, poultry, and fish. This means that the client must avoid the chicken salad sandwich, chef salad (contains meat), and baked fish.

The client who has undergone a nephrolithotomy procedure 24 hours ago now has a fever of 101° F (38.3° C). Which is the nurse's priority intervention?

C -Notifying the physician -The elevated temperature indicates a possible infection. Treatment must be initiated as soon as possible to prevent septic complications.

The client with bladder cancer has undergone a complete cystectomy with ileal conduit. Four hours after the surgery, the nurse observes the stoma to be cyanotic. Which is the nurse's priority action?

C -Notifying the surgeon -A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis.

Which client is not a candidate for intermittent self catheterization training?

C -Older male client with dementia -Clients of any age with a variety of impairments and disabilities can participate in intermittent self-catheterization. The two main requirements are that the client be cognitively intact and can reach the area.

How is urge incontinence different from stress incontinence?

C -Stress incontinence occurs because of weak pelvic floor muscles. Urge incontinence occurs because of abnormal bladder contractions. -Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincters and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities or may occur with no known abnormality.

Confirmed by palpation and x-ray study, the client's right kidney is lower than the left kidney. Which is the nurse's interpretation of this finding?

C -The client has both kidneys in the normal position. -Normally, the right kidney is positioned somewhat lower than the left kidney. This anatomic difference in otherwise symmetric organs is caused by liver displacement. The significance of this difference is that the right kidney is easier to palpate in an adult than is the left kidney.

The client has an elevated blood urea nitrogen (BUN) level and an increased ratio of blood urea nitrogen to creatinine. Which is the nurse's interpretation of these laboratory results?

C -The kidney may be hypoperfused. -When dehydration or renal hypoperfusion exist, the BUN level rises more rapidly than the serum creatinine level, causing the ratio to be increased, even when no renal dysfunction is present.

A client with a mechanical bowel obstruction reports that abdominal pain, which was previously intermittent and colicky, is now more constant. Which is the priority action of the nurse? a. Measure the abdominal girth. b. Place the client in a knee-chest position. c. Medicate the client with an opioid analgesic. d. Assess for bowel sounds and rebound tenderness.

D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure abdominal girth. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.

A client is brought to the emergency department after being shot in the abdomen and is hemorrhaging heavily. Which action by the nurse is the priority? a. Draw blood for type and crossmatch. b. Start two large IVs for fluid resuscitation. c. Obtain vital signs and assess skin perfusion. d. Assess and maintain a patent airway.

D All options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

The nurse is screening clients at a community health fair. Which client is at highest risk for development of colorectal cancer? a. Young adult who drinks eight cups of coffee every day b. Middle-aged client with a history of irritable bowel syndrome c. Older client with a BMI of 19.2 who works 65 hours per week d. Older client who travels extensively and eats fast food frequently

D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.

The nurse is teaching self-care measures for a client who has hemorrhoids. Which nursing intervention does the nurse include in the plan of care for the client? a. Instruct the client to use dibucaine (Nupercainal) ointment whenever needed. b. Teach the client to choose low-fiber foods to make bowels move more easily. c. Tell the client to take his or her time on the toilet when needing to defecate. d. Encourage the client to dab with moist wipes instead of wiping with toilet paper.

D The client should be instructed to use wet wipes and dab the anal area after defecating to avoid further irritation. Dibucaine can be used only for short periods of time because long-term use can mask worsening symptoms. Clients with hemorrhoids require high-fiber foods. The client should not be encouraged to strain at stool or to spend long periods of time on the toilet, because this increases pressure in the rectal area, which can make hemorrhoids worse.

The nurse is caring for a client who has suffered abdominal trauma in a motor vehicle crash. Which laboratory finding indicates that the client's liver was injured? a. Serum lipase, 49 U/L b. Serum amylase, 68 IU/L c. Serum creatinine, 0.8 mg/dL d. Serum transaminase, 129 IU/L

D The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.

Which is priority discharge teaching for a client who has undergone the removal of a renal calculus?

D -"Drink at least 3 L of fluid daily and monitor urine pH." -The client should drink at least 3 L of fluid daily and monitor his or her urine pH as directed. He or she should expect to see some blood in the urine postoperatively and some bruising, but should not experience pain. If there is pain, this might signal the development of another stone and should be reported.

The caretaker of a confused client with functional incontinence asks about having an in-dwelling catheter placed. Which is the nurse's best response?

D -"Pads can be worn to prevent smells and leaks. Social services can help you obtain these supplies at a reasonable cost." -In-dwelling catheters are used only as a last resort because of the risk for ascending urinary tract infections and sepsis. The use of containment pads should be attempted as a means of controlling wetness first. If the client has skin breakdown, an in-dwelling catheter can be placed temporarily until the area has healed.

The client is scheduled to have renography (kidney scan). She is concerned about discomfort during the procedure. Which is the nurse's best response?

D -"The only pain associated with this procedure is a small needle stick when you are given the radioisotope." -The test involves an intravenous injection of the radioisotope and the subsequent recording of the emission by a scintillator.

The client is scheduled to undergo the surgical creation of an ileal conduit. He expresses his anxiety and fear regarding the procedure. Which is an appropriate response from the nurse?

D -"Would you like to speak with another client who has undergone this procedure?" -The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his body image. Medications for anxiety or sleep will not promote this, nor will discussing the procedure once more with his physician. However, discussing the procedure candidly with a former client will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge of the procedure.

Which client is at greatest risk for a fungal urinary tract infection?

D -A middle-aged man with diabetes mellitus -Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal urinary tract infections. The client with an enlarged prostate gland would not be at greater risk. Being sexually active does not place the client at greater risk for developing an infection.

Which client is at highest risk for developing a renal calculus?

D -A young man who had a renal calculus 1 year ago -Age and the other conditions listed do not contribute to the formation of renal calculi. The greatest risk factor for calculus formation is a history of a previous stone.

A nurse observes that the client's left flank region is larger than the right flank region. Which is the nurse's best action?

D -Anticipating further diagnostic testing after informing the physician of this finding -Asymmetry of the flank or a unilateral protrusion may indicate an enlargement of a kidney. The enlargement may be benign or may be associated with a hydronephrosis or mass on the kidney.

Which is an initial priority intervention for the client with stress incontinence?

D -Instructing the client to maintain a diary that records times of urine leakage, activities, and diet -Maintaining a diary detailing times of urine leakage, activities, and foods eaten will aid in the diagnostic process by showing if there is a connection between specific factors that seem to trigger the incontinent episodes. Use of medication, surgical procedures, and absorbent pads or undergarments may be used as part of the physician's treatment plan at some point, but more conservation interventions should be implemented first.

The client reports the regular use of all the following medications. Which one alerts the nurse to the possibility of renal impairment when used consistently?

D -Nonsteroidal anti-inflammatory drugs (NSAIDs) -NSAIDs inhibit prostaglandin production and decrease blood flow to the nephrons. They can cause an interstitial nephritis and renal impairmen

Which change in renal or urinary functioning as a result of the normal aging process increases the older adult client's risk for infection?

D -Urinary retention -Incomplete bladder emptying for whatever reason increases the client's risk for urinary tract infections. This is a result of urine stasis, which provides an excellent culture medium that promotes the growth of microorganisms.

Which intervention is most likely to be effective in stimulating the initiation of voiding for the client with overflow incontinence?

D -Using the Valsalva maneuver -In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate) can initiate voiding.

The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination?

The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination?

A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask?

a. "Have you experienced any constipation?" b. "Have you had any stomach pain or indigestion?" c. "Have you had any difficulty swallowing?" d. "Have you noticed any weight loss lately?" ANS: B Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be assessed for stomach pain or indigestion. This medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this medication.

Which question best assists the nurse in assessing a client with acute diarrhea?

a. "Have you traveled outside the country recently?" b. "Have you had a colonoscopy lately?" c. "Do you have any trouble swallowing?" d. "Do you have any allergies?" ANS: A A history of recent travel may help pinpoint an infectious source for the client's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea

While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer, the client begins to cry. Which is the nurse's best response?

a. "I am so sorry for making you cry!" b. "I will step out for a few minutes until you feel better." c. "I can see that you are upset about this. It is all right to cry." d. "I can see that I am upsetting you. Let's move on to something else." ANS: C The nurse should recognize the client's feelings and should allow the client to cry. Moving on to another topic shows disregard for the client's feelings. The nurse should not leave the room but should stay to offer support. Apologizing to the client does not place the focus on the client or acknowledge the client's feelings and emotions in this situation.

The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure?

a. "I may have gas and abdominal cramps after the test." b. "I will take strong laxatives the afternoon before the test." c. "I will take my Coumadin with a sip of water tomorrow morning." d. "I will take nothing by mouth after midnight on the day of the test." ANS: C Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure.

Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis?

a. Amylase, 129 IU/L; alkaline phosphate, 45 U/L b. Reticulocyte count, 1%; magnesium, 1.5 mEq/L c. Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL d. Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL ANS: D Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired. The other laboratory values are within normal limits and would not be expected with advanced cirrhosis.

When performing an assessment, the nurse detects a fruity odor on the client's breath. What does the nurse do next?

a. Assess the client's blood sugar level. b. Assess the client's stool for occult blood. c. Instruct the client in oral hygiene techniques. d. Assess the client for petechiae, itching, and jaundice. ANS: A A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The client's blood sugar level should be checked immediately for hyperglycemia. The nurse may perform the other assessment tests for the client, but they will not be helpful in determining the cause of the fruity breath.

A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer?

a. Cholesterol b. Serum lipase c. Carcinoembryonic antigen d. Xylose absorption ANS: C The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine.

The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the client may have?

a. Cirrhosis b. Splenomegaly c. Bowel obstruction d. Abdominal aortic aneurysm ANS: B Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the client's left upper quadrant, indicating hepatomegaly. The nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic aneurysm

The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which problem does the nurse anticipate for this client?

a. Failure to absorb nutrients from the stomach b. Inability to digest protein c. Impaired ability to soften and break down food d. Difficulty swallowing food ANS: C Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral cavity can result in reduction of saliva production. Radiation to the mouth will not impair swallowing, ability to digest protein, or ability to absorb nutrients from the stomach.

The nurse performs percussion of a client's abdomen. Which findings may the nurse determine with this assessment technique? (Select all that apply.)

a. Hepatomegaly b. Kidney stones c. Ascites d. Large mass below the liver e. Biliary colic f. Ileus ANS: A, C, D, F Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with percussion.

The nurse is performing an abdominal assessment on an older client. Which assessment finding does the nurse expect as a normal consequence of aging?

a. Increased salivation and drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric acid production and heartburn d. Impaired sensation to defecate and constipation ANS: D Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production

The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action?

a. Keep the client NPO (nothing by mouth). b. Check the client's gag reflex. c. Offer the client sips of clear liquids. d. Provide the client with a few ice chips. ANS: B The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned

The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client's abdomen, the nurse does not hear any bowel sounds. Which is the nurse's best action?

a. Notify the health care provider. b. Percuss the abdomen. c. Document the finding. d. Insert a nasogastric tube. ANS: C Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the client's record for later reference. The provider does not need to be notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may be performed but may be uncomfortable for the client and will not reveal the cause of the ileus.

The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer?

a. Older white client with irritable bowel syndrome b. Middle-aged African-American client who smokes cigars c. Middle-aged Asian client who travels and eats out frequently d. Older American Indian client taking hormone replacement therapy ANS: B Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.