The ugly awful terrible Unit 4 exam review
What is the first priority intervention when the nurse recognizes that a patient is having a transfusion reaction? A. Stop the transfusion B. Notify the rapid response team C. Flush the IV tubing with normal saline D. Apply oxygen via face mask
A. Stop the transfusion
Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? 1. Promoting self-care and independence. 2. Managing diarrhea. 3. Maintaining adequate nutrition. 4. Promoting rest and comfort.
2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.
After insertion of a nasoenteric tube, the nurse should place the client in which position? 1. Supine. 2. Right side-lying. 3. Semi-Fowler's. 4. Upright in a bedside chair.
2. The client is placed in a right side-lying position to facilitate movement of the mercury-weighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops. Placing the client in the supine or semi-Fowler's position, or having the client sitting out of bed in a chair will not facilitate tube progression.
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to: A. Take a laxative B. Follow a clear liquid diet C. Administer an enema D. Take an antiemetic
A. Take a laxative
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when: 1. There is no odor from the stoma. 2. The client is adequately hydrated. 3. There is no skin irritation around the stoma. 4. The client only changes the ostomy pouch once a day.
3. Because of high concentrations of digestive enzymes, ileostomy effluent is irritating to skin and can cause excoriation and ulceration. Some form of protection must be used to keep the effluent from contacting the skin. A skin barrier does not decrease odor formation; odor is controlled by diet. The barrier does not affect the client's hydration status, and the nurse can encourage the client to have an adequate daily intake of fluids. Pouches are usually worn for 4 to 7 days before being changed.
What is an expected outcome for a patient with Peptic Ulcer Disease? The patient will: A. Demonstrate appropriate use of analgesics to control pain B. Explain the importance of eliminating alcohol from the diet C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months D. Eliminate engaging in contact sports
B. Explain the importance of eliminating alcohol from the diet
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis? A. A demanding and stressful job B. Changing to a modified vegitarian diet C. Beginning a weight training program D. Walking 2 miles a day
A. A demanding and stressful job
T nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease (GERD). What should the nurse instruct the client to do? Select all that apply. A. Avoid a diet high in fatty foods B. Avoid beverages that contain caffeine C. Eat 3 meals a day with the largest being dinner in the evening D. Avoid all alcoholic beverages E. Lie down after each meal for 30 minutes F. Use over the counter anti secretory medications rather than prescription meds
A. Avoid a diet high in fatty foods, B. Avoid beverages that contain caffeine, D. Avoid all alcoholic beverages.
Which dietary measures would be useful in preventing esophageal reflux? A. Eating small, frequent meals B. Increasing fluid intake C. Avoiding air swallowing with meals D. Adding a bedtime snack to the dietary plan
A. Eating small, frequent meals
Which people should be advised to get the meningococcal vaccine? Select all that apply A. Healthy 12 year old school child B. 25 year old who had a splenectomy due to an auto accident C. Healthy 18 year old who has enlisted in the military D. Healthy 20 year old who is planning to live in a university dormitory E. Healthy 24 year old who is interning with a lawyer for the summer F. Healthy 22 year old who is unsure about vaccination status and plans to go to Asia
A. Healthy 12 year old school child B. 25 year old who had a splenectomy due to an auto accident C. Healthy 18 year old who has enlisted in the military D. Healthy 20 year old who is planning to live in a university dormitory F. Healthy 22 year old who is unsure about vaccination status and plans to go to Asia
An older patient is receiving a blood transfusion. Which signs/symptoms suggest that the patient is experiencing transfusion associated circulatory overload? A. Hypertension, bounding pulse, and distended neck veins B. Fever, chills, and tachycardia C. Urticaria, itching, and bronchospasm D. Headache, chest pain, and hemoglobinuria
A. Hypertension, bounding pulse, and distended neck veins
A client who has had a laparoscopic cholecystectomy has adhesive strips over the puncture sites. When preparing the client for discharge, which client statements indicate that the teaching has been successful? Select all that apply. A. I can resume my normal diet when I want B. I need to avoid driving for 4 weeks C. I may experience some pain in my right shoulder D. I should spend 2-3 days in bed before resuming activities E. I can take a shower 2 days later
A. I can resume my normal diet when I want C. I may experience some pain in my right shoulder E. I can take a shower 2 days later
The new registered nurse is giving a blood transfusion to a patient. Which statement by the new nurse indicates the need for action by the supervising nurse? A. I will complete the red blood cell transfusion within 6 hours B. I will check the patient verification with another registered nurse C. I will use normal saline solution to begin the blood transfusion D. I will remain with the patient for the first 15-30 minutes of the infusion
A. I will complete the red blood cell transfusion within 6 hours
The healthcare provider (HCP) prescribes intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression, the nurse should evaluate the client to determine if: A. Intestinal fluid and gas have been removed B. The client has had a bowel movement C. The clients urinary output has been adequate D. The client can sit up with out pain
A. Intestinal fluid and gas have been removed
A client's stools are light gray in color. For what finding should the nurse assess the client? Select all that apply. A. Intolerance to fatty foods B. Fever C. Jaundice D. Respiratory distress E. Pain at McBurney's point F. Peptic ulcer disease
A. Intolerance to fatty foods B. Fever C. Jaundice
A patient is receiving a red blood cell transfusion through a double-lumen peripherally inserted central catheter. The patient has 2 other peripheral IVs: 1 is capped and the other has D5/.45NS running at a rate of 50 mL/hr. What can be given concurrently through the line that is selected for the red cell transfusion? A. Normal saline B. Infusion of platelets C. Dextrose In water D. Morphine 2 mg IV push
A. Normal saline
Which patient has the greatest risk for developing a febrile transfusion reaction? A. Patient is an older adult, and transfusion was given too rapidly B. Patient received an intraoperative autologous transfusion C. Patient has received multiple blood transfusions for chronic bleeding D. Patient sustained multiple injuries and needed an emergency transfusion
A. Patient is an older adult, and transfusion was given too rapidly
Which statements about peritonitis are true? Select all that apply A. Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals B. Continuous ambulatory peritoneal dialysis (CAPD) can cause peritonitis C. White blood cell counts are often decreased with peritonitis D. Abdominal wall rigidity is a classic finding in patients with peritonitis E. Chemical peritonitis is caused by leakage of pancreatic enzymes or gastric acids F. Respiratory problems can be caused by increased abdominal pressure against the diaphragm
A. Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals B. Continuous ambulatory peritoneal dialysis (CAPD) can cause peritonitis D. Abdominal wall rigidity is a classic finding in patients with peritonitis E. Chemical peritonitis is caused by leakage of pancreatic enzymes or gastric acids F. Respiratory problems can be caused by increased abdominal pressure against the diaphragm
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which signs and symptoms? Select all that apply. A. Projectile vomiting B. Significant abdominal distention C. Copious diarrhea D. Rapid onset of dehydration E. Increased bowel sounds
A. Projectile vomiting, D. Rapid onset of dehydration E. Increased bowel sounds
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). The nurse should: A. Promptly assess the client for potential perforation B. Tell the assistant to change thermometers and retake the temperature C. Plan to the give the client Acetaminophen to lower the temperature D. Ask the UAP to bathe the client with tepid water
A. Promptly assess the client for potential perforation
A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should: A. Report the findings to the healthcare provider B. Encourage the client to increase fluid intake C. Advise the client to avoid iron rich foods D. Place the client on contact precautions
A. Report the findings to the healthcare provider
Two weeks before a client was scheduled for an ileostomy, and the nurse should instruct the client to: A. Stop taking drugs that will interfere with clotting (aspiring, ibuprofen) B. Follow a low residue diet C. Abstain from having sex D. Report having a temp over 99 degrees
A. Stop taking drugs that will interfere with clotting (aspiring, ibuprofen)
A 40-year-old client is admitted to the hospital with a diagnosis of acute cholecystitis. The nurse should contact the healthcare provider (HCP) to question which prescription? A. IV fluid therapy of normal saline solution to be infused at 100mL/hr until further prescriptions B. Administer 10 mg morphine sulfate IM every 4 hours as needed for severe abdominal pain C. Nothing by mouth (NPO) til further prescriptions D. Insert a nasogastric tube and connect to low intermittent suction
B. Administer 10 mg morphine sulfate IM every 4 hours as needed for severe abdominal pain
Immediately after having surgery to create an ileostomy, which goal has the highest priority? A. Provide relief from constipation B. Assisting client with self-care activities C. Maintaining fluid and electrolyte balance D. Minimizing odor formation.
B. Assisting client with self-care activities
The nurse should assess the client who is being admitted to the hospital with upper GI bleeding for which finding? Select all that apply. A. Dry, flushed skin B. Decreased urine output C. Tachycardia D. Widening pulse pressure E. Rapid respirations F. Thirst
B. Decreased urine output, C. Tachycardia, E. Rapid respiration's, F. Thirst
Which instruction should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? A. Limit caffeine intake to 2 cups of coffee per day B. Do not lie down for 2 hours after eating C. Follow a low protein diet D. Take medications with milk to decrease irritation
B. Do not lie down for 2 hours after eating
The nurse is reviewing the electrolyte value for a patient with bacterial meningitis and notes that the serum sodium is 126 mEq/L. How does the nurse interpret this finding? A. Within normal limits considering the diagnosis of bacterial meningitis but warrants repeat laboratory testing for downward trends B. Evidence of syndrome of inappropriate antidiuretic hormone, which is a complication of bacterial meningitis C. A protective measure that causes increased urination and therefore reduced the risk of increased intracranial pressure D. An early warning sign that the electrolyte imbalances will potentiate an acute myocardial infarction or shock
B. Evidence of syndrome of inappropriate antidiuretic hormone, which is a complication of bacterial meningitis
The patient reports neck stiffness, light sensitivity, noise sensitivity, headache, muscle aches, nausea, vomiting, and "feeling foggy and kind of out of it". Although the nurse recognized that all vital signs are important, which question is the nurse most likely to ask to assist the health care provider to determine the diagnosis? A. Do you feel like your heart is beating too fast? B. Have you had fever or chills? C. Have you been breathing hard or rapidly? D. What is your baseline blood pressure?
B. Have you had fever or chills?
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I am upset because I know I will not be able to have children now that I have an ileostomy." Which response by the nurse is best? A. Many women with ileostomies decide to adopt. Maybe you could consider that option? B. Having a ileostomy does not necessarily mean that you cannot bear children. Let us talk about your concerns C. I can understand your reasons for being upset. Having children must be important to you. D. I am sure you will adjust to this situation with time. Try not to be too upset
B. Having a ileostomy does not necessarily mean that you cannot bear children. Let us talk about your concerns
Which diet would be most appropriate for the client with ulcerative colitis? A. High calorie, low protein B. High protein, low residue C. Low fat, high fiber D. Low sodium, high carbohydrate
B. High protein, low residue
Which electrolyte imbalance can occur related to a blood transfusion? A. Hyponatremia B. Hyperkalemia C. Hypocalcemia D. High blood glucose
B. Hyperkalemia
Which nursing intervention is part of non surgical management for a patient with peritonitis? A. Monitor weekly weight and intake and output B. Insert a nasogastric tube to decompress the stomach C. Order a breakfast tray when the patient is hungry D. Administer NSAIDS for pain
B. Insert a nasogastric tube to decompress the stomach
A patient arrives in the emergency department reporting headache, fever, nausea, and photosensitivity. The patient has been living with 2 people who were diagnosed with meningitis. Which diagnostic test does the nurse anticipate the health care provider will order to rule out meningitis? A. X-ray of the skull B. Lumbar puncture C. Myelography D. Cerebral angiogram
B. Lumbar puncture
When obtaining a nursing history from a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. A. Epigastric pain at night B. Melena C. Relief of epigastric pain after eating D. Vomiting E. Weightloss
B. Melena, D. Vomiting, E. Weight loss
Which is a priority focus of care for a client experiencing an exacerbation of Crohn's disease? A. Encouraging regular ambulation B. Promoting Bowel rest C. Maintaining current weight D. Decreasing episodes of rectal bleeding
B. Promoting Bowel rest
A client with Crohn's disease has concentrated urine; decreased urinary output; dry skin with decreased turgor; hypotension; and weak, thready pulses. What should the nurse do first? A. Encourage the client to drink at least 1000 ml of fluid a day B. Provide parenteral rehydration therapy as provided C. Turn and reposition every 2 hours D. Monitor vital signs every shift
B. Provide parenteral rehydration therapy as provided
The client with ulcerative colitis is to be on bed rest with bathroom privileges. When evaluating the effectiveness of this level of activity, the nurse should determine if the client has: A. Conserved energy B. Reduced intestinal peristalsis C. Obtained needed rest D. Minimize stress
B. Reduced intestinal peristalsis
A patient on the unit has herpes zoster. Which staff members would be best to assign to the care of this patient? A. Any staff member, as long as personal protective equipment (PPE) is utilized B. Staff members who have had chicken pox C. Staff members who have completed training on herpes zoster D. Staff members with no small children at home
B. Staff members who have had chicken pox
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse should tell the client: A. Ulcerative colitis can be cured by the use of steroids B. Steroids are used in severe flare ups because they can decrease the incidence of bleeding C. Long term use of steroids will prolong periods of remission D. The side effects of steroids outweigh their benefits to clients with ulcerative colitis
B. Steroids are used in severe flare ups because they can decrease the incidence of bleeding
The nurse assesses the client's stoma during the initial postoperative period. What observation should the nurse report to the healthcare provider (HCP) immediately? A. The stoma is slightly edematous B. The stoma is dark red to purple C. The stoma oozes a small amount of blood D. The stoma does not expel stool
B. The stoma is dark red to purple
Which blood product is most likely to have stricter monitoring policies requiring that a physician be present on the unit during administration? A. Packed red blood cell transfusion B. White blood cell transfusion C. Fresh frozen plasma transfusion D. Platelet transfusion
B. White blood cell transfusion
The nurse is teaching the client how to care for an ileostomy. The client asks the nurse how long to wear the pouch before changing it. The nurse should tell the client A. The pouch is only changed when it leaks B. You can wear the pouch for about 4-7 days C. You should change the pouch evening before bed D. It depends on your activity level and diet
B. You can wear the pouch for about 4-7 days
What key assessment data would the nurse expect to find in a patient with Peritonitis? A. Fever and headache B. Dizziness with nausea and vomiting C. Abdominal pain, distention, and tenderness D. Nausea and loss of appetite
C. Abdominal pain, distention, and tenderness
What observation should the nurse instruct the client with an ileostomy to report immediately? A. Passage of liquid stool from the stoma B. Occasional Presence of undigested food in the effluent C. Absence of drainage from the ileostomy for 6 or more hours D. Temperature of 99.8 degrees
C. Absence of drainage from the ileostomy for 6 or more hours
The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question? A. Have the client talk with a member of clergy about these concerns B. Tell the client to worry about these concerns after surgery C. Arrange for someone with an ostomy to visit with the client preoperatively D. Notify the surgeon of the clients question
C. Arrange for someone with an ostomy to visit with the client preoperatively
A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a T tube. To evaluate the effectiveness of the T tube, the nurse should: A. Irrigate the tube with normal saline every 4 hours B. Unclamp the T tube and empty the contents every day C. Assess the color and amount of drainage every shift D. Monitor the multiple incision sites for bile drainage
C. Assess the color and amount of drainage every shift
A client is to take one daily dose of ranitidine at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug: A. Before meals B. With meals C. At bedtime D. When pain occurs
C. At bedtime
A patient scheduled for surgery tells the nurse that he is fearful of the possibility of needing a blood transfusion. What is the nurses best response? A. Have you spoken with your health care provider about a family member donating blood for your transfusion? B. With today's technology, typing and receiving blood is a very safe procedure, and there is no need to worry C. Autologous transfusion, where you donate your own blood for later transfusion, may be an option for you D. Have you had previous unpleasant experiences with blood transfusions during past surgeries?
C. Autologous transfusion, where you donate your own blood for later transfusion, may be an option for you
The new registered nurse is identifying a patient for blood transfusion. Which action by the nurse warrants intervention by the supervising nurse? A. Checks the health care provider's order before the blood transfusion B. Compared the identification name band and the number to the blood component tag C. Cross checks the patients room number as a form of identification D. Compares blood bag label and requisition slip to ensure compatibility of ABO and Rh.
C. Cross checks the patients room number as a form of identification
The fluid shift that occurs in peritonitis May result in which of the following events? A. Intercellular fluid moving into the peritoneal cavity B. Significant increase in circulatory volume C. Decreased circulatory volume and hypovolemic shock D. Increased bowel motility caused by increased fluid volume
C. Decreased circulatory volume and hypovolemic shock
A client undergoes a laparoscopic cholecystectomy. Which dietary instructions should the nurse give the client immediately after surgery? A. You cannot eat or drink anything for 24 hours B. You may resume your normal diet the day after the surgery C. Drink liquids today and eat lightly for a few days D. You can progress from liquid to a bland diet as tolerated
C. Drink liquids today and eat lightly for a few days
A client who has been diagnosed with gastroesophageal reflux disease (GERD) has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which item from the diet? A. Lean beef B. Air popped Popcorn C. Hot chocolate D. Raw vegetables
C. Hot chocolate
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? A. Heart failure B. Deep vein thrombosis C. Hypokalemia D. Hypocalcemia
C. Hypokalemia
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: A. Hyperalbunemia B. Thrombocytopenia C. Hypokalemia D. Hypercalcemia
C. Hypokalemia
Which statement about ileostomy care indicates that the client understands the discharge instruction? A. I should be able to resume weight lifting in 2 weeks B. I can return to work in 2 weeks C. I need to drink at least 3000 ml of fluid a day D. I will need to avoid getting my stoma wet while bathing
C. I need to drink at least 3000 ml of fluid a day
The nurse is caring for a patient who has symptoms and risk factors for bacterial meningitis. For which symptom must the nurse alert the health care provider? A. Capillary refill of 3 seconds B. Headache with nausea and vomiting C. Inability to move eyes laterally D. Oral temperature of 101.6
C. Inability to move eyes laterally
A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that the most likely cause of the client's constipation is because the client: A. Has not been including enough fiber in their diet B. Needs to increase the daily exercises C. Is experiencing an adverse effect of the Aluminum Hydroxide D. Has developed a gastrointestinal obstruction
C. Is experiencing an adverse effect of the Aluminum Hydroxide
Which discharge instruction would be appropriate for a client who has had a laparoscopic cholecystectomy and has sutures covered by a dressing? A. Avoid showering for 1 week after surgery B. Return to work within 1 week C. Leave dressing in place until you see the surgeon at the postoperative visit D. Use acetaminophen for any fever
C. Leave dressing in place until you see the surgeon at the postoperative visit
A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain and nausea and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time? A. Manage anxiety B. Restore fluid loss C. Manage the pain D. Replace nutritional loss
C. Manage the pain
The nurse is caring for a patient who was admitted for a diagnosis of meningococcal meningitis. Which nursing action is specific to this type of meningitis? A. Administering an anti fungal agent such as amphotericin B B. Observing the patient for genital lesions C. Placing the patient in isolation precautions per hospital procedure D. Checking to see if the patient is HIV positive
C. Placing the patient in isolation precautions per hospital procedure
A client is scheduled for an ileostomy. Which would be most helpful in preparing the client psychologically for the surgery? A. Include family members in preoperative teaching sessions B. Encourage the family to ask questions about managing the ileostomy C. Provide a brief thorough explanation of all preoperative and post operative procedures D. Invite a member of the ostomy association to visit the client
C. Provide a brief thorough explanation of all preoperative and post operative procedures
Which common complication should the nurse monitor for in an older patient diagnosed with herpes zoster? A. Nausea and vomiting B. Infections of the arms and legs C. Severe pain after the lesions have resolved D. Severe itching after the lesions have resolved
C. Severe pain after the lesions have resolved
A patient with meningitis reports a headache, and the nurse give the appropriate IV push medication. Several hours later, the patient reports pain in the left hand; the radial pulse is very weak, the hand feels cool, the capillary refill is sluggish compared to the other. What does the nurse suspect is occurring in this patient? A. Stroke secondary to increased intracranial pressure resulting from meningitis B. Sickle cell crisis associated with an increased risk of meningitis C. Thrombotic or embolic complication causing vascular compromise D. Local phlebitis from the IV push pain medication that was given
C. Thrombotic or embolic complication causing vascular compromise
A client who has ulcerative colitis has persistent diarrhea and has lost 12 lb (5.5 kg) since the exacerbation of the disease. Which approach will be most effective in helping the client meet nutritional needs? A. Continuous enteral feeding B. Follow a high calorie, high protein diet C. Total parenteral nutrition (TPN) D. Eating 6 small meals a day
C. Total parenteral nutrition (TPN)
To avoid transfusion reaction, the nurse is carefully monitoring the patient during a blood transfusion. When are hemolytic reactions to blood transfusion most likely to occur? A. 1 mL is sufficient B. 5 mL is typical C. Within the first 50 mL D. After 100 mL
C. Within the first 50 mL
A client had a colon resection yesterday. The client's hemoglobin was 14.1 g/dL yesterday and today it is 7.2 g/dL. The client's oxygen saturation is 87%. After reviewing the chart (see chart) and notifying the healthcare provider (HCP), the nurse should first: A. Increase the saline infusion to 150 gtt/hr B. Vital signs every hour C. Determine when pain medication was last administered D. Administer oxygen at 2 L/ min
D. Administer oxygen at 2 L/ min
The client with gastroesophageal reflux disease (GERD) has a chronic cough. This symptom may indicate: A. Development of laryngeal cancer B. Irritation of the esophagus C. Esophageal scar tissue formation D. Aspiration of gastric contents
D. Aspiration of gastric contents
A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing: A. Extreme fatigue B. Disturbed thought C. Sense of isolation D. Difficulty coping
D. Difficulty coping
A client has been admitted to the medical surgical unit following an emergency cholecystectomy. There is a Jackson-Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. What should the nurse do? A. Notify the surgeon B. Remove the drain and suction unit C. Check the dressing for bleeding D. Empty the drainage unit
D. Empty the drainage unit
A client is taking an antacid for treatment of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid? A. I should take me Antacid before I take my other medications B. I need to decrease my intake of fluids so I don't dilute the effects of my antacids C. My antacid will be most effective if I take it whenever I experience stomach pains D. It is best for me to take my antacid 1-3 hours after meals
D. It is best for me to take my antacid 1-3 hours after meals
A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching? A. Empty the bile bag daily B.breathe deeply into a paper bag when nauseated C. Keep adhesive dressings in place for 6 weeks D. Report bile colored drainage from any incision
D. Report bile colored drainage from any incision
After a cholecystectomy, the client is to follow a low-fat diet. Which food would be most appropriate to include in a low-fat diet? A. Cheese omelette with onions B. Peanut butter on wheat toast C. Ham salad sandwich with mayonnaise D. Roast beef sandwich with lettuce and tomato
D. Roast beef sandwich with lettuce and tomato
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?
Notify the Healthcare provider
The respiratory problems that may accompany peritonitis are a result of which factor? A. Associated pain interfering with ventilation B. Decreased pressure against the diaphragm C. Fluid shifts to the thoracic cavity D. Decreased oxygen demands related to the infectious process
a. associated pain interfering with ventilation
