--> QUESTION NUMBER _ 801 _ about (MC)
QUESTION: "Which of the following signs and symptoms would be an early indication that the client's serum potassium level is below normal?"
CHOICES
( X ) a.) Diarrhea.
( X ) b.) Sticky mucous membranes.
( O ) c.) Muscle weakness in the legs.
( X ) d.) Tingling in the fingers.
RATIONALE: An early indication of hypokalemia is muscle weakness in the legs. Potassium is essential for proper neuromuscular impulse transmission. When neuromuscular impulse transmission is impaired, as in hypokalemia, leg muscles become weak and flabby. If hypokalemia progresses, respiratory muscles become involved and the client becomes apneic. Hypokalemia also causes electrocardiogram changes. Diarrhea is common in hyperkalemia. Sticky mucous membranes are common in hypernatremia. Tingling in the fingers and around the mouth occurs in hypocalcemia. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 802 _ about (MC)
QUESTION: "The correct procedure for auscultating the client's abdomen for bowel sounds would include:"
CHOICES
( X ) a.) Palpating the abdomen first to determine correct stethoscope placement.
( X ) b.) Encouraging the client to cough to stimulate movement of fluid and air through the abdomen.
( X ) c.) Placing the client on the left side to aid auscultation.
( O ) d.) Listening for 5 minutes in all four quadrants to confirm absence of bowel sounds.
RATIONALE: Because of the irregularity of bowel sounds, the nurse should listen for 5 minutes in each quadrant to confirm the absence of bowel sounds. Auscultation is performed before palpation because palpation may affect peristaltic activity. Coughing does not stimulate peristalsis. The client should be positioned supine to provide adequate access to the abdomen. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 803 _ about (MC)
QUESTION: "During the first few weeks after a cholecystectomy, the client should follow a diet that includes:"
CHOICES
( X ) a.) A decreased intake of fruits, vegetables, whole grains, and nuts, to minimize pressure within the small intestine.
( X ) b.) At least four servings daily of meat, cheese, and peanut butter to increase protein intake that aids incisional healing.
( O ) c.) A limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time.
( X ) d.) Ingestion of pancreatic enzymes with meals to replace the normal enzyme secretion that has been surgically altered.
RATIONALE: Bile flows almost continuously into the intestine for the first few weeks after gallbladder removal. Limiting the amount of fat in the intestine at any one time ensures that adequate bile will be available to facilitate digestion. There is no need to eliminate high-fiber foods, and doing so would tend to increase (rather than decrease) pressure within the large intestine (not the small intestine). Eating large amounts of meat, cheese, and peanut butter would be undesirable because these foods are often high in fat. Removing the gallbladder does not decrease pancreatic secretions. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 804 _ about (MC)
QUESTION: "A client has had a laparoscopic cholecystectomy. Which of the following statements indicates that the client understands the nurse's discharge instructions about activity restrictions?"
CHOICES
( X ) a.) "I will need to stay in bed the first 2 days I am home."
( X ) b.) "I will not be able to lift objects until 6 weeks after my surgery."
( O ) c.) "I can return to my normal activities within 7 days."
( X ) d.) "I should avoid sitting upright for 1 week after my surgery."
RATIONALE: Laparoscopic cholecystectomy is performed through a small incision at the umbilicus. Hospital stays postoperatively are minimal, and clients are encouraged to ambulate early. Clients typically resume all normal activities within 7 days of surgery. Clients are encouraged to ambulate and not stay in bed. Normal activities are usually resumed within 1 week of surgery. Clients are encouraged to ambulate the day of surgery. There is no need to avoid sitting upright. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 805 _ about (MC)
QUESTION: "The nurse determines that the client's nutritional status has been severely compromised through prolonged episodes of nausea and vomiting. Which of the following therapies would the nurse anticipate to be the most effective in correcting nutritional deficits before surgery?"
CHOICES
( X ) a.) High-protein between-meal nourishment four times a day.
( X ) b.) Continuous enteral feedings at 200 mL/hour.
( O ) c.) Total parenteral nutrition (TPN) for several days.
( X ) d.) Intravenous infusion of normal saline solution at 125 mL/hour.
RATIONALE: TPN bypasses the enteral route and provides total nutrition: protein, carbohydrates, fats, vitamins, minerals, and trace elements. The client is not able to tolerate oral feedings. Enteral feedings would enter the stomach and could increase any feelings of fullness, nausea, and vomiting that the client has had. Intravenous isotonic saline, which contains only water, sodium, and chloride, provides incomplete nutrition. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 806 _ about (MC)
QUESTION: "After a gastrectomy, the client will have a nasogastric tube in place for several days postoperatively to:"
CHOICES
( O ) a.) Prevent excessive pressure on suture lines.
( X ) b.) Prevent the development of ascites.
( X ) c.) Provide enteral feedings in the immediate postoperative period.
( X ) d.) Enable administration of antacids to promote healing of the anastomosis.
RATIONALE: Nasogastric suctioning is ordered to remove accumulated gas or fluid (secretions). Excessive fluid can cause pressure on suture lines, resulting in injury, rupture, or dislodgment. The gastrointestinal tract should remain empty (no food or fluids) until peristalsis returns and suture lines have healed adequately, at which time the nasogastric tube is removed. Ascitic fluid collects in the peritoneal space, not the stomach. Enteral feedings in the immediate postoperative period would be inappropriate. Antacids are not used to promote healing of suture lines. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 807 _ about (MC)
QUESTION: "From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for Ineffective Airway Clearance. To which of the following postoperative factors would this diagnosis be related?"
CHOICES
( O ) a.) Incisional pain.
( X ) b.) Progressive ambulation.
( X ) c.) Nausea.
( X ) d.) Maintenance of a semi-Fowler's position.
RATIONALE: Breathing and coughing cause pain in clients with high abdominal incisions. Chest excursion decreases, which decreases coughing and deep-breathing efforts. Shallow breathing leads to hypoventilation and atelectasis. Frequent ambulation helps decrease the likelihood of respiratory complications. The possibility of recurring nausea is not related to respiratory complications. Semi-Fowler's position facilitates drainage of the remaining stomach contents, thus decreasing the risk of regurgitation that could result in aspiration of gastric contents. The position also allows for greater chest wall expansion and diaphragm contraction. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 808 _ about (MC)
QUESTION: "After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaking anastomosis?"
CHOICES
( O ) a.) Pain, fever, and abdominal rigidity.
( X ) b.) Diarrhea with fat in the stool.
( X ) c.) Palpitations, pallor, and diaphoresis after eating.
( X ) d.) Feelings of fullness and nausea after eating.
RATIONALE: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. Feelings of fullness and nausea after eating are not present in peritonitis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 809 _ about (MC)
QUESTION: "A client is recovering from a gastric resection for peptic ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery?"
CHOICES
( O ) a.) Increases food intake and tolerance gradually.
( X ) b.) Experiences occasional episodes of nausea and vomiting.
( X ) c.) Drinks 2000 mL/day of water.
( X ) d.) Experiences a rapid weight gain within 1 week.
RATIONALE: Weight gain will be slow and gradual because less food can be eaten at one time due to the decreased stomach size. More food and fluid will be tolerated as edema at the suture line decreases and healing progresses. The remaining stomach may stretch over time to accommodate more food. Nausea and vomiting can interfere with nutritional intake. Water provides hydration, but not calories and nutrients. Rapid weight gain may be due to fluid retention and would not reflect adequate nutrition. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 810 _ about (MC)
QUESTION: "Which one of the following expected outcomes about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:"
CHOICES
( X ) a.) Regain any weight lost within 4 weeks of the surgical procedure.
( X ) b.) Eat three full meals a day without experiencing gastric complications.
( X ) c.) Learn to self-administer enteral feedings every 4 hours.
( O ) d.) Maintain adequate nutrition through oral or parenteral feedings.
RATIONALE: An appropriate expected outcome is for the client to maintain nutrition either through oral or total parenteral feedings. Oral and total parenteral nutrition may also be used concurrently. It is not realistic to expect the client to regain weight loss within 4 weeks of surgery. After surgery, it is recommended that the client eat six small meals a day rather than three full meals to decrease symptoms of dumping syndrome. Enteral feedings are not part of the expected outcome for gastric surgery. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 811 _ about (MC)
QUESTION: "Which of the following signs or symptoms would the nurse expect to see in a client with pancreatitis?"
CHOICES
( X ) a.) Hypertension.
( O ) b.) Left upper quadrant abdominal pain.
( X ) c.) Bradycardia.
( X ) d.) Decreased white blood cell count.
RATIONALE: The most common symptom of pancreatitis is intense abdominal pain in the mid-epigastric area or the left upper quadrant. The pain may radiate to the back. Hypotension, not hypertension, may occur as a result of pancreatic hemorrhage or toxemia. Tachycardia, not bradycardia, may occur as a result of pancreatic hemorrhage or toxemia. Elevated white blood cell count occurs as a result of the acute inflammatory process. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 812 _ about (MC)
QUESTION: "Pain control is an important nursing goal for the client with pancreatitis. Which of the following medications would the nurse plan to administer in this situation?"
CHOICES
( O ) a.) Meperidine hydrochloride (Demerol).
( X ) b.) Cimetidine (Tagamet).
( X ) c.) Morphine sulfate.
( X ) d.) Codeine sulfate.
RATIONALE: Meperidine hydrochloride, a strong narcotic analgesic, effectively reduces the pain of acute pancreatitis. Cimetidine, a histamine receptor antagonist, decreases gastric acidity. Morphine sulfate is contraindicated in pancreatitis because it may cause spasm of the pancreatic ducts and exacerbate pain. Codeine sulfate is contraindicated in pancreatitis because it can cause spasm of the pancreatic ducts and exacerbate pain. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 813 _ about (MC)
QUESTION: "The nurse notices muscle twitching in the client's hands and forearms. The nurse would report these symptoms immediately because clients with pancreatitis are at serious risk for:"
CHOICES
( X ) a.) Hypermagnesemia.
( X ) b.) Hypoglycemia.
( X ) c.) Hyperkalemia.
( O ) d.) Hypocalcemia.
RATIONALE: Hypocalcemia is a major potential complication of pancreatitis. Muscle twitching and irritability are primary symptoms of hypocalcemia. Calcium replacement must begin as soon as hypocalcemia is validated. Hypomagnesemia, not hypermagnesemia, may result from vomiting by clients with pancreatitis, especially if they are malnourished. Serum glucose typically is elevated. Hypokalemia, not hyperkalemia, may occur with loss of gastric juice through vomiting or nasogastric suction. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 814 _ about (MC)
QUESTION: "Which of the following techniques would the nurse use first to determine if a nasogastric tube is positioned in the stomach?"
CHOICES
( O ) a.) Aspirating with a syringe and observing for the return of gastric contents.
( X ) b.) Irrigating with normal saline and observing for the return of solution.
( X ) c.) Placing the tube's free end in water and observing for air bubbles.
( X ) d.) Instilling air and auscultating over the epigastric area for the presence of the tube.
RATIONALE: The initial way to determine if a nasogastric tube is in the stomach is to apply suction to the tube with a syringe and observe for the return of stomach contents. Then the pH of the aspirate can be measured. This is the method of choice. One would not irrigate until tube placement is confirmed. Irrigation is not associated with placement confirmation techniques. Observing for air bubbles when the free end of the tube is placed under water is an unacceptable, unsafe method of determining tube placement. Another method is to instill air into the tube with a syringe while auscultating over the epigastric area. Hearing the air enter the stomach helps ensure proper placement, but the method is not foolproof and is no longer considered an effective or preferred way to determine placement. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 815 _ about (MC)
QUESTION: "A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?"
CHOICES
( X ) a.) A low-protein, high-fiber diet distributed over four to five moderate-sized meals daily.
( O ) b.) A low-fat, bland diet distributed over five to six small meals daily.
( X ) c.) A high-calcium, soft diet distributed over three meals and an evening snack daily.
( X ) d.) A diabetic exchange diet distributed over three meals and two snacks daily.
RATIONALE: A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition. Dietary protein and fiber are not directly related to pancreatitis. Although calcium is important, the low-fat content is more significant. The hyperglycemia of acute pancreatitis is usually transient and does not require long-term dietary modification. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 816 _ about (MC)
QUESTION: "The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is:"
CHOICES
( O ) a.) Lying down.
( X ) b.) Physically active.
( X ) c.) Upset or angry.
( X ) d.) Sitting.
RATIONALE: Hiatal hernia produces symptoms of esophageal reflux as the sphincter slides up into the negative-pressure environment of the thorax. The symptoms typically occur when the client is in a recumbent position. Normal activity does not influence incidence of reflux. Emotions do not influence the incidence of reflux. Sitting upright helps prevent reflux. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 817 _ about (MC)
QUESTION: "The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?"
CHOICES
( X ) a.) "I can elevate the foot of the bed 4 to 6 inches."
( X ) b.) "I can sleep on my stomach with my head turned to the left."
( X ) c.) "I can sleep on my back without a pillow under my head."
( O ) d.) "I can elevate the head of the bed 4 to 6 inches."
RATIONALE: Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus. Elevating the foot of the bed does not affect clearance of esophageal acid. This position will not decrease reflux incidence. Sleeping flat without a pillow under the head does not enhance clearance. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 818 _ about (MC)
QUESTION: "A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?"
CHOICES
( X ) a.) Keep the client NPO for 2 days before surgery.
( O ) b.) Administer kanamycin (Kantrex) the night before surgery.
( X ) c.) Inform the client that chest tubes will be in place after surgery.
( X ) d.) Advise the client to limit activity.
RATIONALE: Antibiotics are administered preoperatively to reduce the bacterial count in the colon. The client will be placed on a low residue diet to help cleanse the bowel before surgery but typically is not placed on NPO status until 8 to 12 hours before surgery. Laxatives and enemas may also be administered. Chest tubes would not be expected postoperatively. There is no need to limit the client's activity before surgery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 819 _ about (MC)
QUESTION: "A client who is having an abdominal perineal resection with permanent colostomy asks, "Where will my colostomy be placed?" What would be the nurse's best response?"
CHOICES
( X ) a.) "The surgeon will decide that during surgery."
( X ) b.) "Do you have a preference on the placement of it?"
( X ) c.) "In the midline of the abdomen, near your umbilicus."
( O ) d.) "A permanent colostomy is usually located on the left side of the abdomen."
RATIONALE: Because the colon normally absorbs large quantities of water, placing the colostomy near the end of the colon will result in near-normal stool consistency. Optimal placement of an ostomy is usually determined by an enterostomal therapist before surgery. Client preference will not be the determining factor in ostomy placement. The enterostomal therapist will work closely with the client to select the optimal site. When possible, the preferred site for a permanent colostomy is in the lower portion of the descending colon; hence, placement is on the left side of the body. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 820 _ about (MC)
QUESTION: "A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:"
CHOICES
( X ) a.) Absence of nausea and vomiting.
( X ) b.) Passage of mucus from the rectum.
( O ) c.) Passage of flatus and feces from the colostomy.
( X ) d.) Absence of stomach drainage for 24 hours.
RATIONALE: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. Absence of stomach drainage is not a criterion for judging whether or not gastric suction should be continued. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 821 _ about (MC)
QUESTION: "Which of the following nursing actions would be most appropriate immediately after nasogastric tube removal?"
CHOICES
( O ) a.) Provide the client with mouth care.
( X ) b.) Auscultate for bowel sounds.
( X ) c.) Palpate for abdominal distention.
( X ) d.) Provide orange sherbet.
RATIONALE: Mouth care should be provided after nasogastric tube removal. Auscultating and palpating the abdomen should have been done before tube removal. After tube removal, the nurse will continue to assess the client's abdomen, but there is no need to do this immediately after removal. Giving the client something to eat or drink would not be appropriate until mouth care has been provided. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 822 _ about (MC)
QUESTION: "A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?"
CHOICES
( X ) a.) The client maintains a high-fiber diet.
( O ) b.) The client discusses concerns about his sexual functioning.
( X ) c.) The client maintains bed rest.
( X ) d.) The client limits fluid intake to 1000 ml/day.
RATIONALE: Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning. The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence. The client should be able to ambulate and sit out of bed for several hours at a time at this point. Fluid intake will be encouraged, not restricted. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 823 _ about (MC)
QUESTION: "The nurse irrigates a client's colostomy. If the client complains of abdominal cramping after receiving about 150 mL of solution during the colostomy irrigation, the nurse should temporarily:"
CHOICES
( O ) a.) Stop the flow of solution.
( X ) b.) Have the client sit up in bed.
( X ) c.) Insert the cone or tube further into the colon.
( X ) d.) Remove the irrigating cone or tube.
RATIONALE: Abdominal cramping that may occur during a colostomy irrigation results from colon stimulation by the irrigating solution. The best course of action is to temporarily stop the flow of solution until cramping subsides. Having the client sit up in bed will not help stop cramping. Advancing the cone or tube further will not help stop cramping. There is no need to remove the cone or tube because it will need to be reinserted when irrigation is continued. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 824 _ about (MC)
QUESTION: "Which of the following statements indicates that the client understands the home care of his colostomy?"
CHOICES
( X ) a.) "I can attach my colostomy pouch directly to my skin as long as it is not irritated."
( X ) b.) "I can anticipate some pain around my stoma when I clean it."
( X ) c.) "I can expect to see some blood in my stool on occasion."
( O ) d.) "I should be able to establish a regular pattern of elimination with my colostomy."
RATIONALE: Many colostomies, especially those located in the descending colon, can be regulated to evacuate on a schedule. All ostomy appliances should be applied using a peristomal skin barrier. There should be no pain associated with touching the stoma. After the immediate postoperative period, it is not normal for blood to be present in the stool. Bleeding should be reported to the client's health care provider. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 825 _ about (MC)
QUESTION: "A client with hepatitis A expresses concern that his friends may also acquire hepatitis. Which of the following is most commonly used for prophylactic treatment of people exposed to hepatitis A?"
CHOICES
( X ) a.) Penicillin.
( X ) b.) Sulfadiazine (Microsulfon).
( O ) c.) Immune serum globulin.
( X ) d.) Interferon.
RATIONALE: Immune serum globulin is administered prophylactically to people exposed to hepatitis A. Hepatitis A vaccine (Vaqta) may be used in conjunction with immune globulin for immediate and long-term protection. Antibiotics are not used to prevent or treat viral hepatitis. Antibiotics are not used to treat viral hepatitis. Interferons are a family of naturally occurring proteins that can be used to treat several forms of cancer. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 826 _ about (MC)
QUESTION: "When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:"
CHOICES
( X ) a.) Controlling abdominal pain.
( X ) b.) Maintaining a regular bowel elimination pattern.
( X ) c.) Preventing respiratory complications.
( O ) d.) Maintaining a positive, optimistic outlook.
RATIONALE: Convalescence after hepatitis A may take weeks or even months. Boredom and depression are common problems that the client should anticipate. Abdominal pain is not usually a symptom of hepatitis A. Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis. Problems preventing respiratory complications are unlikely. To support healing, activity is strictly limited but bed rest is not prescribed. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 828 _ about (MC)
QUESTION: "In caring for the client with hepatitis B, which of the following situations would most likely expose the nurse to the virus?"
CHOICES
( X ) a.) Contact with fecal material.
( O ) b.) A blood splash into the nurse's eyes.
( X ) c.) Touching the client's arm with ungloved hands while taking a blood pressure.
( X ) d.) Disposing of syringes and needles without recapping.
RATIONALE: Hepatitis B virus is spread through contact with blood, body fluids contaminated with blood, and such body fluids as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The risk of transmission of hepatitis B through feces is low. Touching the client without gloves is acceptable when there is no danger of contact with blood or body fluids. Recapping a used needle is a common source of needlestick injuries; needles should be properly disposed of uncapped. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 829 _ about (MC)
QUESTION: "The community health nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the community residents identify which of the following activities to be high risk for acquiring hepatitis B?"
CHOICES
( X ) a.) Frequent use of marijuana.
( X ) b.) Ingestion of large amounts of acetaminophen (Tylenol).
( O ) c.) Sharing needles for drug use.
( X ) d.) Ingestion of contaminated seafood.
RATIONALE: Sharing needles is associated with increased incidence of blood-borne diseases such as hepatitis. Hepatitis B is not spread through marijuana use. Acetaminophen taken in large amounts can cause severe hepatic necrosis but does not cause hepatitis B. Contaminated seafood is responsible for transmission of hepatitis A. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 830 _ about (MC)
QUESTION: "Which of the following outcomes would be appropriate for the client with hepatitis B?"
CHOICES
( O ) a.) The client will adhere to measures to prevent the spread of infection to others.
( X ) b.) The client will adhere to a low sodium, low protein diet.
( X ) c.) The client will verbalize the importance of using sedatives to provide adequate rest.
( X ) d.) The client will avoid social activities with friends after discharge from the hospital.
RATIONALE: The client should be taught how to prevent the spread of hepatitis B to others. The client should eat a well-balanced, nutritional diet. There is no need to restrict sodium or protein. Sedatives should be avoided because these are usually detoxified by the liver. It is not necessary for the client to isolate himself from family and friends. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 831 _ about (MC)
QUESTION: "Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids?"
CHOICES
( X ) a.) Decrease fiber in the diet.
( X ) b.) Take laxatives to promote bowel movements.
( O ) c.) Use warm sitz baths.
( X ) d.) Decrease physical activity.
RATIONALE: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 832 _ about (MC)
QUESTION: "A client has an elective hemorrhoidectomy. Immediately after a hemorrhoidectomy, the priority goal of nursing care for the client should be to:"
CHOICES
( X ) a.) Prevent venous stasis.
( X ) b.) Promote ambulation.
( O ) c.) Control pain.
( X ) d.) Prevent infection.
RATIONALE: Rectal surgery is accompanied by severe pain resulting from spasms of sphincters and muscles. Therefore, controlling pain is a priority goal of nursing care. Preventing venous stasis may be an appropriate goal, but controlling the severe pain that can accompany a hemorrhoidectomy is a priority in the immediate postoperative period. Promoting ambulation may be an appropriate goal, but controlling the severe pain that can accompany a hemorrhoidectomy is a priority in the immediate postoperative period. Preventing infection may be an appropriate goal, but controlling the severe pain that can accompany a hemorrhoidectomy is a priority in the immediate postoperative period. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 833 _ about (MC)
QUESTION: "The nurse has been teaching the client strategies to prevent a recurrence of hemorrhoids. One strategy is maintaining a high-fiber diet. The client's selection of which of the following breakfast menus would indicate that she understands the instructions?"
CHOICES
( X ) a.) Danish pastry, prune juice, coffee, and milk.
( O ) b.) Oatmeal, milk, grapefruit wedges, and bran muffin.
( X ) c.) Corn flakes, milk, white toast, and orange juice.
( X ) d.) Scrambled eggs, bacon, English muffin, and apple juice.
RATIONALE: Oatmeal, grapefruit wedges, and bran muffins are all high-fiber foods. Pastries are made from highly processed flour and do not contain much fiber. Prune juice is not high in fiber but has a laxative effect caused by dihydroxyphenyl isatin. Processed foods such as processed cereals and white bread are low in fiber. Protein foods contain little if any fiber. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 834 _ about (MC)
QUESTION: "A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?"
CHOICES
( X ) a.) Constipation.
( O ) b.) Bloody, diarrheal stools.
( X ) c.) Steatorrhea.
( X ) d.) Alternating periods of constipation and diarrhea.
RATIONALE: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 835 _ about (MC)
QUESTION: "The nurse should include which of the following interventions in the care of a client with ulcerative colitis?"
CHOICES
( X ) a.) Encouraging the use of stool softeners.
( O ) b.) Suggesting sitz baths as needed.
( X ) c.) Arrange for the client to have a private bathroom.
( X ) d.) Wearing a gown to provide direct care.
RATIONALE: Anal excoriation is inevitable with profuse diarrhea, and meticulous perianal hygiene is essential. Sitz baths are comforting and cleansing. It is not appropriate to administer stool softeners to a client with diarrhea. The profuse diarrhea and accompanying weakness may make it difficult for the client to access the bathroom, even if it is private. A gown is not indicated because no infectious agent is involved. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 836 _ about (MC)
QUESTION: "Which of the following statements indicates the client understands the lifestyle modifications he needs to make because of his ulcerative colitis?"
CHOICES
( X ) a.) "I may have coffee with my meals."
( X ) b.) "I am allowed to have alcohol as long as I only drink wine."
( O ) c.) "I will have to stop smoking."
( X ) d.) "I can eat popcorn for an evening snack."
RATIONALE: Tobacco is a gastrointestinal stimulant and should be avoided by clients with ulcerative colitis. Caffeine is a gastrointestinal stimulant and should be avoided by clients with ulcerative colitis. Alcohol is a gastrointestinal stimulant and should be avoided by clients with ulcerative colitis. High-fiber foods such as popcorn and nuts are not allowed. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 837 _ about (MC)
QUESTION: "Which of the following would be an appropriate expected outcome of nursing care for the client with ulcerative colitis? "
CHOICES
( O ) a.) The client maintains an ideal body weight.
( X ) b.) The client verbalizes the importance of restricting fluids.
( X ) c.) The client experiences decreased frequency of constipation.
( X ) d.) The client accepts that an ileostomy will be necessary.
RATIONALE: An appropriate expected outcome for a client with ulcerative colitis is maintaining an ideal body weight. It would not be appropriate to restrict fluid intake; the client should strive to remain well-hydrated. Ulcerative colitis produces episodic diarrhea, not constipation. It is not inevitable that the client with ulcerative colitis will need an ileostomy. The decision to perform surgery depends on the extent of the disease and the severity of the symptoms. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 838 _ about (MC)
QUESTION: "Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?"
CHOICES
( O ) a.) Profuse vomiting.
( X ) b.) Cramping abdominal pain.
( X ) c.) Abdominal distention.
( X ) d.) High-pitched bowel sounds above the obstruction.
RATIONALE: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. Abdominal discomfort is present in both small and large bowel obstructions. Abdominal distention occurs with both small and large bowel obstruction but is more common in large bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 839 _ about (MC)
QUESTION: "A client with an incomplete small bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum?"
CHOICES
( X ) a.) Maintain bed rest with bathroom privileges.
( O ) b.) Advance the tube 2 to 4 inches at specified times.
( X ) c.) Avoid frequent mouth care.
( X ) d.) Provide ice chips for the client to suck.
RATIONALE: Once the intestinal tube has passed into the duodenum, it is usually advanced as ordered 2 to 4 inches every 30 to 60 minutes. This, along with gravity and peristalsis, enables passage of the tube forward. The client is encouraged to walk, which also facilitates tube progression. A client with an intestinal tube needs frequent mouth care to stimulate saliva secretion, to maintain a healthy oral cavity, and to promote comfort regardless of where the tube is placed in the intestine. Ice chips are contraindicated because hypotonic fluid will draw extra fluid into an already distended bowel. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 840 _ about (MC)
QUESTION: "Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?"
CHOICES
( X ) a.) Injecting 10 mL of air into the tube to facilitate drainage.
( X ) b.) Applying a water-soluble lubricant to the client's nares.
( X ) c.) Coiling extra tubing on the client's bed.
( O ) d.) Irrigating the tube with 50 mL of normal saline solution.
RATIONALE: Intestinal tubes are not irrigated. This nursing measure is appropriate. This nursing measure is appropriate. This nursing measure is appropriate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 841 _ about (MC)
QUESTION: "The client underwent a bowel resection and was in the post-anesthesia recovery unit for 1 hour. She returns from the recovery room with an intravenous line, a nasogastric tube, and a Foley catheter in place. She complains of pain and asks for medication. What action should the nurse take first?"
CHOICES
( X ) a.) Administer the ordered narcotic.
( O ) b.) Establish the location and severity of pain.
( X ) c.) Determine if she was medicated for pain in the post-anesthesia recovery unit.
( X ) d.) Reposition her and give her a back rub.
RATIONALE: Thorough assessment of the client's pain is always the first step in treating pain. Clients may experience pain for a variety of reasons. You must first determine the probable cause of the pain before administering analgesics. This enables you to eliminate unexpected or complicating factors as the source of pain. Such factors might require immediate medical attention. Because the client spent an hour in the post-anesthesia recovery unit, the nurse would next determine if she had been medicated for pain in that unit. The pain is most likely incisional but could result from positioning, an excessively tight dressing, or anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 842 _ about (MC)
QUESTION: "During the evening shift on the day of the client's surgery, the nasogastric tube drains 500 mL of green-brown fluid. The nurse should:"
CHOICES
( X ) a.) Call the physician immediately.
( X ) b.) Increase the intravenous infusion rate.
( O ) c.) Record the amount of drainage on the client's chart.
( X ) d.) Irrigate the tube with normal saline solution.
RATIONALE: Because peristalsis has not been reestablished, this amount of gastric drainage would be expected. The green-brown color would also be expected. The appropriate nursing action is to chart the amount and color of output and continue monitoring the client. The drainage amount and color are to be expected. There is no need to notify the physician. The assessment data are normal findings and do not support the need for additional intravenous fluids. A patent nasogastric tube does not require irrigation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 843 _ about (MC)
QUESTION: "A male client with a history of cirrhosis related to chronic alcoholism has been experiencing a slow but steady decline in his general health. Recent blood work reveals hypokalemia, anemia, elevated liver function studies, prolonged prothrombin time, and elevated circulating estrogen level. Because of the elevated circulating estrogen level, the nurse would expect the client to exhibit which of the following signs?"
CHOICES
( O ) a.) Gynecomastia.
( X ) b.) Increased chest and body hair.
( X ) c.) Testicular hypertrophy.
( X ) d.) Increased libido.
RATIONALE: The normal liver acts to metabolize and inactivate hormones. Loss of this function increases the levels of circulating hormones. Excess estrogen in a male may cause gynecomastia. Palmar erythema and spider angiomas are also common results of hormone excess. The male client with an elevated estrogen level will experience loss of axillary, chest, and pubic hair. The male client with an elevated estrogen level will experience testicular atrophy and impotence. Elevated estrogen levels will not increase libido. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 844 _ about (MC)
QUESTION: "A client with cirrhosis should be encouraged to follow which diet?"
CHOICES
( X ) a.) High-calorie, restricted protein, low-sodium diet.
( X ) b.) Bland, low-protein, low-sodium diet.
( O ) c.) Well-balanced normal nutrients, low-sodium diet.
( X ) d.) High-protein, high-calorie, high-potassium diet.
RATIONALE: Cirrhosis is a slowly progressive disease. Inadequate nutrition is the primary ongoing problem. Clients are encouraged to eat normal, well-balanced diets and to restrict sodium to prevent fluid retention. Protein is not restricted until the liver actually fails, which is usually late in the disease. It is not necessary to restrict protein or eat a bland diet. A special diet such as this is not necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 845 _ about (MC)
QUESTION: "The client with cirrhosis is put on a sodium-restricted diet and a diuretic. The nurse would expect to administer a potassium-sparing diuretic. Which of the follow medications is a potassium-sparing diuretic?"
CHOICES
( X ) a.) Furosemide (Lasix).
( O ) b.) Spironolactone (Aldactone).
( X ) c.) Hydrochlorothiazide (HydroDIURIL).
( X ) d.) Ethacrynic acid (Edecrin).
RATIONALE: Hypokalemia is an ongoing problem for a client with cirrhosis. When a diuretic is needed, the ideal choice is a potassium-sparing agent. Spironolactone is the diuretic of choice for clients with cirrhosis because it facilitates sodium excretion while conserving potassium. Furosemideis is a thiazide diuretic that causes potassium loss. Hydrochlorothiazide is a thiazide diuretic that causes potassium loss. Ethacrynic acid is a thiazide diuretic which causes potassium loss. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 846 _ about (MC)
QUESTION: "A Sengstaken-Blakemore tube is successfully inserted. Which of the following nursing interventions would be appropriate?"
CHOICES
( O ) a.) Provide him with an emesis basin to expectorate secretions.
( X ) b.) Obtain an order for lozenges to counteract dry mouth.
( X ) c.) Moisten the internal nares with a petroleum-based lubricant.
( X ) d.) Obtain an order for lidocaine hydrochloride (Xylocaine Viscous) to decrease the discomfort of swallowing.
RATIONALE: The Sengstaken-Blakemore tube has a gastric and an esophageal balloon that are inflated to compress bleeding esophageal varices. An inflated esophageal balloon prevents swallowing. Therefore, the nurse should provide the client with tissues and encourage him to spit into the tissues or an emesis basin. If the client cannot manage his secretions, gentle oral suctioning is needed. Oral and nasal care is provided every 1 to 2 hours. Lozenges will increase saliva production, increasing the client's risk for aspiration. A water-soluble lubricant rather than a petroleum-based lubricant is applied to the external nares. The client with a Sengstaken-Blakemore tube cannot swallow. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 847 _ about (MC)
QUESTION: "A client is learning about caring for her ileostomy. Which of the following statements would indicate that she understands how to care for her ileostomy pouch?"
CHOICES
( O ) a.) "I'll empty my pouch when it's about one-third full."
( X ) b.) "I can take my pouch off at night."
( X ) c.) "I should change my pouch immediately after lunch."
( X ) d.) "I must apply a new pouch system every day."
RATIONALE: The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal. The client with an ileostomy must wear a pouch at all times to collect stool. The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time. A pouch can be worn for 3 to 7 days before being changed. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 848 _ about (MC)
QUESTION: "A client who has had an ileostomy is receiving diet instructions from the nurse. Which of the following instructions would be appropriate?"
CHOICES
( X ) a.) "Limit your fluids to 1000 mL/day."
( O ) b.) "Chew your food thoroughly."
( X ) c.) "There's no need to monitor your diet."
( X ) d.) "Six small meals a day will prevent abdominal distention."
RATIONALE: The client is instructed to chew food well to aid digestion and prevent obstruction. The client should maintain an adequate fluid intake. The client is usually placed on a regular diet but is encouraged to eat high-fiber, high-cellulose foods (eg, nuts, popcorn, corn, peas, tomatoes) with caution; these foods may swell in the intestine and cause an obstruction. Eating six small meals a day is not necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 849 _ about (MC)
QUESTION: "The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. The nurse should:"
CHOICES
( X ) a.) Increase the flow rate to infuse an additional 300 mL over the next hour.
( X ) b.) Maintain the flow rate at the current rate and document any discrepancy in the chart.
( O ) c.) Assess the infusion system, note the client's condition, and notify the physician.
( X ) d.) Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
RATIONALE: The nurse's most appropriate action is to assess the infusion system to determine the cause of the inaccurate flow rate and to note the client's response to the decreased infusion, especially signs of hypoglycemia. The physician should be notified of the infusion discrepancy. The flow should never be increased without a physician's order, nor should large volumes of TPN ever be infused over a short period of time. Too rapid administration of TPN can cause hyperglycemia, electrolyte imbalances, and dangerous fluid shifts. This action delays a definitive intervention and does not meet the client's needs. There is no clinical reason to remove the TPN and TPN should never be discontinued abruptly. If there is a need to temporarily discontinue the TPN, such as the client going to surgery or the next bag is unavailable, a 10% dextrose solution should be infused. This prevents a rebound hypoglycemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 850 _ about (MC)
QUESTION: "The nurse is changing the subclavian dressing over the catheter insertion site. Which one of the following actions would be appropriate for the nurse to incorporate into the dressing change?"
CHOICES
( X ) a.) Place the client in high-Fowler's position.
( O ) b.) Check for tubing kinks and leakage.
( X ) c.) Cleanse the area, starting 2 inches from the insertion site and moving inward.
( X ) d.) Remove old ointment from the insertion site with soap and warm water.
RATIONALE: To maintain proper infusion rates and prevent line contamination, it is important to inspect the site carefully for fluid leakage or kinks in the tubing under the dressing. The client should be placed in a low-Fowler's position for the dressing change to provide the nurse with adequate visualization of the site. When cleansing the insertion site, the nurse must always start at the site and work outward to maintain asepsis of the area and to avoid bringing contaminants close to the insertion site. It is inappropriate to remove old ointments with warm water and soap as these are not sterile. The area may be cleansed with acetone or alcohol swabs, as institution policy dictates. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 851 _ about (MC)
QUESTION: "The client with diverticulitis is treated as an outpatient with drug therapy. The nurse would anticipate drug therapy for diverticulitis to include:"
CHOICES
( X ) a.) Tranquilizers.
( X ) b.) Laxatives.
( O ) c.) Broad-spectrum antibiotics.
( X ) d.) Opioid analgesics.
RATIONALE: Clients with diverticulitis are usually treated with broad-spectrum antibiotics. Mild analgesics and anticholinergics may also be administered. Tranquilizers are not used for treatment of diverticulitis. Laxatives are not used because they increase intestinal motility. Clients with severe diverticulitis may be hospitalized for intravenous antibiotic therapy and may receive opioid analgesics such as morphine. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 852 _ about (MC)
QUESTION: "The client with diabetes mellitus says he eats a lot of pasta products such as macaroni and spaghetti. He asks if he can still eat them. Which of the following would be the nurse's best response?"
CHOICES
( X ) a.) "Because you're overweight, it's better to eliminate pasta from your diet."
( O ) b.) "Pasta can be a part of your diet. It's included in the bread and cereal exchange."
( X ) c.) "Pasta can be included in your diet but it shouldn't be served with sauces."
( X ) d.) "Eating pasta can cause hyperglycemia, so it's better to eliminate it."
RATIONALE: Special foods are not required for a client with diabetes, nor should certain foods (except refined sugars) be eliminated entirely from the diet. More important is that meal times, meal size, and meal composition are consistent. Pasta may be included in the diet as part of the bread and cereal exchange. Pasta can be included in the client's diet as long as it is counted in the exchanges. Pasta sauces may be used if they are taken into account in the total diet. A client's ethnic, religious, and cultural food preferences should be taken into account in meal planning. If these preferences are not considered, a client may eat foods without making proper adjustments or may reject the diet entirely. As long as the pasta is counted in the exchanges, it will not necessarily cause hyperglycemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 853 _ about (MC)
QUESTION: "When educating the client with adult-onset diabetes mellitus about activity level, the nurse bases the information on the knowledge that exercise affects the body's physiologic functioning relative to glucose usage in which of the following ways?"
CHOICES
( X ) a.) Exercise helps avoid hypoglycemia.
( X ) b.) Exercise stimulates insulin overproduction.
( X ) c.) Exercise decreases the renal threshold for glucose.
( O ) d.) Exercise increases the use of glucose by muscles.
RATIONALE: Exercise increases the use of blood glucose by the muscles, therefore reducing the body's insulin requirements. Exercise also tends to lower blood cholesterol and triglyceride levels. In addition, exercise is a healthful diversionary activity, helps control weight, and promotes circulation. Exercise can precipitate an episode of hypoglycemia if carbohydrates are not replaced. Exercise does not stimulate overproduction of insulin; it increases carbohydrate metabolism which, for the diabetic, can result in hypoglycemia. Exercise does not affect the renal threshold for glucose. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 854 _ about (MC)
QUESTION: "The nurse teaches the client with diabetes mellitus about the importance of maintaining stable blood glucose levels. What dietary constituent has been found to minimize the rise in blood glucose level after meals?"
CHOICES
( O ) a.) Dietary fiber.
( X ) b.) Dairy products.
( X ) c.) Vitamin-fortified foods.
( X ) d.) Organ meats.
RATIONALE: Foods high in dietary fiber are recommended by the American Diabetes Association because they tend to blunt the rise in blood glucose levels after meals. Dietary fiber is the part of food not broken down and absorbed during digestion. Most fibers come from plants; good sources include whole grains, legumes, vegetables, fruits, and nuts. Dairy products are poor sources of fiber. Foods fortified with vitamins are satisfactory if they also contain fiber. However, many foods fortified with vitamins contain either no dietary fiber (such as fortified milk) or little fiber (such as products fortified with vitamins but made with refined grains). Meats are poor sources of fiber. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 855 _ about (MC)
QUESTION: "The client is being taught to self-administer insulin. Learning goals most likely will be attained when they are established by the:"
CHOICES
( X ) a.) Nurse and client because both need to be responsible for teaching.
( X ) b.) Physician and client because the physician is the manager of care and the client is the main participant.
( X ) c.) Client because the client is best able to identify his or her own needs and how to meet those needs.
( O ) d.) Client, nurse, and physician so the client can participate in planning care with the nurse and physician.
RATIONALE: Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse and the physician. Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse and the physician. Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse and the physician. Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse and physician help the client arrive at his own perception of the need or reason to learn. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 856 _ about (MC)
QUESTION: "Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus? "
CHOICES
( X ) a.) Cataracts.
( O ) b.) Retinopathy.
( X ) c.) Astigmatism.
( X ) d.) Glaucoma.
RATIONALE: The major cause of blindness in people with diabetes mellitus is diabetic retinopathy. Corneal problems, cataracts, refractive changes, glaucoma, and extra-ocular muscle changes are also noted, but retinopathy is the most common problem. Cataracts increase in frequency in clients with diabetes, but retinopathy is the most common problem. Astigmatism has not been associated with diabetes mellitus. Clients with diabetes mellitus may be more prone to glaucoma, but retinopathy is the most common eye disorder. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 857 _ about (MC)
QUESTION: "What is the most important reason why it is vital to recognize and treat hypoglycemia promptly in the client with diabetes mellitus?"
CHOICES
( X ) a.) The client may become dehydrated quickly.
( O ) b.) Hypoglycemia can cause brain damage.
( X ) c.) Hypoglycemia necessitates increased insulin dosage.
( X ) d.) The client may become confused, increasing the risk of injury.
RATIONALE: Hypoglycemia is dangerous because it can lead to permanent brain damage. Changes in cerebral function occur because the brain uses glucose for metabolism and is unable to use alternative sources of energy as well as glucose. Prompt treatment of hypoglycemia is essential to prevent cellular damage. Dehydration is more frequently associated with hyperglycemia. Hypoglycemia is treated with glucose or glucagon, not insulin. Although injury due to confusion is a concern, it is not the most important reason for prompt treatment of hypoglycemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 858 _ about (MC)
QUESTION: "Which of the following factors would be most important in selecting the needle length to use for a subcutaneous injection of hydromorphone hydrochloride?"
CHOICES
( X ) a.) The diameter of the needle.
( O ) b.) The amount of adipose tissue at the administration site.
( X ) c.) The viscosity of the solution to be injected.
( X ) d.) The amount of medication to be administered.
RATIONALE: Needle length depends on the amount of adipose tissue at the site and the angle at which the injection is given. The diameter of the needle is influenced by the viscosity of the medication. The viscosity of the medication determines the needle diameter.
The amount of medication could influence the injection site, which, in turn, could affect the needle length; however, this is not the most important factor in this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 859 _ about (MC)
QUESTION: "The most common symptom associated with bladder cancer is:"
CHOICES
( O ) a.) Painless hematuria.
( X ) b.) Decreasing urine output.
( X ) c.) Burning on urination.
( X ) d.) Frequent infections.
RATIONALE: Painless hematuria is the most common symptom associated with bladder cancer. Bleeding from the lesions occurs fairly early in the disease process, but bladder cancer is basically asymptomatic in early stages. Bladder cancer is not related to renal function. Burning on urination is associated with urinary tract infections. Bladder cancer is not related to infection. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 860 _ about (MC)
QUESTION: "Which of the following postoperative complications would the nurse particularly anticipate in a client undergoing a pelvic surgical procedure such as an ileal conduit?"
CHOICES
( X ) a.) Bleeding.
( X ) b.) Infection.
( O ) c.) Thrombophlebitis.
( X ) d.) Atelectasis.
RATIONALE: Clients undergoing pelvic surgery are at increased risk for thrombophlebitis postoperatively. Extensive pelvic surgery, such as that involved in an ileal conduit, removes lymph nodes from the pelvis and results in circulatory congestion from edema and stasis. Clients undergoing extensive pelvic surgery are not necessarily at greater risk for bleeding than clients undergoing other types of surgeries. Clients undergoing extensive pelvic surgery are not necessarily at greater risk for infection than clients undergoing other types of surgeries. Clients undergoing extensive pelvic surgery are not necessarily at greater risk for atelectasis than clients undergoing other types of surgeries. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 861 _ about (MC)
QUESTION: "The nurse notes that the client's urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data?"
CHOICES
( X ) a.) The client is developing an infection of the urinary tract.
( X ) b.) The mucus is caused by elevated levels of glucose in the urine.
( O ) c.) These findings are normal for a client with an ileal conduit.
( X ) d.) There is irritation of the stoma.
RATIONALE: A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine. Mucus production is not a result of stomal irritation. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 862 _ about (MC)
QUESTION: "The nurse assesses the client's urinary stoma regularly for edema. Which of the following signs and symptoms might indicate excessive stomal edema?"
CHOICES
( X ) a.) Elevated temperature.
( X ) b.) Urine dribbling from the stoma.
( X ) c.) Complaints of discomfort around the stoma.
( O ) d.) Urine output below 30 mL/hour.
RATIONALE: Urine output below 30 mL/hour could indicate stomal edema which obstructs urine output. An elevated temperature should be noted, but it is not related to stomal edema. Urine dribbling from the stoma is normal. Discomfort around the stoma is common postoperatively after construction of an ileal conduit. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 863 _ about (MC)
QUESTION: "When starting the client's intravenous line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet?"
CHOICES
( X ) a.) When the skin has been cleansed.
( O ) b.) As soon as the needle is in the vein.
( X ) c.) As soon as the needle is positioned under the skin.
( X ) d.) When the needle has been secured with tape.
RATIONALE: When starting an intravenous infusion, the nurse should remove the tourniquet as soon as the needle is in the vein. Until then, the tourniquet keeps the vein distended so that it is more visible and easier to enter. The tourniquet is not removed until after the needle is inserted into the vein. The needle must enter the vein before the tourniquet can be removed. Leaving the tourniquet in place longer can impair circulation. The tourniquet is removed after successful insertion of the needle. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 864 _ about (MC)
QUESTION: "The correct procedure for collecting a urine specimen from an indwelling catheter is to:"
CHOICES
( X ) a.) Open the spigot on the collecting bag and allow urine to empty into the specimen container.
( X ) b.) Disconnect the drainage tube from the collecting bag and allow urine to flow from the tubing into the specimen container.
( X ) c.) Disconnect the drainage tube from the indwelling catheter and allow urine to flow from the tubing into the specimen container.
( O ) d.) Remove urine from the drainage tube with a sterile needle and syringe and place urine from the syringe into the specimen container.
RATIONALE: To obtain a urine specimen from a client with an indwelling Foley catheter attached to a closed urine drainage system, the nurse removes the specimen from the drainage tube using a sterile needle and syringe. This technique is not likely to predispose to a urinary tract infection because the drainage system is not opened to the air. Furthermore, this urine specimen would be fresh, unlike the urine collected in the drainage bag. A specimen from the drainage bag spigot is likely to be contaminated. To reduce the risk of infection, closed urinary systems should not be opened anytime. To reduce the risk of infection, closed urinary systems should not be opened anytime. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 865 _ about (MC)
QUESTION: "Of the following findings in the client's history, which would be the least likely to have predisposed her to renal calculi?"
CHOICES
( X ) a.) Having had several urinary tract infections in the past 2 years.
( X ) b.) Having taken large doses of vitamin C over the past several years.
( O ) c.) Drinking less than the recommended amount of milk.
( X ) d.) Having been on prolonged bed rest after an accident the previous year.
RATIONALE: A high, rather than low, milk intake predisposes to renal calculi formation, owing to the calcium in milk. Recurrent urinary tract infections are implicated in stone formation as certain bacteria promote stone formation. High daily doses of vitamins C are a risk factor because they can increase the citric acid level. Prolonged immobility is a risk factor for renal calculi because it causes calcium to be released into the blood stream. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 866 _ about (MC)
QUESTION: "A client undergoes extracorporeal shock wave lithotripsy (ESWL) to break up and remove renal calculi. Which of the following nursing measures is appropriate for the postoperative care of this client?"
CHOICES
( X ) a.) Maintain client on strict bed rest for 48 hours after the procedure.
( X ) b.) Instruct client to anticipate a decrease in urinary output.
( O ) c.) Instruct client to anticipate hematuria for about 24 hours after the procedure.
( X ) d.) Limit fluid intake to 1000 mL/day until all stone fragments have been passed.
RATIONALE: It is normal for hematuria to occur for up to 24 hours after ESWL. Hematuria that occurs for longer than 24 hours should be reported to the physician. ESWL is usually performed on an outpatient basis. Strict bed rest is not necessary after the procedure. Urinary output should not be decreased. Any difficulty urinating should be reported. Fluid intake should be increased to 2 to 3 liters per day, not decreased. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 867 _ about (MC)
QUESTION: "When caring for a client after a closed renal biopsy, the nurse would anticipate implementing which of the following nursing measures?"
CHOICES
( O ) a.) Maintaining the client on strict bed rest in a supine position for 6 hours.
( X ) b.) Inserting an indwelling catheter to monitor urine output.
( X ) c.) Applying a sandbag to the biopsy site to prevent bleeding.
( X ) d.) Administering intravenous narcotic medications to promote comfort.
RATIONALE: After a renal biopsy, the client is maintained on strict bed rest in a supine position for at least 6 hours to prevent bleeding. If no bleeding occurs, the client typically resumes general activity after 24 hours. Urine output is monitored, but an indwelling catheter is not typically inserted. A pressure dressing is applied over the site, but a sandbag is not necessary. Narcotics to control pain would not be anticipated; local discomfort at the biopsy site can be controlled with analgesics. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 868 _ about (MC)
QUESTION: "The most significant sign of acute renal failure is:"
CHOICES
( X ) a.) Elevated body temperature.
( X ) b.) Increased blood pressure.
( O ) c.) Decreased urine output.
( X ) d.) Increased urine specific gravity.
RATIONALE: A sudden change in urine output is typical of acute renal failure. Most commonly, the initial change is greatly decreased urine output. Later in the course of acute renal failure, the client may have marked diuresis (nonoliguric failure). A high body temperature is not typically associated with acute renal failure. Sudden blood pressure elevation is not typically associated with acute renal failure. Urine specific gravity usually is within a low-normal range because the kidneys have difficulty concentrating urine. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 869 _ about (MC)
QUESTION: "The client is on a fluid restriction of 500 mL/day plus replacement for urine output. Because the client's 24-hour urine output yesterday was 150 mL, the total fluid allotment for the next 24 hours is 650 mL. What change-of-shift information given by the nurse who worked 7:30 AM to 3:30 PM would indicate an understanding of how to distribute this fluid? The fluid allotment for this shift was:"
CHOICES
( X ) a.) Supplemented with gelatin and ice cream.
( X ) b.) Divided equally between breakfast and lunch.
( O ) c.) Given in small amounts throughout the shift.
( X ) d.) Given in its entirety in the morning to minimize the client's thirst.
RATIONALE: Thirst is a strong motivation to drink. Giving small amounts of fluid during an 8-hour shift helps minimize thirst. Gelatin and ice cream are inappropriate supplements because they become liquid at room temperature. Some fluids, but not the entire 8-hour allotment, should be given with meals. Giving everything at once would either make the client uncomfortable later in the day when fluids would have to be denied or would result in exceeding the restriction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 870 _ about (MC)
QUESTION: "A midstream urine specimen is ordered, and the nurse teaches the client how to collect the specimen correctly. Which of the following should the nurse include in the instructions?"
CHOICES
( O ) a.) Void directly into the sterile specimen container.
( X ) b.) Save the first voided urine.
( X ) c.) Stop collecting urine after the bladder is empty.
( X ) d.) Cleanse the urethral meatus after obtaining the specimen.
RATIONALE: To collect a midstream urine specimen, the client voids directly into a sterile specimen container. The initial urine voided flushes contaminants out of the urethra and is not saved. The client does not need to empty the bladder. After enough urine has been collected for the specimen, the remainder of the urine may be voided into the toilet, bedpan, or urinal. Cleansing of the urethral meatus is done before obtaining the specimen. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 871 _ about (MC)
QUESTION: "The physician tells the client that the urinary tract infection has likely been precipitated by sexual intercourse and that an antibiotic will be ordered. The client becomes upset and tearfully asks if this means she should abstain from intercourse for the rest of her honeymoon. What advice should the nurse offer her?"
CHOICES
( X ) a.) "Avoid intercourse until you've completed the antibiotic therapy then limit intercourse to once a week."
( X ) b.) "Limit intercourse to once a day in the early morning after your bladder has rested."
( O ) c.) "As long as you're comfortable, you can have intercourse as often as you wish; but be sure to urinate within 15 minutes after intercourse."
( X ) d.) "You and your husband can enjoy intercourse as often as you wish. Just make sure he wears a condom and uses a spermicide."
RATIONALE: Intercourse is not contraindicated in cystitis. Voiding immediately after intercourse flushes bacteria from the urethra, which should help prevent recurrence. There is no reason to wait until the antibiotic therapy is completed or to limit the frequency of intercourse. There is no reason to limit the frequency of intercourse. A condom and spermicide do not prevent cystitis because cystitis results from the introduction of the client's own organisms (usually Escherichia coli) into the urethra. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 872 _ about (MC)
QUESTION: "The client with a urinary tract infection is given a prescription for trimethoprim (Bactrim-DS) for her infection. Which of the following statements would indicate that she understands the principles of antibiotic therapy?"
CHOICES
( X ) a.) "I'll take the pills until I feel better and keep the rest for recurrences."
( O ) b.) "I'll take all the pills then return to my doctor."
( X ) c.) "I'll take the pills until the symptoms go away then reduce the dose to one pill a day."
( X ) d.) "I'll take all the pills then have the prescription renewed once."
RATIONALE: Antibiotics are prescribed for a definite treatment period, and all the pills should be taken. A urine culture should be done after the course of antibiotic therapy to ensure that the urine is bacteria free. Stopping the medication early may cause the infection to recur. Tapering the dosage is inappropriate with antibiotics because it lowers the therapeutic blood level. Refilling the prescription would be indicated only after urine culture indicates that the urine is not bacteria free and the physician prescribes another course of antibiotics. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 873 _ about (MC)
QUESTION: "Which of the following laboratory results would be unexpected in a client with chronic renal failure?"
CHOICES
( X ) a.) Serum potassium 6.0 mEq/L.
( X ) b.) Serum creatinine 9 mg/dL.
( O ) c.) BUN 15 mg/dL.
( X ) d.) Serum phosphate 5.2 mg/dL.
RATIONALE: The stated BUN level is within the normal range of 10 to 15 mg/dL so would be unexpected in renal failure. BUN level is usually significantly elevated in chronic renal failure, which causes retention of waste products and electrolytes. Elevated serum potassium (normal 3.5 to 5.0 mEq/L) commonly occurs in chronic renal failure. Elevated serum creatinine (normal, 0.8 to 7 mg/dL for males, 0.6 to 1 mg/dL for females) commonly occurs in chronic renal failure. Hyperphosphatemia (normal, 5 to 8 mg/dL) commonly occurs in chronic renal failure. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 874 _ about (MC)
QUESTION: "Which of the following laboratory tests is considered the most reliable indicator of renal function?"
CHOICES
( X ) a.) BUN.
( X ) b.) Urinalysis.
( X ) c.) Serum potassium.
( O ) d.) Serum creatinine.
RATIONALE: Serum creatinine is the most reliable indicator of renal function. BUN may be influenced by other factors unrelated to renal disease. Urinalysis may indicate the presence of a renal or urologic disorder. Potassium levels are affected by numerous factors. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 875 _ about (MC)
QUESTION: "A client with stress incontinence asks the nurse what kind of diet she should follow at home. The nurse should recommend that the client:"
CHOICES
( O ) a.) Avoid alcohol and caffeine.
( X ) b.) Decrease her fluid intake.
( X ) c.) Increase her intake of fruit juice.
( X ) d.) Avoid milk products.
RATIONALE: Clients with stress incontinence should be encouraged to avoid alcohol and caffeine products because both are bladder stimulants. The client should not decrease fluid intake. Increasing the intake of fruit juice may be desirable but will not affect the episodes of incontinence. There is no need to avoid milk products. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 876 _ about (MC)
QUESTION: "A client who has stress incontinence has been given a pamphlet that describes Kegel exercises. Which of the following statements indicates to the nurse that the client has understood the instructions contained in the pamphlet?"
CHOICES
( X ) a.) "I should perform these exercises every evening."
( X ) b.) "It will probably take a year before the exercises are effective."
( O ) c.) "I can do these exercises sitting up, lying down, or standing."
( X ) d.) "I need to tighten my abdominal muscles to do these exercises correctly."
RATIONALE: The client can perform the Kegel exercises anytime in any position listed. Pelvic muscles, not the abdominal muscles, should be contracted during these exercises. The client can learn to identify these muscles by urinating and stopping the flow. To be most effective, the exercises should be performed at least twice a day for a total of 10 minutes a day. If performed regularly, the client should begin to note changes after about 6 weeks. Pelvic muscles, not the abdominal muscles, should be contracted during these exercises. The client can learn to identify these muscles by urinating and stopping the flow.. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 877 _ about (MC)
QUESTION: "The physician prescribes 0.4 mg of atropine sulfate and 75 mg of meperidine hydrochloride to be given intramuscularly to a client 1 hour before surgery. The stock ampule of atropine contains 0.8 mg/mL, and the stock ampule of meperidine hydrochloride contains 100 mg/mL. The two drugs are compatible and can be drawn up in one syringe. What is the combined volume of medication in the syringe?"
CHOICES
( X ) a.) 0.75 mL.
( O ) b.) 1.25 mL.
( X ) c.) 1.50 mL.
( X ) d.) 1.75 mL.
RATIONALE: The correct amount to administer is determined by using ratios, as follows: 0.8 mg/1 mL = 0.4 mg/x mL 0.8/x = 0.4 x = 0.5 mL of atropine sulfate 100 mg/1 mL = 75 mg/x mL 100/x = 75 x = 0.75 mL of meperidine hydrochloride 0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total The correct amount to administer is determined by using ratios, as follows: 0.8 mg/1 mL = 0.4 mg/x mL 0.8/x = 0.4 x = 0.5 mL of atropine sulfate 100 mg/1 mL = 75 mg/x mL 100/x = 75 x = 0.75 mL of meperidine hydrochloride 0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total The correct amount to administer is determined by using ratios, as follows: 0.8 mg/1 mL = 0.4 mg/x mL 0.8/x = 0.4 x = 0.5 mL of atropine sulfate 100 mg/1 mL = 75 mg/x mL 100/x = 75 x = 0.75 mL of meperidine hydrochloride 0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total The correct amount to administer is determined by using ratios, as follows: 0.8 mg/1 mL = 0.4 mg/x mL 0.8/x = 0.4 x = 0.5 mL of atropine sulfate 100 mg/1 mL = 75 mg/x mL 100/x = 75 x = 0.75 mL of meperidine hydrochloride 0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 878 _ about (MC)
QUESTION: "A nurse notes that a client is an Orthodox Jew. Because of her religious beliefs, the client refuses to eat hospital food. Hospital policy discourages food from outside the hospital. What step should the nurse take first in this situation?"
CHOICES
( X ) a.) Teach the client that it is important for her to eat what she is served.
( O ) b.) Discuss the situation and possible courses of action with the dietitian and the client.
( X ) c.) Encourage the client's family to bring food for the client because of the special circumstances.
( X ) d.) Explain to the client that if she does not eat, the physician will have to order intravenous therapy.
RATIONALE: The best course of action when a client refuses to eat food that is contrary to her religious beliefs is to discuss the situation with the client and the dietitian. Health team members may need to confer about this client's needs. Telling the client that it is important for her to eat what is served is unlikely to help because she has already refused the food and this approach does not address her concerns. Encouraging her family to bring suitable food to the hospital for her may be acceptable. However, the family should not bear sole responsibility for meeting the client's nutritional needs. Health care team members need to seek ways the hospital can address the client's concerns. Threatening a client by saying that if she does not eat, intravenous therapy will be necessary is not supportive and is unlikely to gain her cooperation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 879 _ about (MC)
QUESTION: "Eight hours after catheterization, the postoperative abdominal hysterectomy client has not voided and says to the nurse, "I don't think I can urinate." The appropriate nursing action is to:"
CHOICES
( X ) a.) Call and inform the surgeon of the client's status.
( X ) b.) Administer additional pain medication.
( X ) c.) Increase the client's fluid intake.
( O ) d.) Assess the client's bladder.
RATIONALE: The nurse should suspect that a client has urinary retention when she is unable to void in an 8-hour period. Before calling the physician for an order to catheterize the client, the nurse should assess the client's bladder for distention. The nurse would need to gather data about the client's ability to void before calling the doctor. Pain medication is not indicated for inability to void. Increasing fluid intake is not indicated at this time in this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 880 _ about (MC)
QUESTION: "The nursing care plan for a client after gynecologic surgery includes nursing orders intended to help reduce the risk of thrombophlebitis. An order that would be contraindicated would be to:"
CHOICES
( X ) a.) Ambulate the client.
( O ) b.) Massage the client's legs.
( X ) c.) Have the client wear elasticized stockings.
( X ) d.) Have the client perform range-of-motion exercises in bed.
RATIONALE: Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems. Ambulation helps reduce the risk of thrombophlebitis. Elasticized stockings help reduce the risk of thrombophlebitis. Having the client move her legs in bed has been found to help reduce the incidence of postoperative thrombophlebitis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 881 _ about (MC)
QUESTION: "The client experiences a wound evisceration on day 2 after the abdominal hysterectomy. The immediate action by the nurse should be to:"
CHOICES
( X ) a.) Replace the abdominal contents into the wound carefully while wearing gloves.
( X ) b.) Apply a loose-fitting sterile abdominal binder over the wound.
( X ) c.) Approximate the wound edges by applying strips of adhesive over the wound.
( O ) d.) Cover the exposed tissues with sterile dressings moistened with normal saline solution.
RATIONALE: If the wound opens and tissues are exposed (wound evisceration), the nurse should cover the exposed tissues with sterile dressings moistened with sterile normal saline solutions. The nurse should also cover an eviscerated wound with sterile dressings moistened with sterile normal saline solution. The physician should be notified immediately when a wound dehisces or eviscerates. The abdominal contents should not be handled because of the potential for infection and strangulation of the intestines. Compressing the abdominal contents with a binder is contraindicated because it could obstruct blood flow to the tissues. Trying to approximate the wound edges with adhesive strips is contraindicated because it could further contaminate the wound and apply pressure to the abdominal contents. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 882 _ about (MC)
QUESTION: "Risk factors for the development of breast cancer include:"
CHOICES
( X ) a.) Early menopause (before age 40).
( O ) b.) Early onset of menstruation.
( X ) c.) Having had more than two children.
( X ) d.) Breast-feeding.
RATIONALE: A family history of breast cancer, early onset of menstruation, delayed onset of menopause, and childlessness all appear to increase a woman's risk of breast cancer. A woman's lifetime exposure to estrogen is implicated in breast cancer development. Therefore, early menopause, which decreases exposure, is not a risk factor for breast cancer. An increased risk of breast cancer is associated with not bearing children or delaying childbearing until late in life. Because menstruation is delayed until breast-feeding ceases, which limits a woman's exposure to estrogen, breast-feeding may reduce, not increase, risk. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 883 _ about (MC)
QUESTION: "Which of the following positions is the one of choice for palpating tissues during breast self-examination?"
CHOICES
( X ) a.) Sitting in a chair with a pillow under both shoulders to elevate the chest.
( X ) b.) Standing facing a mirror.
( X ) c.) Flat on the back with a pillow under the head and arms raised over the head.
( O ) d.) Flat on the back with a pillow under the shoulder of the side being examined.
RATIONALE: For a breast self-examination, placing a pillow or towel under the shoulder of the side being examined elevates the chest wall while the woman lies flat on her back. This positioning allows for better breast tissue distribution over the chest wall and the most thorough examination of tissues by palpation. Sitting is not the desired position for palpating the breasts. A standing position, facing a mirror, is used to inspect the breasts for changes in size and shape, skin dimpling, and nipple changes, but not for palpation. This is not a recommended position as it cannot expose the tissue better than raising only one arm with a pillow under the shoulder. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 884 _ about (MC)
QUESTION: "The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to:"
CHOICES
( X ) a.) Increase her activity level.
( X ) b.) Wear tight supporting garments.
( O ) c.) Avoid caffeine.
( X ) d.) Obtain estrogen therapy from her physician.
RATIONALE: Avoiding caffeine is reported to alleviate discomfort associated with fibrocystic breast disease for many women, but the rationale is not clearly understood. Activity level is not associated with fibrocystic breast disease. Wearing tighter garments could increase discomfort. A nurse should not recommend estrogen therapy as an intervention for discomfort from fibrocystic breast disease. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 885 _ about (MC)
QUESTION: "The client is advised by the physician to have mammography screening annually. Measures to improve adherence with mammography screening include:"
CHOICES
( O ) a.) Making sure that the individual barriers to screening are minimized.
( X ) b.) Emphasizing that mammography screening can prevent breast cancer.
( X ) c.) Emphasizing that mammography screening is a low-cost approach to cancer prevention.
( X ) d.) Informing the client that she is at high risk for breast cancer and needs to follow the physician's recommendation.
RATIONALE: Reducing barriers to mammography is the best way to improve adherence with screening. Mammography can detect breast cancer in the early stages but cannot prevent it. Mammography is not a low-cost approach for all clients. In fact, it may cost the client a significant amount of money. The client is not at high risk for developing breast cancer at this point. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 886 _ about (MC)
QUESTION: "Which of the following observations should the postanesthesia care unit (PACU) nurse plan to make first when the client who has had a modified radical mastectomy returns from the operating room?"
CHOICES
( X ) a.) Obtaining and recording vital signs.
( X ) b.) Observing that drainage tubes are patent and functioning.
( O ) c.) Ensuring that the client's airway is free of obstruction.
( X ) d.) Checking the client's dressings for drainage.
RATIONALE: The highest priority when a nurse receives a client from the operating room is to assess airway patency. If the airway is not clear, immediate steps should be taken so that the client is able to breathe. Vital signs can be assessed after airway patency is assured. Assessing the patency and functioning of drainage tube can be done after the airway is assessed and vital signs are taken. The dressing can be assessed once airway patency has been determined. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 887 _ about (MC)
QUESTION: "On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, "I look horrible! Will it ever look better?" Which of the following responses by the nurse would be most appropriate?"
CHOICES
( X ) a.) "After it heals and you're dressed, you won't even know you had surgery."
( X ) b.) "Don't worry. You know the tumor is gone, and the area will heal very soon."
( X ) c.) "Would you like to meet Ms. Paul? She looks just great and she had a mastectomy, too."
( O ) d.) "You're shocked by the sudden change in your appearance as a result of this surgery, aren't you?"
RATIONALE: When a client appears shocked by her appearance after surgery, such as after having a mastectomy, the nurse should help her express her feelings and offer the supportive care that she needs at this time. Telling the client that her disfigurement will not show when she is dressed dismisses her concerns and blocks expression of her feelings. Telling the client not to worry avoids the issues. Having the client meet someone who has had breast surgery is often helpful but is better done later, when the client is convalescing and accustomed to the appearance of the operative site. The client needs support now when the dressings are removed, not later. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 888 _ about (MC)
QUESTION: "In providing discharge teaching for the client after a modified radical mastectomy, the nurse should instruct the client that she might need to modify or avoid which of the following activities?"
CHOICES
( X ) a.) Shampooing her dog.
( X ) b.) Caring for her tropical fish.
( O ) c.) Working in her rose garden.
( X ) d.) Taking a late-evening swim.
RATIONALE: After a mastectomy, every effort should be made to avoid cuts, bruises, and burns on the affected arm because normal circulation has been impaired. Working in a rose or cactus garden is a risk because of the danger of skin pricks. The client should be advised to wear protective clothing to prevent cuts, bruises, and burns. As long as it doesn't increase the risk of injury, caring for the dog is not contraindicated. Maintaining the fish is not contraindicated. Swimming is not contraindicated for the postmastectomy client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 889 _ about (MC)
QUESTION: "The client with benign prostatic hypertrophy is prepared for admission to the hospital. Which of the following reports by the emergency room nurse would be most helpful to the nurse responsible for admitting the client?"
CHOICES
( X ) a.) "A urine specimen was obtained from the client and sent to the laboratory for analysis."
( O ) b.) "The client was catheterized, and 1100 mL of urine was obtained. The urine appeared cloudy, and a specimen was sent to the laboratory."
( X ) c.) "The client is very cooperative. He is comfortable now that his bladder has been emptied. He had no ill effects from catheterization."
( X ) d.) "The client was in the emergency room for 3 hours because of bladder distention. He is fine now but is being admitted as a possible candidate for surgery."
RATIONALE: A report about the client's condition should be as clear, pertinent, and concise as possible. It should be free of subjective information that could be interpreted differently by different caregivers. This answer does not indicate how much urine had been drained from the client's bladder and how the urine appeared. This report is subjective and provides only limited client data. This report does not mention the treatment provided. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 890 _ about (MC)
QUESTION: "The client has a continuous bladder irrigation after a transurethral resection. A major goal related to the irrigation is to:"
CHOICES
( O ) a.) Maintain catheter patency.
( X ) b.) Reduce incisional bleeding.
( X ) c.) Recognize signs of prostate cancer.
( X ) d.) Perform activities of daily living.
RATIONALE: Maintaining catheter patency during the immediate postoperative period after a transurethral resection is a priority because postoperative bleeding can occlude the catheter. Catheter occlusion can lead to urinary retention, pain, bladder spasm, and the need to replace the catheter. Incisional bleeding is not expected unless a complication occurs. The client in the immediate postoperative period is not ready for teaching. Performing activities of daily living, such as bathing, is not a priority immediately after surgery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 891 _ about (MC)
QUESTION: "Correct preparation of the client for a Papanicolaou (Pap) smear would include which of the following measures?"
CHOICES
( X ) a.) The test should be scheduled while the client is menstruating.
( X ) b.) The client should not bathe on the morning before the examination.
( O ) c.) The woman should not douche on the morning before the examination.
( X ) d.) The woman should take a laxative the night before the examination.
RATIONALE: Douching within 24 to 48 hours before a Pap smear may wash away cells and secretions needed for accurate test results. The test should be scheduled for a time when the client is not menstruating. The client may bathe as desired. No bowel preparation is needed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 892 _ about (MC)
QUESTION: "After examination and diagnostic testing, the client is diagnosed with cancer of the cervix in situ. A conization is scheduled. Which of the following nursing interventions would take priority during the first 24 postoperative hours?"
CHOICES
( X ) a.) Monitoring vital signs hourly.
( X ) b.) Maintaining strict bed rest.
( O ) c.) Monitoring vaginal bleeding.
( X ) d.) Maintaining electrolyte balance.
RATIONALE: Uncontrolled vaginal bleeding is the priority concern during the first 24 hours after conization of the cervix. This is best monitored by keeping an accurate pad count which assesses the extent of bleeding. Hourly vital signs are unnecessary unless complications develop. Strict bed rest is unnecessary unless complications develop. Electrolyte imbalance is not anticipated with this procedure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 893 _ about (MC)
QUESTION: "The client's cancer recurs, and internal radiation treatment with a radium implant is planned. On hospital admission, the client says that she is concerned about being radioactive and has been having nightmares about the treatment. What would be a reasonable explanation for the nurse to give to the client?"
CHOICES
( O ) a.) "The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain."
( X ) b.) "The radioactivity will gradually decrease, and you will be discharged when the radioactive material reaches its half-life."
( X ) c.) "These nightmares indicate that you're in the denial phase of accepting the diagnosis."
( X ) d.) "Careful shielding prevents the area above your waist from radioactivity."
RATIONALE: The radioactivity comes from a radioactive material such as radium or cesium. Radioactivity affects tissues but does not make them radioactive. Once the radioactive source is removed, no radioactivity remains. Accurate information can help alleviate ungrounded fears. The time required for a radioactive substance to be half-dissipated is called its half-life, but this does not determine discharge time. The client receiving sealed internal radiotherapy is not discharged until the radioactive source is removed. Nightmares probably indicate the client's concern about the therapy. With cervical implants, there is no way to shield the area above the waist from radiation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 894 _ about (MC)
QUESTION: "What activity orders would be appropriate for a client with an internal radium implant for cervical cancer?"
CHOICES
( X ) a.) Out of bed as tolerated within the room.
( X ) b.) Bed rest with bathroom privileges.
( X ) c.) Bed rest in position of comfort.
( O ) d.) Bed rest with the head of the bed flat.
RATIONALE: The client with a cervical implant is kept on strict bed rest, flat in bed. Limitation of movement is designed to prevent accidental displacement or implant dislodgment. Client knowledge and understanding are critical to compliance with these restrictions. The client will not be allowed out of bed while the implant is in. The client will not be allowed out of bed while the implant is in. Assuming various positions while in bed can dislodge the implant. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 895 _ about (MC)
QUESTION: "All of the following would be appropriate interventions for a client with acute epididymitis except:"
CHOICES
( X ) a.) Maintaining bed rest.
( X ) b.) Elevating the testes.
( O ) c.) Applying ice packs intermittently.
( X ) d.) Applying hot packs to the scrotum.
RATIONALE: Intermittent ice application will enhance comfort and reduce swelling. Rest is the foundation of treatment. Elevating the scrotum may increase the client's comfort. Hot packs are not used because the temperature in the scrotum should remain below body temperature; excessive exposure to heat can cause destruction of sperm cells. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 896 _ about (MC)
QUESTION: "One year after receiving treatment for epididymitis, a client returns to the physician, saying that he thinks the epididymitis has returned. The physician examines him and makes a preliminary diagnosis of testicular cancer. Which clinical manifestation helps differentiate testicular cancer from epididymitis?"
CHOICES
( X ) a.) The inability to achieve or sustain an erection.
( X ) b.) Scrotal pain.
( O ) c.) A dragging sensation in the scrotum.
( X ) d.) Scrotal swelling.
RATIONALE: A dragging sensation in the scrotum is associated with testicular cancer, not epididymitis. The manifestations of testicular cancer are less dramatic than those of epididymitis. Other clinical manifestations of testicular cancer include a lump in or swelling of the testis, a dull ache in the lower abdomen or inguinal area, and occasional pain. Sexual performance is unaffected. Scrotal pain is more likely to occur in epididymitis. Scrotal swelling occurs in both epididymitis and testicular cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 897 _ about (MC)
QUESTION: "A client with testicular cancer is scheduled for a right orchiectomy. The day before surgery, the client tells the nurse that he is concerned about the effect that losing a testicle will have on his manhood. Which of the following facts about orchiectomy should form the basis for the nurse's response?"
CHOICES
( X ) a.) Testosterone levels are decreased.
( O ) b.) Sexual drive and libido are unchanged.
( X ) c.) Sperm count increases in the remaining testicle.
( X ) d.) Secondary sexual characteristics change.
RATIONALE: The remaining testicle undergoes hyperplasia and produces enough testosterone to maintain sexual drive, libido, and secondary sexual characteristics. Testosterone levels will return to normal. Sperm count can decrease after a unilateral orchiectomy; this is attributed to the stress of the surgery. Secondary sexual characteristics do not change because the remaining testicle continues to produce testosterone. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 898 _ about (MC)
QUESTION: "The initial blood pressure of a client with a head injury is 124/80 mm Hg. As his condition worsens, pulse pressure increases. Which of the following blood pressure readings indicates a pulse pressure greater than the initial pulse pressure?"
CHOICES
( X ) a.) 102/60 mm Hg.
( X ) b.) 110/90 mm Hg.
( X ) c.) 140/100 mm Hg.
( O ) d.) 160/100 mm Hg.
RATIONALE: The pulse pressure is determined by subtracting the diastolic pressure from the systolic pressure. The pulse pressure in this scenario is 60 mm Hg. The client's initial pulse pressure was 44 mm Hg. Widening pulse pressure is a sign of increased intracranial pressure. The pulse pressure is 42 mm Hg. The pulse pressure is 20 mm Hg. The pulse pressure is 40 mm Hg. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 899 _ about (MC)
QUESTION: "The nurse checks the client's gag reflex. The recommended technique for testing the gag reflex is to:"
CHOICES
( O ) a.) touch the back of the client's throat with a tongue depressor.
( X ) b.) observe the client for evidence of spontaneous swallowing when the neck is stroked.
( X ) c.) place a few milliliters of water on the client's tongue and note whether or not he swallows.
( X ) d.) observe the client's response to the introduction of a catheter for endotracheal suctioning.
RATIONALE: The best technique for assessing the gag reflex is to touch the back of the client's throat in the pharyngeal area with a tongue depressor or cotton swab. The reflex is absent if the client does not gag. Reflexes are typically absent or sluggish in the presence of increased intracranial pressure. Swallowing does not indicate the presence of a gag reflex. It is dangerous to place liquids in the mouth of an unconscious client because of the risk of aspiration. Endotracheal suctioning does not test the client's gag reflex. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 900 _ about (MC)
QUESTION: "The client with a head injury receives mannitol (Osmitrol) during surgery to help decrease intracranial pressure. Which of the following nursing observations would most likely indicate that the drug is having the desired effect?"
CHOICES
( O ) a.) Urine output increases.
( X ) b.) Pulse rate decreases.
( X ) c.) Blood pressure decreases.
( X ) d.) Muscular relaxation increases.
RATIONALE: Mannitol is an osmotic diuretic that helps decrease intracranial pressure through its dehydrating effects. The drug is acting in the desired manner when urine output increases. It may be desirable to decrease pulse rate, but mannitol is not used to accomplish this. It may be desirable to decrease blood pressure, but mannitol is not used to accomplish this. It may be desirable to relax the muscles in certain situations, but mannitol is not used to accomplish this. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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