GCC 726 - 750

A suitable diet for a client with cirrhosis and abdominal ascites is one that is:

• High in sodium, low in calories
• Low in potassium, high in calories
• High in protein, high in calories
• Low in calcium, low in calories
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The nurse cares for a client who returns from gastric resection surgery. Which nursing intervention is a priority?

• Assessing for flatus
• Monitoring for symptoms of hemorrhage
• Monitoring patency of the nasogastric tube
• Encouraging ambulation
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A client with tuberculosis who has been receiving combined therapy with INH and Rifampin asks the nurse how long he will have to take medication. The nurse should tell the client that:

• Medication is rarely needed after 2 weeks
• He will need to take medication the rest of his life
• The course of combined therapy is usually 6 months
• He will be re-evaluated in 1 month to see if further medication is needed
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The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby's reflux. The nurse should tell the mother to:

• Feed the baby only when he is hungry
• Burp the baby after the feeding is completed
• Place the baby supine with head elevated
• Burp the baby frequently throughout the feeding
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The nurse knows that case management is:

• The process of managing the outcomes of client care by quality improvement measures and involvement of the interdisciplinary team
• The process of client assessment and direct client care by the primary nurse, utilizing the nursing process and nursing diagnoses to guide delivery of care
• The process used by the health care facility's legal or risk management department to evaluate legal claims filed against the facility or employees of the facility
• The process of overseeing and organizing client care in collaboration with the client's primary health care provider and consulting physicians
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The nurse is palpating the fontanels of a 2-month-old. The fontanels should feel:

• Tense and bulging
• Soft and sunken
• Flat and firm
• Flat and tense
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The nurse performs an admission assessment on a client who is directly admitted to the hospital from the physician's office. The client is worried and distracted, and explains to the nurse that because of the direct admission from the physician's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client?

• An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here beside your bed so that you can contact your family and friends. Is there anything that I can do for you right now to help you?
• I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight.
• An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? You also have a telephone here at your bedside so that you can contact your family and friends.
• I can call your physician for you and ask if you could go home today, then schedule another date for your hospital admission.
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Which post-operative assessment finding on a client with a femoral popliteal graft of the right leg would require immediate charge nurse notification?

• Edema of the right extremity and pain at the incision site
• A temperature of 99.6ºF and redness of the incision
• Serous drainage noted at the surgical area
• A loss of posterior tibial and dorsalis pedis pulses on the right leg
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During client care rounds with the multidisciplinary team, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client, in which the physician participating in rounds writes the order. This is an example of:

• Collaboration of client care with the ancillary care providers.
• Collaboration of client care between the physician and the dietary department.
• Collaboration of care with the risk management team because of the client's risk for aspiration.
• Collaboration of care among members of the multidisciplinary team.
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A patient develops a small-bowel obstruction 5 days after undergoing surgery. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?

• Imbalanced nutrition: Less than body requirements
• Acute pain
• Deficient fluid volume
• Excess fluid volume
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