EAQ #3 Flashcards
1
Q
The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching?
“Before I start the procedure, I will don sterile gloves.”
“Before I start the procedure, I will obtain my body weight.”
“Before I start the procedure, I will measure the residual volume.”
“Before I start the procedure, I will instill 1 oz [30 mL] of a carbonated liquid.”
A
“Before I start the procedure, I will measure the residual volume.”
Measuring the residual volume establishes the absorption amount of the previous feeding. If a residual exceeds the parameter identified by the health care provider or is over 200 mL, a feeding may be held. This safety measure prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. The client obtains and reports weekly or monthly weights, depending on the client’s condition and clinical goals. If the tube becomes clogged, the client may instill 30 mL of a carbonated beverage; this action is not used routinely.
1
Q
After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client’s jaundice?
Necrosis of the parenchyma caused by the neoplasm
Excessive serum bilirubin caused by red blood cell destruction
Obstruction of the common bile duct by the pancreatic neoplasm
Impaired liver function, resulting in incomplete bilirubin metabolism
A
Obstruction of the common bile duct by the pancreatic neoplasm
The common bile duct passes through the head of the pancreas; the neoplasm often constricts or obstructs the duct, causing jaundice. Necrosis of the pancreatic parenchyma caused by the neoplasm will not cause jaundice. Excessive serum bilirubin caused by red blood cell destruction is the prehepatic cause of jaundice. Impaired liver function, resulting in incomplete bilirubin metabolism, is a hepatic cause of jaundice.
2
Q
Which nutrient is broken down into glucose, fructose, and galactose?
Lipids
Proteins
Vitamins
Carbohydrates
A
Carbohydrates
3
Q
A client expresses a complete lack of interest in food. How would the nurse document this finding in the client’s medical record?
Apathy
Aphasia
Adactyly
Anorexia
A
Anorexia
4
Q
Adactyly refers to the absence of digits on:
A
the hands or feet.
5
Q
Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma?
Dry, pale pink, and even with the skin
Moist, skin-colored, and flush with the skin
Moist, red, and raised above the skin surface
Dry, purple, and depressed below the skin surface
A
Moist, red, and raised above the skin surface
6
Q
Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer?
The pain intensifies after vomiting stomach contents.
The pain occurs 1 to 2 hours after having a meal.
The pain increases when ingesting an excess of fatty foods.
The pain begins in the epigastrium and radiates to the abdomen.
A
The pain occurs 1 to 2 hours after having a meal.
7
Q
The nurse identifies which weight category as reflective of a client’s body mass index (BMI) of 25.5 kg/m 2?
Obese
Normal
Overweight
Underweight
A
Overweight
A BMI between 25 and 29.9 kg/m 2 places the client in the overweight category. A BMI of 30 kg/m 2 is considered obese. A normal BMI is between 18.5 kg/m 2 and 24.9 kg/m 2. A BMI below 18.5 kg/m 2 is considered underweight.
8
Q
A BMI between 25 and 29.9 kg/m 2 places the client in the ___________ category
A
overweight
9
Q
A BMI of 30 kg/m 2 is considered ________.
A
obese
10
Q
A normal BMI is between:
A
18.5 kg/m 2 and 24.9 kg/m 2.
11
Q
A BMI below 18.5 kg/m 2 is considered ___________.
A
underweight
12
Q
Which assessment parameter is used to determine the severity of blood loss in a client with an upper gastrointestinal (UGI) bleed? Select all that apply. One, some, or all responses may be correct.
Hematocrit
Hemoglobin
Platelet count
Oxygen saturation
Blood urea nitrogen (BUN)
A
all of the above
13
Q
Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct.
Tachycardia
Hypotension
Rigid abdomen
Nausea and vomiting
Back and shoulder pain
A
All of the above
14
Q
Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease?
Esophageal pain may imitate the symptoms of a heart attack.
GERD may predispose the client to the development of heart disease.
Strenuous exercise may exacerbate reflux problems.
Similar laboratory study changes may occur in both problems.
A
Esophageal pain may imitate the symptoms of a heart attack.
15
Q
When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive?
“The other client’s infection is not contagious.”
“This is the usual practice when antibiotic therapy is started.”
“Placing clients with the same infection in 1 room is safe.”
“As soon as a private room becomes available, we will move the client.”
A
“Placing clients with the same infection in 1 room is safe.”
16
Q
A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change?
Stimulation of the liver to produce an excess quantity of bile pigments
Inability of the liver to remove normal amounts of bilirubin from the blood
Increased destruction of red blood cells during the acute phase of the disease
Decreased prothrombin levels, leading to multiple sites of intradermal bleeding
A
Inability of the liver to remove normal amounts of bilirubin from the blood
17
Q
A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. Which explanation would the nurse give?
Stores and concentrates bile
Releases bile into the pancreatic duct
Connects the common bile duct and the pancreas
Controls the flow of fat through the sphincter of Oddi
A
Stores and concentrates bile
18
Q
The sphincter of Oddi controls the release of ______ into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.
A
bile
19
Q
A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change?
Decrease portion size and fat intake.
Increase protein and vegetable intake.
Decrease carbohydrate and fat intake.
Increase fruits and limit fluid intake.
A
Decrease portion size and fat intake.
20
Q
A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors?
Men are more likely to be affected than women.
Young people are affected more frequently than older people.
Individuals who are obese are more prone to this condition than those who are thin.
People who are physically active are more apt to develop this condition than those who are sedentary.
A
Individuals who are obese are more prone to this condition than those who are thin.
21
Q
Cholelithiasis occurs more frequently in individuals who are _______ and have hyperlipidemia.
Women are more likely to develop cholelithiasis. Middle-aged people, usually over 40 years, are more likely to develop this condition than younger people; aging increases risk. People who have sedentary lifestyles are more likely to develop this condition than those who are active.
A
obese
22
Q
A client with a high cholesterol level says to the nurse, “Why can’t I take a medication that will eliminate all of the cholesterol in my body so it isn’t a problem?” The nurse explains that some cholesterol is needed to perform which body function?
Blood clotting
Bone formation
Muscle contraction
Cellular membrane structure
A
Cellular membrane structure
23
Q
_____________ is an essential structural and functional component of most cellular membranes.
A
Cholesterol
24
A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate?
No protein
Moderate protein
High protein
Strict protein restriction
Moderate protein
Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no-protein restrictions are not required because the client needs protein for healing. The hepatic encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.
25
Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis?
Turkey salad, French fries, sherbet
Cottage cheese, mixed fruit salad, milkshake
Salad, sliced chicken sandwich, gelatin dessert
Cheeseburger, tortilla chips, chocolate pudding
Salad, sliced chicken sandwich, gelatin dessert
The viral hepatitis diet should be high in carbohydrates, with moderate protein and fat content. A salad, chicken, and gelatin meal is the best choice. Turkey salad, French fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the hepatitis virus injures the intestinal mucosa and reduces the client’s ability to metabolize lactose. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.
26
The viral hepatitis diet should be high in ____________ , with moderate protein and fat content.
carbohydrates
27
On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client’s abdomen and determines rigidity. Which action would the nurse perform first?
Assist the client to ambulate.
Obtain the client’s vital signs.
Administer the prescribed analgesic.
Encourage use of the incentive spirometer.
Obtain the client’s vital signs.
Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. The nurse assists the client to ambulate if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and the nurse needs additional data. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.
28
The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis?
Fever and malaise
Nausea and vomiting
Absolute constipation
Pain in right lower quadrant
Pain in right lower quadrant
Pain shifting to the right lower quadrant between the anterior iliac crest and the umbilicus is McBurney point and is indicative of appendicitis. The client may also have fever, nausea, and vomiting, but these can occur with other infectious processes. Absolute constipation occurs with many bowel obstructions.
29
The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct.
Diarrhea
Bradycardia
Rebound tenderness
Diminished bowel sounds
Rigid, boardlike abdomen
Rebound tenderness
Diminished bowel sounds
Rigid, boardlike abdomen
30
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?
Gastritis
Hiatal hernia
Diverticulosis
Bowel obstruction
Bowel obstruction
Causes of peritonitis include bowel obstruction, appendicitis, external penetrating wound, or peritoneal dialysis. Gastritis and hiatal hernias do cause gastrointestinal discomfort, but not peritonitis. Inflammation of the diverticular pockets, diverticulitis, is a cause of peritonitis. Diverticulosis is not an active inflammatory process.
31
Which information would the nurse provide a client with a new colostomy about managing the appliance?
Use stoma powder for fungal rashes.
Wash peristomal area with soap first.
Measure stoma once a month for size.
Cut opening 1/8- to 1/16-inch larger than stoma.
Cut opening 1/8- to 1/16-inch larger than stoma.
The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore it is important to measure the stoma once a week and cut the opening 1/8- to 1/16-inch larger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powder is used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.
32
The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select?
Levin
Dobhoff
Salem sump
Gastrostomy
Salem sump
A Salem sump tube has a vent that prevents the suction from pulling at the gastrointestinal mucosa and should be used for clients requiring continuous suction. A Levin tube does not have a vent and should be used strictly for intermittent suction. A Dobhoff is a nasointestinal tube used for feeding, not suction. A gastrostomy tube is surgically placed for feeding.
33
During a health symposium the nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood?
"Meats and cream-based foods need to be refrigerated."
"Once most food is cooked, it does not need to be refrigerated."
"Poultry should be stuffed and then refrigerated before cooking."
"Cooked food should be cooled before being put into the refrigerator."
"Meats and cream-based foods need to be refrigerated."
A cold environment limits growth of microorganisms. All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. Stuffing and then refrigerating poultry promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator's cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. Letting cooked foods cool before refrigeration promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.
34
Which recommendation would the nurse provide to a client with gastroesophageal reflux disease (GERD) who asks how to reduce heartburn and pain without taking medication?
Chew hard mint candies.
Eat a small bedtime snack.
Elevate the head of the bed 5 inches.
Avoid white wine consumption.
Elevate the head of the bed 5 inches.
The nurse would instruct the client to elevate the head of the bed 4 to 6 inches as this prevents reflux of gastric contents into the esophagus. Mints, especially peppermint, weaken lower esophageal sphincter (LES) pressure and allow gastric contents to reflux. The client should refrain from eating 3 hours before bed as this also affects the LES pressure. Red wine weakens the LES pressure.
35
Which information to promote self-management would the nurse provide to a client being discharged with a new ileostomy?
Consume 1000 mL/day of fluid.
Limit alcohol to one or two glasses daily.
Include plenty of nuts and seeds in the diet.
Change the appliance every 4 to 7 days.
Change the appliance every 4 to 7 days.
A client with an ileostomy should be instructed to change the appliance every 4 to 7 days and cleanse the skin to prevent irritation when changing. Clients should be advised to drink at least 3000 mL of fluid in a 24-hour period and even more when the weather is hot. Clients should avoid alcohol of any kind because it can cause diarrhea. Nuts and seeds can become trapped in the bowel and should be avoided.
36
Which finding indicates that a client is at an increased risk for colorectal cancer (CRC)? Select all that apply. One, some, or all responses may be correct.
Presence of dark, tarry stools
Family history of polyposis
20-year history of ulcerative colitis
Unintentional 20-pound weight loss
Change in bowel pattern for 3 months
all of the above
37
Which factor can be used to determine the source of infection in a client who tests positive for Giardia lamblia?
Sexual orientation
Past antibiotic use
Recent camping trips
Raw egg consumption
Recent camping trips
Giardia is found in freshwater lakes and rivers. Clients who test positive for the bacteria should be asked about recent travel and activity history including outings like camping or hiking. Giardiasis is associated with anal intercourse regardless of sexual orientation. Antibiotic use can cause Clostridium difficile infection. Raw eggs can carry Salmonella.
38
The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step?
Wait until a family member is present.
Assess barriers to learning colostomy care.
Provide simple written instructions concerning the care.
Wait until the client has accepted the change in body image.
Assess barriers to learning colostomy care.
Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.
39
A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client?
Controlling constipation
Meeting nutritional needs
Preventing increased weakness
Anticipating a sexual alteration
Meeting nutritional needs
To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn disease. Preventing an increase in weakness is a secondary concern that results from malnutrition; correcting the malnutrition will increase strength. Anticipating a sexual alteration generally is not a problem with Crohn disease.
40
A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, which would the nurse emphasize?
Medical treatment is curative; surgery is not required.
For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful.
For most clients, surgery is recommended early in the course of treatment.
Medical treatment is all that will be needed if the client can maintain emotional stability.
For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful.
Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. Stating that medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.
41
A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care would be implemented during the postoperative period?
Limiting fluid intake for several days
Withholding fluids for 72 hours
Having the client change the colostomy bag
Keeping the client’s skin around the stoma clean
Keeping the client’s skin around the stoma clean
42
A health care provider prescribes an upper gastrointestinal (GI) series and a barium enema. The client asks, "Why do I need barium for these tests?" Which explanation would the nurse give?
"It gives off visible light, illuminating the alimentary tract."
"It provides fluorescence, thereby lighting up the alimentary tract."
"It dyes the structures of the alimentary tract, making them more visible."
"It gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
"It gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."
43
A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. Which is a nursing responsibility common to preparing both of the clients for these procedures?
Withholding food for several hours
Giving castor oil the afternoon before
Administering soapsuds enemas until clear
Ensuring an understanding of the procedure
Ensuring an understanding of the procedure
44
A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Which topic would the nurse include in the postoperative care teaching?
Gastric suction
Oxygen therapy
Fluid restriction
Urinary catheter
Gastric suction
45
A client with a recent colostomy expresses concern about the inability to control the passage of gas. Which recommendation would the nurse make?
Eliminate foods high in cellulose.
Decrease fluid intake at mealtimes.
Avoid foods that in the past caused flatus.
Adhere to a bland diet before social events.
Avoid foods that in the past caused flatus.
In general, foods that caused flatus preoperatively will continue to do so after a colostomy. Foods high in fiber necessarily are not related to formation of flatus. Reducing foods high in fiber can result in constipation; a regular diet is encouraged. Decreasing fluid intake at mealtimes is not a factor in the formation of flatus. A bland diet may be used initially after the colostomy, but then the client should progress to a regular diet; to control the formation of flatus, the client should eliminate foods that produce gas.
46
A client with a diagnosis of incarcerated hernia asks the nurse for an explanation of the condition. Which description should the nurse give?
The bowel has twisted upon itself.
A piece of the intestine has become stuck in a hole in the abdominal wall.
The intestinal blood supply has been cut off.
The involved intestine has developed an erosion.
A piece of the intestine has become stuck in a hole in the abdominal wall.
47
A client with esophageal varices experiences severe hematemesis, and a Sengstaken-Blakemore tube is inserted. Which design and purpose does the tube have?
Single-lumen; for gastric lavage
Double-lumen; for intestinal decompression
Triple-lumen; for esophageal compression
Multi-lumen; for gastric and intestinal decompression
Triple-lumen; for esophageal compression
48
A client is scheduled for a pyloroplasty and vagotomy because of strictures caused by ulcers unresponsive to medical therapy. Which information about the purpose of a vagotomy would the nurse include in the client’s education?
It increases the heart rate.
It hastens gastric emptying.
It eliminates pain sensations.
It decreases acid in the stomach.
It decreases acid in the stomach.
49
After a subtotal gastrectomy for cancer of the stomach, a client develops dumping syndrome. The client asks the nurse, "What does that mean?" How would the nurse explain dumping syndrome?
It is nausea resulting from a full stomach.
It is the reflux of gastric contents into the esophagus.
It is the buildup of flatulence within the large intestine.
It is the rapid passage of concentrated fluid into the small intestine.
It is the rapid passage of concentrated fluid into the small intestine.
50
A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?
"Tell me more about your concerns."
"Products are available to limit this problem."
"This is a problem, but the surgery is necessary."
"Most people who have this surgery share this same concern."
"Tell me more about your concerns."
The response "Tell me more about what you are thinking" is an open-ended statement that focuses on the client’s concerns and allows further verbalization of feelings. Although true, the response "This is a problem, but the surgery is necessary" may increase anxiety and cut off communication. The responses "Products are available to limit this problem" and "Most people who have this surgery share this same concern" move the focus away from the client and minimize the client’s concerns.
51
A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client’s reaction?
Reflection
Regression
Repudiation
Reconciliation
Repudiation
A refusal to recognize anticipated loss in an attempt to protect oneself against the overpowering stress of illness is called repudiation. The data do not suggest that the client has contemplated the issues of the situation (reflection). The data do not indicate that the client’s behavior demonstrates an earlier stage of development (regression). The data do not suggest that the client has made a realistic adjustment to the illness (reconciliation).
52
The nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?
Mastery of techniques of colostomy care
Readiness to accept an altered body function
Awareness of available community resources
Knowledge of necessary dietary modifications
Readiness to accept an altered body function
The client must be ready to accept changes in body image and function; this acceptance will facilitate mastery of the techniques of colostomy care and optimal use of community resources. Specific knowledge can be imparted only when an individual is ready to learn; it requires acceptance of a new body image.
53
A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, "You think that it looks repulsive." The nurse identifies that the client as using which defense mechanism?
Projection
Sublimation
Compensation
Intellectualization
Projection
54
A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. What would the nurse conclude is the purpose of the T-tube?
Decrease edema
Permit drainage of bile
Insert antibiotic medication
Provide for irrigation of the gallbladder
Permit drainage of bile
55
When caring for a client in the early postoperative period after a hemorrhoidectomy, the nurse will place the client in which position?
Supine
Side-lying
High-Fowler
Trendelenburg
Side-lying
56
The nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks, "How does my drinking relate to my diagnosis?" Which effect of alcohol would the nurse include when responding?
It promotes the formation of calculi in the cystic duct.
It stimulates the pancreas to secrete more insulin than it can immediately produce.
It alters the composition of enzymes so they are capable of damaging the pancreas.
It increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas.
It increases enzyme secretion and pancreatic duct pressure that causes backflow of enzymes into the pancreas.
57
During history-taking, the nurse discovers that a client takes megadoses of vitamin A. How would the nurse interpret this finding?
Vitamin A is highly toxic, even in small amounts.
The body stores excess vitamin A, even in toxic amounts.
Vitamin A cannot be stored; therefore, excess amounts will saturate body tissues.
Although the body's requirement for vitamin A is great, cells can synthesize more as needed.
The body stores excess vitamin A, even in toxic amounts.
58
The nurse is caring for a client with cholelithiasis. Which clinical manifestation would the nurse expect if the client develops obstructive jaundice?
Yellow sclera
Pain on urination
Dark brown stools
Coffee-ground emesis
sclera
59
Which recommendation is important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?
Use lemon juice to season meat.
Put condiments on food to add flavor.
Include canned vegetables in meal preparation.
Drink carbonated beverages instead of decaffeinated coffee.
Use lemon juice to season meat.
60
Discharge planning for a client with chronic pancreatitis includes dietary education. Which client statement indicates to the nurse that further teaching is needed?
"I must eat foods high in calories."
"I should avoid alcoholic beverages."
"I will eat more often but in smaller amounts."
"I can eat foods high in fat now that the acute stage is over."
"I can eat foods high in fat now that the acute stage is over."
The nurse needs to follow up on the client statement that indicates eating foods high in fat can be allowed. A low-fat diet should be followed to avoid diarrhea. All the rest of the client responses are correct and do not require additional teaching. The response to eating foods high in calories is appropriate because additional calories are needed to maintain weight. The response to avoiding alcoholic beverages is appropriate to prevent overstimulation of the pancreas. Small, frequent meals limit stimulation of the pancreas and are appropriate.
61
A client who had a severe weight loss is told the importance of eating more protein to provide the essential amino acids. The client asks the nurse why these substances in protein foods are essential. How should the nurse respond?
"They will give you the added energy you need."
"They contain the necessary nitrogen you need for healing."
"They are essential for rebuilding your body tissue protein."
"They must come from your food because your body cannot make them."
"They must come from your food because your body cannot make them."
62
The nurse is teaching a client about a sodium-restricted diet. Which foods should the nurse encourage the client to consume? Select all that apply. One, some, or all responses may be correct.
Fruits
Sliced deli meats
Condiments
Fresh vegetables
Processed cheese
Fruits
Fresh vegetables
63
The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention?
Weigh the client daily.
Restrict the client’s oral fluid intake.
Measure the client’s urine specific gravity.
Observe the client for increasing confusion.
Observe the client for increasing confusion.
64
A client with Laënnec cirrhosis experiences ascites, jaundice, and confusion. Which is a nursing priority when caring for this client?
Correcting nutritional deficiencies
Measuring abdominal girth every day
Providing for the client’s physical safety
Placing the client in the high-Fowler position
Providing for the client’s physical safety
Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement; physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority. Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be uncomfortable because of the pressure of the distended abdomen against the legs. The semi-Fowler position is more appropriate, and it promotes respiration.
65
A client with a history of gastrointestinal varices develops severe hematemesis, and insertion of a Sengstaken-Blakemore tube has been scheduled. Which information about the design and purpose of the tube would the nurse provide to the client?
Single-lumen for gastric lavage
Double-lumen for intestinal decompression
Triple-lumen to compress the esophagus
Multi-lumen for gastric and intestinal decompression
Triple-lumen to compress the esophagus
66
The nurse is assisting a health care provider to perform a sigmoidoscopy. In which position would the nurse place the client for this procedure?
Left lateral recumbent
Prone
Lithotomy
Knee-chest
Knee-chest
The knee-chest position maximally exposes the rectal area and facilitates entry of the sigmoidoscope. The modified left lateral recumbent position does not expose the rectal area to the same extent as does the knee-chest position; it can be used for a sigmoidoscopy if a client is unable to maintain the knee-chest position. Although prone refers to a facedown position, the rectal area is not exposed. The lithotomy position is appropriate for gynecological examinations.
67
An older adult is hospitalized for weight loss and dehydration due to nutritional deficit. Which factor would the nurse consider when planning care for this client?
Financial resources usually are unrelated to nutritional status.
An older adult’s daily fluid intake must be markedly increased.
The client’s diet should be high in carbohydrates and low in proteins.
The nutritional needs of an older adult are basically unchanged except for a decreased need for calories.
The nutritional needs of an older adult are basically unchanged except for a decreased need for calories.
68
The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client?
Permanent sigmoid colostomy
Permanent ascending colostomy
Temporary double-barrel colostomy
Temporary transverse loop colostomy
Permanent sigmoid colostomy
69
Six hours after major abdominal surgery, a client reports severe abdominal pain and faintness. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) and determines that the client can receive another injection of pain medication in an hour. Which action would the nurse take?
Notify the health care provider about the client’s symptoms.
Explain to the client that it is too early to have an injection for pain.
Reposition the client for greater comfort and turn on the television as a distraction.
Prepare the injection to administer it to the client early because of the severe pain.
Notify the health care provider about the client’s symptoms.
The client’s signs and symptoms suggest the possibility of shock; the primary health care provider must be alerted to this possibly life-threatening condition. Explaining to the client that it is too early is missing the big picture; the client may be hemorrhaging. The client has unmet needs that must be addressed first. Distraction is effective with mild, not severe, pain. Preparing and administering the pain medication early are outside the scope of nursing practice. Health care provider prescriptions must be followed as prescribed, or the health care provider should be notified.
70
A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain?
Infusion pump
Tall intravenous (IV) pole
Clamp that will be taped at the bedside
Infusion set that delivers 60 drops/mL
Infusion pump
Hypertonic solution should be administered in an infusion pump for continuous and uniform infusion to prevent hyperosmolar diuresis or fluctuations in glucose. The height of the IV pole is not as significant as the stability needed to safely support the infusion pump. There is no reason to keep a clamp at the bedside. The tubing set should be appropriate for the type of infusion pump being used.
71
An in-home babysitter phones a health clinic, stating that a child swallowed dish soap. Which advice would the nurse give?
Call a Poison Control Center.
Induce vomiting immediately.
Give syrup of ipecac, 1 tablespoon.
Give activated charcoal and expect black stools for 24 hours.
Call a Poison Control Center.
Advise the babysitter to call a Poison Control Center immediately. Information as to what needs to be done for virtually every product is available. This also would be the fastest source for obtaining details for treatment. Inducing vomiting may cause further damage if the substance is caustic, such as drain cleaner, or contains lye. Giving syrup of ipecac is no longer advised, and the substance is not in most homes. Activated charcoal is given in an emergency facility.
72
The nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes which statement?
"I should wash my hands frequently."
"I should launder my clothes separately."
"I should put used tissues in the garbage."
"I should wear a mask when leaving the house."
"I should wash my hands frequently."
Hepatitis A microorganisms are transmitted via the anal-oral route; hand washing, particularly after toileting, is the most important precaution. The response "I should launder my clothes separately" will not deter the spread of the virus; hand washing is necessary. Putting used tissue in the garbage is important, but hand washing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.
73
The nurse is providing dietary teaching to a client receiving a high-protein diet while recovering from an acute episode of colitis. Which would the nurse include in the rationale for this diet?
Repairs tissues
Slows peristalsis
Corrects anemia
Improves muscle tone
Repairs tissues
Protein is required for the building and repair of intestinal tissues. Increased protein will not affect peristalsis significantly. Anemia may result from chronic bleeding; usually, it is corrected with increased iron intake. Muscle tone is affected by exercise or lack of exercise.
74
A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema?
Left lateral recumbent
Back lying
Knee-chest
Mid-Fowler
Left lateral recumbent
75
The nurse provides postoperative teaching to a client who is scheduled for a bilateral herniorrhaphy. Which client statement indicates correct understanding of the teaching?
"I will have a nasogastric tube in place."
"I should cough and deep breathe regularly."
"I will need to be on bed rest for several days."
"I will have a portable wound drainage system in place."
"I should cough and deep breathe regularly."
After general anesthesia, coughing and breathing deeply can help expand alveoli and prevent atelectasis. A nasogastric tube is not necessary; the abdomen is not entered, and there should be no interference with peristalsis. Clients can ambulate after recovery from anesthesia. A portable wound drainage system is not necessary.
76
A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for the surgery to create an ileostomy." Which nursing intervention best meets the client’s needs at this time?
Parenterally replace the client’s fluids and electrolytes.
Adjust client’s diet to promote weight gain.
Provide anticipatory teaching on the use of ileostomy appliances.
Encourage client interaction with other clients who have an ileostomy.
Parenterally replace the client’s fluids and electrolytes.
When a client has an ulcerative colitis exacerbation, the client may have more than 10 stools per day, and the stools are bloody and full of mucus. The client can become dehydrated and lose vital electrolytes. Parenterally replacing fluids and electrolytes is a life-saving strategy; replacement occurs before performing the surgery to stabilize the client. Helping the client regain former body weight is not the priority at this time. The client is neither physically nor cognitively ready to learn the psychomotor skill of how to manage an ileostomy. The client is not demonstrating a readiness for contact with other persons with ileostomies at this time.
77
Which priority medication will the nurse prepare to administer to the client admitted with acute salmonellosis?
Opioids
Antacids
Electrolytes
Antidiarrheals
Electrolytes
Administering fluids of dextrose and normal saline and electrolytes to prevent profound dehydration caused by an excessive loss of water and electrolytes through diarrheal output is the priority. The administration of electrolytes takes priority over antidiarrheals. When there is a possibility of bacterial infection, prescribed medications do not include opioids and antidiarrheals because slowed peristalsis decreases excretion of the salmonella organism. Salmonellosis is an infection and not a condition caused by hyperacidity and does not require antacids.
78
Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas?
Milk
Cheese
Coffee
Cabbage
Cabbage
Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee should not cause excessive gas problems in moderation. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.
79
After a subtotal gastrectomy (Billroth I), the client begins eating a variety of food textures and forms. After meals, the client reports cramping discomfort, rapid pulse, and waves of weakness, often followed by nausea and vomiting. Which physiological response does the nurse suspect occurs after the client eats?
Slow movement of food from the stomach into the small intestine
Rapid routing of diluted food mixture into the small intestine
Quick passage of hyperosmolar food solution into the small intestine
Entry of less concentrated food than the surrounding fluid into the small intestine
Quick passage of hyperosmolar food solution into the small intestine
80
The client with a permanent sigmoid colostomy has colostomy irrigations prescribed and inquires as to why they are prescribed. Which response would the nurse use?
"The irrigations provide electrolytes and lessen intestinal fluid loss."
"The irrigations help establish an elimination schedule."
"The irrigations decrease the amount of flatus in the bowel."
"The irrigations assist in minimizing bowel movement straining."
"The irrigations help establish an elimination schedule."
Irrigations regulate the bowel to function at a specific time for the convenience of the client. The response, "Less fluid is lost from the intestine," is not the function of the irrigation; most ingested fluid is already absorbed in the large intestine by the time it reaches the sigmoid colon. Irrigations facilitate expulsion of flatus but do not decrease the amount; avoidance of gas-forming foods will reduce the production of flatus. Although irrigations will prevent straining, this is not their purpose.
81
The nurse provides education related to the relationship between aerobic exercise and weight loss to a client who is obese. The nurse evaluates that teaching is effective when the client states which effect of exercise?
"It will decrease my appetite."
"It will decrease my metabolic rate."
"It will increase my lean body mass."
"It will increase my resting heart rate."
"It will increase my lean body mass."
82
A client is admitted to the hospital with Laënnec cirrhosis and chronic pancreatitis. Bile salts (bile acid factor) are prescribed, and the client asks why they are needed. How would the nurse respond?
"They stimulate prothrombin production."
"They aid in the absorption of fat-soluble vitamins."
"They promote bilirubin secretion in the urine."
"They help the common bile duct contract stronger."
"They aid in the absorption of fat-soluble vitamins."
83
The nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos would the nurse include in the teaching plan?
Hepatitis A
Hepatitis C
Hepatitis D
Hepatitis E
Hepatitis C
Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or water.
84
Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion?
Choking
Redness
Gagging
Cyanosis
Cyanosis
85
A health care provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a choledochostomy. Which would the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary?
Drain bile from the cystic duct
Keep the common bile duct patent
Prevent abscess formation at the surgical site
Provide a port for contrast dye in a cholangiogram
Keep the common bile duct patent
Exploration of the common bile duct may cause edema; a T-tube prevents edema from obstructing the duct. The cystic duct is ligated when the gallbladder is removed. The T-tube will not prevent the formation of an abscess. A T-tube can be used to inject dye for a cholangiogram, but it is not inserted for that purpose.
86
Which action would the nurse include in the plan of care to prevent oral infections in a client preparing to undergo surgical resection for esophageal cancer? Select all that apply. One, some, or all responses may be correct.
Soaking dentures every night
Providing Yankauer suctioning
Swishing and spitting with chlorhexidine
Administering intravenous (IV) fluids
Offering sugar-free candies to moisten the mouth
all of the above
87
Which action would the nurse include in the plan of care for a client admitted with peritonitis secondary to a ruptured appendix?
Placing the client in the supine position
Providing a low-residue diet
Inserting a nasogastric tube
Scheduling an obstructive series
Inserting a nasogastric tube
A client with peritonitis would most likely require a nasogastric tube and low intermittent suction to decompress the gut. The client would be placed in the semi-Fowler position to promote lung expansion. The client would be NPO status. Clients with peritonitis should never have an obstructive series as these can perforate the bowel.
88
A client is prescribed gastric lavage after an overdose of acetaminophen. In which position would the nurse place the client when the nasogastric tube is being inserted?
Supine
Semi-Fowler’s
High-Fowler’s
Trendelenburg
High-Fowler’s
89
Transmission-based precautions are implemented for a client with salmonellosis and would include which component?
Wearing a gown if soiling is likely
Providing isolation in a private room
Wearing a mask when emptying the bedpan
Limiting visiting hours during the acute phase
Wearing a gown if soiling is likely
Wearing a gown and gloves if soiling is likely reduces the possibility that the organisms may be transmitted to others. Providing isolation in a private room is not necessary as long as fecally contaminated articles are handled and disposed of appropriately. The organism is not transmitted via the airborne route. The type of exposure, not the length of exposure, increases the risk for transmission; visitors are allowed as long as appropriate precautions are implemented.
90
A client who is obese is diagnosed with a hiatal hernia. The nurse provides teaching about how to prevent esophageal reflux and should include which instruction?
"Lie down after eating."
"Eat less food at each meal."
"Increase your intake of fat."
"Drink more fluids with each meal."
"Eat less food at each meal."
Eating less food not only relieves intraabdominal pressure, but it promotes weight loss, which helps decrease the tendency of gastric contents to reflux into the esophagus. The response "Lie down after eating" increases pressure against the diaphragmatic hernia, thereby increasing symptoms. Fats decrease emptying of the stomach and promote gas, extending the period during which reflux can occur; fats should be decreased. The response "Drink more fluid with each meal" will increase intra-abdominal pressure; fluid should be discouraged with meals.
91
Which pain description would the nurse expect a client to report when describing pain associated with a suspected duodenal peptic ulcer?
An ache radiating to McBurney point
An intermittent, colicky right-flank pain
A gnawing sensation in the epigastric area
A generalized abdominal pain intensified by movement
A gnawing sensation in the epigastric area
92
The nurse is caring for a client with chronic inflammation of the bowel. For which most serious complication would the nurse monitor in this client?
Ileus
Pain
Perforation
Obstruction
Perforation
Because of chronic inflammation, the colon becomes thin and may perforate, causing peritonitis. Perforation will lead to a life-threatening sepsis. Other common complications such as ileus, pain, or obstruction require urgent intervention but are not initially life-threatening. Signs of acute perforation include severe abdominal pain, fever, chills, nausea, and vomiting.
93
The nurse provides teaching for a client with gastroesophageal reflux disease. The nurse should recommend that the client take which action after meals?
Drink 8 oz (240 mL) of water.
Take a walk for 30 minutes.
Lie down for at least 20 minutes.
Rest in a sitting position for 1 hour.
Rest in a sitting position for 1 hour.
Gravity facilitates digestion and prevents reflux of stomach contents into the esophagus. Water should not be taken with or immediately after meals because it overly distends the stomach. Exercising immediately after eating may prolong the digestive process. Lying down immediately after eating facilitates reflux of the stomach contents into the esophagus.
94
The nurse provides postoperative care for a client who had total abdominoperineal resection surgery. Which position would the nurse encourage the client to maintain when in bed to promote perineal wound healing?
Knee-chest
Dorsal recumbent
Left or right lateral recumbent
Left or right side-lying
Left or right side-lying
The left or right side-lying position puts the least strain or pressure on the perineal suture line. The knee-chest position is difficult to maintain and places stress on the suture line. The dorsal recumbent position places undue stress on the suture line and is the most uncomfortable position. Flexion of one hip and knee will increase tension on the perineal suture line.
95
The nurse is caring for a client who had surgery for removal of a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period?
Offering psychological support
Monitoring the client’s fluid balance
Keeping the client’s respiratory passages patent
Providing a pad and pencil for writing messages
Keeping the client’s respiratory passages patent
A patent airway is always the priority; therefore removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client’s fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.
96
A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. How would the nurse implement the plan?
Offering a firm-bristled toothbrush
Providing an antiseptic mouthwash
Using a gentle spray of normal saline
Swabbing the mouth with a moistened gauze square
Using a gentle spray of normal saline
97
A client who has just been transferred to the inpatient unit after surgery for oral carcinoma indicates to the nurse that the client’s spouse is the only person who is allowed to visit. To support the client at this time, which action would the nurse take?
Comply with the client’s wishes.
Ask the client why other visitors should be restricted.
Have the spouse explain to the client that everything will be okay.
Promote communication to find out how the client really feels.
Comply with the client’s wishes.
98
A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching?
"I wanted another child, and now pregnancy is not an option for me."
"I must allow extra time for irrigating my colostomy when traveling."
"It is good to know that I can swim every day after my incision heals."
"I’m glad I won’t have to have special clothing and I can wear what I have."
"I wanted another child, and now pregnancy is not an option for me."
Pregnancy is possible; it should be determined whether the client is referring to physiological capability or emotional concern about sexual relationships. Extra time usually is necessary in an unfamiliar environment and should be calculated into traveling plans. Swimming is permitted; the water will not injure the stoma or intestine. There are no adaptations or restrictions on the types of clothing.
99
A client is admitted to the hospital with jaundiced skin and acute abdominal pain. Which is a therapeutic nursing response when the client refuses all visitors?
Listen to the client’s fears.
Encourage the client to socialize.
Place a sign on the door indicating visitor restrictions.
Darken the client’s room by pulling the drapes.
Listen to the client’s fears.
99
A client with the diagnosis of Crohn disease tells the nurse, "My partner dates other people. I believe that behavior has caused an increase in my symptoms." Which is an appropriate initial nursing response?
Help the client explore personal attitudes.
Educate the partner about the illness and events that affect the client’s symptoms.
Suggest the client should not date the partner to determine if symptoms change.
Schedule the client and the partner for a counseling session.
Help the client explore personal attitudes.
Because emotional stress can influence the progress of Crohn disease, initially the nurse should help the client explore self-attitudes to aid in better understanding the feelings engendered by the partner dating others. Initially, the nurse should help the client explore the situation and the feelings it engenders rather than involve the partner. The client should make the decision about continuing to date the partner. Scheduling the client and the partner for a counseling session is premature; the client is not ready for a joint counseling session.
100
A client has laparoscopic surgery to remove a calculus from the common bile duct. Which postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished?
Stools become brown.
Liver tenderness is relieved.
Colic is absent after ingestion of fats.
Serum bilirubin level returns to the expected range.
Stools become brown.
The return of brown color to the stool indicates that bile is entering the duodenum and being converted to urobilinogen by bacteria. Liver tenderness is unrelated to bile flow. The absence of biliary colic is related to the removal of the calculus, not the flow of bile. The serum bilirubin level is not affected.
101
A client has surgery for an incarcerated hernia. The health care provider returns the incarcerated tissue to the abdominal cavity and uses a mesh to reinforce the muscle wall. Which specific instructions should be included in the discharge instructions?
Reduce dietary roughage.
Avoid lifting heavy items.
Increase dietary potassium intake.
Keep the head of the bed elevated.
Avoid lifting heavy items.
