Quiz #7 Questions Flashcards

1
Q

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client’s urine to appear which of the following colors?

  1. Pale yellow
  2. Greenish-brown
  3. Red
  4. Dark and foamy
A
  1. Dark and foamy
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2
Q

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

  1. Include foods high in starch and proteins.
  2. Include foods high in fiber
  3. Avoid foods high in fat
  4. Avoid foods high in sodium
A
  1. Avoid foods high in fat
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3
Q

A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply)

A. take baths rather than showers
B. resume a diet of choice
C. cleanse the puncture site using mild soap and water
D. remove adhesive strips from the puncture site in 24 hr
E. report nausea and vomiting to the surgeon

A

B. resume a diet of choice
C. cleanse the puncture site using mild soap and water
E. report nausea and vomiting to the surgeon

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4
Q

A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the
following findings is the priority to be reported to the provider?

A. History of cholelithiasis
B. Serum amylase levels three times greater than the expected value
C. Client report of severe pain radiating to the back that is rated at an “8”
D. Hand spasms present when blood pressure is checked

A

D. Hand spasms present when blood pressure is checked

The greatest risk to the client is hypocalcemia due to the risk of cardiac dysrhythmia.
Hand spasms when taking a blood pressure is an indication of hypocalcemia and is the priority
finding to report to the provider.

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5
Q

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following
statements by the client requires further teaching?

A. “I plan to eat small, frequent meals.”
B. “I will eat easy-to-digest foods with limited spice.”
C. “I will use skim milk when cooking.”
D. “I plan to drink regular cola.”

A

D. “I plan to drink regular cola.”

Caffeine-free beverages are recommended for the client who has pancreatitis. Regular
cola contains caffeine.

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6
Q

The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. What instruction should the nurse discuss with the client?

A. Instruct the importance to avoid all stress
B. Explain the correct way to take pancreatic enzymes
C. Instruct the client to decrease alcohol intake
D. Discuss the importance of stopping smoking

A

D. Discuss the importance of stopping smoking

Alcohol must be avoided completely due to its destruction of the pancreas. Stress stimulates the liver, but it is unrational to avoid all stress. Pancreatic enzymes are only needed for chronic pancreatitis. Smoking stimulates the pancreas to release pancreatic enzymes.

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7
Q

A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements should the nurse make?

a. “You should decrease your caloric intake when abdominal pain is present.”
b. “You should increase fat intake when experiencing loose stools.”
c. “You should increase your daily intake of protein.”
d. “You should limit alcohol intake to 2-3 drinks per week.”

A

c. “You should increase your daily intake of protein.”

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8
Q

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client’s history?

a.Gallstones
b.Hypolipidemia
c.COPD
d.Diabetes mellitus

A

a.Gallstones

Acute pancreatitis is often associated with gallstones as one of the common causes. When the nurse is interviewing a client with acute pancreatitis, they should anticipate finding a history of gallstones. Other common causes include excessive alcohol consumption, certain medications, high lipid levels in the blood, infections, trauma, and certain medical conditions. However, among the options provided, gallstones are the most directly associated with acute pancreatitis.

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9
Q

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include?

A. A family history increases your risk for acquiring hepatitis A.
B. Hepatitis A infects the kidneys
C. Manifestations of the virus are similar to flu-like symptoms
D. The incubation of the virus is 5 days

A

C. Manifestations of the virus are similar to flu-like symptoms

The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

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10
Q

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

A. Avoid covering sores with bandages
B. Avoid handwashing after eating
C. Avoid food prepared with tap water
D. Avoid eating meat

A

C. Avoid foods prepared with tap water.

To decrease the risk for acquiring hepatitis, clients should prepare foods with purified water.

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11
Q

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?

A. Avoid eating at fast food restaurants
B. Avoid serving raw food
C. Practice effective hand hygiene
D. Wear barrier protection during vaginal intercourse

A

C. Practice effective hand hygiene.

Effective hand hygiene - along with immunization, sanitation, and a safe water supply - are the most effective strategies for preventing the transmission of hepatitis A.
This type of hepatitis is usually contracted by consuming food or water contaminated with the feces of an infected person.

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12
Q

A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?

A. You may donate blood 6 months after completing the medication regimen.
B. Consume a high protein diet
C. Rest frequently throughout the day
D. Take acetaminophen every 4 hours as needed for discomfort.

A

C. Rest frequently throughout the day.

Limiting activity is usually recommended until the symptoms of hepatitis have subsided. The nurse should recommend the client rest frequently throughout the day to reduce metabolic demands upon the liver and decrease energy demands

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13
Q

A nurse is admitting a client who has Hepatitis C. Which of the following precautions should the nurse implement?

A. Droplet
B. Contact
C. Airborne
D. Standard

A

D. Standard

Hepatitis C is a blood-borne pathogen that is commonly spread by needle stick injury, sharing of IV drug paraphernalia and sexual contact. The nurse should implement standard precautions when in contact with blood, body fluids (except swear), broken skin, and mucous membranes. The nurse should schedule wear additional personal protective equipment if there is a possible blood contact or a risk for splashes or sprays of blood or body fluids.

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14
Q

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?
A. Administer antibiotics
B. Provide a diet high in fat
C. Restrict fluids
D. Encourage short periods of ambulation

A

D. Encourage short periods of ambulation

The nurse should encourage a client who has hepatitis B to alternate between activity and rest.

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15
Q

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?

A. A client who eats raw shellfish
B. A client who has multiple tattoos
C. A client who works in a child care center
D. A client who has recently traveled to a underdeveloped country

A

B. A client who has multiple tattoos

Hepatitis C is transmitted via blood-to-blood contact. The nurse should recognize that improperly maintained tattoo equipment may aid in transmission and could increase the client’s risk for contracting hepatitis C.

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16
Q

Teaching in relation to home management after a laparoscopic cholecystectomy should include

a. keeping the bandages on the puncture sites for 48 hours.
b. reporting any bile-colored drainage or pus from any incision.
c. using over-the-counter antiemetics if nausea and vomiting occur.
d. emptying and measuring the contents of the bile bag from the T tube every day. (Lewis 1042)

A

b. reporting any bile-colored drainage or pus from any incision.

This is crucial after a laparoscopic cholecystectomy because it helps in monitoring for signs of infection or complications. Bile-colored drainage or pus can indicate issues with wound healing or infection, so it’s essential to report such occurrences to healthcare providers promptly.

17
Q
  1. A nurse is completing teaching for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which of the following statements made by the client indicates understanding of the teaching?

A. “I will be fully awake during the procedure.”
B. “Lithotripsy will reduce my chances of having stones in the future.”
C. “I will report any bruising that occurs to my doctor.”
D. “Straining my urine following the procedure is important.”

A

D. “Straining my urine following the procedure is important.”

A client is instructed to strain urine following lithotripsy to verify that the stone has been passed.

18
Q

A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify which of the following findings is the priority?

A

A. Dysrhythmias

19
Q

a nurse is caring for a client who is 4 hour postoperative following a laparoscopic cholecystectomy. which of the following findings should the nurse expect

A. right shoulder pain
B. urine output 20 mL/hr
C. Temperature 38.4 C (101.1 F)
D oxygen saturation 92%

A

A. Right shoulder pain

  • the client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the should area. the pain disappears in 1 to 2 days. mild analgesics and recumbent position can help with client comfort
20
Q

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply)

A. Offer the client a back rub
B. Remind the client to use incisional splinting
C. Identify the client’s pain level
D. Assist the client to ambulate
E. Change the clients position

A

A. Offer the client a back rub
B. Remind the client to use incisional splinting
C. Identify the clients pain level
E. Change the clients position

21
Q

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

A. Prone
B. Semi-Fowler’s
C. Supported Sims’
D. Dorsal recumbent

A

B. Semi-Fowler’s

After a traditional cholecystectomy, the nurse should place the client in the B. Semi-Fowler’s position. This position helps to reduce strain on the incision site and promotes respiratory function.

22
Q

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse’s priority?

A. Bowel sounds
B. Surgical dressing
C. Temperature
D. Oxygen Saturation

A

D. Oxygen saturation

The priority action the nurse should take when using the airway, breathing, circulation approach to pt care is to access pt’s O2 sat. The nurse should check the pt’s airway, listen to breath sounds, and check pulse ox to assess for respiratory depression.

23
Q

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.)
A. Broth
B. Grape juice
C. Nonfat milk
D. Custard
E. Lemon gelatin

A

A. Broth
B. Grape juice
E. Lemon gelatin

Fat-free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable.
Lemon gelatin is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops.
Grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice.

24
Q

A nurse is reviewing the provider’s prescriptions for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?

A. Administer an antacid.
B. Provide a bulk-forming agent.
C. Insert nasogastric tube.
D. Administer tap water enema

A

C. Insert nasogastric tube.

The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus.

25
Q

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

A. Monitor oral temperature every 4 hr.
B. Administer sodium biphosphate/sodium phosphate.
C. Maintain NPO status.
D. Medicate the client for pain every 4 hr as needed.

A

B. Administer sodium biphosphate/sodium phosphate.

The nurse should clarify prescription B, which is “Administer sodium biphosphate/sodium phosphate.” This prescription seems unrelated to the suspected appendicitis and may not be appropriate for the child’s condition. It’s important to ensure that all medications administered are relevant to the diagnosis and treatment plan.

26
Q

Expected findings for peritonitis

A

Diminished bowel sounds is an expected finding for a client who has peritonitis.

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

27
Q

A nurse is collecting data on a client who has appendicitis. Identify the site the nurse should palpate to determine the presence of tenderness at McBurney’s point. (Selectable areas, or “Hot Spots,” can be found by moving the cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds with your answer.)

A

McBurney’s point is located in the lower right quadrant midway between the anterior iliac crest and the umbilicus. Pressure over this point will elicit pain in the later stages of appendicitis. Remember, the screen is not a mirror image.

28
Q

A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect?

A. Decreased blood lipase level
B. Decreased blood amylase level
C. Increased blood calcium level
D. Increased blood glucose level

A

D: Increased blood glucose level

29
Q

A nurse is assessing a client who is African- American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice?

A. Palms of hands
B. Hard palate
C. Conjunctiva
D. Back of neck

A

B. Hard palate

According to EBP, inspecting the client’s oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African- American

30
Q

A nurse is educating a client about hepatitis C transmission. Which statement by the client indicates a need for further teaching?

A.”I can get hepatitis C through unprotected sexual contact.”
B.”Sharing needles for drug use can transmit hepatitis C.”
C.”Eating contaminated food can spread hepatitis C.”
D.”Getting a tattoo with unsterilized equipment can transmit hepatitis C.”

A

C.”Eating contaminated food can spread hepatitis C.”

Hepatitis C is primarily transmitted through blood-to-blood contact, such as sharing needles for drug use, unprotected sexual contact, or getting a tattoo with unsterilized equipment. It is not typically spread through contaminated food. Therefore, option C indicates a need for further teaching.