Yea

A client returns from the operating room after extensive abdominal surgery. He has 1,000mL of lactated Ringer's solution infusing via central line. The physician orders the I.V. fluid to be infused at 125mL/hr. The drop factor of the tubing is 15gtt/min. How many drops per minute should the nurse set the I.V. flow rate?

31

A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take? a. Add a new container of PN using the current tubing and filter. b. Hang a new container of PN and change the IV tubing and filter. c. Infuse the remaining 50 mL and then hang a new container of PN. d. Ask the health care provider to clarify the written PN prescription.

A

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? A) A 65-year-old man with alcoholism who smokes B) A 45-year-old woman who has type 1 diabetes and who wears dentures C) A 32-year-old man who is obese and uses smokeless tobacco D) A 57-year-old man with GERD and dental caries

A

In planning care for a patient with metastatic liver cancer, the nurse should include interventions that: a. Focus primarily on symptomatic and comfort measures b. Reassure the patient that chemo offers a good prognosis c. Promote the patients confidence that surgical excision of the tumor will be successful d. Provide information necessary for the patient to make decisions regarding liver transplants

A

The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus? A. Cullen sign B. Rovsing sign C. McBurney sign D. Grey-Turner's sign

A

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

A

Which patient should the nurse assess first after receiving change-of-shift report? A. A 30-yr-old patient who has a distended abdomen and an apical heart rate of 136 beats/minute B. A 60-yr-old patient whose ileostomy has drained 800 mL over 8 hours C. A 40-yr-old patient with ulcerative colitis who had six liquid stools in 4 hours D. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool

A

Which patient should the nurse first after receiving change-of-shift report? A. A patient with esophageal varices who has a rapid heart rate B. A patient with a history of gastrointestinal bleeding who has melena C. A patient with nausea who has a dose of metoclopramide (Reglan) due D. A patient who is crying after receiving a diagnosis of esophageal cancer

A

You are caring for a patient with cirrhosis and portal hypertension. Which statement by the patient concerns you the most? a. "I'm very constipated and have been straining during bowel movements." b. "I have a tight sensation in my lower legs when I forget to put my feet up." c. "I can't button my pants anymore because my belly is so swollen." d. "When I sleep, I have to sit in a recliner so that I can breathe more easily."

A

A patient who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the tube feeding. b. Check gastric residual volumes more frequently. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.

ANS: A

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Do you have a history of IV drug use? b. "Do you use any over-the-counter drugs?" c. "Have you used corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

B

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? A. Insert a urinary catheter to drainage. B. Infuse metronidazole (Flagyl) 500 mg IV. C. Send the patient for a computerized tomography scan. D. Place a nasogastric (NG) tube to intermittent low suction.

B

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea

B

A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Ask the health care provider to reschedule the scan. b. Shut the feeding off 30 to 60 minutes before the scan. c. Connect the feeding tube to continuous suction before and during the scan. d. Send a suction catheter with the patient in case of aspiration during the scan.

B

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. What is the highest priority action by the nurse? A. Monitor drainage B. Contact the surgeon. C. Irrigate the NG tube. D. Give prescribed morphine.

B

A patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns from brown fecal drainage, which action will the nurse plan to take NEXT? A. Auscultate the bowel sounds. B. Prepare the patient for surgery. C. Check the patient's oral temperature. D. Obtain information about the accident.

B

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). What should the nurse explain about the action of the medication? A. "It decreases nausea and vomiting." B. "It inhibits development of stress ulcers." C. "It lowers the risk for H. pylori infection." D. "It prevents aspiration of gastric contents."

B

After change-of-shift report, which patient will the nurse assess first? a. A 40-yr-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles c. A 30-yr-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition d. A 30-yr-old woman whose gastrostomy tube is plugged after crushed medications were administered

B

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? A. The bowel sounds are hyperactive in all four quadrants. B. The patient's lungs have crackles audible to the midchest. C. The nasogastric (NG) suction is returning coffee-ground material. D. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

B

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? A. Hemoglobin (Hgb) 10.8 g/dL B. Temperature 102.1° F (38.9° C) C. Absent bowel sounds in all quadrants D. Scant nasogastric (NG) tube drainage

B

Using the accompanying figure below, identify the stage of colorectal cancer using the following classification system: A. Stage II B. Stage III C. Stage IV D. Stage I

B

What should the nurse teach a client about how to avoid the dumping syndrome? A. Eat in a hectic environment B. Reduce fluids with meals, but take them between meals C. Eat a diet with high carbohydrate foods with each meal. D. Consume three regularly-spaced meals per day

B

Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify source of hepatitis exposure.

B

Which goal of the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? A. Promoting self-care and independence B. Managing diarrhea C. Maintaining adequate nutrition D. Promoting rest and comfort

B

Which of the following lifestyle modifications should the nurse encourage the client with a hiatal hernia to include in activities of daily living? A. Daily aerobic exercise. B. Eliminating smoking and alcohol use. C. Balancing activity and rest. D. Avoiding high-stress situations.

B

Which of the following should be 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

The nurse is caring for a client admitted with cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply. A. Potassium 4.0 mEq/L B. Prothrombin time 22 seconds C. Albumin 3.2 g/dL D. Amalyse 250 units/L E. Ammonia 96 mg/dL (68.54 mmol/L) F. Platelets 75,000 cells/mm3 (75 x 109/L)

Bcef

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. What should the nurse do during the initial assessment of the patient? A. Remove the knife and assess the wound. B. Determine the presence of Rovsing sign. C. Check for circulation and tissue perfusion. D. Insert a urinary catheter and assess for hematuria.

C

A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

C

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. perform leg exercises hourly while awake. b. ambulate the evening of the operative day. c. turn, cough, and deep breathe every 2 hours. d. choose preferred low-fat foods from the menu.

C

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient? A. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) B. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine C. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) D. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix)

C

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should the nurse ask the patient about to determine possible risk factors for gastritis? A. The amount of saturated fat in the diet B. A family history of gastric or colon cancer C. Use of nonsteroidal antiinflammatory drugs (NSAIDS) D. A history of a large recent weight gain or loss

C

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

C

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? A. Maintain a low-residue diet until the surgical area is healed. B. Use ice packs on the perianal area to relieve pain and swelling. C. Take prescribed pain medications before you expect a bowel movement. D. Delay having bowel movement for several days until you are well healed.

C

At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart) A. Report the 24 hr drainage amount at 1200 B. Clamp the T-tube C. Evaluate tube for patency D. Irrigate the T-tube

C

At the beginning of the shift, the nurse is assigned a client with an ascending colostomy. Which picture identifies the correct placement where the nurse will assess the stoma? A. Image A B. Image C C. Image D D. Image B

C

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. What should be the nurse's first action? A. Auscultate for hypotonic bowel sounds. B. Notify the patient's health care provider. C. Check for tube placement and reposition it. D. Remove the tube and replace it with a new one.

C

In the care of a client with gastroesophageal reflux disease, which task would be appropriate to delegate to unlicensed assistive personnel (UAP)? A. Sharing successful strategies for weight reduction B. Encouraging the client to express concerns about lifestyle modification C. Reminding the client not to lie down for 2 to 3 hours after eating D. Explaining the rationale for eating small frequent meals

C

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: A. Contact the surgeon to request an order for a narcotic for the pain. B. Maintain the client in a recumbent position. C. Place the client on nothing-by-mouth (NPO) status. D. Apply heat to the abdomen in the area of the pain.

C

The nurse is obtaining a nursing history of a client suspected of having hepatitis C. What information should the nurse obtain from the client? A. Drunk contaminated water. B. Traveled to India. C. Had a tattoo. D. Eaten shellfish.

C

To prepare a patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

C

What is a likely finding in the nurse's assessment of a patient who has a large bowel obstruction? A. Projectile vomiting B. Referred back pain C. Abdominal distention D Metabolic alkalosis

C

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding

C

A 73-year-old patient is diagnosed with stomach cancer after an unintended 20 lb weight loss. Which nursing action will be included in the plan of care? A. Refer the patient for hospice services. B. Infuse IV fluids through a central line. C. Teach the patient about antiemetic therapy. D. Offer supplemental feedings between meals.

D

A nurse is caring for a client who recently had a bowel resection. Dextrose 5% in half NS solution (D3 12 NS) is infusing through a triple-lumen central catheter at 125 mL/hr. The healthcare provider also orders the following: • Gentamicin 80 mg IV piggyback in 50 mL D5W over 30 minutes • Ranitidine 50 mg IV in 50 mL D5W over 30 minutes • 1 unit of 250 mL of packed RBC over 3 hours • NG Tube flushes with 30 mL of NS solution q2h How many mL would the nurse document as the total intake for the 8-hour shift? Record your answer as a whole number. A. 470 mL B. 380 mL C. 1470 mL D. 1380 mL

D

A patient who takes a non-steroidal anti-inflammatory drug (NSAID) daily for the management of severe rheumatoid arthritis has recently developed melena. What should the nurse anticipate teaching the patient? A. Substitution of acetaminophen (Tylenol) for the NSAID B. Use of enteric-coated NSAIDs to reduce gastric irritation C. Reasons for using corticosteroids to treat the rheumatoid arthritis D. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa

D

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. The nurse should first: A. assess heart sounds B. obtain a prescription for blood cultures. C. prepare for a paracentesis. D. raise the head of the bed.

D

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

D

Which information will the nurse provide for a patient with achalasia? A. A liquid diet will be necessary. B. Avoid drinking fluids with meals C. Lying down after meals is recommended. D. Treatment may include endoscopic procedures

D

Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose high-calorie, high-protein foods? a. Baked fish with applesauce b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Fried chicken with potatoes and gravy

D. Fried chicken with potatoes and gravy Foods that are high in calories include fried foods and those covered with sauces. High-protein foods include meat and dairy products. The other choices are lower in calories and protein.