NURSING 3165 week 1 to 13- NC III- Questions & Answers

NURSING 3165 week 1 to 13- NC III- Questions & Answers Adequate nutrition is required for healing after treatment for recurrent aphthous ulcers (RAU). Which client response indicates that nursing teaching has been effective? A. “I've ordered a snack of milk and pretzels.” B. “I‘ll try to drink orange juice twice per day.” C. “I ordered my sandwich on a crusty roll.” D. “I'd like scrambled eggs and a banana for breakfast.” The nurse is caring for four clients. Which is at the highest risk for development of oral cancer? A. 32-year-old client with ankle fracture B. 41-year-old with human papilloma virus (HPV) infection C. 60-year-old who quit smoking 20 years ago D. 83-year-old who lives in a warm climate during the winter A client with a bleeding peptic ulcer develops sudden, severe upper abdominal pain, becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report immediately? A. Increased amylase levels. B. A rigid, board-like abdomen. C. Vomiting tar like feces. D. Bowel sounds increased in frequency and pitch. A client with peptic ulcer disease has a nasogastric tube. Suddenly he complains of severe abdominal pain and the nurse notes that his abdomen is rigid. What action should be implemented first? A. Administer the next scheduled dose of intravenous H2 blocker B. Assess the client’s vital signs. C. Irrigate the nasogastric tube with normal saline D. Administer a prescribed PRN antacid A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and melena. He complains of feeling weak and dizzy. He needs to urinate and move his bowels. The nurse should intervene by: A. Helping him to the bed side commode B. Offering him the bedpan and the urinal C. Transferring him to BR in a wheelchair D. Asking a male UAP to transfer him to BR for privacy The healthcare provider prescribes high-protein, high-fat, with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? A. It is quickly digested. B. It does not cause diarrhea. C. It does not dilate the stomach. D. It is slow to leave the stomach. A stressed client, who smokes 13 cigarettes/day, consumes fast-food, and is a strong drinker of coffee, is consulting to the healthcare facility for heartburn, specially after ingesting spicy food. The triage nurse should recommend: A. Avoid spicy food and increase consume of dairy B. Consume Decaf instead of regular coffee C. Schedule an appointment for a physical D. Use over the count omeprazole every day until relief of symptoms The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. gallbladder disease. b. overuse of laxatives. c. upper gastrointestinal bleeding. d. localized bleeding around the anus. In a paracentesis 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? A. Pedal pulses. B. Breath sounds. C. Gag reflex. D. Blood pressure. What finding is a priority in a patient with peptic ulcer disease (PUD)? A. Tarry stools 3 times during the day B. Dizziness when sitting in bed C. Epigastric pain 2 hours after meals D. Loss of 10 pounds of weight since the last month The nurse is teaching a client with advanced COPD who was prescribed theophylline. Which client statement indicates that additional teaching is required? a. I need to avoid caffeinated products b. I need to get my blood drug levels checked periodically c. I need to report anorexia and sleeplessness d. I take cimetidine for my heartburn A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client? a. Are you drinking plenty of water with the medication? b. Are you taking the medication after meals? c. Have you had a bone density test recently? d. Have you had your blood pressure taken regularly? The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? 1. Obtain informed consent from the client for the diagnostic procedure. 2. Discuss the need to increase oral fluid intake after the procedure. 3. Explain to the client that he or she will have to drink a white, chalky substance. 4. Tell the client not to eat or drink anything prior to the procedure. At 0830, the day shift nurse is preparing to administer medications to the client NPO for an endoscopy. Which medication should the nurse question administering? 1. Digoxin 0.125 mg PO every day. 2. Furosemide 40 mg PO bid. 3. Ranitidine 150 mg in 250 mL NS IV continuous infusion every 24 hours. 4. Vancomycin 850 mg IVPB every 24 hours. The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse? 1. The client’s hemoglobin/hematocrit is 11.4/32. 2. The client’s abdomen is soft to touch and non-tender. 3. The client’s vital signs are T 99, AP 114, RR 18, B/P 88/60. 4. The client’s nasogastric tube has coffee ground drainage. The client 2 days postoperative from a laparoscopic cholecystectomy tells the office nurse, “My right shoulder hurts so bad I can’t stand it.” Which statement is the nurse’s best response? 1. “This is a result of the carbon dioxide gas used in surgery.” 2. “Call 911 and go to the emergency department immediately.” 3. “Increase the pain medication the surgeon ordered.” 4. “You need to ambulate in the hall to walk off the gas pains.” The male client is 30 minutes post-procedure liver biopsy. Which action by the unlicensed assistive personnel (UAP) requires the nurse to intervene? 1. The UAP offered the client a urinal to void. 2. The UAP gave the client a glass of water. 3. The UAP turned the client on the left side. 4. The UAP took the client’s vital signs. After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Baked tilapia with brown rice, steamed broccoli, glass of orange juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Broiled chicken, mashed potatoes, cup of coffee with low-fat milk The emergency department nurse is assessing a client with a known inguinal hernia. Which assessment findings indicate that the hernia may have strangulated? Select all that apply. A. Fever B. Tachycardia C. Abdominal distention D. Nausea and vomiting E. Mild abdominal pain – (no because it is moderate to severe) The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan? 1. Restricting pain medication 2. Maintaining bedrest 3. Avoiding coughing 4. Irrigating the drain The community nurse is talking with a group of individuals about colorectal cancer (CRC) risk factors. Which community participant is at the highest risk for development of CRC? A. 43-year-old facto-vegetarian B. 30-year-old with Crohn's disease C. 69-year-old with no family history of cancer D. 46-year-old with grand parent who died of CRC Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to intermittent suction. What assessment is the best to determine proper placement of the NGT? A. Auscultate epigastric sounds while insufflating air through NGT. B. Percuss abdomen for stomach distention. C. Check residual and test the pH. (PH should be acid) D. Review the X-ray report done when NGT was inserted. The nurse administers a tube feeding to a patient with a baseline decreased mental status. Immediately after completing the tube feeding, it is MOST important for the nurse to place the client in which of the following positions? A. Supine with the lower extremities elevated on pillows. B. High Fowler’s or semi-Fowler’s position. C. Supine with the head of the bed elevated 45°. D. On the right side with the head of the bed elevated. The nurse is providing preoperative teaching to a patient who will undergo surgery to create a temporary colostomy. The patient asks the nurse about the difference between colostomies and ileostomies. The best response by the nurse is: A. “A colostomy occurs in the GI tract, and an ileostomy occurs in the urinary tract.” B. “A colostomy is temporary, and an ileostomy is always permanent.” C. “A colostomy is in the large intestine, and an ileostomy is in the small intestine.” D. “Dietary restrictions are required for the patient with an ileostomy but not a colostomy.” The nurse working in the emergency department realizes that which of the following patients with acute abdominal pain is most likely to have acute appendicitis? A. an 8-month-old female B. a 14-year-old male C. an 85-year-old woman D. a 70-year-old male Assessment of the patient’s gag response is a priority nursing intervention following which of the following procedures? A. colon biopsy B. small bowel biopsy C. barium enema D. colonoscopy The nurse intends to participate in a health screening clinic and is preparing teaching materials about colorectal cancer. The nurse should plan to include which of the following in a list of risk factors for colorectal cancer? A. age older than 30 years B. high fiber, low fat diet C. distant relative with colorectal cancer D. personal history of GI polyps The nurse understands that which of the following is a viral pathogen that frequently causes acute diarrhea in young children? A. giardia B. shigella C. rotavirus D. salmonella The nurse knows that acute diarrhea in children is often caused by which of the following? A. celiac disease B. antibiotic therapy C. vitamin deficiency D. protein malnutrition The nurse is caring for a 4-year-old child with celiac disease. The nurse expects to find which of the following manifestations of the disease while assessing the child and obtaining the health history from the patient’s mother? A. anorexia, abdominal distention, steatorrhea B. vomiting, diarrhea, abdominal pain, jaundice C. constipation, abdominal cramping, flatulence D. nausea, vomiting, diarrhea When caring for a child with probable appendicitis, the nurse must be alert to recognize which of the following signs of perforation? A. nausea and vomiting B. anorexia C. sudden relief from pain D. decreased abdominal distention The nurse is caring for a patient with an ileostomy. The nurse anticipates that a normal stoma should appear: A. pale pink. B. reddish pink. C. red with white edges. D. purple. The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority? 1. Altered nutrition. 2. Self-care deficit. 3. Impaired body image. 4. Fluid and electrolyte imbalance. The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority. 1. Cleanse the stomal site with mild soap and water. 2. Assess the stoma for a pink, moist appearance. 3. Attach the ostomy drainage bag to the abdomen. 4. Apply stoma adhesive paste to the skin around the stoma. 5. Monitor the drainage in the ostomy drainage bag. The nurse is transcribing the HCP’s orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first? 1. Obtain the client’s informed consent. 2. Administer 2 mg of IV morphine, every 4 hours, PRN. 3. Shave the lower right abdominal quadrant. 4. Administer the on-call IVPB antibiotic. The female client, diagnosed with diverticulosis, called the home healthcare agency and told the nurse, “I am having really bad pain in my left lower stomach and I think I have a fever.” Which action should the nurse take? 1. Recommend the client take an antacid and lie flat in the bed. 2. Instruct one of the nurses to visit the client immediately. 3. Tell the client to have someone drive them to the emergency room. 4. Ask the client what she has had to eat in the last 8 hours. What information in a client's history indicates the highest risk factor for Hepatitis C? A. Homosexuality. B. Intravenous drug abuse. C. Eating contaminated shellfish. D. Recent travel to an underdeveloped country. In a paracentesis 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? A. Pedal pulses. B. Breath sounds. C. Gag reflex. D. Blood pressure. Which data is the most important in the history of a patient with hepatitis C? A. Frequency and amount of alcohol consume B. Number of sexual partners and use of condoms C. Time since the first time a blood transfusion was received D. Presence of jaundice and dark urine The nurse understands that only one of the following clients needs total parenteral nutrition. Which client has a formal indication of TPN? a. Stroke and dysphagia; history of aspiration pneumonia b. Head trauma, bed sore, and comma c. Anorexia nervosa, BMI 16, chronic diarrhea d. Obstructive esophageal cancer, radiotherapy A nurse is caring for a client who is receiving TPN, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? a. Administer 10% dextrose in water IV until the next bag is available. b. Slow the infusion rate of the current bag until the solution is available. c. Monitor for hyperglycemia d. Monitor for hyperosmolar diuresis. A client who has begun receiving TPN with lipids develops sudden shaking chills, shortness of breath, and chest pain. The priority action by the nurse is to immediately a. call the physician. b. obtain a 12-lead ECG. c. stop the infusion. d. take a set of vitals. A young adult female client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority? A. Schedule the client for group therapy with other bulimic clients B. Assign an UAP to observe the patient all time, including trips to the bathroom C. Monitor the client carefully for binging activities D. Assess an report the client’s electrolyte status to the healthcare provider An adolescent girl with anorexia nervosa is being discharged from the mental health unit with a prescription for fluoxetine. Which instruction is most important for the nurse to provide the parents? A. Encourage activities that allow the daughter to exhibit control B. Check the daughter mouth to ensure that she swallows the Prozac C. Observe the daughter weigh herself at the same time every day D. Listen for the daughter’s expressions of wanting to harm herself The nurse observes that a male client on a clear liquid diet has a cup of coffee on his breakfast tray. What action should the nurse implement? a. Remind the client that no milk or creamer can be added to the coffee b. Remove the coffee f