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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.
Which of the following muscle actions results in voluntary urination?
A. Detrusor contraction, external sphincter contraction
B. Detrusor contraction, external sphincter relaxation
C. Detrusor relaxation, external sphincter contraction
D. Detrusor relaxation, external sphincter relaxation
Voiding becomes a voluntary act as a result of learned responses controlled by the cerebral cortex that cause contraction of the bladder detrusor muscle and simultaneous relaxation of the external urethral sphincter muscle.
3. Which change in renal or urinary functioning as a result of the normal aging process increases the older client's risk for infection?
A. Decreased glomerular filtration
B. Decreased filtrate reabsorption
C. Weakened sphincter muscles
D. Urinary retention
Incomplete bladder emptying for whatever reason increases the client's risk for urinary tract infections as a result of urine stasis providing an excellent culture medium that promotes the growth of microorganisms.
4. The client has an elevated blood urea nitrogen (BUN) level and an increased ratio of blood urea nitrogen to creatinine. What is the nurse's interpretation of these laboratory results?
A. The client probably has a urinary tract infection.
B. The client may be overhydrated.
C. The kidney may be hypoperfused.
D. The kidney may be damaged.
When dehydration or renal hypoperfusion exist, the BUN level rises more rapidly than the serum creatinine level, causing the ratio to be increased, even when no renal dysfunction is present.
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.
6. Which client is at greatest risk for development of a bacterial cystitis?
A. Older female client not taking estrogen replacement
B. Older male client with mild congestive heart failure
C. Middle-aged female client who has never been pregnant
D. Middle-aged male client who is taking cyclophosphamide for cancer therapy
Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at an increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina.
7. The client with severe bacterial cystitis is prescribed to take cefadroxil (Duricef) and phenazopyridine (Pyridium). What precaution or instruction should the nurse teach this client regarding the drug regimen?
A. "Do not take these drugs with food or milk."
B. "Stop these drugs if you think you are pregnant."
C. "Do not be alarmed by the discoloration of your urine."
D. "Drink a liter of cranberry juice each day to acidify your urine."
Phenazopyridine discolors urine most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this coloration. In addition, the urine can permanently stain clothing.
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.
9. The client has just been diagnosed with acute glomerular nephritis. Which question should the nurse ask this client in attempting to establish a cause?
A. "Are you sexually active?"
B. "Do you have pain or burning on urination?"
C. "Has anyone in your family had chronic kidney problems?"
D. "Have you had any type of infection within the last 2 weeks?"
The most common cause of acute glomerular nephritis is the presence of a systemic infection resulting in the formation of antigen-antibody complexes, which precipitate in the kidney tissues.
10. A client with renal failure continues to put out adequate urine. What form of acute renal failure is the client experiencing?
Some clients have a nonoliguric form of ARF, in which urine output remains near normal.
11. Which laboratory data would reflect early signs of renal tubular damage?
A. Decreased hemoglobin level
B. Increased serum sodium level
C. Increased serum calcium level
D. Decreased urine specific gravity
A decrease in urine specific gravity indicates a loss of urine-concentrating ability and is the earliest sign of renal tubular damage.
12. Which laboratory data alteration would the nurse expect to see manifested in a client with renal failure?
A. Hypokalemia and metabolic acidosis
B. Hyperkalemia and metabolic alkalosis
C. Hyperphosphatemia and hypocalcemia
D. Hypophosphatemia and hypercalcemia
Normally, a reciprocal relationship exists between calcium and phosphate, which is mediated by vitamin D. In renal failure, hyperphosphatemia and hypocalcemia result from a deficiency of activated vitamin D and decreased tubular excretion of phosphate. A decrease in the GFR (glomerular filtration rate) increases the plasma phosphate level, leading to hyperphosphatemia. As phosphate levels increase, phosphate binds to calcium, resulting in a decrease in the serum calcium levels. In the presence of less activated vitamin D, less calcium can be absorbed through the intestinal mucosa.
13. A client has been diagnosed with prerenal azotemia. What clinical manifestations can the nurse expect this client to exhibit?
A. Tachycardia, decreased urinary output, and hypotension
B. Bradycardia, decreased urinary output, and hypotension
C. Bradycardia, scanty urine output, and rising serum electrolyte levels
D. Tachycardia, large quantities of dilute urine, and normal serum electrolyte levels
The signs and symptoms of prerenal azotemia are tachycardia, decreased urinary output, hypotension, decreased CVP, and lethargy.
14. A client with acute renal failure has been prescribed a fluid restriction. The client asks how much fluid will be permitted each day. What is the nurse's best response?
A. "Each health care provider decides this individually, based on the amount of permanent damage to your kidneys."
B. "You will be permitted to drink an amount equal to the urine you excrete, plus 500 mL."
C. "The amount of fluid you can drink is dependent on how much protein you eat each day."
D. "You will be permitted to drink approximately 2 L of fluid each day."
Fluid intake is generally calculated to equal the amount of urine excreted plus 500 mL.
15. A nurse is caring for a client with acute renal failure who has had a femoral vein cannulation for hemodialysis access. For what complication of this procedure should the nurse remain alert?
C. Skin necrosis
D. Renal artery occlusion
The puncture site of the femoral vein is prone to hematoma formation, because positioning the extremity can cause movement of the cannula and subsequent bleeding at the site.
16. A client with suspected diminished renal functioning has come to the outpatient clinic for an appointment. What laboratory test would be most accurate in assessing this client's renal reserve?
A. 24-hour urine for creatinine clearance
B. Serum blood urea nitrogen level
C. Urine specific gravity
D. Serum sodium level
A 24-hour creatinine clearance test is necessary to detect changes in renal reserve. Creatinine clearance is a measure of the glomerular filtration rate. The ability of the glomeruli to act as a filter is decreased in renal disease.
17. What statement regarding renal insufficiency (stage II) is true?
A. Renal function is reduced, but there is no accumulation of metabolic wastes.
B. The healthier kidney compensates for the diseased kidney.
C. There is decreased responsiveness to diuretics.
D. The kidneys are unable to maintain homeostasis.
Stage II renal insufficiency is characterized by a decreased responsiveness to diuretics, the beginning accumulation of metabolic wastes, and decreasing GFR.
18. Which of the following manifestations would alert the nurse to a potentially dangerous complication in the client with chronic renal failure?
A. Nausea and vomiting
B. Soft, less audible heart sounds
C. Paresthesias of the hands and feet
D. Anemia accompanied by folic acid deficiencies
Soft, less audible heart sounds can signal the accumulation of fluid within the pericardial sac. Fluid accumulation results from the accumulation of uremic toxins causing inflammation of the pericardium and subsequent fluid buildup. Excessive amounts of fluid within the pericardial sac can result in cardiac tamponade, a medical-surgical emergency.
19. A nurse is providing dietary teaching to a client who is on hemodialysis. What instruction should the nurse provide to this client regarding protein intake?
A. "Your protein needs will not change, but you may take more fluids."
B. "You will need more protein now, because some protein is lost by dialysis."
C. "You will need less protein, because dialysis makes more amino acids available for use."
D. "Dialysis removes wastes from the body, so it does not matter how much protein you eat."
When renal disease has progressed and requires treatment with dialysis, increased protein is required in the diet to compensate for protein losses through dialysis.
20. A client with chronic renal failure says that he will be going to the dentist for a planned tooth extraction. What would be the nurse's best response?
A. "You may take any medication for pain that the dentist prescribes."
B. "You should receive prophylactic antibiotics before any dental procedure."
C. "You should rinse your mouth with an antiseptic solution once the tooth is removed."
D. "Have your dentist check all of your teeth, because kidney problems can cause tooth decay."
To prevent sepsis from oral cavity bacteria, the client should be given prophylactic antibiotics before any dental procedure.
21. A client has hypertension chronic renal insufficiency. Which of the following are the most effective drugs for controlling hypertension and preserving renal function?
A. Angiotension-converting enzyme inhibitors
B. Beta-adrenergic blockers
C. Calcium channel blockers
D. Alpha-adrenergic blockers
Research indicates that ACE inhibitors appear to be the most effective drugs to slow the progression of renal failure.
22. To reduce the occurrence of AV fistula thrombus, which action by the nurse would be most appropriate?
A. Instruct the client to restrict use of the arm with the fistula for 1 hour after dialysis.
B. Run IV fluids as ordered directly into the fistula after dialysis to prevent clotting.
C. Rotate needle insertion sites with each dialysis treatment.
D. Apply pressure to the puncture site.
Rotation of needle insertion sites with each treatment reduces the risk of thrombus formation at the puncture site.
23. The physician has prescribed lisinopril for a client with chronic renal failure and hypertension. Which intervention is appropriate for the administration of this drug?
A. Administer the drug at 9 AM every morning.
B. Administer the drug before hemodialysis.
C. Administer the drug during hemodialysis.
D. Administer the drug after hemodialysis.
Vasoactive drugs can cause hypotension during hemodialysis and should be held until after hemodialysis.
24. During hemodialysis, a client with chronic renal failure develops headache, nausea and vomiting and restlessness. Which initial action by the nurse would be most appropriate?
A. Notify the physician immediately.
B. Discontinue the hemodialysis immediately.
C. Order a blood urea nitrogen level STAT.
D. Administer an intravenous bolus of dextrose solution.
Headache, nausea, vomiting, and restlessness may be signs of dialysis disequilibrium syndrome. Rapid decreases in fluid and the BUN level can cause cerebral edema and increased ICP. Early recognition and treatment of this syndrome are essential in preventing a life-threatening situation.
25. A client who underwent kidney transplantation 7 days ago has developed oliguria, an increased temperature, lethargy, and elevations in the serum creatinine, BUN, and potassium levels. Which intervention should the nurse anticipate for this client?
A. Conservative management of symptoms, until dialysis is required as a result of chronic rejection
B. Increase in the doses of immunosuppressive drugs to combat acute rejection
C. Immediate removal of the transplanted kidney because of hyperacute rejection
D. Institution of peritoneal dialysis to aid the transplanted kidney
Oliguria, lethargy, elevated temperature, and increases in serum electrolyte levels 1 week to 2 years post-transplantation are hallmarks of acute rejection, which can be reversible with increased immunosuppressive therapy.
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.
3. The client has been taking an oral cortisol preparation for 2 years to manage an autoimmune disease. What effects does the nurse expect this therapy to have on this client's circulating levels of ACTH and aldosterone?
A. Increased ACTH, increased aldosterone
B. Increased ACTH, decreased aldosterone
C. Decreased ACTH, increased aldosterone
D. Decreased ACTH, decreased aldosterone
Taking exogenous cortisol increases the blood levels of cortisol, causing the negative feedback loops to be inhibited. The elevated cortisol levels will suppress hypothalamic secretion of corticotropin-releasing hormone (CRH). Low levels of CRH suppress the anterior pituitary production of adrenocorticotropic hormone (ACTH). Elevated blood levels of cortisol cause increased sodium retention and water reabsorption, inhibiting aldosterone synthesis.
4. What would be the expected clinical manifestation for a client who has excessive production of melanocyte-stimulating hormone?
A. Hypoglycemia and hyperkalemia
B. Irritability and insomnia
C. Increased urine output
D. Darkening of the skin
Melanocyte-stimulating hormone increases the size of melanocytes in the skin and increases the amount of pigment (melanin) they produce.
5. What is the major hormone secreted by the adrenal medulla?
The adrenal medulla secretes norepinephrine and epinephrine in proportions of 15% and 85%, respectively.
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.
8. The client has a deficiency of all the following pituitary hormones. Which one should be addressed first?
A. Growth hormone
B. Luteinizing hormone
C. Thyroid-stimulating hormone
D. Follicle-stimulating hormone
A deficiency of thyroid-stimulating hormone (TSH) is the most life-threatening deficiency of the hormones listed in this question. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones, whose functions are essential for life.
9. What safety measure should the nurse use for the adult client who has growth hormone deficiency?
A. Avoid intramuscular medications.
B. Place the client in protective isolation.
C. Use a lift sheet to reposition the client.
D. Assist the client to move slowly from a sitting to a standing position.
In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones.
10. The client just diagnosed with hyperpituitarism and acromegaly is scheduled for a hypophysectomy. Which statement made by the client indicates a need for clarification regarding this treatment?
A. "I will drink whenever I feel thirsty after surgery."
B. "I'm glad there will be no visible incision from this surgery."
C. "I hope I can go back to wearing size 8 shoes instead of size 12."
D. "I will wear slip-on shoes after surgery so I don't have to bend over."
Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible.
11. The "mustache" dressing of a client postoperative from a transsphenoidal hypophysectomy is saturated with clear, yellow-tinged fluid. What is the nurse's best first action?
A. Document the finding as the only action.
B. Obtain a specimen for culture.
C. Test the drainage for glucose.
D. Notify the physician.
Clear, yellow-tinged drainage could be serous or could contain cerebrospinal fluid (CSF). CSF contains a relatively high concentration of glucose; serous drainage does not.
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.
13. Which medication should the nurse be prepared to administer to a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion?
C. Dextrose 5% in water
D. Tricyclic antidepressants
Demeclocycline, a tetracycline derivative, antagonizes antidiuretic hormone and corrects the water and sodium imbalance resulting from SIADH.
14. Which clinical manifestation alerts the nurse to the possibility of Graves' disease as the cause of hyperthyroidism?
A. Weight loss
C. Menstrual irregularities
D. Increased heart rate and blood pressure
Graves' disease causes edema in the extraocular muscles and increased retro-orbital fat that pushes the globe of the eye forward. This exophthalmos is not a feature of hyperthyroidism from any other cause.
15. What is the priority nursing diagnosis for the client newly diagnosed with hyperthyroidism?
A. Decreased cardiac output related to tachycardia
B. Disturbed Body Image related to weight loss
C. Hyperthermia related to hypermetabolism
D. Fatigue related to energy depletion
The cardiac problems of hyperthyroidism include increased systolic blood pressure, a widened pulse pressure, tachycardia, and other dysrhythmias. The goals of nonsurgical management are to decrease the effect of thyroid hormone on cardiac function and to reduce thyroid hormone secretion.
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.
25. After receiving lactulose the day before, the client reports having seven loose stools in the past 12 hours. Based on this data, what laboratory findings would the nurse expect?
Because lactulose can cause the client to have several loose stools daily, the nurse should monitor serum electrolyte levels, particularly the serum potassium level for hypokalemia.
26. Which of the following clients is most at risk of developing hepatitis B?
A. 24-year-old college student who has had several sexual partners
B. 54-year-old woman who takes acetaminophen daily for headaches
C. 33-year-old business man who travels frequently
D. 72-year-old woman who has eaten raw shellfish
Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route.
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.
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