Question: Upon entering the room of a patient who has just returned from surgery for total laryngectomy and radical neck dissection, a nurse should recognize a need for intervention when finding

A. a gastrostomy tube that is clamped.
B. the patient coughing blood-tinged secretions from the tracheostomy.
C. the patient positioned in a lateral position with the head of the bed flat.
D. 200 ml of serosanguineous drainage in the patient's portable drainage device.

Answer: C. the patient positioned in a lateral position with the head of the bed flat. After total laryngectomy and radical neck dissection, a patient should be placed in a semi-Fowler's position to decrease edema and limit tension on the suture line.

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Question: A 78-year-old does not want to eat lunch and complains that the food that is serve does not taste good. Consistent with knowledge about age-related changes to taste, the nurse may find that the client is more willing to eat.

A) Greasy foods
B) Sour foods
C) Sweet foods
D) Salty foods.

Answer: C = the older adults' taste buds retain their sensitivity to carbohydrates. In addition, carbohydrates. Tend to be food items that are easy to chew. Older adults lose their sensitivity to sour and salty foods. Older adults may find greasy foods harder to digest and therefore may avoid them; however, preference for greasy foods is not related to changes in taste associated with age.

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Question: The nurse is preparing a discharge plan to a female client with peptic ulcer for the dietary modification she will need to follow at home. Which of the following statements indicates that the client understands the instruction of the nurse?

A) "I should not drink alcohol and caffeine."
B) "I should eat a bland, soft diet."
C) "It is important to eat six small meals a day."
D) "I should drink several glasses of milk a day."

Answer: A = caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa.

The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet.

Eating six small meals daily is no longer a common treatment for peptic ulcer disease.

Milk in large quantities is not recommended because it actually stimulates further production of gastric acids.

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Question: A community health nurse is teaching smoking cessation program to a group of healthy adult smokers. What type of prevention activity is this?

A) Primary
B) Secondary
C) Tertiary
D) None of the above

Answer: A = primary cancer prevention targets healthy individuals and includes steps to avoid factors that might lead to the development of diseases.

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Question: A female client with breast cancer is currently receiving radiation therapy for treatment. The client is complaining of apathy, hard to concentrate on something, and feeling tired despite of having time to rest and more sleep. These complains suggest symptoms of:

A) Hypocalcemia
B) radiation pneumonitis
C) advanced breast cancer
D) fatigue

Answer: D = Fatigue is a common complaint of individuals receiving medication therapy.

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Question: The nurse is removing the client's staples from an abdominal when the client cough continuously and the incision splits open exposing the intestines. Which of the following is the immediate nursing action of the nurse?

A) Call the surgeon to come to the client's room immediately
B) Have all visitors and family member leave the room
C) Press the emergency alarm to call the resuscitation team
D) Cover the abdominal organs with sterile dressing moistened with sterile normal saline.

Answer: D = When a wound eviscerates, the nurse should cover the open area with sterile dressing moistened with sterile normal saline and then cover it with a dry dressing.

The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia.

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Question: A male client is receiving chemotherapy for lung cancer. He asks the nurse how the drug will work. Which of the following is the correct response of the nurse?

A) "Chemotherapy affects all rapidly dividing cells."
B) "Structure of the DNA is altered."
C) "Chemotherapy encourages cancer cells to divide."
D) "Cancer cells have susceptible drug toxins."

Answer: A = There are many mechanisms of action for chemotherapeutic agents, but most affect the rapidly dividing cells-both cancerous and noncancerous. Cancer cells are characterized by rapid cell division. Chemotherapy slows cell division

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Question: A client will be receiving general anesthesia. The nurse reviews the laboratory result of the client and found out that the serum potassium level is 5.8 mEq/L. What should be the nurse's initial response?

A) Send the client to surgery
B) Notify the anesthesiologist
C) Call the surgeon
D) Send the client to surgery

Answer: B = the nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L places the client at risk for dysrhythmias when under general anesthesia.

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Question: The nurse is instructing the unlicensed assistant on how to care for a client with chest tubes that are connected to water seal drainage. Which of the following instruction would be appropriate for the nurse to give the unlicensed assistant?

A) Mark the time and amount of drainage collected in the container
B) Raise the collection apparatus to the height of the bed to measure the fluid level.
C) Milk the test tubes every 4 hours
D) Attach the chest tubes to bed linen to avoid tension of the tubing

Answer: A = It is appropriate for an unlicensed assistant to mark the time of measurement and fluid level in the collection container.

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Question: The nurse is caring for a client after a lung lobectomy. The nurse notes fluctuating water levels in the water-seal chamber of the client's chest tube. What action should the nurse take?

A. Do nothing, but continue to monitor the client.
B. Call the physician immediately.
C. Check the chest tube for a loose connection.
D. Add more water to the water-seal chamber

Answer: Correct answer: A

Fluctuation in the water-seal chamber is a normal finding that occurs as the client breathes. No action is required except for continued monitoring of the client. The nurse doesn't need to notify the physician. Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, such as from a loose connection in the chest tube tubing. The water-seal chamber should be filled initially to the 2 cm line, and no more water should be added.

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Question: A client with type 2 diabetes has a hemoglobin A1C level of 8.8 after 6 months of oral therapy with metformin (Glucophage®). The client tells the nurse that she often forgets to take her medication and doesn't really follow her diet. Which of the following is the nurse's best first response?

A. "If you don't get control of your blood sugar, you'll need to take insulin."
B. "It can be hard to get used to having a disease like diabetes. What are some of the things you find challenging about it?"
C. "Uncontrolled diabetes can lead to eye problems and kidneys problems."
D. "Many people have diabetes."

Answer: Correct answer: B

Acknowledging that the client is going through changes and allowing her to express her concerns will help the nurse assess her needs. Hemoglobin AIC shows the average blood glucose levels over a 3-month period. Diabetes should maintain the AIC <7%. Lecturing, threatening and comparing the clients to others belittles the client and discourages discussion, but the patient must be provided adequate information in order to make informed decisions about self-care.

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Question: The nurse is teaching a client newly diagnosed with type 1 diabetes how to self-administer subcutaneous insulin injections. How does the nurse best evaluate the effectiveness of her teaching?

A. Have the client repeat the steps back to the nurse.
B. Give the client a written test on self-administration of insulin.
C. Ask the client to write out the steps for self-administration of insulin injections.
D. Ask the client to give a return demonstration of self-administration of insulin.

Answer: Correct answer: D

Asking the client to give a return demonstration of his injection technique is the best way to assess whether the client can perform the procedure. It also gives the nurse the opportunity to provide feedback. Asking the client to recite the steps, pass a written test, or write out the steps shows the nurse whether the client is able to recall the steps but doesn't show that he has the necessary motor skills or the ability to perform the procedure.

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Question: The nurse is writing the teaching plan for a client undergoing a radioactive iodine uptake test to study thyroid function. Which of the following instructions should the nurse include?

A. "You need to stay at least 4 feet (1.2 m) away from other people after the test because you'll be radioactive."
B. "You need to lie very still on a stretcher that is placed in a long tube for the scan"
C. "Don't take any iodine or thyroid medication before the test."
D. "Schedule the bone scans before your radioactive iodine uptake test."

Answer: Correct answer: C

Medications such as iodine, contrast media, and antithyroid and thyroid drugs can affect the test results and should be withheld by the client for a week or longer, as directed by the physician. During a radioactive iodine uptake test, the client receives radioactive iodine by mouth or I.V. in small doses and doesn't require isolation. During magnetic resonance imaging--not radioactive iodine uptake testing--a client needs to lie still inside a long tube. Any test, such as a bone scan, that requires iodine contrast media should be scheduled after the radioactive iodine uptake test because the iodinated contrast medium can decrease uptake.

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Question: 31. A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) who is undergoing induction therapy with chemotherapeutic agents tells the nurse, "I feel so sick that I don't know if the treatment is worth completing." The nurse's best response to the patient is

a. "I know you feel really ill right now, but after this therapy your disease will go into a remission and you will feel normal again."
b. "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed you won't feel so ill."
c. "Your type of leukemia has an 80% survival rate if aggressive therapy is started, so the effects of treatment will be worth it to you."
d. "The chemotherapy is difficult, but it is necessary to put the disease into remission and give you time to make choices about your life.

Answer: D
Rationale: AML is very aggressive, and survival after diagnosis is short without treatment. Induction therapy is followed by more chemotherapy, so the nurse should not tell the patient that he or she will feel normal or not so ill. The survival with AML is not 80%.

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Question: The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed?

a. "I take antacids between meals and at bedtime each night."
b. "I quit smoking several years ago, but I still chew a lot of gum."
c. "I sleep with the head of the bed elevated on 4-inch blocks."
d. "I eat small meals throughout the day and have a bedtime snack."

Answer: D

Rationale: GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

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Question: A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug

a. reduces the reflux of gastric acid by increasing the rate of gastric emptying.
b. coats and protects the lining of the stomach and esophagus from gastric acid.
c. treats gastroesophageal reflux disease by decreasing stomach acid production.
d. neutralizes stomach acid and provides relief of symptoms in a few minutes.

Answer: C
Rationale: The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

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Question: A nurse is performing an initial post op assessment on a client following upper GI surgery. The client has a NG tube to low, intermittent suction. To best assess the client for the presence of bowel sounds, the nurse should:

A. place the stethoscope to the left of the umbilicus.
B. turn off the nasogastric suction.
C. use the bell of the stethoscope.
D. turn the suction on the NG tube to continuous.

Answer: B. turn off the nasogastric suction.

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Question: A nurse is caring for a client diagnosed with Chron's disease, who has undergone a barium enema that demonstrated the presence of strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of:

A. peritonitis
B. obstruction
C. malaborsorption.
D. fluid imbalance.

Answer: B. obstruction

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Question: While conducting a home visit with a client who had a partial resection of the ileum for Chron's Disease 4 weeks previously, a nurse becomes concerned when the client states:

A. My stools float and seem to have fat in them.
B. I have gaiend 5 pounds since I left the hospital.
C. I am still avoiding milk products.
D. I only have 2 formed stools per day.

Answer: A. My stools float and seem to have fat in them.

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Question: A nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client's medical record?

A. Abdominal pain and bloody diarrhea.
B. Weight gain and elevated blood glucose.
C. Abdominal distention and hypoactive bowel sounds.
D. Heartburn and regurgitation.

Answer: A. Abdominal pain and bloody diarrhea

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Question: A RN overhears a LPN talking with a client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. To decrease the client's anxiety, the RN should intervene to clarify the information given by the LPN when the LPN is heard saying:

A. this surgery will prevent you from developing colon cancer.
B. after this surgery you will no longer have ulcerative colitis.
C. when you return from surgery you will not be able to eat solid food for several days.
D. you will have an ileostomy when you return from the surgery.

Answer: D. you will have an ileostomy when you return from the surgery.

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Question: The nurse is assessing a client 24 hours following a cholecystectomy. The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?

A. Clamp the T tube
B. Irrigate the T tube
C. Notify the physician
D. Document the findings

Answer: D. Document the findings

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Question: .The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

A. Hypotension
B. Bloody diarrhea
C. Rebound tenderness
D. A hemoglobin level of 12 mg/dL

Answer: C. Rebound tenderness

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Question: A nurse is preparing to remove a nasogartric tube from a client. The nurse should instruct the client to do which of the following just before the nurse removes the tube?

A. Exhale
B. Inhale and exhale quickly
C. Take and hold a deep breath
D. Perform a Valsalva maneuver

Answer: C. Take and hold a deep breath

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