Reproductive
. Nursing responsibilities related to the patient with endometrial cancer who has a total abdominal hysterectomy and salpingectomy and oophorectomy include
a. maintaining absolute bed rest.
b. keeping the patient in high Fowler's position.
c. need for supplemental estrogen after removal of ovaries.
d. encouraging movement and walking as much as tolerated.
d. encouraging movement and walking as much as tolerated.
A patient has an elevated blood level of indirect (unconjugated) bilirubin. One cause of this finding is that
a. the gallbladder is unable to contract to release stored bile.
b. bilirubin is not being conjugated and excreted into the bile by the liver.
c. the Kupffer cells in the liver are unable to remove bilirubin from the blood.
d. there is an obstruction in the biliary tract preventing flow of bile into the small intestine.
b. bilirubin is not being conjugated and excreted into the bile by the liver.
Teaching in relation to home management after a laparoscopic cholecystectomy should include
a. keeping the bandages on the puncture sites for 48 hours.
b. reporting any bile-colored drainage or pus from any incision.
c. using over-the-counter antiemetics if nausea and vomiting occur.
d. emptying and measuring the contents of the bile bag from the T tube every day.
b. reporting any bile-colored drainage or pus from any incision.
A nurse is reviewing client laboratory data. The nurse should recognize that which of the following findings is expected for a client with stage 4 CKD? (pg. 385)
BUN= 15
GFR= 20
Creatinine= 1.1
Potassium= 5
2. GFR= 20
Increased intraocular pressure may occur as a result of
a. edema of the corneal stroma.
b. dilation of the retinal arterioles.
c. blockage of the lacrimal canals and ducts.
d. increased production of aqueous humor by the ciliary process.
d. increased production of aqueous humor by the ciliary process.
The first nursing intervention for the patient who has been sexually assaulted is to
a. treat urgent medical problems.
b. contact support person for the patient.
c. provide supplies for the patient to cleanse self.
d. document bruises and lacerations of the perineum and the cervix.
a. treat urgent medical problems.
A patient is admitted to the hospital with a diagnosis of diarrhea with dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to
a. sympathetic inhibition.
b. mixing and propulsion.
c. sympathetic stimulation.
d. parasympathetic stimulation.
d. parasympathetic stimulation.
A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that
a. pruritus is a common problem with jaundice in this phase.
b. the patient is most likely to transmit the disease during this phase.
c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B.
d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.
a. pruritus is a common problem with jaundice in this phase.
A nurse is preparing to initiate HD for client in AKI. Which of the following actions should the nurse take? (Select all that apply) (pg. 371)
Review current medications
Assess the AV fistula for a bruit
Calculate the client’s hourly urine output
Measure the client’s weight
Check serum electrolytes
Use the access site area for a venipuncture
1. Review current medications
Assess the AV fistula for a bruit
Measure the client’s weight
Check serum electrolytes
Always assess the patient with an ophthalmic problem for
a. visual acuity.
b. pupillary reactions.
c. intraocular pressure.
d. confrontation visual fields.
a. visual acuity.
To prevent or decrease age-related changes that occur after menopause in a patient who chooses not to take hormone therapy, the most important self-care measure to teach is
a. maintaining usual sexual activity.
b. increasing the intake of dairy products.
c. performing regular aerobic, weight-bearing exercise.
c. performing regular aerobic, weight-bearing exercise.
A patient is jaundiced and her stools are clay colored (gray). This is most likely related to
a. decreased bile flow into the intestine.
b. increased production of urobilinogen.
c. increased bile and bilirubin in the blood.
d. increased production of cholecystokinin.
a. decreased bile flow into the intestine.
A patient with acute hepatitis B is being discharged in 2 days. The discharge teaching plan should include instructions to
a. avoid alcohol for the first 3 weeks.
b. use a condom during sexual intercourse.
c. have family members get an injection of immunoglobulin.
d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.
b. use a condom during sexual intercourse.
A nurse is planning care for a client who has stage 4 CKD. Hich of the following actions should the nurse include in the plan of care? (Select all that apply) (pg. 385)
Assess for JVD
Provide frequent mouth rinses
Auscultate for a pleural fiction rub
Provide a high-sodium diet
Monitor for dysrhythmias
Assess for JVD
Provide frequent mouth rinses
Auscultate for a pleural fiction rub
5. Monitor for dysrhythmias
During an assessment of hearing, the nurse would expect that a normal finding would be
a. absent cone of light.
b. bluish purple tympanic membrane.
c. midline tone heard equally in both ears.
d. fluid level at hairline in the tympanum.
c. midline tone heard equally in both ears.
The nurse should explain to the patient who has erectile dysfunction (ED) that (select all that apply)
a. the most common cause is benign prostatic hypertrophy.
b. ED may be due to medications or conditions such as diabetes.
c. only men who are over 65 years or older benefit from PDE5 inhibitors.
d. there are medications and devices that can be used to help with erections.
e. this condition is primarily due to anxiety and best treated with psychotherapy.
b. ED may be due to medications or conditions such as diabetes.
During an examination of the abdomen the nurse should
a. position the patient in the supine position with the bed flat and knees straight.
b. listen for bowel sounds in the epigastrium and all four quadrants for 2 minutes.
c. describe bowel sounds as absent if no sound is heard in a quadrant after 2 minutes.
d. use the following order of techniques: inspection, palpation, percussion, auscultation.
b. listen for bowel sounds in the epigastrium and all four quadrants for 2 minutes.
Nursing management of the patient with acute pancreatitis includes (select all that apply)
a. checking for signs of hypocalcemia.
b. providing a diet low in carbohydrates.
c. giving insulin based on a sliding scale.
d. observing stools for signs of steatorrhea.
e. monitoring for infection, particularly respiratory tract infection.
a. checking for signs of hypocalcemia.
e. monitoring for infection, particularly respiratory tract infection.
A nurse is planning care for a client with pre-renal AKI after an abdominal aneurysm repair. Urinary output is 60ml in the last 2 hrs, blood pressure is 92/58 mm Hg. The nurse should anticipate which of the following interventions? (pg. 385)
Prepare the client for a CT scan with contrast
Plan to administer nitroprusside
Prepare to administer a fluid challenge
Plan to Trendelenberg the client
3. Prepare to administer a fluid challenge
Before injecting fluorescein for angiography, it is important for the nurse to (select all that apply)
a. obtain an emesis basin.
b. ask if the patient is fatigued.
c. administer a topical anesthetic.
d. inform patient that skin may turn yellow.
e. assess for allergies to iodine-based contrast media.
a. obtain an emesis basin.
d. inform patient that skin may turn yellow.
The nurse explains to the patient with chronic bacterial prostatitis who is undergoing antibiotic therapy that (select all that apply)
a. all patients require hospitalization.
b. pain will lessen once treatment has ended.
c. course of treatment is generally 2 to 4 weeks.
d. long-term therapy may be indicated in immunocompromised patient.
e. if the condition is unresolved and untreated, he is at risk for prostate cancer.
b. pain will lessen once treatment has ended.
d. long-term therapy may be indicated in immunocompromised patient.
Normal physical assessment findings of the GI system are (select all that apply)
a. nonpalpable liver and spleen.
b. borborygmi in upper right quadrant.
c. tympany on percussion of the abdomen.
d. liver edge 2 to 4 cm below the costal margin.
e. finding of a firm, nodular edge on the rectal examination.
b. borborygmi in upper right quadrant.
A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves
a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum.
b. resection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum.
c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum.
d. radical removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy.
c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum.
A nurse is planning postoperative care for a client who received HD. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) (pg. 371)
Check BUN and creatinine
Administer meds the nurse withheld prior to HD
Observe for signs of hypovolemia
Assess the access site for bleeding
Evaluate BP on the arm with AV access
Rationale: To determine presence of uremia after HD. It is appropriate to give at this time. Rapid loss of volume puts this patient at risk. Client receives heparin during procedure.
Check BUN and creatinine
Administer meds the nurse withheld prior to HD
Observe for signs of hypovolemia
Assess the access site for bleeding
Age-related changes in the auditory system commonly include (select all that apply)
a. drier cerumen.
b. tinnitus in both ears.
c. auditory nerve degeneration.
d. atrophy of the tympanic membrane.
e. greater ability to hear high-pitched sounds.
a. drier cerumen.
c. auditory nerve degeneration.
d. atrophy of the tympanic membrane.