A client with hiatal hernia reports to the nurse that he has trouble sleeping because of abdominal pain. The nurse should instruct the client to sleep:
1) With his upper body elevated
2) In a prone position
3) Flat or in a side lying position
4) With his lower body slightly elevated
1) Upper body elevation can reduce the gastric reflux associated with hiatal hernia.
Sleeping in a prone or side lying position, or with his lower body slightly elevated, won't help the client.
A client is admitted to the med-surg. Floor with a diagnosis of acute pancreatitis. His BP 136/76, P 96 bpm, R 22 breaths/min, and T 101F/38.3C. His PMHx reveals hyperlipidemia and alcohol abuse. The physician prescribes an NG tube for the client. The nurse knows the NG tube will:
1) Empty the stomach of fluids and gas
2) Prevent spasms at the spincter of Oddi
3) Prevent air from forming in the small and large intestines
4) Remove bile from the gallbladder
1) an NG tube is inserted into the client's stomach to drain fluids and gas.
An NG tube doesn't prevent spasms at the sphincter of Oddi or prevent air from forming in the small and large intestine.
A T tube collects bile drainage from the common bile duct.
While preparing a client for an upper GI endoscopy, which interventions should the nurse implement?
SELECT ALL THAT APPLY!
1) Administer a preparation, such as polyethylene glycol (GoLYTELY), to clean the GI tract
2) Tell the client not to eat or drink 6-12 hrs prior to procedure
3) Tell the client to consume only clear liquids for 24 hrs prior to procedure
4) Inform the client that he'll receive a sedative before the procedure
5) Inform the client that he may eat and drink immediately after the procedure.
2) and 4) The client shouldn't eat or drink for 6-12 hrs before the procedure to ensure that his upper GI tract is clear for viewing.
The client will receive a sedative before the endoscope is inserted that will help him relax while allowing him to remain conscious.
GI tract cleansing and liquid diet are interventions before a lower GI tract procedure such as colonoscopy. Food and fluids must be withheld until the gag reflex returns.
A client returns from the operating room after extensive abdominal surgery. He has 1,000ml of lactated Ringer's solution infusing via central line. The physician orders the I.V. fluid to be infused at 125ml/hr plus the total output of the previous hour. The drip factor of the tubing is 15gtt/min. The client's output for the previous hour was 75m. via Foley catheter, 50ml via NG tube, and 10ml via Jackson-Pratt tube. How many drops per minute should the nurse set the I.V. flow rate at to deliver the correct amount of fluid? Record as a whole number. ______ ggt/minute.
65ggt/min. First calculate the volume to be infused in milliliters: 75ml + 50ml + 10ml = 135ml total output for the previous hour; 135ml + 125ml ordered as a constant flow = 260ml to be infused over the next hour.
Next, used the formula: Volume to be infused/ Total minutes to be infused x Drip Factor = Drops per min.
In this case, 260ml divided by 60min x 15 ggt/min = 65 ggt/min
A nurse is caring for a client who requires a NG tube for feeding. What should the nurse do immediately after inserting an NG tube for enteral feedings.
1) Aspirate for gastric secretions with a syringe
2) Begin feeding slowly to prevent cramping
3) Get an xray of the tip of the tube within 24 hrs
4) Clamp off tube until feedings begin.
1) Before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspirating for stomach contents confirms correct placement.
Giving the feeding without proper placement puts the client at risk for aspiration.
If an X-ray is ordered, it should be done immediately, not in the next 24 hrs. Clamp tube provided no informal about the tube placement.
A client with a history of long term anti inflammatory use has dark, tarry stools. The nurse knows that this indicates bleeding in the:
1) Upper colon
2) Lower colon
3) Upper GI tract
4) Small intestine
3) Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It occurs with bleeding from the upper GI tract.
Passage of red blood from the rectum indicates lower GI (colon, small intestine, and rectum) bleeding.
Bleeding in the lower colon would cause bright red blood in the stool.
After an abdominal resection for colon cancer, the client returns to his room with a Jackson-Pratt drain in place. The client's spouse asks the nurse about the purpose of the drain. The best response would be for the nurse to say:
1) It irrigates the incision with a saline solution
2) It helps prevent bacterial infection of the incision
3) It measures the amount of fluid lost after surgery
4) It helps prevent the accumulation of drainage in the wound.
4) The accumulation of fluid in a surgical wound interferes with the healing process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. The drain may be placed in the client's incision, or it may be placed in the wound and brought out to the skin surface through a stab wound near the incision.
The incision doesn't need to be irrigated.
Fluid from the drain is absorbed into the dressings and can't be measured accurately.
A Jackson-Pratt drain doesn't prevent infection.
A nurse is doing preoperative teaching with a client expected to undergo a herniorrhaphy (surgical repair of a hernia). The nurse should instruct the client to:
1) Avoid the use of pain medication
2) Cough and deep breathe every 2 hrs
3) Splint the incision if he can't avoid sneezing or coughing
4) Apply heat to scrotal swelling.
3) After herniorrhaphy, teach the client to avoid activities that increase intra-abdominal pressure, such as coughing, sneezing, or straining with bowel movement. If the client must cough or sneeze, splinting the incision with a pillow is helpful. Encourage the use of analgesics for pain or discomfort. The client should be instructed not to cough, but deep-breathing exercises should be still be preformed q2hrs. Ice may be used to reduce scrotal edema and pain after herniorrhaphy.
Following abdominal surgery, a client has developed a gaping incision due to delayed wound healing. The nurse is preparing to irrigate the incision using a piston syringe and sterile normal saline solution. Which method should the nurse use as a part of the irrigation process.
1) Rapidly instill a stream of irrigating solution into the wound
2) Apply a wet-to-dry dressing to the wound after the irrigation
3) Moisten the area around the wound with normal saline solution after the irrigation
4) Irrigate continuously until the solution becomes clear or until all of the solution is used.
4) To wash away tissue debris and drainage effectively, irrigate the wound until the solution becomes clear or until all of the solution is used.
After the irrigation, dry the area around the wound; moistening it promotes microorganism growth and skin irritation.
When the area is dry, apply sterile dressing rather than a wet-to-dry dressing.
Always instill the irrigating solution gently; rapid or forceful instillation can damage tissues.
Daily abdominal girth measurements are prescribed for a client with liver dysfunction and ascites. To increase accuracy, the nurse should use which landmark?
1) Xiphoid process
3) Illiac crest
4) Symphysis pubis
2) The proper technique for measuring abdominal girth involves using the umbilicus as a landmark while encircling the abdomen with a tape measure.
Using the xiphoid process, the iliac crest, or the symphysis pubis as a landmark would yield inaccurate measurements.
A nurse is caring for a client who requires total parenteral nutrition (TPN). The client asks the nurse why he's getting TPN. The nurse best response is:
1) It adds necessary fluids and electrolytes to the body
2) It gives you complete nutrition by the I.V. route until you can eat again.
3) These tube feedings provide nutritional supplementation.
4) It contains liquid protein to supplement your diet between meals.
2) TPN is given I.V. to provide all the nutrients the client needs; it provides more than just fluids and electrolytes.
TPN solutions typically provide glucose, amino acids, trace elements and vitamins, and fats.
TPN is neither a tube feeding nor a liquid dietary supplement.
The nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following should the nurse include?
1) Administering a lactulose enema as ordered.
2) Encouraging a protein rich diet
3) Adminis.tering sedatives as needed.
4) Encouraging ambulation at least 4 times a day.
1) Hepatic encephalopathy is a degenerative disease of the brain that is a complication of cirrhosis. For the client with hepatic encephalopathy, the nurse may administer the laxative lactulose to reduce ammonia levels in the colon.
Protein intake is usually restricted to reduce serum ammonia levels until the client's mental status begins to improve.
Sedatives are avoided because they can cause respiratory or circulatory failure.
Bed rest is encouraged because physical activity increases metabolism, leading to an increased production of ammonia.
A nurse is caring for a client diagnosed with diverticulous. Which should be the nurse expect to institute?
1) Low Fiber diet and fluid restriction
2) Total parenteral nutrition and bed rest.
3) High fiber diet and administration of psyllium
4) Administer of analgesics and antacids
3) Diverticulosis is characterized by an out-pouching of the colon. The client needs a high fiber diet and psyllim (bulk laxative) administration to promote normal soft stools.
A low fiber diet, decreased fluid intake, bed rest, analgesics, and some antacids can lead to constipation.
A client is admitted with inflammatory bowel syndrome (Crohn's disease). Which treatment measures should the nurse expect to be part of the care plan?
SELECT ALL THAT APPLY!
1) Laculose therapy
2) High fiber diet
3) High protein milkshakes
4) Corticosteroid therapy
5) Antidiarrheal medications
4) and 5) Corticosteroids, such as prednisone, reduce the S/S of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.
Lactulose is used to treat chronic constipation and would aggravate the symptoms.
A high fiber diet, milk, and milk products are contraindicated in clients with Crohn's disease because they may promote diarrhea.
A client who recently had abdominal surgery tells the nurse he felt a popping sensation in his incision during a coughing spell, following by severe pain. The nurse anticipates an evisceration.
Which supplies should she bring to the client's room?
1) A suture kit
2) Sterile water and a suture kit
3) Sterile water and sterile dressings
4) Sterile saline solution and sterile dressings
4) Saline solution is isotonic, or close to body fluids in content, and is used along with sterile dressings to cover an eviscerated wound (a wound that opened, allowing the intestines to protrude outside the body) and keep it moist.
Sterile water and a suture kit aren't used. The physician will contacted, and the client will most likely return to the operating room for closure.
A client is admitted with upper GI bleeding. The nurse promotes hemodynamic stability by:
1) Encouraging oral fluid intake
2) Monitoring central venous pressure (CVP)
3) Monitoring laboratory test results and vital signs
4) Giving blood, electrolyte, and fluid replacement.
4) to stabilize a client with acute bleeding, normal saline solution or lactated Ringer's solution is given until blood pressure rises and urine output returns to 30ml/hr.
A CVP line is inserted to monitor circulatory volume.
When shock is severe, plasma expanders are given until typed and crossmatched blood is available. Oral fluid intake is contraindicated with upper GI bleeding.
Monitoring vital signs and laboratory values enables the nurse to evaluate the results of treatment, but these measures don't facilitate hemodynamic stabilization.
A client has undergone a colostomy for a ruptured diverticulum. The nurse is assessing the client's colostomy stoma 2 days after surgery. Which assessment finding should the nurse report to the physician?
1) Blanched stoma
2) Edematous stoma
3) Reddish pink stoma
4) Brownish black stoma
4) A brownish black stoma color indicates a lack of blood flow to the stoma, and necrosis is likely.
A blanched or pale stoma indicates possible decreased blood flow and should be assessed regularly.
2 days postoperatively, the stoma should be edematous and reddish pink.
A nurse is caring for a client with liver cirrhosis who has developed ascites and requires paracentesis. Relief of which symptom indicates that the paracentesis was effective?
4) Peripheral neuropathy
2) Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm.
The goal is to improve the client's breathing.
Pruritus, jaundice, and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis.
A client admitted with peritonitis is under a NPO order. The client is complaining of thirst. Which action is the most appropriate for the nurse to take?
1) Increase the I.V. infusion rate
2) Use diversion activities
3) Provide frequent mouth care
4) Give ice chips every 15 minutes
3) frequent mouth care helps relieve dry mouth. Increasing the I.V. infusion rate does not alleviate the feeling of thirst. Diversion activities aren't specific. Ice chips are a form of liquid and shouldn't be given as long as the client is under an NPO order.
A nurse is preparing to teach a client who has been newly diagnosed with stomach cancer.
Which statement should the nurse include in her teaching?
1) Stomach pain is typically a late symptom of stomach cancer.
2) Surgery is commonly a successful treatment for stomach cancer.
3) Chemotherapy and radiation are usually successful treatments for stomach cancer.
4) You may be on TPN for an extended time.
1) Stomach pain is typically a late sign of stomach cancer; outcomes are particularly poor when the cancer reaches that point.
Surgery, chemotherapy, and radiation have minimal positive effects on stomach cancer.
TPN may increase the growth of cancer cells.
A client is admitted with possible bowel obstruction. Which intervention is most important for the nurse to perform?
1) Obtain daily weights.
2) Measure abdominal girth.
3) Keep strict intake and output.
4) Encourage the client to increase fluids.
2) With a bowel obstruction, abdominal distention occurs. Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention.
Monitoring daily weights provides information about fluid status. An increase In daily weight usually indicates fluid retention.
Measuring intake and output provides no information about abdominal distention or obstruction. A client with an obstruction would receive a NPO order.
A nurse is advising a client with a colostomy who reports problems with flatus. Which food should the nurse recommend?
4)High fiber food stimulate peristalsis and thus, flatulence.
Tell the client to include yogurt in his diet to reduce gas formation. Other helpful foods include crackers and toast.
Peas, cabbage, and broccoli are all gas forming foods.
True or False
An anti-diarrheal is contraindicated w/a bowel obstruction:
True - colitis, N/V, and diarrhea should not be suppressed if underlying cause is not known
What classification of meds decreases bowel motility?
What is acid reflux?
when stomach acid splashes up into esophagus
Maalox & Mylanta commonly interfere w/absorption of other meds. T or F
true - especially when kidneys have failed
What classification is Pepcid and what does it treat?
H2 antagonist (blocks histamine receptor)
Treats dyspepsia, GERD, PUD, esohagitits
When teaching a patient about taking Pepcid what should you include:
Take 1 hr before meals (causes acid-producing parietal cells of stomach to be less responsive to stimulation-blocks 90% of acid secretion)
Bowel obstruction :
Blockage in small intestine or colon that prevents food and fluid from passing through. Tissue death & perforation of intestine can lead to severe infection and shock.
Can be life-threatening.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
◦ A. Sternal rub
◦ B. Nail bed pressure
◦ C. Pressure on the orbital rim
◦ D. Squeezing of the sternocleidomastoid muscle
B- Nail bed pressure
Rationale: Motor testing in the unconscious client can be done only by testing response painful stimuli. Nail bed pressure tests a basic peripheral pressure on the orbital rim, or squeezing the clavical or sternoleidomastoid muscle.
T or F Antacids promote premature dissolving of enteric-coated meds
T - separate administration of other meds by 1-2 hours
Medications used to treat H pylori
prilosec and prevacid - acid reducers and proton pump inhibitors
Teaching for prilosec and prevacid should include:
1) take 30-60 mins before meals
2) highly protein bound. Stronger than Pepsid (H2 antagonist)
T or F Nauseas & vomitting should not be treated until pt acutally vomits.
F- n/v should be treated aggressively; preventing comfort,safety, and compliance w/Tx regimen
Compazine is a(an)______ and results in _______
An antiemetic and is calming and sedating (putting pt at risk for aspiration)
This drug is an antiemetic that should never be given IV and when given IM MUST be Z-tracked
Vistaril (hydroxyzine) - is also antihistamine and antidepressant that is often used for post-op pts
Reglan (metoclopramide) is a (an) _______ that is most effective when given prophylactically (at least 30 min prior to chemo/radiation)
an antiemetic that blocks CTZ (no response to vomitus stimulus) and stimulates gastric emptying (downward into GI)
antiemetic; antiserotonergic (blocks serotonin receptor in GI tract and CTZ)
Ginger is a herbal remedy thought to be effective in treating _______
nausea and vomiting (n/v) particularly w/ chemo & radiation Tx and hyperemesis in pregnancyand hyperemesis in pregnancy
Ipecac should not be used if____
ingested substance is sedating (may become too lethargic to prevent aspiration) or caustic (cause more oral and esophageal damage).
Lomotil inhibits what?
GI motility - it is a non-analgesic opiod that stops diarrhea in its tracks and is contraindicated w/ infectious diarrhea
What category is simethicone (Gas-X, Mylicon) and how does it work?
anti-flatulent that reduces surface tension of air bubbles which helps alleviate the pain associated with gas
RN implications before GI meds can be given:
-Upper and lower GI assessment
-Assess fluid/electrolyte status
Post surgery for stone removal hematuria is expected
T or F
True bright red blood would be cause for concern
if pt needs a blood transfusion what must be obtained?
Post EGD procedure pt would need to remain NPO until ___________ :
gag reflex returns (pt is at risk for aspiration until it has returned)
(upper GI endoscopy)
EGD pt what must be checked every 15 to 30 mins for 1-2 hrs and why
temp must be checked
a spike could mean possible perforation
if you are teaching a GI pt to push fluids and that his stool may be white for up to 72 hrs after test, what test has this pt just undergone?
barium swallow - detects structural abnormalities
If you want to view a pts gallbladder and ducts what would be ordered?
an ERCP - gag is paralyzed so NPO until returns
Hematocrit (HCT) and Hemaglobin(Hgb) can be ordered to detect what in a GI pt?
GI bleed results would indicate anemia
T or F
Cardiac enzymes are ordered for GI pts?
T - they will rule out if s/s are due to cardiac issue rather than GI issue
T or F
While caring for pt w/suspected appendicitis you would give enema or laxatives in prep for surgery?
False - peristalsis can cause appendix to ruputure
Pt has severe pain in periumbilical area that gets increasing worse and then goes away, what may have just happened?
inflamed matter trapped in the diverticula (out pouches)
out pouching in intestinal wall
What would you teach a pt that has diverticulitis?
increase fiber, decrease fat and red meat, increase activity to increase peristalsis, avoid tight restrictive clothing
If auscultating bowel sounds in pt w/obstruction what would you expect to hear?
high pitch above obstruction and absent below obstruction
In diagnosing bowel obstruction what must you do before barium enema?
must see xray - may not be administered if peritonitis is present
1. With a renal threshold for glucose of 220 mg/dL, what is the expected response when a client has a blood glucose level of 400 mg/dL?
A. 400 mg/dL of excreted glucose in the urine
B. 220 mg/dL of excreted glucose in the urine
C. 180 mg/dL of glucose is excreted in the urine
D. No excreted glucose in the urine
Blood glucose is freely filtered at the glomerulus. Therefore, if a client has a blood sugar level of 400 mg/dl, the filtrate in the proximal convoluted tubule will have a glucose concentration of 400 mg/dL. With a renal threshold of 220 mg/dl, a total of 220 mg/dL of the 400 mg/dL will be reabsorbed back into the systemic circulation, and the final urine will have a glucose concentration of 180 mg/dL.
5. The client scheduled to have an intravenous urogram is a diabetic and taking the antidiabetic agent metformin. What should the nurse tell this client?
A. "Call your diabetes doctor and tell him or her that you are having an intravenous urogram performed using dye."
B. "Do not take your metformin the morning of the test because you are not going to be eating anything and could become hypoglycemic."
C. "You must start on an antibiotic before this test because your risk of infection is greater as a result of your diabetes."
D. "You must take your metformin immediately before the test is performed because the IV fluid and the dye contain a significant amount of sugar."
Metformin can cause a lactic acidosis and renal impairment as an interaction with the dye. This drug must be discontinued for 48 hours before the procedure and not started again after the procedure until urine output is well established.
8. The 48-year-old client with diabetes mellitus is being treated for her third episode of acute pyelonephritis in the past year. She asks what she could do to help prevent these infections. What is the nurse's best response?
A. "Test your urine daily for the presence of ketone bodies and proteins."
B. "Use tampons rather than sanitary napkins during your menstrual period."
C. "Drink more water and try to empty your bladder at least every 2 to 3 hours while you are awake."
D. "Inject your insulin in larger doses or more frequently to keep your blood sugar lower so the microorganisms have fewer nutrients for growth."
Clients with long-standing diabetes mellitus are at risk for pyelonephritis for many reasons. Chronically elevated blood glucose levels spill glucose into the urine, changing the pH and providing a favorable climate for bacterial growth. The neuropathy associated with diabetes reduces bladder tone and reduces the client's sensation of bladder fullness. Thus, even with large amounts of urine, the client voids less frequently, allowing stasis and overgrowth of microorganisms. Increasing fluid intake (specifically water) and voiding frequently prevent stasis and bacterial overgrowth.
1. What would be the effect on the client's hormone response to a naturally occurring hormone if the client were taking a drug that "blocked" that hormone's receptor site?
A. The client's response would indicate greater hormone metabolism.
B. The client's response would resemble decreased hormone activity.
C. The client's response would resemble increased hormone activity.
D. The client's response would be unchanged.
Hormones cause an activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the cell's activity. When the receptor sites are occupied by other substances that block hormone binding, the cell's response is the same as when there is a decreased level of the hormone.
2. The client who is taking corticosteroids daily for severe asthma now has an elevated blood glucose level. He asks the nurse if he is now considered diabetic. What is the nurse's best response?
A. "Yes, the corticosteroids have destroyed the ability of the pancreas to synthesize insulin."
B. "Yes, whenever blood glucose levels are abnormally high, the condition is called diabetes."
C. "No, the blood glucose level is elevated because corticosteroids increase the synthesis of glucose."
D. "No, the lack of insulin is temporary and will return to a normal level when the asthma is better."
Corticosteroids cause a "pseudodiabetes" with increased blood glucose levels by stimulating liver synthesis of glucose and suppressing glucose use by cells. The ability of the pancreas to synthesize insulin is unaffected.
6. Which clinical manifestation alerts the nurse to the possibility of an endocrine disorder?
A. Chronic constipation
B. Weight gain of 5 pounds in the past 12 months
C. Increased sense of thirst and increased urine output
D. Muscle cramps after heavy exercise and during hot weather
Increased thirst and increased urine output are associated with at least two endocrine disorders, diabetes mellitus and diabetes insipidus.
7. Which test results should the nurse check to ascertain how well the client is managing her diabetes mellitus overall?
A. Blood glucose level
B. Glucose tolerance test
C. Glycosylated hemoglobin
D. Radioimmunoassay of insulin
The glycosylated hemoglobin level reveals the average blood glucose level over a period of 2 to 3 months. Its primary use is in assessing overall control of the glucose level in diabetes mellitus.
12. Which client responses demonstrate to the nurse that treatment for diabetes insipidus is effective?
A. Urine output is increased; specific gravity is increased.
B. Urine output is increased; specific gravity is decreased.
C. Urine output is decreased; specific gravity is increased.
D. Urine output is decreased; specific gravity is decreased.
Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolarity, as evidenced by a low specific gravity. Effective treatment results in a decreased urine output that is more concentrated, as evidenced by an increased specific gravity.
16. Which statement regarding diabetes mellitus is true?
A. Diabetes increases the risk for development of epilepsy.
B. The cure for diabetes is the administration of insulin.
C. Diabetes increases the risk for development of cardiovascular disease.
D. Carbohydrate metabolism is disturbed in diabetes, but protein and lipid metabolism are normal.
Diabetes mellitus is a major risk factor for morbidity and mortality caused by coronary artery disease, cerebrovascular disease, and peripheral vascular disease.
17. The client diabetic client asks the nurse why it is necessary to maintain blood glucose levels no lower than about 74 mg/dL. What is the nurse's best response?
A. "Glucose is the only fuel form used by body cells to produce energy needed for physiologic activity."
B. "The central nervous system, which cannot store glucose, requires a continuous supply of glucose for fuel."
C. "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP."
D. "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis."
Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.
18. What is the basic underlying pathology of diabetes mellitus?
A. A disruption of the cellular glycolytic pathway
B. An inability of the liver to catabolize glycogen
C. A failure to synthesize and/or utilize insulin
D. An inhibition of the conversion of protein to amino acids
The lack of insulin in diabetes, either from a lack of insulin secretion or from insulin receptor pathology, prevents insulin-sensitive cells from using glucose as an energy source.
19. While assessing the client who has had diabetes for 15 years, the nurse notes that the client has decreased tactile sensation in both feet. What is the nurse's best first action?
A. Document the finding as the only action.
B. Test sensory perception in the client's hands.
C. Examine the client's feet for signs of injury.
D. Notify the physician.
Diabetic neuropathy is common when the disease is long-standing. It cannot be reversed and the client is at great risk for injury in any area with decreased sensation, because he or she is less able to feel injurious events.
20. Which action should the nurse teach the diabetic client as being most beneficial in delaying the onset of microvascular and macrovascular complications?
A. Controlling hyperglycemia
B. Preventing hypoglycemia
C. Restricting fluid intake
D. Preventing ketosis
The Diabetes Control and Complications Trial, a prospective study involving 29 medical centers and more than 1400 people with type 1 diabetes, provides convincing evidence that hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications.
1. A client has developed diabetes mellitus type 1 and no longer produces insulin. What cells of the pancreas have become dysfunctional?
A. Beta cells
B. Alpha cells
C. Acinar cells
D. Kupffer cells
The endocrine part of the pancreas is composed of the islets of Langerhans, with alpha cells producing glucagon and beta cells producing insulin.
2. What is the role of the liver in response to increased energy requirements?
A. Storage of fatty acids and triglycerides
B. Activation of Kupffer cells
C. Storage and release of glycogen
D. Removal of ammonia
The liver's role in carbohydrate metabolism involves the storage and release of glycogen as energy requirements change. An increase in energy requirements results in the release of glycogen.
3. During an initial assessment, a client with gastrointestinal problems reports the use of nonsteroidal anti-inflammatory drugs (NSAIDs) three times a day for arthritis pain. What would be the nurse's best response?
A. "NSAIDs are not helpful for arthritis pain."
B. "NSAIDs should be taken only twice daily."
C. "NSAIDs can interfere with the absorption of nutrients."
D. "NSAIDs can result in ulcers or bleeding."
Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through the inhibition of prostaglandins.
4. While examining the oral cavity of a client, the nurse detects a fruity odor to the client's breath. The nurse should do which of the following?
A. Instruct the client to use mouthwash after all meals.
B. Instruct the client in good oral hygiene.
C. Document the finding as the only action.
D. Notify the physician.
A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The nurse should notify the physician or health care provider so that the appropriate steps to investigate this finding can be taken.
5. While auscultating the abdomen of a client, the nurse notes increased, loud, gurgling bowel sounds. What would be the nurse's best action?
A. Palpate the abdomen.
B. Percuss the abdomen.
C. Notify the physician.
D. Document the finding as the only action.
The presence of increased, loud, gurgling bowel sounds is associated with hypermotility, which can be associated with diarrhea or gastroenteritis. This sound also is heard above a complete intestinal obstruction, and the physician should be notified because the client requires measures to relieve the obstruction, if present.
6. In a client admitted with cirrhosis of the liver, which serum levels would the nurse expect to be elevated?
A. Serum amylase and lipase
B. Serum ammonia
C. Serum calcium
D. Serum CEA
Serum ammonia levels are elevated in conditions that incur hepatocellular injury, such as cirrhosis of the liver. Increased serum amylase and lipase levels are indicators of pancreatitis. CEA levels are useful in assessing the success of cancer therapy or the recurrence of cancer.
7. The nurse is preparing a client for a CT (computed tomography) scanning of the abdomen with contrast. What question should be asked before the examination?
A. "Are you allergic to iodine or seafood?"
B. "Have you had anything to eat or drink within the past 12 hours?"
C. "Have you finished drinking all the required fluid?"
D. "Can you tolerate being tilted from side to side during the procedure?"
Allergies to iodine or seafood can mean a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies are scheduled for CT without contrast to avoid anaphylactic reactions.
8. Twenty-four hours after endoscopic retrograde cholangiopancreatography (ERCP), a client develops left upper quadrant abdominal pain and has a temperature of 101° F (38.3° C). What is the nurse's best action?
A. Administer acetaminophen for control of fever and pain.
B. Document the finding, because it is a normal postprocedure event.
C. Notify the health care provider.
D. Increase the IV fluid rate.
The client who has undergone an ERCP may develop complications such as perforation or sepsis manifested by fever and abdominal pain. The nurse should report these symptoms to the health care provider immediately.
9. After a colonoscopy, a client reports that he is experiencing abdominal fullness and cramping. What is the nurse's best action?
A. Insert a rectal tube to assist in passing of flatus.
B. Notify the physician immediately because a bowel perforation is suspected.
C. Have the client consume only liquids for 4 to 6 hours after the test.
D. Explain to the client that this feeling can be expected for several hours after the test.
Feelings of abdominal fullness, cramping, and the passing of flatus are normally expected after a colonoscopy.
10. The client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication?
Regurgitation of stomach contents while the client is recumbent poses a risk of aspiration for the client.
11. Which is the priority assessment in the client experiencing regurgitation?
A. Auscultation for crackles
B. Inspection of the oral cavity
C. Palpation of the cervical lymph nodes
D. Culture of the throat for bacterial infection
The client with regurgitation is at risk of aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs for crackles, an indication of aspiration.
12. What intervention should the nurse suggest to a client to prevent nighttime reflux?
A. "Sleep in the right lateral decubitus position."
B. "Have a light evening snack before bedtime."
C. "Have alcoholic beverages early in the evening."
D. "Elevate the head of the bed 8 to 12 inches for sleep."
Elevation of the head of the bed 8 to 12 inches for sleep is helpful in preventing nighttime reflux episodes related to the recumbent position. Wooden blocks or foam wedges can be used to achieve this level of elevation.
13. Which dietary instructions should be included in a teaching plan for the client newly diagnosed with diverticula?
A. "You should eat soft foods and smaller meals because they are better tolerated."
B. "You have no dietary restrictions; you may eat anything you wish."
C. "You should avoid drinking liquids with your meals."
D. "You should avoid dairy products."
Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany diverticula.
14. Which of the following nursing diagnoses would be considered a priority for the client with peptic ulcer disease?
A. Acute Pain
B. Ineffective Coping
C. Potential for Metabolic Alkalosis
D. Ineffective Therapeutic Regimen Management
Peptic ulcer disease can cause significant discomfort from gastric or duodenal ulceration.
15. A client has been prescribed an antacid for the treatment of a duodenal ulcer. What instructions should the client receive?
A. "Take the antacid 2 hours before meals."
B. "Take the antacid 1 hour before meals."
C. "Take the antacid 2 hours after meals."
D. "Take the antacid only when you have pain."
For optimal effect, antacids should be given 2 hours after meals to reduce the hydrogen ion load in the duodenum.
16. A client with a history of heart failure has been prescribed an antacid for the treatment of peptic ulcer disease. What instructions should the nurse include when teaching this client about antacids?
A. "Some antacids have a high sodium content."
B. "Some antacids could potentiate digoxin toxicity."
C. "Some antacids could cause potassium depletion."
D. "Some antacids could trigger irregular heartbeats."
Some antacids, such as aluminum hydroxide and magnesium hydroxide, have a high sodium content and could exacerbate CHF.
17. A client with peptic ulcer disease has developed upper gastrointestinal bleeding. The client complains of chills and, on assessment, the nurse notes the following: diaphoresis, a pulse of 94 and thready, and blood pressure of 100/50. What is the nurse's priority action?
A. Document the finding as the only action.
B. Notify the health care provider.
C. Increase the flow rate of the intravenous fluids.
D. Place the client on the side in the left lateral decubitus position.
The development of major bleeding, as manifested by symptoms of shock, is an emergency that requires intervention. The nurse should notify the health care provider immediately in order to institute treatment.
18. Which of the following is a possible complication of strangulated obstruction?
A. Pulmonary edema
B. Bacterial peritonitis
C. Deep vein thrombosis
D. Acute tubular necrosis
A strangulated obstruction compromises blood flow to the area. Bacteria in intestinal contents stagnate and form an endotoxin, which is released into the peritoneum and circulatory system, causing septic shock.
19. What statement made by the client would indicate the possibility of intestinal obstruction?
A. "My stools have become firmer and harder."
B. "I am able to pass urine only in small amounts at a time."
C. "My abdomen appears to have become enlarged."
D. "I seem to be full after eating only a few bites."
Abdominal distention is a hallmark sign of intestinal obstruction.
20. What clinical manifestations represent the early symptoms of classic appendicitis?
A. Crampy periumbilical pain
B. Severe lower right quadrant pain
C. Lower right quadrant pain that decreases with movement
D. Abdominal pain that increases with flexion of the knees
In classic appendicitis, the initial symptom is mild, crampy epigastric or periumbilical pain.
21. Which of the following preoperative interventions would be contraindicated for the client with acute appendicitis?
A. Keeping the client NPO
B. Administering IV fluids
C. Placing a heating pad on the abdomen
D. Placing the client in a semi-Fowler's position
Placing heat on the abdomen increases circulation to the area, which increases inflammation and possibly contributes to perforation.
22. A client with an exacerbation of ulcerative colitis has been placed on total parenteral nutrition (TPN). The client asks why nutrition is being supplied in this manner and not by mouth. What is the nurse's best response?
A. "TPN contains a high percentage of glucose that is more readily absorbed into the bloodstream than into the ulcerated colon."
B. "TPN will be given in addition to your meals to help you gain any weight that you may have lost through diarrhea."
C. "TPN is considered an elemental formula and, as such, is easier to digest."
D. "TPN will be given during this period to allow your bowel to rest."
Bowel rest during severe exacerbations of ulcerative colitis is part of the nonsurgical management of the disease.
23. What assessment technique should be used to measure abdominal girth?
A. Measure the girth by placing the tape measure directly below the umbilicus.
B. Measure the girth while the client is in a standing position.
C. Measure the girth with the client lying on the left side.
D. Measure the girth at the end of exhalation.
The abdominal girth is measured at the end of exhalation, at the level of the umbilicus, while the client lies flat.
24. For the client with cirrhosis, what nursing intervention(s) would be most appropriate to control fluid accumulation in the abdominal cavity?
A. Monitoring intake and output
B. Providing a low-sodium diet
C. Increasing PO fluid intake
D. Weighing the client daily
A low-sodium diet is one means of controlling abdominal fluid collection. Sodium intake may be restricted to 500 mg to 1 g daily.
27. What is the nurse's best action for the client who has undergone a laparoscopic cholecystectomy and complains of "free air pain."
A. Ambulate the client.
B. Instruct the client to breathe deeply and cough.
C. Maintain the client on bedrest with his or her legs elevated.
D. Insert a rectal tube to facilitate the passage of flatus.
The client who has undergone a laparoscopic cholecystectomy may complain of free air pain because of the retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide.
28. Which client is most at risk for the development of gallstones?
A. 22-year-old woman who is 1 month postpartum
B. 65-year-old woman after a liquid protein diet
C. 70-year-old man with peptic ulcer disease
D. 33-year-old man with type 2 diabetes
Liquid protein diets increase susceptibility to gallstones by releasing cholesterol from tissues, which is then excreted as crystals in the bile.
29. A client had a transhepatic biliary catheter placed 3 days ago. Which clinical manifestation would indicate that the procedure was successful?
A. The client's sclera remains icteric.
B. The client's stools are brown in color.
C. The client's urine is a dark amber color.
D. The client's catheter has blood return on aspiration.
A transhepatic biliary catheter decompresses extrahepatic ducts to promote the flow of bile. When bile flows normally, it reaches the large intestine where bile is converted to urobilinogen, coloring the stools brown.
30. In the client with Crohn's disease experiencing severe diarrhea, what should the nurse monitor for as the priority assessment?
A. Cardiac dysrhythmias
B. Skin irritation
Although the client with severe diarrhea may experience skin irritation and anemia, the client is most at risk of cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have electrolyte levels monitored, and electrolyte replacement may be necessary.
A nurse is reviewing results of preoperative screening test and notes the patient's PT (prothrombin time) is very elevated. What should the nurse do next?
A. Nothing; an elevated PT is not going to affect the surgical outcome.
B. Document the data and notify the physician who will do the surgery
C. Review the patient's medications and note he is on coumadin, so it is ok to proceed.
D. Document the data and report it to the intraoperative nurse.
B. Document the data and notify the physician who will do the surgery
Which of the following interventions is of major importance during preoperative teaching?
A. Ensure the patient has adequate breakfast the morning of surgery
B. Encouraging the patient to identify and verbalize fears
C. Discussing the site and extent of the surgical incision
D. Telling the patient not to worry or be afraid of surgery
C. Discussing the site and extent of the surgical incision
A 40 year old female is having a right mastectomy. She is currently taking 1 baby Aspirin a day for prophylactic reasons and is allergic to latex; otherwise she is healthy. You observe her fidgeting with her admission papers and is expressing anxiety regarding the surgery.
In planning her care which intervention should be used
A) Avoid using medication from glass ampules.
B) Avoid using IV tubing that is made of polyvinyl chloride.
C) Make all OR personnel aware of latex allergy and check all package labels for latex
D) Place a rubber urinary catheter
C) Make all OR personnel aware of latex allergy and check all package labels for latex
Your patient is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified: