Unit 2 part 2
A nurse is discussing the use of a low-profile gastrostomy device with the parent of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse? A. "The device can be uncomfortable for children." B. "Checking residual is much easier with this device." C. "Tub baths are allowed with this device." D. "Mobility of the child is limited with this device."
"Tub baths are allowed with this device."
A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? (Select all that apply.) A. A client who has a wired jaw due to a motor vehicle crash B. A client who is 24 hr postoperative following temporomandibular joint repair C. A client who has difficulty chewing due to a traumatic brain injury D. A client who has hypercholesterolemia due to coronary artery disease E. A client who is scheduled for a colonoscopy the next mornin
A client who has a wired jaw due to a motor vehicle crash A client who is 24 hr postoperative following temporomandibular joint repair A client who has difficulty chewing due to a traumatic brain injury
A charge nurse is providing information about fat emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by the nurse are appropriate? (Select all that apply.) A. "Concentration of lipid emulsion can be up to 30%." B. "Adding lipid emulsion gives the solution a milky appearance." C. "Check for allergies to soybean oil." D. "Lipid emulsion prevents essential fatty acid deficiency." E. "Lipids provide calories by increasing the osmolality of the PN solution."
A. "Concentration of lipid emulsion can be up to 30%." B. "Adding lipid emulsion gives the solution a milky appearance." C. "Check for allergies to soybean oil." D. "Lipid emulsion prevents essential fatty acid deficiency."
A nurse in a clinic is reviewing self-care information with a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? A. "I will plan to limit fiber in my diet." B. "I will eat my meals and plan fluid intake between meals." C. "I will drink coffee with breakfast rather than citrus juice." D. "I will try to eat three moderate to large meals a day."
A. "I will plan to limit fiber in my diet."
A nurse is caring for a client who is receiving TPN, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? A. Administer 20% dextrose in water IV until the next bag is available. B. Slow the infusion rate of the current bag until the solution is available. C. Monitor for hyperglycemia. D. Monitor for hyperosmolar diuresis
A. Administer 20% dextrose in water IV until the next bag is available.
A nurse is planning care for a client who is receiving continuous drip enteral nutrition. Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Administer with an infusion pump. B. Measure residual every 8 hr. C. Flush the feeding tube every 4 hr. D. Reinstill the residual feeding into the stomach. E. Reduce the flow rate if residual exceeds infused volume over the previous 3-hr period.
A. Administer with an infusion pump. C. Flush the feeding tube every 4 hr. D. Reinstill the residual feeding into the stomach.
2. A nurse is reviewing nutrition information with a client who has cholecystitis. Which of the following food choices can trigger cholecystitis? A. Brownie with nuts B. Bowl of mixed fruit C. Grilled turkey D. Baked potato
A. Brownie with nuts
A nurse at a long term facility is instructing a new graduate nurse on age-related changes that can cause electrolyte imbalance among older adults. Which of the following age-related changes should the nurse include as a risk for hypernatremia? (Select all that apply.) A. Decreased total body water content B. Inadequate water intake C. Inadequate intake of calcium D. Altered thirst mechanism E. Muscle weakness
A. Decreased total body water content B. Inadequate water intake D. Altered thirst mechanism
A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose (Cephulac) E. Sedative
A. Diuretic B. Beta-blocking agent D. Lactulose (Cephulac)
A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should monitor the client for which of the following clinical manifestations? A. ECG changes B. Constipation C. Polyuria D. Hypotension
A. ECG changes
A nurse in a provider's office is collecting data from a client who has dehydration. Which of the following findings should the nurse expect? (Select all that apply.) A. Elevated temperature B. Jugular vein distention C. Skin tenting D. Dizziness E. Orthopnea
A. Elevated temperature C. Skin tenting D. Dizziness
A nurse is caring for a client who has a small bowel obstruction from adhesions. Which of the following findings are consistent with this diagnosis? (Select all that apply.) A. Emesis greater than 500 mL with a fecal odor B. Report of spasmodic abdominal pain C. Pain relieved with vomiting D. Abdomen flat with rebound tenderness to palpation E. Laboratory findings indicating metabolic acidosis
A. Emesis greater than 500 mL with a fecal odor B. Report of spasmodic abdominal pain C. Pain relieved with vomiting
A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Examine trends in weight loss. B. Review prealbumin finding. C. Administer an IV solution of 20% dextrose. D. Add a micron filter to IV tubing. E. Use an IV infusion pump.
A. Examine trends in weight loss. B. Review prealbumin finding. D. Add a micron filter to IV tubing. E. Use an IV infusion pump.
A nurse is reinforcing teaching with a client who has hepatitis B about home care. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Limit physical activity. B. Avoid alcohol consumption. C. Take acetaminophen for comfort. D. Wear a mask when in public places. E. Eat small frequent meals.
A. Limit physical activity. B. Avoid alcohol consumption. E. Eat small frequent meals.
A nurse is caring for a client who has hypervolemia secondary to congestive heart failure. Which of the following should the nurse expect to include in the plan of care? (Select all that apply.) A. Monitor for edema. B. Have client lie supine. C. Administer sodium polystyrene sulfonate (Kayexalate). D. Reduce IV fluid rate. E. Encourage intake of sodium-rich foods.
A. Monitor for edema. D. Reduce IV fluid rate.
A nurse is reviewing the medical record of a newly admitted client. The laboratory results for the client are sodium 136 mEq/L and magnesium 1.0 mEq/L. Which of the following is the likely cause of these results? A. Recent alcohol ingestion B. Having been NPO for 4 hr C. IV administration of dextrose 5% in water (D5W) at 75 mL/hr D. Administration of a potassium-sparing diuretic
A. Recent alcohol ingestion
1. A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory findings? A. Tap water enema B. Lactose intolerance C. Hypoparathyroidism D. Water deprivation
A. Tap water enema
A nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? (Select all that apply.) A. Verify the presence of bowel sounds. B. Flush the feeding tube with warm water. C. Elevate the head of the bed 20°. D. Administer the feeding at room temperature. E. Inspect the tube insertion site
A. Verify the presence of bowel sounds. B. Flush the feeding tube with warm water. D. Administer the feeding at room temperature. E. Inspect the tube insertion site
A nurse is caring for a client who is to receive a full liquid diet due to dysphagia. Which of the following nursing actions is the highest priority? A. Add thickener to liquids. B. Educate the client about acceptable liquids. C. Perform a calorie count of consumed liquids. D. Offer high-protein liquid supplements.
Add thickener to liquids.
A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements by the nurse is appropriate? A. "Use the Y-port on the TPN IV tubing to administer antibiotics." B. "Regular insulin may be added to the TPN solution." C. "Administer heparin through a port on the TPN tubing." D. "Administer vitamin K IV bolus via a Y-port on the TPN tubing."
B. "Regular insulin may be added to the TPN solution."
A nurse is reinforcing teaching on prevention of transmission of hepatitis A with a recently infected client. Which of the following should the nurse include? A. "Don't share razors with other individuals." B. "Wash your hands after toileting." C. "Cough and sneeze into a tissue." D. "Use spermicide during intercourse."
B. "Wash your hands after toileting."
A nurse is reinforcing preoperative teaching with a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."
B. "You may have shoulder pain after surgery."
A nurse is obtaining an admission history from a client who is being evaluated for peptic ulcer disease (PUD). Which of the following findings are indicative of this condition? (Select all that apply.) A. Steatorrhea B. Anemia C. Tarry stools D. Epigastric pain E. Swollen lymph nodes
B. Anemia C. Tarry stools D. Epigastric pain
3. A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopathy. Which of the following is an expected assessment finding? (Select all that apply.) A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus
B. Change in orientation C. Asterixis E. Fetor hepaticus
A nurse is reinforcing discharge teaching with a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Take baths rather than showers. B. Clamp T-tube for 1 to 2 hr before and after meals. C. Keep the drainage system above the level of the gallbladder. D. Expect to have constipation. E. Empty drainage bag every 8 hr.
B. Clamp T-tube for 1 to 2 hr before and after meals. E. Empty drainage bag every 8 hr.
A nurse is preparing to administer intermittent enteral feeding to a client who has neuromuscular disorder. Which of the following are appropriate nursing interventions? (Select all that apply.) A. Fill the feeding bag with 24 hr worth of formula. B. Discard irrigation equipment after 24 hr. C. Leave unused portions of formula at the bedside. D. Label the unused portion of the formula. E. Replace administration tubing and feeding bag every 48 hr.
B. Discard irrigation equipment after 24 hr. D. Label the unused portion of the formula. E. Replace administration tubing and feeding bag every 48 hr.
A nurse is assessing a client who is postoperative from a gastric bypass and who just finished a meal. Which of the following clinical findings are early indications of dumping syndrome? (Select all that apply.) A. Bradycardia B. Dizziness C. Dry skin D. Hypotension E. Diarrhea
B. Dizziness D. Hypotension E. Diarrhea
5. A nurse is reviewing discharge teaching to a client who has Crohn's disease. Which of the following should be included in the teaching? A. Decrease intake of calorie-dense foods. B. Drink canned protein supplements. C. Take calcium supplements daily. D. Take a bulk-forming laxative daily.
B. Drink canned protein
A nurse is reviewing the laboratory findings of a client who has an acute exacerbation of Crohn's disease. Which of the following laboratory findings should the nurse expect to be increased with Crohn's disease? (Select all that apply.) A. Hematocrit B. Erythrocyte sedimentation rate (ESR) C. WBC D. Folic acid E. Serum albumin
B. Erythrocyte sedimentation rate (ESR) C. WBC
A nurse is providing instructions to a client who has a new diagnosis of celiac disease. Which of the following food choices by the client indicates a need for further teaching? A. Potatoes B. Graham crackers C. Wild rice D. Canned pears
B. Graham crackers
A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? (Select all that apply.) A. Dried prunes B. Ground turkey C. Mashed carrots D. Fresh strawberries E. Cottage cheese
B. Ground turkey C. Mashed carrots E. Cottage cheese
A nurse is providing dietary instructions to a client who is recovering from acute gastroenteritis and has been advised to limit his intake to low-fat foods. The nurse should suggest that the client eat which of the following foods? (Select all that apply.) A. Saltine crackers B. Oatmeal C. Ice cream D. Canned peaches E. Pretzels
B. Oatmeal D. Canned peaches E. Pretzels
2. A nurse is preparing to administer pancrelipase (Viokase) to a client who has pancreatitis. Which of the following is an appropriate nursing action? A. Administer medication 30 min after a snack. B. Offer a glass of water following medication administration. C. Administer the medication 30 min before meals. D. Sprinkle the contents on peanut butter.
B. Offer a glass of water following medication administration.
A nurse is caring for an older adult client in an extended care facility. Which of the following findings indicates the client has a stool impaction causing a large intestine obstruction? A. Last bowel movement was the previous day B. Small, frequent liquid stools C. Flatluence D. One episode of vomiting this morning
B. Small, frequent liquid stools
1. A nurse is reviewing the medical record of a client who has a small bowel obstruction. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Profuse emesis prior to insertion of the nasogastric tube B. Urine specific gravity 1.040 C. Hematocrit 60% D. Serum potassium 3.0 mEq/L E. WBC 10,000/mm3
B. Urine specific gravity 1.040 C. Hematocrit 60% D. Serum potassium 3.0 mEq/L
3. A nurse is reinforcing teaching with a client who has a prescription for sulfasalazine (Azulfidine). Which of the following should the nurse include in the teaching? A. "Take the medication 1 or 2 hr after eating." B. "This medication may cause yellowing of the sclera." C. "Notify the provider if you experience a sore throat." D. "This medication may cause your stools to turn black."
C. "Notify the provider if you experience a sore throat."
2. A nurse is contributing to the plan of care for a client who has a small bowel instruction and a nasogastric (NG) tube in place. Which of the following nursing interventions should be included in the plan of care? (Select all that apply.) A. Subtract the NG drainage from the client's output. B. Irrigate the NG tube every 8 hr. C. Auscultate bowel sounds. D. Provide oral hygiene every 2 hr. E. Clamp the NG tube during ambulation.
C. Auscultate bowel sounds. D. Provide oral hygiene every 2 hr. E. Clamp the NG tube during ambulation.
A nurse is collecting data from a client who has been taking prednisone following an exacerbation of inflammatory bowel disease (IBD). Which of the following findings is the priority? A. Client reports difficulty sleeping. B. Blood glucose at 0800 is 140 mg/dL. C. Client reports having a sore throat. D. Client reports gaining 4 lb in last 6 months.
C. Client reports having a sore throat.
5. A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Serum albumin 4.1 g/dL B. WBC 9,511/uL C. Direct bilirubin 2.1 mg/dL D. Serum cholesterol 171 mg/dL
C. Direct bilirubin 2.1 mg/dL
4. A nurse is reviewing the medical record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the client's back. B. Palpate the client's right lower quadrant. C. Inspect the skin around the umbilicus. D. Auscultate the area below the client's scapula.
C. Inspect the skin around the umbilicus.
A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription, which reads "discontinue NPO status; advance diet as tolerated." Which of the following are appropriate for the nurse to offer the client? (Select all that apply.) A. Applesauce B. Chicken broth C. Sherbet D. Wheat toast E. Cranberry juice
Chicken broth Cranberry juice
5. A nurse is reinforcing nutrition teaching with a client who has pancreatitis. Which of the following statements by the client requires further teaching? A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods." C. "I will use skim milk when cooking." D. "I plan to drink diet cola."
D. "I plan to drink diet cola."
A nurse is providing instructions to a client who reports constipation and has a prescription for a high‑fiber, low-fat diet. Which of the following food choices by the client indicates he understands the teaching? A. Peanut butter B. Peeled apples C. Hardboiled egg D. Brown rice
D. Brown rice
A nurse is reinforcing discharge teaching with a client who has irritable bowel syndrome (IBS). Which of the following should be included in the teaching? A. Increase intake of dairy products. B. Consume 15 to 20 g of fiber daily. C. Plan three moderate to large meals per day. D. Drink at least 2 L of fluids each day.
D. Drink at least 2 L of fluids each day.
3. A nurse is collecting data from a client who has pancreatitis. Which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder
D. Epigastric pain radiating to left shoulder
A nurse is assisting with the admission of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. History of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked
D. Hand spasms present when blood pressure is checked
A nurse on a medical-surgical unit is helping admit a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. Follow contact precautions. B. Weigh client weekly. C. Measure abdominal girth 7.5 cm (3 in) above the umbilicus. D. Provide a high-calorie, high-carbohydrate diet.
D. Provide a high-calorie, high-carbohydrate diet.
4. A nurse is reviewing a new prescription for ursodiol (ursodeoxycholic acid) with a client who has cholelithiasis. Which of the following should be included in the teaching? A. This medication reduces biliary spasms. B. This medication reduces inflammation in the biliary tract. C. This medication dilates the bile duct to promote passage of bile. D. This medication dissolves gall stones.
D. This medication dissolves gall stones.
A nurse is assessing a client who is postoperative following a colon resection. Which of the following findings indicates that the client is ready to transition from NPO to oral intake? A. Client report of hunger B. Urinary output exceeding 30 mL/hr C. Decrease in incisional pain D. Passage of flatus
Passage of flatus
A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following is an appropriate action by the nurse? A. Shake the bag to mix the fat. B. Turn the bag upside down one time. C. Return the bag to the pharmacy. D. Administer the bag of solution.
Return the bag to the pharmacy.
A nurse is teaching a client who is starting continuous feedings about the various types of enteral nutrition (EN) formulas. Which of the following should the nurse include in the teaching? A. Formula rich in fiber is recommended when starting EN. B. Standard formula contains whole protein. C. Hydrolyzed formula is recommended for a full-functioning GI tract. D. The high-calorie formula has increased water content.
Standard formula contains whole protein.
19. A nurse is providing information on pain control for a client who has acute pain following a subtotal gastric reaction. Which of the following client statement indicate an understanding of pain control a. "I will call for pain medication before the previous dose wears off." b. "I will call for pain medication as my pain starts to increase again." c. "I will wait for you to evaluate my pain before asking for more." d. "I will ask for less medication to avoid addiction."
a. "I will call for pain medication before the previous dose wears off."
6. A nurse is plnning for a cient who has cirrhosis of the liver. Which of the following should the nurse implement (select all that apply) a. Administration of furosemide (Lasix) b. Administration of warfarin c. Implement a low sodium diet d. Measure the abdominal girth e. Encourage weight lifting during physical therapy
a. Administration of furosemide (Lasix) c. Implement a low sodium diet d. Measure the abdominal girth
18. A nurse is planning a menu for a client who has folic acid deficiency anemia and is selecting food high in folic acid. Which of the following should the nurse include? a. Asparagus b. Eggs c. Shrimp d. Raisins
a. Asparagus
21. A nurse is caring for a client who has had a dilation and curettage (D&C) following a spontaneous abortion. The client tells the nurse that she is hungry. Which of the following initial actions by the nurse is appropriate? a. Auscultate the clients abdomen b. Offer clear liquids c. Ask the client if she is experiencing pain d. Check the clients chart for a diet prescription
a. Auscultate the clients abdomen
2. A nurse is caring for a client who has a potassium level of 5.4 mEq/L. The nurse should assess the client for a. ECG changes b. Constipation c. Polyuria d. Hypotension
a. ECG changes
9. The nurse is reinforcing teaching for a client who had an acute attack of cholecystitis. The patient should be cautioned to avoid which of these foods? (Select all that apply) a. Eggs b. Rice c. Fresh fruits d. Lean meats e. Cheese
a. Eggs e. Cheese
11. The nurse is collecting data from a client with acute liver failure. Which of the following laboratory test findings would the nurse recognize as supporting this diagnosis? (Select all that apply) a. Elevated aspartate aminotransferase level (AST) b. Elevated alanine aminotransferase level (ALT) c. Elevated serum potassium level d. Elevated platelet count e. Elevated prothrombin time f. Elevated serum bilirubin level
a. Elevated aspartate aminotransferase level (AST) b. Elevated alanine aminotransferase level (ALT) e. Elevated prothrombin time f. Elevated serum bilirubin level
10. The nurse is providing education for a client who had a recent cholecystectomy. Which of the following should the nurse include in the teaching? (Select all that apply) a. Fat is introduced slowly and adjusted accordingly to individual tolerance b. Raw fruits and vegetables should be avoided c. There are no dietary restrictions once you leave the hospital d. It is important to increase the protein intake in your diet e. If you are overweight, it is suggested that you lose weight f. Fat should be less than 20% of total diet
a. Fat is introduced slowly and adjusted accordingly to individual tolerance d. It is important to increase the protein intake in your diet e. If you are overweight, it is suggested that you lose weight
15. The nurse is participating in a community health fair program on risk factors for cancer. Which of the following would be included as increasing the risk for colon cancer? (Select all that apply) a. History of rectal polyps b. Family history of breast cancer c. Low-fiber diet d. History of ulcerative colitis e. Low-sodium diet f. Low-fat diet
a. History of rectal polyps c. Low-fiber diet d. History of ulcerative colitis
16. The nurse is reinforcing teaching for a client who reports constipation and straining and has a distended abdomen and intestinal rumbling. What should be included in the teaching? (Select all that apply) a. Increase intake of fiber, especially bran in the diet b. Drink water each morning and about 2 to 3 L throughout the day c. Use enemas and rectal suppositories if constipation persists after 2 days d. Increase the intake of foods containing vitamin K e. Set a time for defecation every day f. Sit on the toilet with feet planted firmly on the floor.
a. Increase intake of fiber, especially bran in the diet b. Drink water each morning and about 2 to 3 L throughout the day e. Set a time for defecation every day
24. A nurse is reviewing medications for a client who has a diagnosis of a small bowel obstruction. The nurse should withhold senna (Senoket) prescribed orally based on understanding of which of the following? a. Laxatives are contraindicated in clients who have a small bowel obstruction b. Only bulk-forming laxatives such as psyllium (Metamucil) should be prescribed c. Medication should be administered via NG tube rather than the oral route d. Opioid analgesics rather than laxatives should prescribed to alleviate discomfort
a. Laxatives are contraindicated in clients who have a small bowel obstruction
13. The nurse contributes to the plan of care for a client who has a nursing diagnosis of deficient fluid volume related to anorexia, nausea, vomiting, and excessive T-tube drainage related to clolecystitis. Which interventions should the nurse recommend be included in the plan of care? (Select all that apply) a. Monitor daily weight and intake and output b. Contact the physician if T-tube drainage is greater than 150 mL within 24 hours of surgery c. Encourage use of incentive spirometer every hour while awake d. Administer antiemetic as ordered e. Monitor skin turgor f. Clamp T-tube for 2 hours each shift
a. Monitor daily weight and intake and output d. Administer antiemetic as ordered e. Monitor skin turgo
14. A client tells the nurse she took a dose of dimenhydrinate (Dramamine) before coming to the health care clinic. The nurse determines that the medication is effective when the client reports relief of a. Nausea b. Dry mouth c. Headache d. Diarrhea
a. Nausea
16. The nurse is caring for a client immediately following a tonsillectomy. Which of the appropriate for the nurse to offer the client a. Orange popsicle b. Hot tea c. Ice cream d. Cranberry juice
a. Orange popsicle
2. The nurse is caring for a client diagnosed with acute pancreatitis, and focuses the plan of care to: Select all that apply a. Reduce pain b. Meet nutritional needs c. Replace enzymes and hormones d. Manage care of the nasogastric tube e. Prepare the client for surgery
a. Reduce pain b. Meet nutritional needs c. Replace enzymes and hormones
23. A nurse is reinforcing teaching about dietary recommendation to a client with iron deficiency anemia. Which of the following should the nurse include as a food that enhances iron absorption when consumed with nonheme iron a. Tomato juice b. Tea c. Milk d. Dried beans
a. Tomato juice
7. A nurse is preparing to administer a pre-packaged medication to a client and complete the final medication check. Which of the following is an appropriate action by the nurse? Check the medication a. at the client's bedside before administration b. in the area where the medication is obtained c. at the time of documentation d. in the nurses station while reviewing the providers order
a. at the client's bedside before administration
3. The nurse is caring for a client postoperative repair of a bowel obstruction. The nurse's priority of care is: a. Encouraging mobility b. Auscultating bowel sounds c. Monitoring intake and output d. Promoting weight loss
b. Auscultating bowel sounds
22. A client who is postoperative has an NG tube that has drained 2,500 mL in the past 6 hours. Because of this the nurse should monitor the client for which of the following electrolyte imbalances? a. Elevated sodium level b. Decreased potassium level c. Elevated magnesium level d. Decreased calcium level
b. Decreased potassium level
11. A nurse is caring for a client with cirrhosis who has a new prescription for cephulac(lactulose). Following administrations the nurse will monitor the client for which adverse effect of this medication a. Dry mouth b. Diarrhea c. Headache d. Peripheral edema
b. Diarrhea
8. The nurse is caring for a client who had an incisional cholecystectomy. Which activities should the nurse prioritize highest? (Select all that apply) a. Choosing low-fat foods from the menu b. Encouraging use of an incentive spirometer c. Coughing and deep breathing d. Performing leg exercises e. Ambulating early and frequently f. Managing pain
b. Encouraging use of an incentive spirometer c. Coughing and deep breathing e. Ambulating early and frequently f. Managing pain
20. The nurse receives a call from an adult who reports recent development of diarrhea with five liquid stools in the past 24 hours. Which of the following additional symptoms would cause the nurse to suggest the client seek immediate/emergent medical attention? (Select all that apply) a. Weight loss of 1 pound in the past week b. Fever c. Oral intake of 3 L of fluid in 24 hours d. Blood pressure of 138/72 mm/Hg e. Blood in the stool f. Severe abdominal cramping
b. Fever e. Blood in the stool f. Severe abdominal cramping
18. Which statements by a client who has been instructed on use of the medication budesonide (Entocort EC) to reduce local inflammation from Chron's disease indicate that more teaching is needed? a. I might experience mood swings or weight gain on this medication b. I can just stop taking this medication once I feel better c. I should swallow the pill whole, not crushed d. I must avoid the sun while taking this drug e. I will take the pill each evening before going to bed f. I should avoid grapefruit juice
b. I can just stop taking this medication once I feel better d. I must avoid the sun while taking this drug e. I will take the pill each evening before going to bed
14. The nurse is reinforcing teaching for a client about appropriate diet modifications to help prevent exacerbations of inflammatory bowel disease. The nurse evaluates teaching as effective by which of the following patient statements? (Select all that apply) a. I should increase my intake of fresh fruits and vegetables b. I should avoid caffeine and spicy fiber foods c. It is important to eat more whole grains and brans d. High-fiber foods should not be included in my diet e. I should avoid concentrated sweets and starches f. Milk and other dairy products should be limited in my diet.
b. I should avoid caffeine and spicy fiber foods d. High-fiber foods should not be included in my diet f. Milk and other dairy products should be limited in my diet.
17. The nurse is reinforcing teaching for a client who is being discharged after a colostomy. Which comments by the client indicates understanding of the discharge teaching? (Select all that apply) a. I should change the pouch each morning and evening to prevent infection b. I will empty the pouch when it is less than half full c. I'm so glad I can eat all the foods a like now, including hot dogs d. I always check the seal and tape around the stoma after I shower e. I can spray deodorant into the pouch after I clean it. f. I will not be concerned if there is no stool for several days
b. I will empty the pouch when it is less than half full d. I always check the seal and tape around the stoma after I shower e. I can spray deodorant into the pouch after I clean it.
15. A client has a magnesium deficit in addition to congestive heart failure (CHF). The most appropriate nursing diagnosis is a. Impaired skin integrity b. Risk for decrease cardiac output c. High risk or injury d. Altered comfort
b. Risk for decrease cardiac output
12. The nurse contributes to the plan of care for a client who has pancreatitis. A nursing diagnosis of imbalanced nutrition: Less than required related to pain, NPO, and nasogastric suction is developed. After 10 days of treatment, which of the following would indicate to the nurse that the treatment plan has been effective? (Select all that apply) a. The client reports pain relief b. The client has returned to baseline body weight c. The client's albumin level is 3.8 g/L d. The client has mild diarrhea and steatorrhea e. The serum potassium level is 3.7 mEq/L f. The serum sodium is 130 mEq/L
b. The client has returned to baseline body weight c. The client's albumin level is 3.8 g/L
4. A nurse is planning to reinforce teaching for a client who has hemorrhoids. Which of the following should the nurse plan to include in the teaching? a. The client should use a stimulant laxative to prevent constipation b. The client should follow a high-fiber diet to establish bowel regularity c. The client should practice a high carbohydrate diet to prevent hemorrhoid enlargement d. The client should limit the intake of fruit juice to prevent loose stools
b. The client should follow a high-fiber diet to establish bowel regularity
8. a nurse is planning to assign obtaining the vital signs of a postop client to an assistive personnel (AP) the nurse should assign obtaining vital signs for which of the following clients? a. A client who is 3 hr. postoperative following a thyroidectomy b. A client who is 3 hrs. postoperative following an abdominal hysterectomy c. A client who is 3 days postoperative following gastric bypass surgery d. A client who is 3 days postoperative following a craniotomy
c. A client who is 3 days postoperative following gastric bypass surgery
13. A nurse is reinforching dietary instruction for a client who has episodes of biliary colic for chronic cholecystitis. Which of the following should the nurse reinforce in the teaching plan a. An acid-ash diet b. A high fiber diet c. A low fat diet d. A low sodium diet
c. A low fat diet
5. A nurse is caring for a client who is post-op following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following item should the nurse include on the client's lunch tray? a. Lemon sherbet b. Plain yogurt c. Cranberry juice d. Carrot juice
c. Cranberry juice
17. A client has a serum sodium level of 115 mEq/L. The nurse has initiates a slow IV infusion of hypertonic saline solution per IV pump in a large vein. Which other intervention should the nurse implement as a priority? a. Assess the client for dysphagia b. Have on hand a calcium channel-blocker in care of overdose c. Initiate seizure and safety precaution d. Start a second IV in case the first on infiltrates
c. Initiate seizure and safety precaution
20. A nurse is planning to collect data on a client's abdomen who reports "stomach pain". Which of the following action should the nurse do first? a. Auscultate b. Percuss c. Inspect d. Palpate
c. Inspect
7. When performing a cleansing on a client postoperative left hip replacement, the nurse properly positions the client: a. Lying on the right side with legs abducted b. Lying on the left side with legs abducted c. Lying on the back with legs abducted d. Sitting on a bedside commode or toilet with legs abducted
c. Lying on the back with legs abducted
1. A nurse is reinforcing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching? a. Eggs b. Dried peas c. Pasta d. Dried fruit
c. Pasta
19. The nurse is caring for a client with fecal incontinence of liquid stool and notes the client's perianal area is excoriated. Which of the following interventions should be discussed with the RN? (Select all that apply) a. Nasogastric (NG) tube to suction b. Baby powder to peri area c. Stool culture d. A low-pressure rectal tube e. Protective barrier cream f. Antibiotic therapy
c. Stool culture d. A low-pressure rectal tube e. Protective barrier cream
6. The nurse listens as the physician informs the client of the diagnosis of colon cancer and explains the need to remove the colon and create an ileostomy. When the physician leaves, the nurse's priority of care is directed at: a. Instructing the client how to prepare for surgery b. Instructing the client about care of the postoperative ostomy c. Supporting the client and family's emotional needs d. Leaving the client and family alone to grieve
c. Supporting the client and family's emotional needs
5. The nurse is preparing the client for a barium enema to be performed tomorrow, and instructs the client to: a. Eat a high-fiber diet for two days prior to the procedure b. Perform a cleansing enema the morning of the procedure c. Take a laxative the night before the procedure d. NPO after 6 p.m. the night before the procedure
c. Take a laxative the night before the procedure
3. A school-age child is brought to the emergency department with a 2-day history of nausea, Vomiting and report of severe right lower quadrant pain. The child's WBC is 17,000/mm3 so appendicitis is suspected. Which of the following statements made by the child is most concerning to the nurse? a. "I am scared and I want to go home." b. "I am hungry and thirsty." c. "I'm tired and want to take a nap." d. "My belly doesn't hurt anymore."
d. "My belly doesn't hurt anymore."
4. The nurse is caring for several clients complaining of constipation. A digital rectal examination can be safely performed on the client with a diagnosis of: a. Transurethral resection of the prostate gland b. Myocardial infarction c. Increased intracranial pressure d. Hiatal hernia repair
d. Hiatal hernia repair
9. Which of the following should the nurse look for when assessing fluid volume deficit a. Moist skin b. Distended neck vein c. Increased urinary output d. Hypotention
d. Hypotention
1. The nurse caring for a client diagnosed with cirrhosis of the liver promotes a diet: a. High in protein and carbohydrates b. High in vitamin B and fats c. High in fat, and vitamin K, low in protein d. Low in protein, with vitamin K and B supplements
d. Low in protein, with vitamin K and B supplements
