N433 Final clicker questions (solution)

N433 Final clicker questions (solution) The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? A. A client awaiting surgery for a hiatal hernia repair @ 11 AM. B. A client with suspected gastric cancer who is nothing by mouth (NPO) status for tests. C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain. D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw. C,B, D, A A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A. Ineffective coping related to fear of diagnosis of chronic illness B. Deficient knowledge related to unfamiliarity with significant signs and symptoms. C. Constipation related to decreased gastric motility. D. Imbalanced nutrition: Less than body requirements related to gastric bleeding. B. Peptic Ulcer disease-may be referred as gastric, duodenal or esophageal ulcer, depending on it's location. A peptic ulcer is an excavation (hollowed out area) that forms in in the mucosal wall. It is caused from an erosion of the mucous membrane. May be caused from H pylori. Black tarry stools are a warning of bleeding in peptic ulcer disease A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply A. Administering an antacid hourly until nausea subsides. B. Monitoring the client's vital signs. C. Notifying the physician of the client's symptoms. D. Initiating oxygen therapy E. Reassessing the client in an hour. B,C The nausea and dizziness may be indicative of a hemorrhage Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? A. Limit caffeine intake to two cups of coffee per day. B. Do not lie down for 2 hours after eating. C. Follow a low protein diet. D. Take medication with milk to decrease irritation. B CAFFEINATED BEVERAGES decease pressure in the lower esophageal sphincter and milk increases gastric secretion so these beverages should be avoided The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? A. Bland Foods. B. High protein foods. C. Any foods that are tolerated. D. Large amounts of milk. C A patient presents to the emergency department complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left sided heart failure. The patient is agitated and coughing up pink tinged, foamy sputum. What should the nurse recognize these signs and symptoms of? A) Right sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock Answer B: decreased perfusion to the brain - agitation You are assessing a patient suspected of having right-sided heart failure. What assessment finding may indicate right- sided heart failure? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea B: distended neck veins with left sided failure you will hear S3 (ken-tuck-y) ventricular gallop A patient with heart failure cannot take ACE inhibitors because of cough. What drugs can be used as an alternative to ACE inhibitors? A) Calcium channel blockers B) Loop diuretics C) Anti-hypertensives D) Angiotensin II receptor blockers Answer D: Angiotensin II receptor blockers You are caring for a patient with heart failure. You know the overall goals of management for this patient are what? (mark all that apply) A. Improve functional status B. Increase cardiac contractility C. Extend survival D. Decrease pulmonary venous pressure E. Relieve patient symptoms A, C, E A patient with left-sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide (Lasix), spironolactone (Aldactone), and enalapril (Vasotec). Which assessment should the nurse complete to best evaluate the patient's response to these drugs? A. Observe skin turgor B. Auscultate lung sounds C. Measure blood pressure D. Review intake and output Answer B: auscultate lung sounds - looking for a reduction in adventitious lung sounds-crackles The home care nurse visits a patient with chronic heart failure who is taking digoxin (Lanoxin) and furosemide (Lasix). The patient complains of nausea and vomiting. Which action is most appropriate for the nurse to take? A. Perform a dipstick urine test for protein. B. Notify the health care provider immediately. C. Have the patient eat foods high in potassium. D. Ask the patient to record a weight every morning. Answer B: Notify the health care provider immediately Administration of furosemide increases excretion of potassium and may cause hypokalemia. The risk for digitalis toxicity increases if potassium levels are below normal and digoxin is administered. Signs and symptoms of digitalis toxicity include anorexia, nausea and vomiting, visual disturbances (such as "yellow" vision), and dysrhythmias. As a nursing student you are assigned to the cardiac unit for clinical. You are reviewing your assessment data, which one of following would indicate an increase in a patient's risk for heart failure (HF)? A) Lasix 20 mg/day B) potassium level of 5.7 mEq/L C) African-American man D) Age of 65 years or older D: age of 65 years or older What are 7 warning signs of advanced cancer? CAUTION Change in bowel or bladder habits, a sore throat that does not heal, unusual bleeding or discharge from any orifice, thickening or a lump in the breast or lsquare, indigestion or difficulty with swallowing, obvious change in wart or mole, nagging cough or hoarseness After 3 weeks of radiation therapy, H.J. has lost 10 pounds and does not eat well because of mucositis. An appropriate nursing diagnosis for the patient is: a. Risk for infection related to poor nutrition b. Ineffective self-health management related to refusal to eat c. Imbalanced nutrition: less than body requirements related to oral inflammation and ulceration d. Ineffective health maintenance related to lack of knowledge of nutritional requirements during radiation therapy c. Imbalanced nutrition: less than body requirements related to oral inflammation and ulceration The most frequent symptom and complication of anemia is: A. Bleeding gums B. Ecchymosis C. Fatigue D. Jaundice C. Fatigue A patient is diagnosed with hypoproliferative anemia. The nurse is aware that this type of anemia is due to: A. Lack of production of RBC's B. Loss of RBC's C. Injury to the RBC's in circulation D. Abnormality of RBC's D: abnormality of RBCs When assessing a patient with anemia, the nurse notes that the patient has developed peripheral numbness and poor coordination. The patient's family states that the patient appears to be confused at times at home. Neurologic symptoms most often accompany which type of anemia? A. Iron deficiency anemia B. Folic acid deficiency C. Pernicious anemia D. Thalassemia major C: Pernicious anemia- impaired uptake of vitamin b12 due to the lack of intrinsic factor in the gastric mucosa- megablastomic anemia A nurse is evaluating the response of a client with anemia to therapy. Which laboratory test result would the nurse review that best reflects bone marrow production of red blood cells? A. Hematocrit B. Hemoglobin C. Serum ferritin D. Reticulocyte D: Reticulocyte The nurse notes that a patient, who is a vegetarian, has an abnormal number of megaloblasts. The nurse suspects a deficiency in? A. Iron B. Zinc C. Vitamin C D. Vitamin B12 D: Vitamin B12 Which of the following food choices made by a client with anemia best indicates that the nurse's instructions about food s high in iron has been successful? A. Oranges and grapefruits B. Spinach and broccoli C. Eggs, milk, and milk products D. liver and muscle meats D: liver and muscle meats A patient is admitted with sickle cell anemia. The nurse is aware that the care of this patient often requires: A. Chronic transfusions with RBC's B. Platelet transfusions C. Vitamin B 12 replacement D. Phlebotomy A: Chronic transfusions with RBCs What is agnosia? a. Failure to recognize familiar objects perceived by the senses. b. Inability to express oneself or to understand language. c. Inability to perform previously learned purposeful motor acts on a voluntary basis. d. Impaired ability to coordinate movement, often seen as a staggering gait or postural imbalance. a. Failure to recognize familiar objects perceived by the senses. A patient who experienced a thrombotic stroke and has residual hemiparesis of the right side is undergoing rehabilitation. The nurse caring for this client reinforces occupational therapy recommendations by placing items for personal hygiene: A. On the overbed table on the right side B. On the overbed table on the left side. C. One foot away from the bed on the right side D. One foot away from the bed on the left side B: on the overbed table on the left side What is a positive Kernig's sign? a. Extreme sensitivity to light. b. Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. c. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. d. When the patient's neck is flexed, flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity.