NSG 4100 Nclex Questions Exam 1|
100% VERIFIED
A client admitted to the hospital with a suspected diagnosis of acute
pancreatitis is being assessed by the nurse. Which assessment findings would
be consistent with acute pancreatitis? Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
5.Abdominal guarding and tenderness 6.Left upper quadrant pain with
radiation to the back - ----ANS:4, 5, 6
Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's
sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue
from the peritoneal cavity. The client may demonstrate abdominal guarding
and may complain of tenderness with palpation. The pain associated with
acute pancreatitis is often sudden in onset and is located in the epigastric
region or left upper quadrant with radiation to the back. The other options are
incorrect.
A client being discharged home after renal transplantation has a risk for
infection related to immunosuppressive medication therapy. The nurse
determines that the client needs further teaching on measures to prevent and
control infection if the client states that it is necessary to take which action?
1.Take an oral temperature daily.
2.Use good hand-washing technique.
3.Take all scheduled medications exactly as prescribed.
4.Monitor urine character and output at least 1 day each week. - ----ANS:4
Rationale:The client receiving immunosuppressive medication therapy must
learn and use infection control methods for use at home. The client
self-monitors urine output and its characteristics on a daily basis. The client
must learn proper hand-washing technique and should take the temperature
daily to detect early infection. This is especially important because the client
also takes corticosteroids, which mask signs and symptoms of infection. All
medications should be taken exactly as prescribed.
,A client experiencing end-stage kidney disease has an arteriovenous (AV)
fistula placed surgically for hemodialysis. Which action is most appropriate for
the nurse to document in the plan for care of the AV fistula?
1.Palpate the bruit of the AV fistula weekly to assess for thrombosis.
2.Use the AV fistula site for blood draws to prevent increased pain of multiple
blood draws.
3.Take the blood pressure readings in the extremity with the AV fistula to get a
more accurate reading.
4.Teach the client to avoid carrying heavy objects that would compress the AV
fistula and cause thrombosis. - ----ANS:4
Rationale:An AV fistula is a vascular access system that is required for
hemodialysis. It is a device established for clients who need long-term
hemodialysis. It is created by connecting an artery to a vein inside the body to
create a vessel that can handle the amount of blood flow necessary for
effective dialysis. Bleeding, clotting, and infection are risks with all vascular
devices. It also is very important to avoid any activity that would promote the
status of blood or increase the risk for infection. Taking the blood pressure in
the affected arm, carrying heavy objects in the arm, and lying on the arm at
night could increase the risk for clotting in the fistula. To check circulation of
the fistula, the nurse should palpate or feel for the thrill or auscultate (listen
with a stethoscope) for the bruit. It is important to do this at least daily to
ascertain the patency of the fistula. To avoid infection, that extremity is never
used for peripheral intravenous access (placement of an intravenous line) or
for blood draws. Strict aseptic technique is used in accessing the fistula for
dialysis.
A client is admitted to the hospital with a diagnosis of acute pancreatitis.
Which would the nurse expect the client to report about the pain?
1.Eating helps to decrease the pain.
2.The pain usually increases after vomiting.
3.The pain is mostly around the umbilicus and comes and goes.
4.The pain increases when the client sits up and bends forward. - ----ANS:2
Rationale:Pain with acute pancreatitis usually increases after vomiting
because of an increase in intraductal pressure caused by retching, which
leads to further obstruction of the outflow of pancreatic secretions. The pain is
a steady and intense epigastric pain that radiates to the client's back and
flank. The pain may lessen when the client sits up or bends forward. Eating
exacerbates the pain by stimulating the secretion of enzymes.
, A client is admitted to the hospital with suspected bladder cancer. The nurse
assesses the client for which early signs and symptoms of the disease?
1.Proteinuria and dysuria
2.Hematuria and absence of pain
3.Painful urination and hematuria
4.Pyuria and palpable abdominal mass - ----ANS:2
Rationale:The most common earliest manifestation of bladder cancer is
hematuria that is not accompanied by pain. The hematuria is intermittent at
first. Later signs and symptoms include hematuria with dysuria and frequency
because of bladder irritation. Pyuria and proteinuria are not part of the clinical
picture. A mass usually is not palpable.
A client is being evaluated as a potential kidney donor for a family member.
The client asks the nurse why separate teams are evaluating donor and
recipient. What is the most appropriate response by the nurse?
1.Helps reduce the cost of the preoperative workup
2.Saves the client and the recipient valuable preoperative time
3.Avoids a conflict of interest between the team evaluating the recipient and
the team evaluating the donor
4.Provides for a sufficient number of persons reviewing the case so that no
information is overlooked - ----ANS:3
Rationale:Both the kidney donor and the kidney recipient need thorough
medical and psychological evaluation before transplant surgery. Separate
teams evaluate the donor and the recipient to avoid a conflict of interest in
providing care for the 2 clients. Options 1, 2, and 4 are not related to the
purpose of this approach.
A client is having difficulty coughing and deep-breathing because of pain after
a nephrectomy. Which action by the nurse is helpful in promoting optimal
respiratory function?
1.Administering pain medication just before ambulation
2.Administering pain medication when the client asks for it
3.Encouraging the use of the incentive spirometer every 8 hours
4.Assisting the client to splint the incision during respiratory exercise -
----ANS:4
100% VERIFIED
A client admitted to the hospital with a suspected diagnosis of acute
pancreatitis is being assessed by the nurse. Which assessment findings would
be consistent with acute pancreatitis? Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
5.Abdominal guarding and tenderness 6.Left upper quadrant pain with
radiation to the back - ----ANS:4, 5, 6
Rationale:Grayish-blue discoloration at the flank is known as Grey-Turner's
sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue
from the peritoneal cavity. The client may demonstrate abdominal guarding
and may complain of tenderness with palpation. The pain associated with
acute pancreatitis is often sudden in onset and is located in the epigastric
region or left upper quadrant with radiation to the back. The other options are
incorrect.
A client being discharged home after renal transplantation has a risk for
infection related to immunosuppressive medication therapy. The nurse
determines that the client needs further teaching on measures to prevent and
control infection if the client states that it is necessary to take which action?
1.Take an oral temperature daily.
2.Use good hand-washing technique.
3.Take all scheduled medications exactly as prescribed.
4.Monitor urine character and output at least 1 day each week. - ----ANS:4
Rationale:The client receiving immunosuppressive medication therapy must
learn and use infection control methods for use at home. The client
self-monitors urine output and its characteristics on a daily basis. The client
must learn proper hand-washing technique and should take the temperature
daily to detect early infection. This is especially important because the client
also takes corticosteroids, which mask signs and symptoms of infection. All
medications should be taken exactly as prescribed.
,A client experiencing end-stage kidney disease has an arteriovenous (AV)
fistula placed surgically for hemodialysis. Which action is most appropriate for
the nurse to document in the plan for care of the AV fistula?
1.Palpate the bruit of the AV fistula weekly to assess for thrombosis.
2.Use the AV fistula site for blood draws to prevent increased pain of multiple
blood draws.
3.Take the blood pressure readings in the extremity with the AV fistula to get a
more accurate reading.
4.Teach the client to avoid carrying heavy objects that would compress the AV
fistula and cause thrombosis. - ----ANS:4
Rationale:An AV fistula is a vascular access system that is required for
hemodialysis. It is a device established for clients who need long-term
hemodialysis. It is created by connecting an artery to a vein inside the body to
create a vessel that can handle the amount of blood flow necessary for
effective dialysis. Bleeding, clotting, and infection are risks with all vascular
devices. It also is very important to avoid any activity that would promote the
status of blood or increase the risk for infection. Taking the blood pressure in
the affected arm, carrying heavy objects in the arm, and lying on the arm at
night could increase the risk for clotting in the fistula. To check circulation of
the fistula, the nurse should palpate or feel for the thrill or auscultate (listen
with a stethoscope) for the bruit. It is important to do this at least daily to
ascertain the patency of the fistula. To avoid infection, that extremity is never
used for peripheral intravenous access (placement of an intravenous line) or
for blood draws. Strict aseptic technique is used in accessing the fistula for
dialysis.
A client is admitted to the hospital with a diagnosis of acute pancreatitis.
Which would the nurse expect the client to report about the pain?
1.Eating helps to decrease the pain.
2.The pain usually increases after vomiting.
3.The pain is mostly around the umbilicus and comes and goes.
4.The pain increases when the client sits up and bends forward. - ----ANS:2
Rationale:Pain with acute pancreatitis usually increases after vomiting
because of an increase in intraductal pressure caused by retching, which
leads to further obstruction of the outflow of pancreatic secretions. The pain is
a steady and intense epigastric pain that radiates to the client's back and
flank. The pain may lessen when the client sits up or bends forward. Eating
exacerbates the pain by stimulating the secretion of enzymes.
, A client is admitted to the hospital with suspected bladder cancer. The nurse
assesses the client for which early signs and symptoms of the disease?
1.Proteinuria and dysuria
2.Hematuria and absence of pain
3.Painful urination and hematuria
4.Pyuria and palpable abdominal mass - ----ANS:2
Rationale:The most common earliest manifestation of bladder cancer is
hematuria that is not accompanied by pain. The hematuria is intermittent at
first. Later signs and symptoms include hematuria with dysuria and frequency
because of bladder irritation. Pyuria and proteinuria are not part of the clinical
picture. A mass usually is not palpable.
A client is being evaluated as a potential kidney donor for a family member.
The client asks the nurse why separate teams are evaluating donor and
recipient. What is the most appropriate response by the nurse?
1.Helps reduce the cost of the preoperative workup
2.Saves the client and the recipient valuable preoperative time
3.Avoids a conflict of interest between the team evaluating the recipient and
the team evaluating the donor
4.Provides for a sufficient number of persons reviewing the case so that no
information is overlooked - ----ANS:3
Rationale:Both the kidney donor and the kidney recipient need thorough
medical and psychological evaluation before transplant surgery. Separate
teams evaluate the donor and the recipient to avoid a conflict of interest in
providing care for the 2 clients. Options 1, 2, and 4 are not related to the
purpose of this approach.
A client is having difficulty coughing and deep-breathing because of pain after
a nephrectomy. Which action by the nurse is helpful in promoting optimal
respiratory function?
1.Administering pain medication just before ambulation
2.Administering pain medication when the client asks for it
3.Encouraging the use of the incentive spirometer every 8 hours
4.Assisting the client to splint the incision during respiratory exercise -
----ANS:4
