Question 1

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention?

Accepted Answer

11ecbb05_c9bc_8b8f_b433_15f047b0909e_MD0009_00 Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase) (Option C). (Option A) Abdominal cramps can occur after a colonoscopy due to air inflation during the procedure. (Option B) The barium contrast solution used during the procedure may make the client's stool white for up to 3 days. The nurse should encourage fluids, if appropriate, to assist in expulsion of the contrast medium. (Option D) Copious, bile-colored (greenish-brown) drainage is expected in a client with a small bowel obstruction. The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis. Educational objective: Acute pancreatitis, a potentially life-threatening complication, can occur following an endoscopic retrograde cholangiopancreatography. Manifestations include acute abdominal pain, often radiating to the back, and a rise in pancreatic enzymes (eg, amylase, lipase).

Question 2

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply.

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. 11ecbb05_c9c1_e1c0_b433_c5bf80c69d57_MD0009_00 Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian). Symptoms of colorectal cancer may include: Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors (Option B) Abdominal discomfort and/or mass (not common) (Option A) Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion (Option D) Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors (Option C) Unexplained weight loss due to impaired nutrition from altered intestinal absorption (Option E) Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests (eg, occult blood test every year, colonoscopy every 10 years). Educational objective: Clients over age 50 should receive routine colorectal cancer screening for symptoms such as blood in the stool, anemia, abdominal discomfort, change in bowel habits, and weight loss. Symptoms result from intestinal polyps or tumors that cause intestinal bleeding, obstruction, and impaired intestinal absorption.

Question 3

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first?

Accepted Answer

Paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability. (Option A) Post-paracentesis vital signs are frequently monitored for the first 4 hours to assess for complications (eg, hypotension, bleeding). The nurse can ask the UAP to take another set of vital signs, but this should not be the nurse's first intervention. (Option C) Diuretics (eg, spironolactone, furosemide) are prescribed for clients with ascites. If the client is hypotensive or hypovolemic, the nurse can hold the prescribed diuretics, but this should not be the nurse's first intervention. (Option D) The nurse can instruct the UAP to assist the client back to bed if this is an appropriate action after assessing the client, but this should not be the nurse's first intervention. Educational objective: A client who is experiencing lightheadedness and unsteady gait following paracentesis requires immediate assessment because these manifestations can signal hypovolemia with hypotension, which can lead to hemodynamic instability and hypovolemic shock.

Question 4

A client is receiving an infusion of total parenteral nutrition (TPN) with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action?

Accepted Answer

Total parenteral nutrition (TPN) is administered via a central venous catheter to meet the nutritional needs (eg, glucose, amino acids, vitamins, minerals) of clients who cannot digest nutrients via the gastrointestinal tract. The nurse should hang 10% dextrose in water at the same infusion rate of 75 mL/hr until the new bag arrives. If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose (eg, normal saline, lactated Ringer's [LR]), the pancreas will continue to produce insulin in response to the residual glucose, which may cause hypoglycemia (Option B). (Option A) The infusion of 0.9% saline solution without dextrose can lead to hypoglycemia. Rapid infusion (150 mL/hr) of the hypertonic TPN solution can increase the risk for fluid overload and hyperglycemia. The nurse should never increase the rate of central TPN to make up for volume lost during previous hours. (Option C) Dextran in saline solution is a colloid used to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and so is not an appropriate action. (Option D) LR contains electrolytes but no glucose; hypoglycemia may result. Educational objective: Abrupt cessation of central total parenteral nutrition (TPN), which usually contains 20%-50% dextrose, increases the risk for hypoglycemia, as the pancreas will continue to produce insulin in response to the residual glucose. When TPN is discontinued, the infusion rate is gradually reduced and then replaced with a solution containing dextrose.

Question 5

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client?

Accepted Answer

Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridium difficile). (Option A) Instructions on eating bulk-forming foods may be helpful with diarrhea; however, this option does not seek to address the underlying problem causing the 4 days of diarrhea and fever. The client should see the HCP. (Option B) Instructions on rest, fluids, and acetaminophen are helpful and would be the primary choice if the diarrhea had been occurring ≤48 hours without other symptoms. (Option D) Loperamide (Imodium) is a synthetic opioid used as an antidiarrheal. It slows peristalsis and subsequently increases fluid absorption. It should not be used more than 2 days or if fever is present as retention of bacteria or toxins inside the colon can make the process worse and cause toxic megacolon. Educational objective: Clients experiencing diarrhea lasting >48 hours or accompanied by fever or bloody stool should see their health care provider for assessment of fluid status, electrolyte levels, and identification of underlying causes.

Question 6

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away.  How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?

Accepted Answer

A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day) Adding an exercise regimen to the client's daily routine would facilitate additional weight loss and/or reduce the need for severe caloric restriction. (Option A) Reducing intake by 450 kcal/day over 16 weeks would result in a weight loss of 14.5 lb (6.5 kg). (Option C) Reducing intake by 860 kcal/day over 16 weeks would result in a weight loss of 27.5 lb (12.4 kg). (Option D) Reducing intake by 1000 kcal/day over 16 weeks would result in a weight loss of 32 lb (14.5 kg). Educational objective: A reduction or energy expenditure of 3500 calories (kcal) will result in a weight loss of 1 lb.

Question 7

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention?

Accepted Answer

11ecbb05_c9b7_345d_b433_89b28f8cc55c_MD0009_00 A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option C). (Options A and D) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option B) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention. Educational objective: A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis.

Question 8

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply.

Accepted Answer

Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option A). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option B). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option C) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option D) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option E) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis. Educational objective: HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis and elevated ammonia are characteristic of HE.

Question 9

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ?10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? Select all that apply.

Accepted Answer

NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. 11ecbb05_c9b1_dd2a_b433_fbf6b9dad8fc_MD0009_00 Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the large intestine (colon) that results in abdominal pain, frequent bouts of bloody diarrhea, anorexia, and anemia. The nurse planning care for a client with UC should: Manage pain: Intestinal inflammation often produces severe abdominal pain that limits treatment compliance. Provide prescribed analgesics to promote comfort and treatment adherence (Option A). Address psychosocial needs: Chronic illness may increase the risk of hopelessness and/or depression due to prolonged treatment and frustration over lack of improvement or symptom control. Encourage clients to discuss emotions and feelings (Option B). Assess fluid balance: Diarrhea, blood loss, and poor oral intake contribute to dehydration. Strict intake and output monitoring helps ensure adequate fluid intake and prevent dehydration (Option C). Evaluate treatment adherence: UC exacerbations may be spontaneous or may be precipitated by certain foods or lack of adherence to prescribed treatments (eg, medications). Assess compliance with prescribed treatments and provide education as needed to promote adherence (Option D). Promote nutrition: Pain after eating may lead to anorexia, and intestinal inflammation decreases nutrient absorption; both result in nutritional deficiency. Help clients select nutrient-dense, high-protein foods to promote recovery and meet nutritional needs (Option E). Educational objective: Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by bouts of bloody diarrhea, abdominal pain, anorexia, and anemia. Nurses caring for clients with UC should provide pain management, promote adequate nutrition and hydration, address psychosocial needs, and evaluate client compliance with treatment.

Question 10

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area?

Accepted Answer

11ecbb05_c9b6_22ec_b433_83325c7919ce_MD0009_00 The client with acute pancreatitis will report a sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric area of the abdomen that often radiates to the back. The pain is referred to the back as the pancreas is a retroperitoneal organ. Pain improves with leaning forward and worsens with lying flat. The pain is often preceded or made worse by a high-fat meal. Nausea and vomiting are common due to severe pain. Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to intense systemic inflammatory response), and hypocalcemia (necrosed fat binding calcium). (Option A) Kidney stones cause sudden, excruciating pain in the flank, back, or lower abdomen due to stretching of the ureter. The pain radiates to the groin area. (Option C) Appendicitis presents as periumbilical pain progressing to the right lower quadrant. Tenderness at McBurney's point is present as pressure is applied, and rebound tenderness occurs when pressure is released. (Option D) Cholecystitis (inflammation of the gallbladder) causes pain in the right upper quadrant that often radiates to the right shoulder area. Educational objective: The client with acute pancreatitis has sudden, severe pain in the left upper quadrant or midepigastric area of the abdomen, often radiating to the back. Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to intense systemic inflammatory response), and hypocalcemia (necrosed fat binding calcium).

Question 11

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction?

Accepted Answer

11ecbb05_c9b7_f7ae_b433_a56cce5f952d_MD0009_00 A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis. Preprocedure instructions include: Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon. Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and purple liquids. Do not eat or drink anything 8 hours before the test (Option B). Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to defecate (Option C). Postprocedure instructions include: Expect the passage of chalky, white stool until all barium contrast has been expelled (Option A). Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling the barium. Retained barium can lead to fecal impaction (Option D). Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation. Educational objective: A barium enema uses fluoroscopy with contrast to evaluate for colon abnormalities. Before the procedure, clients undergo bowel preparation using cathartics and a clear liquid diet. Laxatives after the procedure assist in expelling the contrast.

Question 12

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply.

Accepted Answer

11ecbb05_c9b4_9c4b_b433_2d414e876e5c_MD0009_00 Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option C). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option D). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option B). (Options A and E) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium). Educational objective: The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and hypoalbuminemia are to be expected.

Question 13

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L).  Which assessment finding does the nurse anticipate?

Accepted Answer

Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. (Option A) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. (Option B) Increased thirst with dry mucous membranes indicates hypernatremia. (Option C) Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias. Educational objective: Clients who abuse alcohol often have low magnesium levels that manifest as ventricular arrhythmias and/or neuromuscular excitability (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and seizures.

Question 14

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery?

Accepted Answer

11ecbb05_c9c3_1a41_b433_917c7c00b039_MD0009_00 Bariatric surgery (eg, gastric banding, sleeve gastrectomy) reduces stomach capacity. A client's bariatric postoperative diet is restricted to foods that are low in simple carbohydrates and high in nutrients (eg, protein, fiber). After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome (ie, cramping, diarrhea). The client will tolerate only small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery, and then progress gradually to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the pouch and to prevent nausea, vomiting, and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereals, sugar-free drinks, and low-sugar protein shakes and dairy foods (Option C). (Option A) Fruit juices and puddings are high in sugar and not acceptable for a bariatric full liquid diet. Mashed potatoes are considered appropriate for a soft diet. (Option B) Ice cream is high in sugar and not acceptable for a bariatric full liquid diet. Eggs are appropriate for a soft diet. (Option D) Yogurt is high in sugar and not appropriate for a bariatric full liquid diet. Peanut butter and vegetable juice are appropriate for a soft diet. Educational objective: Clients recovering from bariatric surgery are given small, frequent meals to prevent nausea, vomiting, and regurgitation related to overstretching of the stomach. The bariatric postoperative diet is restricted to foods that are high in nutrients (eg, protein, fiber) and low in simple carbohydrates to prevent dumping syndrome.

Question 15

A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first?

Accepted Answer

Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. (Option A) Assessing and recording vital signs is appropriate and should be reported to the health care provider, but this is not the priority. (Option B) Monitoring hemoglobin and hematocrit levels is appropriate to assess the severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; therefore, this is not the priority. (Option D) Ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. This can be done after lowering the head of the bed. Educational objective: A client with significant blood loss has a medical emergency, and interventions that will hemodynamically stabilize the client should take priority.

Question 16

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L).  Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing?

Accepted Answer

Oncotic pressure (or colloid osmotic pressure) is a form of osmotic pressure exerted by plasma proteins (albumin) in the blood that pulls water into the circulatory system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites (Option D). (Options A, B, and C) Altered mental status, easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Altered mental status (hepatic encephalopathy) is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism. Educational objective: Serum albumin plays an important role in maintaining intravascular oncotic pressure. Very low levels of albumin result in fluid leak from the vessels into the interstitial tissue and can lead to pitting edema of the lower extremities, periorbital edema, and ascites.

Question 17

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses (NDs) are appropriate to include in the client's care plan? Select all that apply.

Accepted Answer

The following NDs are appropriate to include in this client's care plan: Acute pain related to tissue damage as evidenced by the use of PCA with an opioid. Pain is usually most intense 12-36 hours after surgery (Option A). Dysfunctional gastric motility related to bowel manipulation during surgery, anesthesia, and opioid analgesia as evidenced by absent or hypoactive bowel sounds 48-72 hours following surgery secondary to a paralytic ileus. It is a common complication following abdominal surgery (Option B). Imbalanced nutrition, less than body requirements related to the increased metabolic demand needed for tissue and wound healing as evidenced by the inability to ingest adequate caloric intake secondary to a paralytic ileus and the lack of interest in eating secondary to the ileus, the adverse effects of anesthesia, and analgesic medications (Option C). Risk for infection - The risk for being invaded by pathogenic organisms is increased in this client due to loss of primary defenses (ie, protective skin barrier), lack of adequate nutrition to meet the body demands, and altered immunity due to the presence of cancer cells (Option E). (Option D) Ineffective self-health management is the inability to integrate a therapeutic treatment regimen into one's own activities of daily living to meet specific health goals. There are no data to support this ND at this time. Educational objective: NDs associated with impaired skin integrity and wound healing following abdominal surgery that guide supportive and preventive nursing care include acute pain, dysfunctional gastric motility, imbalanced nutrition (less than body requirements), and risk for infection.

Question 18

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply.

Accepted Answer

ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake (Option C), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option E). IV illicit drug use increases the risk for hepatitis B and C infection (Option B). (Option A) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option D) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high. Educational objective: ALT/AST are enzymes indicating liver injury. Besides the obvious viral hepatitis, it can result from excess chronic alcohol intake or some over-the-counter drugs, including acetaminophen.

Question 19

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred.  The nurse stays with the client while another staff member gets sterile gauze and saline.  How should the nurse position the client while waiting to cover the wound?

Accepted Answer

Wound evisceration is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. It is considered a medical emergency. The nurse should remain with the client while calling for help. The health care provider should be notified immediately and supplies brought to the room by another staff member. The wound should be covered with sterile normal saline dressings. While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent. This position lessens abdominal tension on the suture line and can prevent further evisceration. The client should be prepared for immediate return to surgery. (Option B) Prone positioning would put undue pressure on an open incision and protruding bowel and could contaminate the open wound. (Option C) A side-lying lateral position (recovery position) is often used following emergency situations such as cardiac arrest or seizure, but it will not lessen the tension placed on this open wound. (Option D) Supine with the head of the bed flat may actually increase tension placed on the open wound. Educational objective: Wound evisceration is a medical emergency. The client should be placed in low Fowler's position with the knees bent to reduce tension on the open wound. The nurse should remain with the client while another staff member obtains sterile saline and gauze to cover the wound.

Question 20

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration?

Accepted Answer

Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg, anorexia nervosa, chronic alcoholism). The client's lack of oral intake results in the pancreas making less insulin. After the client receives food or IV fluids with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting intracellularly. Phosphorus is the primary deficient electrolyte as it is required for energy (adenosine triphosphate). Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrhythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure. (Option A) Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment but are not the most important assessment as failure to monitor these does not result in death. (Option C) Dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the stomach. Eating concentrated carbohydrates or excess fluids causes the food to be "dumped"/emptied rapidly into the small intestine. Symptoms include diaphoresis, cramping, weakness, and diarrhea within 30 minutes of eating. Dumping syndrome is not seen with anorexia nervosa. (Option D) The central lines carry a risk of infection. The signs of infection include leukocytosis and left shift. However, risk of infection is not greatest in the first few days of parenteral nutrition. Educational objective: Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. Electrolytes, especially phosphorous, potassium, and magnesium, must be monitored frequently during the first few days of nutritional replenishment.

Exam 1: Adult Health

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention?

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply.

The unlicensed assistive personnel (UAP) assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first?

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client?

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ?10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? Select all that apply.

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area?

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction?

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L) . Which assessment finding does the nurse anticipate?

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery?

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L) . Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing?

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses (NDs) are appropriate to include in the client's care plan? Select all that apply.

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's alanine aminotransferase /aspartate aminotransferase (ALT/AST) levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings? Select all that apply.

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration?