Semester 4 - Exam 2

A patient with delirium who has been treated with haloperidol begins to display involuntary movements of the face, trunk, and arms. Which complication has occurred? - Athetosis - Severe agitation - Tardive dyskinesia - Anticholinergic effects

- Tardive dyskinesia

A patient has been diagnosed with terminal esophageal cancer. The patient is interested in obtaining support from hospice but expresses concern that pain management will not be adequate. What is the nurse's best response? - "Talk to your HCP about hospice services" - "Haven't you received adequate pain management in the hospital?" - "Would you like me to get a nurse from hospice to come talk with you?" -"Do you want me to call the hospital chaplain to explain hospice to you?"

- "Would you like me to get a nurse from hospice to come talk with you?"

The nurse administers a dose of lactulose syrup and informs the patient that the medication will likely take effect within which timeframe? - 2 to 5 minutes - 15 minutes to 3 hours - 2 to 4 hours - 6 to 8 hours

- 15 minutes to 3 hours

Prealbumin

15-35 mg/dL

The nurse is working at a community health fair and speaks with a group of individuals about the risk factors for colorectal cancer (CRC). Which individual does the nurse identify as most at risk for developing CRC? - 33 year old who has Crohn's Disease - 28 year old who has type 2 diabetes - 19 year old who maintains a vegetarian diet - 41 year old who does not have a family history of cancer

- 33 year old who has Crohn's Disease

Which patient is most at risk for developing stomach cancer? - A 55 year old African American female who has been smoking a pack a day for 30 years and regularly drinks alcohol. - A 62 year old Irish male who has been following a vegetarian diet for the 5 years. - A 69 year old Pacific Islander male who had H. Pylori as a child and enjoys salted fish and meat. - A 65 year old Caucasian male who has Hepatitis C and drinks 5 beers a night.

- A 69 year old Pacific Islander male who had H. Pylori as a child and enjoys salted fish and meat.

A client is having a diagnostic workup for colorectal cancer. Which factors in the client's history place the client at increased risk for this type of cancer? Select all that apply. - A high-fiber diet - A diet high in fats - Minimal alcohol intake - A diet high in carbohydrates - A history of inflammatory bowel disease - A maternal grandfather who had a history of heart disease

- A diet high in fats - A diet high in carbohydrates - A history of inflammatory bowel disease

The community nurse is conducting a health promotion program, and the topic of the discussion relates to the risk factors for gastric cancer. Which item, if identified as a risk factor by a client, indicates a need for further discussion? - Smoking - A low-fat diet - Foods containing nitrates - A diet of smoked, highly salted, and spiced foods

- A low-fat diet

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? - Age younger than 50 years - History of colorectal polyps - Family history of colorectal cancer - Chronic inflammatory bowel disease

- Age younger than 50 years

The health care provider prescribes lactulose for a patient with hepatic encephalopathy. Which data would the nurse monitor for effectiveness of this medication? - Liver enzymes - Stool frequency - Abdominal pain - Ammonia levels

- Ammonia levels

A patient has been admitted with a C5 level spinal cord injury and experiences severe hypotension. Which pharmacologic therapies does the nurse expect to be prescribed for this patient? Select all that apply. - Nitrates - Diuretics - Beta blockers - Anticoagulants - IV fluids

- Anticoagulants - IV fluids

A patient who has just undergone a Whipple procedure for pancreatic cancer has frank blood and an increased output from the biliary drainage tubes. What action by the nurse is priority? - Contact the surgeon - Document the output - Assess the patient's vital signs - Clamp the nasogastric (NG) tube

- Contact the surgeon

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? - Measure abdominal girth. - Irrigate the nasogastric tube. - Continue to monitor the drainage. - Notify the primary health care provider (PHCP).

- Continue to monitor the drainage.

A patient has undergone surgery for treatment of colorectal cancer (CRC). The surgical note indicates that the procedure performed was sphincter-sparing. The nurse closely monitors the patient for which common complication? - Diarrhea - Hemorrhoids - Diverticulitis - Malabsorption syndrome

- Diarrhea

In a loop stoma or a double-barrel stoma, which opening is used for draining mucus? - Proximal - Distal

- Distal

The nurse is performing an admission assessment of a client with a possible right colon tumor. Which sign or symptom should the nurse anticipate the client may report? - Frequent diarrhea - Crampy gas pains - Flat, ribbon-like stools - Dull abdominal pain exacerbated by walking

- Dull abdominal pain exacerbated by walking

A post-op Billroth patient experiences weakness, sweating, borborygmi, and the urge to defecate 20 minutes after eating. What is the patient experiencing? - Dumping Syndrome - Postprandial hypoglycemia - Bile reflux gastritis - Peritontitis

- Dumping Syndrome

The patient is having a gastroduodenostomy (Billroth I operation) for stomach cancer. Which complication is occurring when the patient reports generalized weakness, sweating, palpitations, and dizziness 15 minutes after eating? - Malnutrition - Bile reflux gastritis - Dumping syndrome - Postprandial hypoglycemia

- Dumping syndrome

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The primary health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? - Atropine sulfate - Morphine sulfate - Protamine sulfate - Pyridostigmine bromide

- Atropine sulfate

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? - Dysfunction of vagus nerve (cranial nerve X) - Dysfunction of trigeminal nerve (cranial nerve V) - Dysfunction of hypoglossal nerve (cranial nerve XII) - Dysfunction of spinal accessory nerve (cranial nerve XI)

- Dysfunction of trigeminal nerve (cranial nerve V)

Which is a priority nonoperative treatment following a spinal cord injury? - Stabilization - Spinal fusion - Cervical traction - Pain management

- Stabilization

A patient is stable after treatment of recently diagnosed esophageal varices. Which information would the nurse include in the teaching plan for this patient? - Decrease fluid intake to avoid irritating the varices. - Eat foods quickly so they do not get cold and cause distress. - Avoid exercise because it may cause bleeding of the varices. - Avoid straining during defecation to keep venous pressure low.

- Avoid straining during defecation to keep venous pressure low.

The nurse is providing postprocedural care to a patient following a colonoscopy. The nurse reports which assessment finding to the health care provider immediately? - Vomiting - Blood in the feces - Abdominal cramps - An urge to defecate

- Blood in the feces

Temp: 98.9 F, HR 110, BP 94/60, RR 30/min, O2 Sat 92% on 2L NC Height 5' 8", 130 pounds, BMI 17.5 WBC 9.5 cells/mm3, RBC 3.8 cells/mm3, Hgb 12.5 g/dL, Hct 35%, Platelets 200,000 cells/mcL The nurse obtains the assessment data and laboratory results of a female patient with stomach cancer who is scheduled for a Billroth II procedure. The nurse questions the recommended treatment based on which finding? - White blood cells (WBC) 9.5 cells/mm3 - Body mass index (BMI) 17.5 - Respiratory rate (RR) 30/min - Hemoglobin (Hgb) 12.5 g/dL

- Body mass index (BMI) 17.5

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? - Clamp the surgical drain. - Change the dressing as prescribed. - Notify the surgeon. - Remove and replace the perineal packing.

- Change the dressing as prescribed.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? - "We need to discourage him from wearing eyeglasses." - "We need to place objects in his impaired field of vision." - "We need to approach him from the impaired field of vision." - "We need to remind him to turn his head to scan the lost visual field."

- "We need to remind him to turn his head to scan the lost visual field."

The patient with a history of lung cancer and hepatitis C has developed liver failure. Which factor may be a contraindication for liver transplantation? - The patient has a high school education. - The chest x-ray showed another lung cancer lesion. - The patient has been able to stop smoking cigarettes. - The patient has well-controlled type 1 diabetes mellitus.

- The chest x-ray showed another lung cancer lesion.

Ammonia

10-80 mcg/dL

Albumin

3.5-5 g/dL

The registered nurse is teaching a student nurse about the complications of liver transplantation for patients with liver cancer. Which statement made by the student nurse requires further teaching? - "Remove invasive lines to prevent infection" - "Conduct a frequent culture of tubes, lines, and drainage" - "Use vaccines and prophylactic antibiotics to prevent infection" - "The use of immunosuppressants should be discontinued if there is an infection"

- "The use of immunosuppressants should be discontinued if there is an infection"

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? - Hyperreflexia - Positive reflexes - Flaccid paralysis - Reflex emptying of the bladder

- Flaccid paralysis

A certified WOCN is teaching a patient about caring for a new ileostomy. What information is most important to include? - "Remember that you must wear a pouch system at all times." - "Call the HCP if your stoma has a bluish or pale look." - "Notify the HCP if output from your stoma has a sweetish odor." - "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present."

- "Call the HCP if your stoma has a bluish or pale look."

The nurse is preparing education regarding ostomy self-care for a patient with a new colostomy. Which statement made by the patient is most indicative that the patient is ready to learn? - "I'm ready for discharge and have no questions." - "I'd like for my spouse to be taught about ostomy care first." - "I'd like to arrange for a visiting nurse at home for a short period of time." - "I need more information about the procedure for changing the bag."

- "I need more information about the procedure for changing the bag."

The nurse is teaching a patient about skin care around a colostomy. Which statement made by the patient indicates effective learning? - "I should clean the skin around the aroma using moisturizing soaps." - "I should refrain from using anti-fungal to treat a fungal rash." - "I should apply a skin sealant and allow it to dry before applying the pouch." - "I should refrain from using both stoma powder and a paste if the skin becomes raw."

- "I should apply a skin sealant and allow it to dry before applying the pouch."

The nurse has provided teaching for an adult client about screening for colon cancer. Which statement by the client indicates that education was effective? - "I should have an annual fecal occult blood test." - "I should have an annual colonoscopy when I become 60." - "I will have a colonoscopy before the fecal occult blood test." - "I will not need to have further fecal occult blood tests after a colonoscopy."

- "I should have an annual fecal occult blood test."

The nurse is completing an admission assessment for a client with suspected esophageal cancer. Which statement made by the client indicates the presence of a risk factor for esophageal cancer? - "I've been smoking for 20 years now." - "I eat plenty of fresh fruits and vegetables." - "I'm 5 feet, 8 inches tall and weigh 160 pounds." - "My alcohol consumption is about 2 beers per month."

- "I've been smoking for 20 years now."

The nurse is reviewing the preoperative prescriptions for a client with a colon tumor who is scheduled for abdominal perineal resection and notes that the primary health care provider has prescribed neomycin for the client. After discussing a prescription for neomycin with the nursing student who is caring for the client, the nurse determines that the student understands the rationale for administration if which statement is made? - "The client is allergic to penicillin." - "It will help to decrease the bacteria in the bowel." - "It is given to prevent an immune dysfunction postoperatively." - "It is given because the client has an infection that must be treated prior to surgery."

- "It will help to decrease the bacteria in the bowel."

A family member expressed concern regarding the patient's sudden focus on religion, despite rare participation prior to having pancreatic cancer. Which therapeutic statement would the hospice nurse use to explain the patient's behavior? - "Sometimes near the end of life, patients begin to have visions that often are religiously based." - "Patients facing death commonly turn to religion to help provide order to the world." - "Your family member's decision to turn to religion is so their soul will be saved upon leaving the body." - "I wouldn't worry too much about the religion; we just need to support whatever your family member needs."

- "Patients facing death commonly turn to religion to help provide order to the world."

A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? - No change in the condition - Complaints of muscle spasms - An improvement of the weakness - A temporary worsening of the condition

- A temporary worsening of the condition

The nurse is caring for a patient with colorectal cancer (CRC) who had a polypectomy during colonoscopy. Which finding indicates a positive outcome? - Clear-yellow, liquid stools - Normal control over defecation - Increased white blood cell count - Absence of malignancy at the resected margin of the polyp

- Absence of malignancy at the resected margin of the polyp

When caring for a patient with pancreatic cancer who is having severe pain, which intervention is the priority? - Supplementation with non narcotic medications to minimize opioid use - Reassurance that pain medication doses will be increased when needed - Use of adjunctive pain management strategies to prevent drug dependency - Administration of high-dose opioid analgesics when the patient reports pain

- Administration of high-dose opioid analgesics when the patient reports pain

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. - Basilar artery - Vertebral artery - Anterior cerebral artery - Internal carotid arteries - Posterior cerebral artery

- Anterior cerebral artery - Internal carotid arteries - Posterior cerebral artery

The nurse provides information for a new graduate who is working in an intensive care unit about mechanical ventilation in patients with a spinal cord injury (SCI). The nurse lists which patient conditions that warrant intubation? Select all that apply. - Arterial blood gases (ABGs) showing inadequate oxygenation - A patient with a complete SCI at the T4 level. - A pCO2 > 20 mm Hg above baseline - A patient with decreased vital capacity - A patient who experiences severe dyspnea

- Arterial blood gases (ABGs) showing inadequate oxygenation - A pCO2 > 20 mm Hg above baseline - A patient with decreased vital capacity - A patient who experiences severe dyspnea

Which instruction would the nurse provide the patient when assessing the patient's accessory nerve? - Ask the patient to shrug the shoulders against resistance. - Ask the patient to push the tongue to either side against resistance. - Invite the patient to say "ah" while the nurse visualizes elevation of the soft palate. - Have the patient stick the tongue out while the nurse strokes the posterior pharynx.

- Ask the patient to shrug the shoulders against resistance.

Which medical condition places a patient at a higher risk for an embolic stroke? - Atrial fibrillation - Atherosclerosis - Cancer of the brain - Anticoagulant therapy

- Atrial fibrillation

The nurse is teaching a patient about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the patient? - Self suctioning - Respiratory protection - Body image counseling - Tobacco cessation education

- Body image counseling

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? - Bradycardia - Hyperthermia - Hypoglycemia - Increased cardiac output

- Bradycardia

Which cranial nerves (CNs) are functioning when the nurse documents "PERRLA, EOMs intact"? Select all that apply. - CN II (optic) - CN III (oculomotor) - CN IV (trochlear) - CN V (trigeminal) - CN VI (abducens) - CN VII (facial)

- CN III (oculomotor) - CN IV (trochlear) - CN VI (abducens)

Which action will the nurse take when assessing a patient with possible oral cancer? - Check mouth for leukoplakia. - Ask about productive cough. - Palpate over the maxillary sinuses. - Observe for purulent nasal drainage.

- Check mouth for leukoplakia.

Which test is considered the best method for colorectal cancer (CRC) screening? - Colonoscopy - Barium enema - Sigmoidoscopy - Fecal occult blood test (FOBT)

- Colonoscopy

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? - Gets angry with family if they interrupt a task - Experiences bouts of depression and irritability - Has difficulty with using modified feeding utensils - Consistently uses adaptive equipment in dressing self

- Consistently uses adaptive equipment in dressing self

The nurse assesses the stoma of a patient who has undergone ostomy surgery and identifies that which finding indicates ischemia? - Pale stoma - Dark-pink stoma - Dusky-blue stoma - Brown-black stoma

- Dusky-blue stoma

A patient with CRC had colostomy surgery performed yesterday. The patient is very anxious about caring for the colostomy and states that the HCP's instructions "seem overwhelming." What does the nurse do first for this patient? - Instruct the patient about complete care of the colostomy. - Encourage the patient to look at and touch the colostomy stoma. - Schedule a visit from a patient who has a colostomy and is successfully caring for it. - Suggest that the patient involve family members in the care of the colostomy.

- Encourage the patient to look at and touch the colostomy stoma.

Which diagnostic study is used to stage esophageal cancer? - Radionuclide tests - Manometric studies - Esophagram (barium swallow) - Endoscopic ultrasonography (EUS)

- Endoscopic ultrasonography (EUS)

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? - Blowing the nose - Isometric exercises - Coughing vigorously - Exhaling during repositioning

- Exhaling during repositioning

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? - Extend the arms. - Extend the tongue. - Turn the head toward the nurse's arm. - Focus the eyes on the object held by the nurse.

- Extend the tongue.

A 51-year-old female patient receives an annual wellness check. The patient does not have a personal or family history of colorectal cancer, but the nurse plans to discuss screening recommendations with the patient. What will the nurse include in the teaching. - Get a colonoscopy every 10 years - Get a sigmoidoscopy every 7 years - Get a fecal occult blood test every 2 years - Get a double-contrast barium enema every 15 years

- Get a colonoscopy every 10 years

A patient is diagnosed with chronic liver cirrhosis. The nurse expects which assessment finding when examining the abdomen? - Liver dullness - Hard, enlarged liver - Rebound tenderness - Absence of liver dullness

- Hard, enlarged liver

Which common cause of gastritis is also linked to development of stomach cancer? - Syphilis - Cytomegalovirus - Helicobacter pylori - Mycobacterium species

- Helicobacter pylori

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would indicate that the patient may have developed liver cancer? - Serum bilirubin level - Ventilation-perfusion scan - Hepatic structure ultrasound - Abdominal girth measurement

- Hepatic structure ultrasound

A patient with esophageal cancer is scheduled for surgery in a few weeks. For which purpose would the health care provider schedule an endoscopy with stent placement before the surgery? - Prevent regurgitation - Improve nutrition status - Improve gastric emptying - Prevent respiratory complications

- Improve nutrition status

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? - Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure - Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure - Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure - Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

- Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

Which clinical manifestation would the nurse identify when admitting a patient suspected of having lesions in Broca's area? - Visual defects - Difficulty in swallowing - Irregular speech patterns - Decreased sense of smell

- Irregular speech patterns

The nurse is caring for a patient following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? - Leg exercises - Early ambulation - Irrigating the nasogastric tube - Coughing and deep-breathing exercises

- Irrigating the nasogastric tube

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. - Keeping the linens wrinkle-free under the client - Preventing unnecessary pressure on the lower limbs - Limiting bladder catheterization to once every 12 hours - Turning and repositioning the client at least every 2 hours - Ensuring that the client has a bowel movement at least once a week

- Keeping the linens wrinkle-free under the client - Preventing unnecessary pressure on the lower limbs - Turning and repositioning the client at least every 2 hours

Which condition would the nurse suspect in a patient with oral cancer who has "smoker's patch" on the mucosa of the mouth? - Pyrosis - Leukoplakia - Erythroplasia - Hyperkeratosis

- Leukoplakia

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? - Ambulate following a meal - Eat high-carbohydrate foods - Limit the fluids taken with meals - Sit in a high-Fowler's position during meals

- Limit the fluids taken with meals

A patient is admitted with esophageal varices and portal hypertension. Which underlying cause of these conditions would the nurse suspect? - Kyphosis - Liver cirrhosis - Throat lacerations - Squamous cell cancer

- Liver cirrhosis

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. - Loosening restrictive clothing. - Restraining the client's limbs. - Removing the pillow and raising padded side rails. - Positioning the client to the side, if possible, with the head flexed forward. - Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

- Loosening restrictive clothing. - Removing the pillow and raising padded side rails. - Positioning the client to the side, if possible, with the head flexed forward.

A male patient with a T7 complete spinal cord injury (SCI) asks the nurse about sexual problems that he may experience. The nurse recalls which information related to sexual function that is associated with SCIs? Select all that apply. - Men with complete injuries are less likely to have psychogenic erections. - Most men with SCI can have a reflex erection with physical stimulation if the S2-S4 nerve pathways are not damaged. - Signals from the brain about sexual thoughts are sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. - The prognosis for men with SCI to father children is unlikely. - Phosphodiesterase inhibitors have become the first-line treatment in men with SCI between T6 and L5.

- Men with complete injuries are less likely to have psychogenic erections. - Most men with SCI can have a reflex erection with physical stimulation if the S2-S4 nerve pathways are not damaged. - Signals from the brain about sexual thoughts are sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. - Phosphodiesterase inhibitors have become the first-line treatment in men with SCI between T6 and L5.

The nurse is providing dietary teaching for a client who underwent a partial gastrectomy to treat gastric cancer about foods high in vitamin B12. The nurse would instruct the client to include which food items in the diet that are high in this vitamin? Select all that apply. - Milk - Fish - Beef - Apples - Turkey - Bananas

- Milk - Fish - Beef - Turkey

The nurse is assessing a patient with a T2 level spinal cord injury (SCI). The nurse notes that there is a kink in the catheter, the bladder is distended, and the BP is 220/100 mm Hg. Which interventions does the nurse implement? Select all that apply. - Lower the head of the bed. - Monitor BP regularly. - Place the patient in a flat-lying position. - Notify the primary health care provider. - Check for the presence of bowel impaction. - Remove the kink in the catheter and drain the bladder.

- Monitor BP regularly. - Notify the primary health care provider. - Check for the presence of bowel impaction. - Remove the kink in the catheter and drain the bladder.

Which population group would the nurse identify as having the lowest rate of stomach cancer? - Hispanics - Pacific Islanders - Asian Americans - Non-Hispanic whites

- Non-Hispanic whites

A patient with a history of esophageal varices has just been admitted to the ER after vomiting a large quantity of blood. Which action should the nurse take first? - Ask about abdominal pain - Obtain pulse and blood pressure - Listen for bowel sounds in all quadrants - Obtain the charts from the previous admission

- Obtain pulse and blood pressure

The nurse performs a respiratory assessment on a patient with uncomplicated tetraplegia and identifies that which finding is acceptable? - PaO2 >60 mm Hg - PaCO2 <55 mm Hg - Respiratory rate 30 breaths/minute - Bibasilar crackles

- PaO2 >60 mm Hg

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? - Roast pork - Cheese omelet - Pasta with sauce - Tuna fish sandwich

- Pasta with sauce

Patient A: pale stoma Patient B: purple stoma Patient C: Brick-red Patient D: Brown-black The nurse is assessing the stomas of four patients who have undergone an ileostomy. Which patient's findings indicate necrosis? - Patient A - Patient B - Patient C - Patient D

- Patient D

A client is diagnosed as having a intestinal tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. - Flatulence - Peritonitis - Hemorrhage - Fistula formation - Bowel perforation - Lactose intolerance

- Peritonitis - Hemorrhage - Fistula formation - Bowel perforation

The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? - High-fiber, low-fat diet - Age older than 30 years - Distant relative with colorectal cancer - Personal history of ulcerative colitis or gastrointestinal polyps

- Personal history of ulcerative colitis or gastrointestinal polyps

What is low prealbumin indicative of? - Upper GI bleed - Lower GI bleed - Poor nutritional status - Smoking

- Poor nutritional status

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? - Assessing hearing loss - Monitoring urine output - Changing body position every 2 hours - Providing a quiet atmosphere with dimmed lighting

- Providing a quiet atmosphere with dimmed lighting

A patient develops diarrhea after colostomy surgery. After reviewing the patient's list of foods consumed regularly, the nurse suspects that which item is the cause of the condition? - Fish - Eggs - Strong cheeses - Raw fruits in the diet

- Raw fruits in the diet

The nurse provides education for a community group about ways to reduce the risk for colorectal cancer (CRC). The nurse includes a recommendation to decrease the intake of which food item? - Red meat - Grains - Fruits - Vegetables

- Red meat

For which purpose would a patient with pancreatic cancer receive radiation therapy? - Relieve pain - Reduce ascites - Increase survival time - Inhibit tumor metastasis

- Relieve pain

A patient returns to the floor post-op from surgery for esophageal cancer. What action by the nurse indicates a need for further teaching? - Monitoring the drainage from the nasogastric tube and chest tube. - Repositioning the nasogastric tube. - Making sure the patient is wearing their TEDs/SCDs. - Teaching the patient to turn/cough/deep breathe.

- Repositioning the nasogastric tube.

Which food does the nurse instruct a patient undergoing chemotherapy for oral cancer with secondary stomatitis to avoid? - Ice cream - Broiled fish - Salted pretzels - Scrambled eggs

- Salted pretzels

Social History: Smoker, 2 packs/day, quit 30 days ago Sex/Gender: Female identifies as female Surgical History: wisdom teeth removed as teenager BMI: 42 kg/m2 Which aspect of the patient health history below may be linked to an increased risk for developing oral cancer? - Female - Obesity - Smoking - Oral surgery

- Smoking

What diet or nutrition strategy can a nurse plan for to decrease weight loss in a patient diagnosed with esophageal cancer who is experiencing dysphagia? Select all that apply. - Soft foods - Thin liquids - Larger meals - Total parenteral nutrition (TPN) - Liquid nutrition supplements

- Soft foods - Liquid nutrition supplements

A client with colon cancer has received a course of chemotherapy with fluorouracil. The nurse should tell the client to report which finding immediately? - Alopecia - Headache - Stomatitis and diarrhea - Changes in color vision

- Stomatitis and diarrhea

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? - Taking medications as scheduled - Eating large, well-balanced meals - Doing muscle-strengthening exercises - Doing all chores early in the day while less fatigued

- Taking medications as scheduled

A 67-year-old man is receiving outpatient radiation treatments for carcinoma of the oropharynx and has developed dysphagia. The nurse develops a teaching plan regarding dysphagia and includes which interventions in the plan? Select all that apply. - Teach the man to speak slowly. - Teach the man to enunciate clearly. - Encourage the man to drink only thin liquids. - Teach the man to examine his oral mucosa daily. - Encourage the man to use artificial saliva to manage dryness.

- Teach the man to examine his oral mucosa daily. - Encourage the man to use artificial saliva to manage dryness.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? - Sudden loss of consciousness occurred. - Signs and symptoms occurred suddenly. - The client experienced paresthesias a few days before admission to the hospital. - The client complained of a severe headache, which was followed by sudden onset of paralysis.

- The client experienced paresthesias a few days before admission to the hospital.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. - The client is aphasic. - The client has weakness on the right side of the body. - The client has complete bilateral paralysis of the arms and legs. - The client has weakness on the right side of the face and tongue. - The client has lost the ability to move the right arm but is able to walk independently. - The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

- The client is aphasic. - The client has weakness on the right side of the body. - The client has weakness on the right side of the face and tongue.

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? - The passage of flatus - Absent bowel sounds - The client's ability to tolerate food - Bloody drainage from the colostomy

- The passage of flatus

When selecting the site for a patient's ostomy, which consideration does the health care team make? - The patient should be able to see the site. - Outside the rectus muscle area is the best site. - It is ideal if an abdominal stoma site can easily bend. - The ostomy should be conveniently located to allow for routine irrigations.

- The patient should be able to see the site.

A patient with hepatic encephalopathy may require which dietary or pharmacological therapy to help decrease serum ammonia levels? - Non-absorbable antibiotics given for long-term therapy - Trial of lactulose to increase the excretion of ammonia - Diet high in carbohydrates and protein with moderate fats - Diet low in protein and moderate in fats and carbohydrates

- Trial of lactulose to increase the excretion of ammonia

The nurse is caring for a patient with suspected liver cancer. Which diagnostic test would confirm the diagnosis? - Serum bilirubin - Ultrasound guided liver biopsy - Alkaline phosphatase - CT with contrast

- Ultrasound guided liver biopsy

A patient with advanced liver disease has esophageal varices. Which interventions would the nurse use to prevent bleeding? Select all that apply. - Apply gentle pressure for a short time period after performing venipuncture. - Use the smallest gauge needle possible when giving injections or drawing blood. - Teach the patient to avoid straining at stool, vigorous nose blowing, and coughing. - Advise the patient to use soft-bristle toothbrush and to avoid ingesting irritating food. - Instruct the patient to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

- Use the smallest gauge needle possible when giving injections or drawing blood. - Teach the patient to avoid straining at stool, vigorous nose blowing, and coughing. - Advise the patient to use soft-bristle toothbrush and to avoid ingesting irritating food. - Instruct the patient to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

Glucose: 120 mg/dL Sodium: 135 mEq/L Chloride: 100 mEq/L Potassium: 3.5 mEq/L BUN: 25 md/dL Creatinine: 0.8 mg/dL Albumin 2.0 g/dL Calcium: 8.5 mEq/L A patient underwent a radical neck dissection due to oral cancer and is receiving enteral nutrition at 50 mL/hour. The nurse reviews the patient's medical record and completes an assessment. Considering the patient's laboratory results, the nurse identifies that which assessment finding should be reported to the health care provider immediately? - Tube feeding residual 10 mL - Difficulty swallowing secretions - Formed daily bowel movements - Weight loss of 4 pounds in one week

- Weight loss of 4 pounds in one week

A colostomy is scheduled for a patient with a bowel obstruction. The nurse expects that which intervention will be included in the patient's preoperative preparation? -Instruction on irrigating a colostomy -Administration of an IV antibiotic -A high-fiber diet on the day of the surgery -Administration of IV dextrose or lactated Ringer's solution

-Administration of an IV antibiotic

HR: 110, BP: 90/58, Temp: 98.2, O2: 95% on RA, diaphoresis, Borborygmi, dizziness The nurse is caring for a patient who underwent a gastrojejunostomy due to stomach cancer. The nurse performs an assessment 20 minutes after the patient ate lunch. Based on the assessment findings, which action does the nurse take? -Administer an antiemetic. -Notify the rapid response team. -Assist the patient in lying down. -Provide a carbonated beverage.

-Assist the patient in lying down.

Which assessment finding would the nurse expect in a patient with a high ammonia level associated with hepatic encephalopathy? -Aphasia -Asterixis -Hyperactivity -Acute dementia

-Asterixis (a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy)

A patient underwent pancreaticoduodenectomy (Whipple procedure) for pancreatic cancer. Which dietary instructions would the nurse give to this patient? Select all that apply. -Avoid high-fat foods. -Eat a diet high in proteins. -Consume a high-calorie diet. -Consume a low-carbohydrate diet. -Resume normal diet without any restrictions.

-Avoid high-fat foods. -Eat a diet high in proteins. -Consume a high-calorie diet.

The nurse provides postoperative care one day after a patient undergoes colostomy surgery. The patient's stoma is moist and dark pink, with no obvious drainage. Which action does the nurse take? -Document the normal findings. -Consult the wound, ostomy, and continence nurse (WOCN). -Irrigate the ostomy with normal saline. -Palpate the abdomen around the stoma.

-Document the normal findings.

A patient is admitted with esophageal varices and portal hypertension. Which underlying cause of these conditions would the nurse suspect? -Kyphosis -Liver cirrhosis -Throat lacerations -Squamous cell cancer

-Liver cirrhosis

A patient with a family history of colon cancer undergoes a screening colonoscopy. After the procedure, the nurse performs which interventions? Select all that apply. -Obtains vital signs -Checks for return of the gag reflex -Assesses for abdominal cramping -Assesses for abdominal distention -Administers an enema to empty the bowel -Monitors for tenesmus

-Obtains vital signs -Assesses for abdominal cramping -Assesses for abdominal distention -Monitors for tenesmus

A patient develops diarrhea after colostomy surgery. After reviewing the patient's list of foods consumed regularly, the nurse suspects that which item is the cause of the condition? -Fish -Eggs -Strong cheeses -Raw fruits in the diet.

-Raw fruits in the diet.

A patient with advanced liver disease has esophageal varices. Which interventions would the nurse use to prevent bleeding? Select all that apply. -Apply gentle pressure for a short time period after performing venipuncture. -Use the smallest gauge needle possible when giving injections or drawing blood. -Teach the patient to avoid straining at stool, vigorous nose blowing, and coughing. -Advise the patient to use soft-bristle toothbrush and to avoid ingesting irritating food. -Instruct the patient to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

-Use the smallest gauge needle possible when giving injections or drawing blood. -Teach the patient to avoid straining at stool, vigorous nose blowing, and coughing. -Advise the patient to use soft-bristle toothbrush and to avoid ingesting irritating food. -Instruct the patient to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

Glucose: 120, Sodium: 135, Chloride: 100, Potassium: 3.5, BUN 25, Creatinine: 0.8, Albumin: 2.0, Calcium 8.5 A patient underwent a radical neck dissection due to oral cancer and is receiving enteral nutrition at 50 mL/hour. The nurse reviews the patient's medical record and completes an assessment. Considering the patient's laboratory results, the nurse identifies that which assessment finding should be reported to the health care provider immediately? -Tube feeding residual 10 mL -Difficulty swallowing secretions -Formed daily bowel movements -Weight loss of 4 pounds in one week

-Weight loss of 4 pounds in one week Albumin Range: 3.4-5.4

Lipase

0-160

Bilirubin

0.3-1.0

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. 1. Raise the head of the bed. 2. Check for bladder distention. 3. Contact the primary health care provider (PHCP). 4. Loosen tight clothing on the client. 5. Administer an antihypertensive medication. 6. Document the occurrence, treatment, and response.

1, 4, 2, 3, 5, 6 1. Raise the head of the bed. 4. Loosen tight clothing on the client. 2. Check for bladder distention. 3. Contact the primary health care provider (PHCP). 5. Administer an antihypertensive medication. 6. Document the occurrence, treatment, and response.

Alkaline Phosphate

30-120

ALT AST

4-36 0-35

Amylase

60-120

Pernicious Anemia diagnosed by a B12 level of:

<160

AFP

<40