Questions second clip minute 45:37 second recording:
1. 38-year-old women is admitted for relative surgical producer which information
obtained by the nurse during pre-operative assessment is most important to
communicate to the anesthesiologists and surgeon before surgery
a. -The patient reports that her last menstrual period was 8 weeks ago
2. A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip.
The nurse notes that the client is confused and restless. The client's vital signs are heart
rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and
SpO2 88%. Which action should the nurse take first?
a. -Administer oxygen via nasal cannula
3. The nurse is caring for a client who has sustained blunt trauma to the forearm. The
nurse assesses the client for which early sign of compartment syndrome?
a. -Escalating pain in the fingers
4. The nurse is assessing a client with an open fracture who is in a trauma condition. What
are the nursing interventions in order of priority?
- Assessing for airway patency, breathing, and circulation
b. Cutting away the clothing from the fracture site
c. Applying direct pressure on the injured area
d. Administering morphine sulfate intravenously
5. A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical
indicator identified by the nurse suggests the client may be experiencing a complication
of fractured ribs?
a. -Diminished breath sounds on the effected side
6. A client has rotator cuff surgery. What should be included when the nurse performs a
neurovascular assessment of the affected extremity immediately after surgery? Select
all that apply.
a. -Skin color
Movement of the hand
Sensations in the extremity
7. A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse
monitors this client for signs and symptoms of a fat embolism. Which client assessment
finding reflects this complication?
a. -Tachycardia and petechiae over the chest
8. A nurse is caring for a client with compartment syndrome. Which nursing actions are
appropriate? Select all that apply.
- Assisting with splitting the cast
Assessing urine output
Evaluating the pain on a scale
9. The nurse is caring for an elderly client who has a right hip fracture. Which priority
intervention should be included in the plan of care?
a. -Venous thromboembolism (VTE) prevention
10. While assessing a client, the nurse suspects that the client has acute osteomyelitis.
Which symptoms in the client support the nurse's suspicion? Select all that apply.
- Temperature of 102° F
b. Erythema of the affected area
c. Tenderness of the affected area
11. After teaching the client about the precautions to be taken during bisphosphonate
therapy, the nurse is evaluating the statements of the client. Which statement made by
the client indicates the need for further teaching?
- "I should take the medication with a meal."
12. A client is taking prednisone to prevent transplant rejection. What instruction by the
nurse is most important?
- Avoid large crowds and people who are ill.
1. A clinic nurse is working with an older client. What assessment is most important for
preventing infections in this client?
i. Assessing vaccination records for booster shot needs
2. The nurse understands that which type of immunity is the longest acting?
i. Natural active
3. A patient has just received a kidney transplant nursing care includes teaching on which
of the following potential signs of acute rejection
a. -Fever
b. Decreased urinary output
c. Increase blood pressure
d. Pain at transplant site
4. The nurse is presenting information to a community group on safer sex practices. The
nurse should teach that which sexual practice is the riskiest?
a. -Anal intercourse
5. A client with human immune deficiency virus is admitted to the hospital with fever,
night sweats, and severe cough. Laboratory results include a CD4+ cell count of
180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the
nurse take first?
i. Place the client under Airborne Precautions.
6. A client with human immune deficiency virus (HIV) has had a sudden decline in status
with a large increase in viral load. What action should the nurse take first?
i. Assess the patient for adherence to the drug regimen.
7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports
shortness of breath with activity and extreme fatigue. What intervention is best to
promote comfort?
i. Pace activities, allowing for adequate rest.
8. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding
by the nurse best indicates that goals have been met for this client problem?
i. Has a weight gain of 2 pounds/1 month
9. A client with acquired immune deficiency syndrome has been hospitalized with
suspected cryptosporidiosis. What physical assessment would be most consistent with
this condition?
i. Assessing mucous membranes
10. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug
regimen when the client does not have a history of seizures. What response by the
nurse is best?
i. "This drug helps treat the pain from nerve irritation."
11. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving
Truvada (emtricitabine and tenofovir). What information is most important to teach the
client about this drug?
i. "Truvada does not reduce the need for safe sex practices."
12. Which medication would the nurse expect to administer to a patient with a history of
asthma who developed shortness of breath and stridor and becomes hypotensive
during allergy skin testing.
a. -Epinephrine
13. Which nursing action is first when caring for a patient who is experiencing reduced chest
movement and impair air flow, hypotension and a weak irregular pulse.
a. -assessing gas exchange
14. Which medication Is most likely to have cause a hyper sensitivity reaction of sever
angioedema of the lips face and tongue.
a. -ACE inhibitors Benazepril
15. The nurse’s evaluation of the care plan for a patient who sustained a anaphylactic
reaction to a bee sting which finding indicates the treatment is successful.
a. -ability to swallow
16. What nursing intervention is an immediate priority when caring for a patient with the
following symptoms wheezing difficulty breathing angioedema blood pressure of 70/52,
apical pulse of 122 bpm that is irregular.
17. Apply oxygen using a high flow mask at 90 to 100%
18. A client who is receiving an intravenous antibiotic begins to cough and states, "My
throat feels like it is swelling." Which action will the nurse take next?
i. Discontinue infusing the antibiotic.
19. Instruction is appropriate when teaching a patient with sever food allergies about using
an automatic epinephrine injector
a. -Protect the injector from light and extreme temperatures
20. Based on the information provided in the health record below a patient with systemic
glucosamine erythropoiesis who is experiencing an exacerbations disease which
interventions must the nurse prioritize in the plan of care (Chart should show Low WBC,
and patient is on immune suppressive meds)
21. Prevent infection
22. After reviewing vital signs on the current medications list for a patient with systemic
erythropoiesis who reports skin darkening and carving salty foods which question would
the nurse ask next.
a. -have you missed and doses of prednisone
23. A patient present to the clinic after removing several ticks 10 days ago and ask the nurse
about diseases such as Lyme disease after completing a health history a nurse would
assess for which symptom first.
24. A round raised bulls eye rash
25. The nurse is advising a clinic patient who was exposed a week ago to human
immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's
antigen and antibody test has just been reported as negative for HIV. What instructions
should the nurse give to this patient?
i. "You will need to be retested in 2 weeks."
26. A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is
admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell
count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for
Disease Control and Prevention (CDC), which statement by the nurse is correct?
i. "The patient has developed acquired immunodeficiency syndrome
(AIDS)."
27. A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV)
infection is seen at the clinic. The patient states, "I am very nervous about making my
baby sick." Which information will the nurse include when teaching the patient?
i. Most infants born to HIV-positive mothers are not infected with the virus.
28. Which patient exposure by the nurse is most likely to require postexposure prophylaxis
when the patient's human immunodeficiency virus (HIV) status is unknown?
i. Needle stick with a needle and syringe used for a venipuncture
29. The nurse administers an iv dose of chemotherapeutic agent to the patient. which
action is most important for the nurse to make
i. Stop the infusion if swelling is observed at the site.
30. A patient has been with a nursing diagnosis of imbalanced nutrition less than moderate
leading to painful oral ulcers. which nursing action would be the most effective in
improving the oral intake.
a. -apply prescribed anesthetic gel to oral lesions before meals.
31. The patient is admitted with reports of chronic fatigue and shortness of breath. The
nurse notices that the patient is tachycardic and has multiple bruises and petechiae on
the body and arms. The patient also complains of frequent nosebleeds. The nurse
should evaluate the patient's
a. -complete blood count (CBC)
32. The patient is admitted for chemotherapy, but the nurse notices laboratory values
indicating that the patient is immunosuppressed. The nurse should
i. place the patient in a single room with a HEPA filtration system
33. A client is admitted with possible sepsis which action would the nurse perform first.
a. -Obtain specified cultures
34. A nurse is observing as assistive personnel (AP) performs hygiene and provides comfort
35. measures to a client with an infection. What action by the AP requires intervention by
the
36. nurse?
i. Ordering an oscillating fan for the client
37. A nurse manager is preparing an educational session for floor nurses on drug-resistant
38. organisms. Which statement below indicates the need to review this information?
i. "If you leave work wearing your scrubs, go directly home and wash them
right
b. away."
39. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)
40. infection cultured from the urine. What action by the nurse is most appropriate?
i. Prepare to administer vancomycin.
41. The nurse assess patient for cardinal signs of inflammation which signs or symptoms
does this include. (SATA)
a. -Edema
b. Redness
c. Warmth
42. ? Which symptoms is associated with an anaphylactic reaction ( MINUTE 21:15)
a. -Red blotches, itching, erythema, angioedema,
43. Which disease can be categorized as an autoimmune disease?
a. -scleroderma,
b. rheumatic fever,
c. Goodpasture syndrome
44. A client is hospitalized and is on multiple antibiotics the client develops frequent
diarrhea what action by the nurse Is most important.
i. Consult with the provider about obtaining stool cultures.
45. A hospitalized patient who has received chemotherapy for leukemia develops
neutropenia. Which observation by the nurse would indicate a need for further
teaching?
i. The patient's visitors bring in fresh peaches.
46. A patient develops neutropenia after receiving chemotherapy. Which information about
ways to prevent infection will the nurse include in the teaching plan (select all that
47. apply)?
i. Cook food thoroughly before eating.
b. -Avoid public transportation such as buses.
c. -Talk to the oncologist before having any dental work.
48. A patient receiving head and neck radiation for larynx cancer has ulcerations over the
oral mucosa and tongue and thick, ropey saliva. Which instructions should the
49. nurse gives to this patient?
a. -Rinse the mouth before and after each meal and at bedtime with a saline
solution.
50. A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years.
Which nursing action is most likely to detect early signs of infection in this patient?
a. -Ask about feelings of fatigue or malaise.
51. According to the CDC guidelines which personal protective equipment would the nurse
put on before assessing a patient who is on contact precautions for C. diff diarrhea.
a. -Gown and gloves
52. After a change of shift report on an oncology unit which patient should the nurse assess
first.
i. Patient who is neutropenic and has a temperature of 100.5
53. Which patient exposure by the nurse is most likely to require postexposure prophylaxis
when the patient's human immunodeficiency virus (HIV) status is unknown?
i. Needle stick with a needle and syringe used to draw blood
54. When caring for a patient who is pancytopenic, which action by unlicensed assistive
personnel (UAP) indicates a need for the nurse to intervene?
i. The UAP assists the patient to use dental floss after eating.
55. The nurse reviews the laboratory results of a patient who is receiving chemotherapy.
Which laboratory result is most important to report to the health care provider?
i. White blood cells (WBC) 2700/µL
56. The nurse receives change-of-shift report on the oncology unit. Which patient should
the nurse assess first?
i. A 24-yr-old patient who received neck radiation and has blood oozing
from the neck
57. External-beam radiation is planned for a patient with cervical cancer. What instructions
should the nurse give to the patient to prevent complications from the effects of the
radiation?
i. Clean the perianal area carefully after every bowel movement.
58. An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in
conjunction with the prescribed chemotherapy. Which finding by the nurse is most
important to report to the health care provider?
i. Patient has crackles up to the
midline posterior chest.
START
1. A nurse is assessing a patient who has numerous petechia on both arms which question
should the nurse ask the patient
a. -Do you take medications that contain salicylates?
2. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac
crest. Which action would be important for the nurse to take after the procedure?
i. Have the patient lie on the left side for 1 hour.
3. The nurse assesses a patient with pernicious anemia. Which assessment finding would
the nurse expect?
i. Numbness of the extremities
4. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic
tests. The nurse will provide a consent form to sign for which test?
i. Bone marrow biopsy
5. Which information shown in the table below about a patient who has just arrived in the
emergency department is most urgent for the nurse to communicate to the health care
provider?
i. Platelet count
6. A 62-year-old man with chronic anemia is experiencing increased fatigue and occasional
palpitations at rest. The nurse would expect the patient's laboratory test findings to
include
i. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
7. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The
nurse will plan to check the laboratory results for the.
i. bilirubin level
8. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a
deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT)
when the platelet level drops to 110,000/μL. Which action will the nurse include in the
plan of care?
i. Discontinue the heparin infusion.
9. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma
whose platelet count drops to 18,000/μL during chemotherapy is to.
i. check all stools for occult blood.
10.
Which assessment finding should the nurse caring for a patient with thrombocytopenia
11. communicate immediately to the health care provider?
i. The patient is difficult to arouse.
12. A patient in the emergency department complains of back pain and difficulty breathing
15 minutes after a transfusion of packed red blood cells is started. The nurse's first
action should be to.
i. disconnect the transfusion and infuse normal saline.
13. Which action for a patient with neutropenia is appropriate for the registered nurse (RN)
14. to delegate to a licensed practical/vocational nurse (LPN/LVN)?
i. Administering subcutaneous filgrastim (Neupogen) injection
15. The nurse will plan to monitor a patient with an obstructed common bile duct for
a. -Steatorrhea
16. After assisting with a needle biopsy of the liver at a patient bed side the nurse should
a. -place the patient on the right side with the bed flat*
17. Which area of the abdomen shown in the accompanying figure will the nurse palpate to
assess for splenomegaly?
a. -2 (just in case LUQ)
18. A young adult with extensive facial injuries from a motor vehicle crash is receiving tube
feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the
nurse include in the plan of care?
i. Check the gastric residual volume every 4 to 6 hours
19. After change-of-shift report, which patient will the nurse assess first?
i. A 40-yr-old man with continuous enteral feedings who has developed
pulmonary crackles
20. On the first postoperative day the nurse is caring for a patient who has had a Roux-en-Y
gastric bypass procedure. Which assessment finding should be reported immediately to
the surgeon?
i. Emesis of bile colored fluid past the nasogastric
21. The nurse will anticipate teaching a patient experiencing frequent heartburn about
a. -Proton pump inhibitors (PPI)
22. A patient has peptic ulcer disease that has been associated with Helicobacter
pylori. About which medications will the nurse plan to teach the patient?
i. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole
(Prilosec)
23. The nurse will anticipate preparing an older patient who is vomiting "coffeeground" emesis for
i. endoscopy.
24. A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago
complains of increasing abdominal pain. The patient has no bowel sounds and
200 mL of bright red nasogastric (NG) drainage in the past hour. The highest
priority action by the nurse is to
i. contact the surgeon.
25. The health care provider prescribes antacids and sucralfate (Carafate) for
treatment of a patient's peptic ulcer. The nurse will teach the patient to take
i. antacids after meals and sucralfate 30 minutes before meals.
26. The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What
information is most important to report to the health care provider?
i. Temperature 102.1°F (38.9°C)
27. A 58-yr-old patient has just been admitted to the emergency department with
nausea and vomiting. Which information requires the most rapid intervention by
the nurse?
i. The patient is lethargic and difficult to arouse.
28. Which patient should the nurse assess first after receiving change-of-shift report?
i. A patient with esophageal varices who has a blood pressure of
92/58 mm Hg
29. A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4
hours ago. Which assessment finding is most important for the nurse to address
immediately?
i. The patient has no breath sounds in the left anterior chest.
30. Which prescribed action will the nurse implement first for a patient who has vomited
1100 mL of blood?
i. Administer 1 L of lactated Ringer's solution.
31. A 24-year-old woman with Crohn’s disease develops a fever and symptoms of a
urinary tract infection (UTI) with tan, fecal-smelling urine. What information will
the nurse add to a general teaching plan about UTIs in order to individualize the
teaching for this patient?
i. Fistulas can form between the bowel and bladder.
32. A patient with diverticulosis has a large bowel obstruction the nurse will monitor
for
a. -abdominal distention
33. The nurse preparing for the annual physical exam of a 50-year-old man will plan
to teach the patient about
i. colonoscopy.
34. A 71-year-old patient had an abdominal-perineal resection for colon cancer.
Which nursing action is most important to include in the plan of care for the day
after surgery?
i. Assess the perineal drainage and incision.
35. The nurse is assessing a patient with abdominal pain. The nurse, who notes that
there is ecchymosis around the area of umbilicus, will document this finding as
a. -Cullen sign
36. A patient in the emergency department has just been diagnosed with peritonitis
caused by a ruptured diverticulum. Which prescribed intervention will the nurse
implement first?
i. Infuse metronidazole (Flagyl) 500 mg IV
37. A patient is admitted to the emergency department with severe abdominal pain
and rebound tenderness. Vital signs include temperature 102 F (38.3 C), pulse
120, respirations 32, and blood pressure (BP) 82/54. Which prescribed
intervention should the nurse implement first?
i. Infuse 1 liter of lactated Ringer’s solution over 30 minutes.
38. Four hours after a bowel resection, a 74-year-old male patient with a nasogastric
tube to suction complains of nausea and abdominal distention. The first action by
the nurse should be to.
a. -reposition the tube and check for placement.
39. A 19-yr-old woman is brought to the emergency department with a knife handle
protruding from her abdomen. During the initial assessment of the patient, the
nurse should?
i. Check for circulation and tissue perfusion
40. After several days of antibiotic therapy, an older hospitalized patient develops
watery diarrhea. Which action should the nurse take first?
i. Place the patient on contact precautions.
41. Which patient should the nurse assess first after receiving change-of-shift report?
i. 30-year-old patient who has abdominal distention and an apical
heart rate of 136 beats/minute
42. A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the
outpatient clinic about new symptoms. Which symptom is most important to
communicate to the health care provider?
i. Fever
43. A female patient is awaiting surgery for acute peritonitis. Which action will the nurse
include in the plan of care?
i. Position patient with the knees flexed.
44. A client who had a partial gastrectomy 3 days ago begins to experience vertigo,
sweating, and tachycardia about 30 minutes after eating breakfast. What
postoperative complication would the nurse suspect?
a. -Dumping syndrome
45. A client who has peptic ulcer disease is prescribed quadruple drug therapy for
Helicobacter pylori infection. What health teaching related to bismuth would the
nurse include?
i. "Do not take aspirin or aspirin products of any kind while on
bismuth."
46. A nurse is caring for a patient diagnosed with diverticulosis and assesses a
temperature of 102.4 F and abdominal rigidity. What should the nurse be aware
is the most likely cause of these signs and symptoms?
i. Perforation
47. During an interview, the client tells the nurse that the client has a duodenal ulcer.
Which assessment finding would the nurse expect?
i. Melena
48. The nurse is caring for a client with a long history of peptic ulcer disease. What
assessment findings would the nurse anticipate if the client experiences upper
gastrointestinal (GI) bleeding? (Select all that apply.)
i. Decreased blood pressure
b. Dizziness
c. Hematemesis
d. Decreased urinary output
49. The nurse is teaching a client about risk factors for esophageal cancer. Which
risk factors would the nurse include? (Select all that apply.)
i. Alcohol intake
Obesity
Smoking
Lack of fresh fruits and vegetables
Untreated GERD
50. The nurse is teaching a client about the risk of uncontrolled or untreated the
client's gastroesophageal reflux disease (GERD). What complication(s) may
occur if the GERD is not successfully managed? (Select all that apply.)
i. Asthma
b. Laryngitis
c. Dental caries
d. Cardiac disease
e. Cancer
51. To promote comfort after a colonoscopy, in what position does the nurse place
the client?
i. Left lateral
52. What happens to sickle shaped red blood cells during a sickle cell crisis.
a. -obstruction of major arteries
53. A client is awaiting bariatric surgery in the morning. What action by the nurse is
most important?
i. Beginning venous thromboembolism prophylaxis
54. A patient is being treated for bleeding esophageal varices with balloon
tamponade. Which nursing action will be included in the plan of care?
i. Monitor the patient for shortness of breath.
55. A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago
complains of increasing abdominal pain. The patient has no bowel sounds and
200 mL of bright red nasogastric (NG) drainage in the past hour. The highest
priority action by the nurse is to
i. contact the surgeon.
56. A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse
initiated a parenteral nutrition (PN) infusion. The appropriate action by the nurse
is to.
i. recheck the capillary blood glucose level in 4 to 6 hours.
57. After change-of-shift report, which patient will the nurse assess first?
a. -a 60-year-old patient with nausea and vomiting who has dry mucosa and
lethargy
58. During change-of-shift report, the nurse learns about the following four patients.
Which patient requires assessment first?
a. -55-year-old with cirrhosis and ascites who has an oral temperature of
102° F (38.8° C)
59. A nurse assesses a client who is recovering from an ileostomy placement. Which
clinical manifestation should alert the nurse to urgently contact the health care
provider?
i. Pale and bluish stoma
60. After gastric bypass surgery the patient is being provided a B 12 injection the
patient asks about the purpose of this vitamin the nurse explains that.
a. -Vitamin b12 is needed for the formation of red blood cells
FINISH
61. A nurse cares for a client who is prescribed lactulose (Heptalac). The client
states, "I do not want to take this medication because it causes diarrhea." How
should the nurse respond?
i. "Diarrhea is expected; that's how your body gets rid of ammonia."
To detect possible complications in a patient with severe cirrhosis who has bleeding
esophageal varices, it is most important for the nurse to monitor
- Ammonia levels
When taking the blood pressure (BP) on the right arm of a patient with severe acute
pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action
should the nurse take next?
- Check the calcium level in the chart.
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse
during the assessment will be of most concern?
- The patient's hands flap back and forth when the arms are extended.
Which assessment finding is of most concern for a patient with acute pancreatitis?
- Palpable abdominal mass
Which assessment information will be most important for the nurse to report to the health care
provider about a patient who has acute cholecystitis?
- The patient's stools are tan colored.
Which finding indicates to the nurse that lactulose is effective for an older adult who has
advanced cirrhosis?
- The patient is alert and oriented.
Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a
patient who has acute pancreatitis?
-Amylase
Which patient should the nurse assess first after receiving a change of shift report?
-a patient who has esophageal varices who has a blood pressure of 92/58
Which patient should the nurse assess first after receiving a change of shift report
-a 38-year-old patient who has abdominal distention and an apical heart rate of 136
BPM
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse
expect to find?
- Severe, steady right lower quadrant pain
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment
should the nurse complete first?
- Heart rate and rhythm
A nurse assesses a client who is prescribed an infusion of vasopressin for bleeding esophageal
varices. Which clinical manifestation should alert the nurse to a serious adverse effect?
-Mid-sternal chest pain
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent
abdominal pain. An hour later the client reports constant abdominal pain. Which action should
the nurse take next?
- Assess the client's bowel sounds.
A nurse cares for a client who has a Giardia infection. Which medication should the nurse
anticipate being prescribed for this client?
- Metronidazole (Flagyl)
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an
esophagogastric tube. Which action should the nurse take first?
- Assess the client for airway patency
A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin
and cachectic in appearance, and the family expresses distress that the client is receiving little
dietary protein. How should the nurse respond?
- Less protein in the diet will help prevent confusion associated with liver failure.
A nurse cares for a client with hepatitis C. The client's brother states, "I do not want to contract
this infection, so I will not go into his hospital room." How should the nurse respond?
- Viral hepatitis is not spread through casual contact."
A nurse cares for an older adult client who has Salmonella food poisoning. The client’s vital
signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22
breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first?
-Administer intravenous fluids
A nurse works on the surgical unit. After receiving the hand-off report, which client should the
nurse see first?
- Patient who had an esophagectomy with a respiratory rate of 32/min
A patient is in the emergency department with an esophageal trauma. The nurse palpates
subcutaneous emphysema in the mediastinal area and up into the lower part of the client's
neck. What action by the nurse takes priority?
- Assess the patients oxygenation.
A client presents to the emergency department reporting severe abdominal pain. On
assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the
nurse is the priority?
- Notify the provider immediately.
A patient reports pain in the right upper quadrant (RUQ) after a high-fat meal. Which organ
does the nurse expect to be affected?
-Gallbladder
A client had a routine sigmoidoscopy with a tissue biopsy. What common complication is the
nurse looking for in a post procedure assessment?
-Heavy bleeding (Excessive bleeding)
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago.
The client states, I am experiencing right flank pain and have a temperature of 101 F. How
should the nurse respond?
-You should go to the hospital immediately to have your new liver checked out.
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients
understanding. Which statement made by the client indicates a need for additional teaching?
- I need to avoid protein in my diet.
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's
understanding. Which menu selection indicates that the client correctly understands the
dietary teaching?
- Broiled chicken with brown rice, steamed broccoli, glass of apple juice
The following data related to an older adult, who’s 2 hours post op after an esophageal
gastrostomy what action by the nurse is best?
-consult the surgeon about increased IV fluids.
which patient does the charge nurse assign to an experienced LPN/ LVN working on an adult
medical unit?
- a 32-year-old who needs a NG tube inserted for gastric acid masses
A client with inflammatory bowel disease is receiving total parenteral nutrition via infusion
pump what is most important for the nurse to do when administering
-change the TPN bag every 24 hours even if there is no solution left in the bag.
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The
nurse discovers that the TPN bag is empty and the next bag has not been received yet from the
pharmacy. What is the most appropriate action for the nurse to take?
- Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for
the next TPN bag.
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common
causes for which the nurse assesses in these clients? (Select all that apply.)
- a. Colon cancer
b. Diverticulitis
c. Inflammatory bowel disease
d. Peptic ulcer disease
A patient has undergone an EGD to detect lesions in the gastrointestinal tract what nursing
interventions are preformed within a few hours after an EGD?
-raise the side rails of the bed,
check vital signs every 30 mins until sedation wears off,
monitor for signs of perforation such as pain and bleeding,
avoid fluids until the gag reflex returns.
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which
of the following? (Select all that apply.).
-Malnutrition
Ascites
Disseminated intravascular coagulation
“MAD”
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect
to find? (Select all that apply.)
- distended abdomen
inability to pass flatus or feces
decreased urine output secondary to dehydration
A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse
expect? (Select all that apply.)
- Anorexia
Constipation
Abdominal pain
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of
these clinical manifestations support this diagnosis? Select all that apply.
-Fever
complaint of indigestion
pain the RUQ after a fatty meal
A client with bleeding esophageal varices is to be treated via infusion of medication through an
intravenous line. Which medication should the nurse anticipate will be prescribed?
-Vasopressin
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which
assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that
apply.
Mental confusion
Flapping hand tremors
Musty, sweet breath odor
A nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are
important to include in this client's diet? Select all that apply.
Low sodium
High vitamins
Moderate protein
A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For which immediate
response is it most important for the nurse to monitor?
- Rapid, thready pulse
A paracentesis is prescribed for a client recently admitted to a medical unit. The nurse recalls
that the procedure is performed for what reasons? (Select all that apply.)
-Extract peritoneal fluid
Improve respiratory status
Obtain peritoneal fluid for culture