Midterm

Question 1

You’re preparing to help the neurologist with conducting a Tensilon test. Which antidote will you have on hand in case of an emergency?

A. Atropine
B. Protamine sulfate
C. Narcan
D. Leucovorin

Answer 1

A. Atropine

Question 2

Priority action for patient with intermittent abdominal pain

Answer 2

Assess the clients bowel sounds

Question 3

A nurse is preparing a client for a colonoscopy. The client has a family history of colon cancer. Which of the following types of prevention is the nurse demonstrating?

A. Primary
B. Quaternary
C. Secondary
D. Tertiary

Answer 3

C. Secondary

Secondary is screenings

Question 4

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

A. “Don’t worry, most clients dislike the prep more than the procedure itself.”
B. “Before the examination, your provider will give you a sedative that will make you sleepy.”
C. “I know you’re anxious, but this procedure is recommended for people your age.”
D. “After you have signed the consent form, we can talk more about this.”

Answer 4

B. “Before the examination, your provider will give you a sedative that will make you sleepy.

Question 5

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

A. Chronic blood loss
B. Intestinal malabsorption syndrome
C. Dietary iron restrictions
D. Intestinal parasites

Answer 5

A. Chronic blood loss

Chronic blood loss is a common complication of ulcerative colitis. Inflammation and ulcers in the colon can lead to ongoing bleeding, resulting in iron deficiency anemia.

Question 6

Which question from the nurse would help determine if a patients abdominal pain might indicate irritable bowel syndrome?

a. Have you been passing a lot of gas?
b. What foods affect your bowel patterns?
c. Do you have any abdominal distention?
d. How long have you had abdominal pain?

Answer 6

d. How long have you had abdominal pain?

One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are also associated with IBS, but are not diagnostic criteria.

Question 7

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.

Answer 7

b. Infuse metronidazole (Flagyl) 500 mg IV.

Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

Question 8

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan?

a. Turkey sandwich with celery sticks.
b. Sliced ham with green salad
c. Pork tenderloin with green peas
d. Grilled chicken breast with white rice

Answer 8

d. Grilled chicken breast with white rice

Grilled chicken breast with white rice are both low in fiber which is advised during the inflammation of diverticulitis. In the presence of diverticulosis, a high-fiber diet is indicated.

Question 9

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

A. “These tests help determine the degree of damage to the heart tissues.”
B. “Cardiac enzymes will identify the location of the MI.”
C. “These tests will enable the provider to determine the heart structure and mobility of the heart valves.”
D. “Cardiac enzymes assist in diagnosing the presence of pulmonary congestion.”

Answer 9

A. “These tests help determine the degree of damage to the heart tissues.”

Question 10

A nurse is caring for a client who will begin using transdermal nitroglycerin to treat angina pectoris. When speaking to the client about the drug, which of the following instructions should the nurse include? (Select all that apply)

A) “Apply a new patch at the onset of anginal pain.”
B) “Apply the patch to dry skin and cover the area with plastic wrap.”
C) “Apply the patch to a hairless area and rotate sites.”
D) “Apply a new patch when you start your day.”
E) “Remove patches for 10 to 12 hours each day.”

Answer 10

C) “Apply the patch to a hairless area and rotate sites.”
D) “Apply a new patch when you start your day.”
E) “Remove patches for 10 to 12 hours each day.”

Question 11

A nurse is providing 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 fruits

Answer 11

C. Pasta

Pasta may thicken stool and is an appropriate food choice for a client with a colostomy.

Question 12

(NGN) Bowtie question.

Answer 12

Actions to take:
- Administer transdermal nitro
- Administer O2 nasal cannula

Potential Condition:
- Myocardial Infarction

Parameters to monitor:
- Serum glucose level
- ECG rhythm

Question 13

(NGN) Bowtie question.

Answer 13

Actions to take:
- Obtain blood cultures
- Request antibiotic prescription

Potential condition:
- Endocarditis

Parameters to monitor:
- Temperature
- Neuro status

Question 14

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

A. “I will empty my pouch when it becomes 1/3 full.”
B. “I will be certain to take enteric-coated medications.”
C. “I will change my entire pouch-system at least weekly.”
D. “ I will use caution when eating high fiber foods.”

Answer 14

B. “I will be certain to take enteric-coated medications.”

Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. However, in clients with an ileostomy (where the small intestine is brought to the surface of the abdomen), the medication might not dissolve properly or be absorbed correctly because the large intestine, where absorption is optimized, is absent or bypassed. Therefore, clients with ileostomies should avoid enteric-coated medications unless specifically instructed by their healthcare provider.

Question 15

(NGN) Highlight appropriate nursing interventions.

• Client will not look at stoma
• Not interested in learning about stoma care
• Skin surrounding stoma is red and has open are

Question 16

A nurse is providing teaching to a client who has a new colostomy. What information should the nurse include in the teaching?

A. “You can expect fecal output within 24 hours”
B. “You will need to increase your dietary intake of raw vegetables”
C. “You can expect the stoma to be purplish in color for the first week”
D. “You may experience a small amount of bleeding around the stoma”

Answer 16

D. “You may experience a small amount of bleeding around the stoma”

Question 17

Which activity in the care of a 48-year-old female patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?

a. Document the appearance of the stoma.
b. Place a pouching system over the ostomy.
c. Drain and measure the output from the ostomy.
d. Check the skin around the stoma for breakdown.

Answer 17

c. Drain and measure the output from the ostomy.

Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

Question 18

Understanding of extended-release pyridostigmine.
- “The client may hold the medication when feeling stronger to avoid drowsiness”

Question 19

A nurse is assisting with teaching a client who has a new colostomy. Which of the following outcomes should the nurse expect?

A. Increase in length of care in the health care facility
B. Increase in need for pain medication
C. Report of empowerment
D. Report of anxiety

Answer 19

C. Report of empowerment

(Education about the colostomy should provide the client with feelings of empowerment and assist the client in taking control of their care.)

Question 20

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?

a. Have you been experiencing any constipation?
b. Are you eating a diet high in fiber and fluids?
c. Do you have a history of high blood pressure?
d. What vitamins and supplements are you taking?

Answer 20

a. Have you been experiencing any constipation?

Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.

Question 21

A nurse is monitoring a client who has two chest tubes inserted for a right-sided pneumothorax. The client complains of chest burning. Which of the following is an appropriate nursing action?

A. increase the client’s wall suction
B. strip the client’s chest tube
C. clamp the client’s chest tube
D. reposition the client

Answer 21

D. reposition the client

Repositioning the client relieves chest burning from the chest tube

Question 22

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.)

A. Orthopnea
B. Headache
C. Nausea
D. Tachycardia
E. Diaphores

Answer 22

C. Nausea
D. Tachycardia
E. Diaphores

Question 23

Anurse assesses a client who has ulcerative colitis and severe diarrhea. Which priority assessment should the nurse complete first.

A. inspection of oral mucosa
B. recent dietary intake
C. heart rate and rhythm
D. percussion of abdomen

Answer 23

C. heart rate and rhythm

Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this client than heart rate and rhythm.

Question 24

A nurse cares for a client with ulcerative colitis. The client states I feel like I am tied to the toliet. This disease is controlling my life. How should the nurse respond?

A. Lets discuss potential factors that increase your symptoms
B. If you take the prescribed medications you will no longer have diarrhea
C. to decrease distress do no eat anything before you go out.
D. you must retake control of your life. I will consult a therapist to help

Answer 24

A. Lets discuss potential factors that increase your symptoms

Question 25

Discharge for diverticulitis patient need for additional teaching

Answer 25

“ I must try to include at least 30-40 grams of fiber”

Question 26

A patient with Crohn’s disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?

A. Fever
B. Nausea
C. Joint pain
D. Headache

Answer 26

A. Fever

Since infliximab suppresses the immune response, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

Question 27

A nurse is reinforcing teaching with a client who has Parkinson’s disease and has received a prescription for bromocriptine (parlodel). Which of the following instructions should the nurse include in the teaching?

A. Rise slowly when standing.
B. Increase carbohydrate intake
C. Limit exposure to heat.
D. Report any skin discoloration.

Answer 27

A. Rise slowly when standing.

Orthostatic hypotension is a common side effect

Question 28

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

A. Confusion
B. Weakness
C.Increased intracranial pressure
D.Increased urinary output

Answer 28

B. Weakness

Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.

Question 29

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

A. Review the client’s electrolyte values
B. Check the clients perianal skin integrity
C. Investigate the client’s emotional concerns
D. Obtain a dietary history from the client.

Answer 29

A. Review the client’s electrolyte values

This is the correct action. During an acute exacerbation of ulcerative colitis, the client is at risk of electrolyte imbalances due to diarrhea, dehydration, and potential fluid and electrolyte losses. Promptly reviewing the electrolyte values helps identify any imbalances that might require immediate intervention.

Question 30

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?

a. Auscultation for bowel sounds
b. Nasogastric (NG) tube irrigation
c. Applying petroleum jelly to the lips
d. Assessment of the nares for irritation

Answer 30

c. Applying petroleum jelly to the lips

Question 31

(NGN) Nurse is caring for pt w chest tube.

Answer 31

• The nurse should CALL THE PROVIDER to prevent ATELECTASIS.

Question 32

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider Tensilon test. Which of the following findings indicates a positive test?

a. Electrical charge in a muscle increases in intensity
b. A pill-rolling tremor appears
C. Muscle strength shows no change
d. Muscle contractions become progressively stronger.

Answer 32

d. Muscle contractions become progressively stronger.

A positive Tensilon test is indicated by a 4 to 5 min period of improved muscle tone and strength.

Question 33

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction Which of the following prescriptions should the nurse take first?

a. Attach the leads for a 12- lead ECG.
b. Obtain a blood sample.
c. Initiate oxygen therapy
D. Insert the IV Catheter

Answer 33

a. Attach the leads for a 12- lead ECG.

Choice a) is correct because ataching the leads for a 12-lead ECG is the first priority for a client who has signs and symptoms of a myocardial infarction. A 12-lead ECG is a diagnostic test that records the electrical activity of the heart and can detect any abnormalities, such as ischemia, injury, or infarction. A 12-lead ECG can help confirm the diagnosis, identify the location and extent of the damage, and guide the treatment plan for the client.

Question 34

A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

A. Respiratory alkalosis
B. Increased venous return
C. Decreased cardiac output
D. Dilated ventricles

Answer 34

C. Decreased cardiac output

Decreased cardiac output is correct. Tension pneumothorax can indeed lead to decreased cardiac output due to compression of the heart and the great vessels by the accumulating air in the pleural space. This compression decreases venous return and impairs cardiac function.

Question 35

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

A. Bloody diarrhea
B. Board-like abdomen
C. Periumbilical cyanosis
D. Increased bowel sounds

Answer 35

B. Board-like abdomen

A board-like (rigidity), distended abdomen, accompanied by extreme pain and tenderness, is an expected finding in a client who has peritonitis.

Question 36

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?

A. “Take the medication 2 hours after eating.”
B. “Discontinue this medication if your skin turns yellow‑orange.”
C. “Notify the provider if you experience a sore throat.”
D. “Expect your stools to turn black.”

Answer 36

C. “Notify the provider if you experience a sore throat.”

Rationale: Sulfasalazine can cause blood dyscrasias. The client should monitor and report any manifestations of infection, such as a sore throat

Question 37

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?

A. “Take the medication 2 hours after eating.”
B. “Discontinue this medication if your skin turns yellow‑orange.”
C. “Notify the provider if you experience a sore throat.”
D. “Expect your stools to turn black.”

Answer 37

C. “Notify the provider if you experience a sore throat.”

Rationale: Sulfasalazine can cause blood dyscrasias. The client should monitor and report any manifestations of infection, such as a sore throat

Question 38

A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following statements should the nurse make?

“Use sunscreen and protective clothing while taking sulfasalazine to prevent sunburn.”
“The medication can stain your contact lenses green.”
“The medication can color your urine dark brown.”
“Take an iron supplement when you take sulfasalazine to prevent anemia.”

Answer 38

“Use sunscreen and protective clothing while taking sulfasalazine to prevent sunburn.”

Rationale: Photosensitivity is a possible adverse effect of sulfasalazine that makes the skin sensitive to light. The nurse should instruct the client to wear sunscreen and protective clothing when outdoors to prevent burning.

Question 39

A nurse is assessing a client who has a pleural effusion. Which of the following findings should the nurse expect?

a. Dullness percussed over the client’s lung fields.
b. Substernal retractions noted on the client’s chest.
c. Crepitus palpated on the client’s chest.
d. Crackles auscultated over the client’s lung fields.

Answer 39

a. Dullness percussed over the client’s lung fields.

Areas of dullness percussed over the client’s lung fields indicates areas of fluid in the lung. This is an expected finding for a client who has a pleural effusion.

Question 40

A nurse is planning care for a client who has diverticulitis.
The nurse should plan to monitor the client for which of the following complications of diverticulitis?

A. Dysphagia.
B. Ulcerative colitis.
C. Peritonitis.
D. Crohn’s disease.

Answer 40

C. Peritonitis.

Peritonitis is a potential complication of diverticulitis. When diverticula become infected and rupture, they can spill their contents into the abdominal cavity, leading to peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity). This condition can be life-threatening and requires prompt medical intervention.

Question 41

A nurse is caring for a client with infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?

A. anorexia
B. dyspnea
C. fever
D. malaise

Answer 41

B. Dyspnea

When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization

Question 42

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

A. “Take this medication after each meal and at bedtime.”
B. “Take one tablet every 15 min during an acute attack.”
C. “Take one tablet at the first indication of chest pain.”
D. “Take this medication with 8 ounces of water.”

Answer 42

C. “Take one tablet at the first indication of chest pain.”

Question 43

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

a. assess for the presence of chest pain.
b. inquire about urinary tract problems.
c. inspect the skin for rashes or discoloration.
d. ask the patient about any increase in libido

Answer 43

C. inquire about urinary tract problems.

Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

Question 44

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis?

a. Navy bean soup and vegetable salad
b. Whole grain pasta with tomato sauce
c. Baked potato with low-fat sour cream
d. Roast beef sandwich on whole wheat bread

Answer 44

a. Navy bean soup and vegetable salad

A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

Question 45

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?

a. Scrambled eggs
b. White toast and jam
c. Oatmeal with cream
d. Pancakes with syrup

Answer 45

c. Oatmeal with cream

During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

Question 46

A nurse is providing teaching to a client who has a new diagnosis of Parkinson’s disease. On what medications should the nurse prepare to instruct the client?

A. Levodopa/carbidopa
B. Piperacillin/tazobactam
C. Levothyroxine
D. Carbamazepine

Answer 46

A. Levodopa/carbidopa.

Rationale: Levodopa/carbidopa is the cornerstone of Parkinson’s treatment. The nurse should prepare to instruct the client on the use of this medication.

Question 47

A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for
the nurse to monitor?

A. Heart atack
B. Diabetes
C. Respiratory failure
D. Sepsis

Answer 47

D. Sepsis

Sepsis is a life-threatening condition that can occur as a complication of peritonitis. It happens when the body’s response to infection causes injury to its own tissues and organs. Monitoring for signs of sepsis is crucial because early intervention can be lifesaving.

Question 48

A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for

a. referred back pain.
b. metabolic alkalosis.
c. projectile vomiting.
d. abdominal distention.

Answer 48

d. abdominal distention.

Rationale:
Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

Question 49

The nurse is admitting a 67-year-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask?

a. “How much milk do you usually drink?”
b. “Have you noticed a recent weight loss?”
c. “What time of day do your bowels move?”
d. “Do you eat meat or other animal products?”

Answer 49

ANS: B

Although all of the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

Question 50

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)?

a. Encourage the patient to express concerns and ask questions about IBS.
b. Suggest that the patient increase the intake of milk and other dairy products.
c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).
d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

Answer 50

a. Encourage the patient to express concerns and ask questions about IBS.

Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

Question 51

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to:

a. administer IV fluids.
b. give stool softeners and enemas.
c. order a diet high in fiber and fluids.
d. prepare the patient for colonoscopy.

Answer 51

a. administer IV fluids.

A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

Question 52

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first?

a. Notify the health care provider.
b. Obtain a stool specimen for analysis.
c. Teach the patient about handwashing.
d. Place the patient on contact precautions.

Answer 52

d. Place the patient on contact precautions.

The patient’s history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

Question 53

A nurse is preparing to administer medications to a client who has pericarditis. Which of the following medications should the nurse anticipate administering to this client? (Select All That Apply)

A. Colchicine
B. Acetaminophen
C. Indomethacin
D. Amiodarone
E. Nitroglycerine

Answer 53

A. Colchicine
C. Indomethacin

Colchicine is often used in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids for the management of pericarditis.
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain associated with pericarditis.