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WorksheetsNUR114 EXAM 2 NCLEX style practice
Total questions: 70
Worksheet time: 38mins
What nursing action is appropriate if a client has a Potassium level (K+) of 8 mEq/L?
no change required
restrict intake of K+ and give sodium polystyrene sulfonate (Kayexalate)
Restrict fluids to reduce K+
Give insulin, glucose, calcium and or bicarbonate STAT as orderd
Which client has the greatest need for K+ replacement?
a client in renal failure with a postdialysis serum K+ of 3.4
A client with a large NG output who is receiving Kayexalate with a serum K+ of 5.5
A client with cardiac disease who is about to recieve furosemide with a K+ of 3.5
A client with cardiac disease who is about to recieve spironolactone with a K+ of 3.5
Which symptom would a nurse most likely observe in a client with cholecystits?
Black Stools
Nausea after a high-fat meal
Temp of 104
colicky LUQ pain
If a client's bowel sounds are absent the nurse should listen for at least:
30 seconds
60 seconds
2 min
3 min
What is the first nursing action if an NG tube is not draining?
irrigate the tube
reposition the client
determine tube placement
remove the tube and reinsert
A nurse is observing a client for possible complications of postoperative peritonitis. Which manifestations are most indicative of peritonitis? select all that apply
hyperactive bowel sounds
localized or diffuse pain
abdominal rigidity
shallow respirations
Temp above 102
When a client is on chemotherapy, for which manifestations of bone marrow depression should a nurse continuously assess?
night sweats/fatigue
loss of skin turgor/ wt loss
low urine output and elevated BUN
ecchymosis, weakness, fatigue
A client is admitted to a hospital in the terminal stage of illness. At this time, a nurse, who is planning end-of-life care, should recognize that the client is most likely to fear:
the terminal diagnosis
further chemo
being socially inadequate
dying alone and in pain
An indicator of worsening hypovolemic shock related to GI bleeding would be:
Decreased LOC
complaints of abdominal pain with hematemesis
deeping, rapid respirations
increasingly rapid, thready pulse
A nurse should expect that a client with severe loss of potassium (hypokalemia) from diarrhea will have:
fatigue ,tetany, cardiac standstill
Kussmaul's respirations, thirst, furrowed tongue
muscle weakness, cramps, cardiac irritability
confusion, pitting edema, irregular pulse
A bowel obstruction occurs from inflammatory bowel disease at the transverse colon, a nurse will initially hear bowel sounds that are:
increased RLQ; decreased LLQ
decreased RLQ; decreased LLQ
absent RLQ; absent LLQ
decreased RLQ; increased LLQ
A nurse notes that a client has a total bilirubin of 1.0mg/dl. The nurse should:
Record this as a normal finding
check urine for blood
check stool for guaicac
assess the sclerae for yellow discoloration
A client asks a nurse what to expect with a condition of uncomplicated gallstones. The best response would be:
There may be blood in the stools, with increased mucus
There may be RLQ cramping with pain relieved after eating a fatty meal
You may feel fatigue because of low hemoglobin level
Most clients do not notice any affects
A client with gallstones asks the nurse what might have caused the condition. The nurse knows the risk of developing this conditions is greater in:
african americans
men
significant weight loss
drinking a lot of coffee
The correct time for a nurse to administer pancrelipase (pancrease) is:
one hour after meals
with meals
at bedtime
with insulin
The most important nursing assessment to make before a client is started on indomethacin (Tivorbex) an NSAID for arthritis, is:
asking if there is a history of sulfa allergies
asking if there is a history of gastric bleeding
checking blood pressure
checking blood sugar
A client with a duodenal ulcer has been taking sucralfate (Carafate) Which statement by the client would be a priority for the nurse to address?
I dont like the taste so i mix it with pudding
i wish i could take carafate at the same time as my other pills
i have found that stewed prunes help prevent constipation from the drug
taking carafate with H20 has helped my fluid intake
In preparation fro surgery, a client is placed on a low-residue diet. In discussing the kinds of food that will be allowed, a nurse should list:
ground lean beef, soft-boiled eggs
lettuce, spinach, corn
prunes, grapes, apples
bran cereal, whole wheat toast, milk
A client would demonstrate awareness of dietary influences in the prevention of dumping syndrome if the intake were adjusted by: select all that apply
increasing fats as tolerated
eating more dry items than liquid
consuming fluids before or after meal times
avoiding concentrated carbs
increasing simple carbs
What would be allowed in the diet of a client with PUD; peptic ulcer disease?
milk
caffinated coffee
alcohol
tomato juice
A client is scheduled for an ultrasound to rule out bile duct obstruction. What preparation is required for an ultrasound test?
NPO 48 hours
Explaination of procedure
Enemas until clear
pain meds and sedation
A nurse is assessing a client who had an (EGD) esophagogastroduodenoscopy. The first priority for the nurse should be:
checking for bowel sounds
giving warm gargles for sore throat
administering pain medication
monitoring for return of gag reflex
Gallstones can be diagnosed and sometimes removed by ERCP endoscopic retrograde cholangiopancreatograpy. Preparation of a client scheduled for this procedure should include:
Planning for a 2 to 3 day hospitalization
drinking 500 mL of dye-containing juice 30 min beforehand
recieving a sedative but not general anesthesia
planning on a 5 to 10 min procedure
A client will return to the floor from PACU folloing a laparoscopic cholecystectomy when:
The oral airway is removed
Pain is controlled
the client can move both legs
the client is awake with stable vital signs
A client is scheduled for a cholecystogram. In preperation for the test the nurse should ask the client about allergies to: select all that apply
eggs
organ meats
clams
shrimp
crab
A client has a T-tube inserted in the surgical wound following a cholecystectomy. The most important nursing function in managing the tube is:
recording the quantity and color of drainage
changing the dressing every shift
preventing the tube from kinking
teaching the client about the reason for the tube
A client reports pain in the right shoulder following a laparoscopic cholecystectomy. A nurse explains that the pain is related to:
migration of the gas used to insufflate the abdomen during the procedure
nerve irritation from leakage of bile
strain on the shoulder due to a right side-lying positon during the procedure
refferred pain from an obstructed common bile duct
Which situation could lead to metabolic acidosis in a client?
Frequent vomitting
Nasogastric suctioning
Hyperventilation
ASA overdose
A client with acute pancreatitis and fluid volume deficit is in an ICU. Which assessment findng should the nurse report to the MD?
Urne output of 35 mL/hr
CVP of 12mm Hg
cardiac output of 5L/min
decreased pain in fetal position
A client with acute pancreatitis reports numbness with circumoral tingling and muscle cramps. Which nursing intervention is most appropriate?
Assess for hypocalcemia
Request an order for serum sodium
assess for hypoglycemia
check the chart for a current dose of Lasix
A client admitted with acute pancreatitis after a holiday celebration including excessive food and alcohol intake. Which assessment finding reflects this diagnosis?
Hyperactive bowel sounds
Sudden onset of continuous epigastric and back pain
Moist crackles in both lung fields
elevated temp and BP
A client is admitted for a cholecystectomy due to cholelithiasis. A nurse notes that the serum amylase report shows a level of 900 units/L. Which action should the RN take?
prepare the client for surgery
assess the client for jaundice
check RBC, Hgb, and Hct reports
call and report the findings to the physician
A client with chronic pancreatits is placed on pancrelipase (pancrease) three times daily. What information is essential to teach with this medication?
observe for diarrhea
take with meals
chew tablets or allow enteric coated tablets to dissolve in the mouth
take every 8 hours
Which of the following best describes the pain associated with duodenal ulcer?
dull, epigastric pain that occurs one-half hour after eating
sharp, intermittent pain in the LUQ
Gnawing, epigastric pain 1 to 3 hours after eating
continuous, dull pain in the RLQ
The nurse evaluates the patient as understanding the primary reason that food and fluids are held until the gag reflex returns after an EGD procedure if the patient states which of the following?
to rest the vocal cords
to prevent aspiration
to keep the throat dry
to prevent vomitting
What action should the nurse take prior to initiating an enteral feeding using a newly inserted NG tube?
asucultate bowel sounds
flush feeding tube
review chest xray results
review abd xray results
Which structure carries bile and pancreatic juices to the duodenum?
pancreatic duct
common bile duct
cystic duct
hepatic duct
An asymptomatic patient is admitted with gastric bleeding. For which of the following signs or symptoms of sever gastric bleeding should the nurse monitor?select all that apply
restlessness
diaphoresis
bounding pulse
hypotension
confusion
A patient who has ulcerative colitis is taken to the ER with severe rectal bleeding. Which of the following is the best option for maintaining nutritional status for this patient who must be NPO for an extended period of time?
NG tube feeds
PEG tube feeds
Parenteral Nutrition
IV 5% dextrose and water
Patients with a history of pancreatitis commonly have a history of which of the following?
high protein diet
very low fat diet
excessive alcohol consumption
excessive intake of vitamin K
The nurse is collecting data for a patient with acute pancreatitis. Which of these descriptions of pain would the nurse associate with acute pancreatitis?
Dull, boring, beginning in the mid-epigastrium and radiating to the back
Knifelike; centered in the LLQ
Burning, focusing over the left flank and radiating to the shoulder
Sharp, severe pain that begins in the RUQ
The nurse recieves a patient from the OR after he undergoes a whipple procedure. The nurse recognizes that this procedure is indicated for the patient who has which disorder?
Acute pancreatitis
Peritonitis
Cholecystitis
Pancreatic Cancer
The nurse assesses for which finding in a patient with a positive Cullen's sign?
periumbillical brusing
rebound tenderness
RUQ pain with radiation to shoulder
Flank bruising
What is the rationale for the healthcare provider to more likely prescribe merperidine (demerol) for pain in a patient with pancreatitis
morphine causes spasms in the sphincter of oddi
meperidine can be given IM or IV
morphine is not absorbed in the pancreas
meperidine is better tolerated in patients with substance abuse
What laboratory finding is the primary diagnostic indicator for pancreatitis?
elevated BUN
elevated serum lipase
elevated AST
elevated LDH
A patient has just admitted with acute pancreatitis, which of the following orders would the RN anticipate?
maintain NPO status
oral fluid restriction
low-fat diet
regular diet
A nurse is performing a physical assessment on a patient admitted with acute pancreatitis. Which of the following clinical manifestations correlates with this diagnosis?
constipation
steatorrhea
clear lung sounds througout all fields
diarrhea
The nurse recognizes which of the following as risk factors for cholecystitis? select all that apply
Obesity
Male
Female
African American descent
European descent
The nurse correlates which clinical manifestation with cholecystitis?
retroperitoneal pain
absence of bowel sounds
diarrhea
RUQ pain
The nurse correlates which clinicial manifestation to the pathophysiology of gastric ulcer?
Pernicious anemia
Constipation
Acute epigastric pain after eating
Hypertension
A 67 year old male is suspected of having a peptic ulcer. The nurse monitors for a decrease in which diagnostic value with GI hemorrhage in this patient?
reticulocyte count
hematocrit
PTT
IgG antibodies to H.pylori
The nurse monitors for which clinicial manifestations in the patient diagnosed with a duodenal ulcer? Select all that apply
intermittent abd pain which is relieved after eating and taking antacids but becomes worse at night
nausea and vomitting
RUQ tenderness and positive fecal occult
complaints of heartburn or regurgitation and vomiting
bloating and flatulence
The nurse incorporates which information in to the teaching plan for a patient diagnosed with a duodenal ulcer?
You will probably have increased pain after eating
smoking cigarettes can make PUD worse
antacids are not usually effective for pain
eating bland foods will aid in healing
A nurse is having difficulty arousing a patient following EGD. Which of the following is the priority action by the nurse?
assess the patients airway
allow the client to sleep
prepare to administer an antidote to the sedative
evaluate preprocedure lab findings
A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing 3 specimens. Which of the following statements by the client indicates an understanding?
I will continue taking my warfarin while i complete the tests
im glad i dont have to follow a special diet
the test determines if i have parasites
this is an easy way to screen for colon cancer
A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? select all that apply
obtain capillary blood glucose 4x a day
administer prescribed meds through a secondary port in the TPN IV tubing
monitor vital signs 3x during a 12 hr shift
Change TPN IV tubing every 24 hrs
ensure a daily aPTT is obtained
A nurse in the Emergency dept is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? select all that apply
Rigid abdomen
tachycardia
elevated BP
circumoral cyanosis
rebound tenderness
A nurse is providing discharge teaching to a client who has an infection due to H.pylori. Which of the following statements by the client indicates an understanding of the teaching?
I will continue my prescription for corticosteroids
I will schedule a CT scan to monitor improvement
I will take a combination of medications for treatment
I will have my throat swabbed to recheck for bacteria
A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? select all that apply
client reports pain relieved by eating
client states pain often occurs at night
client reports sensation of bloating
client states pain occurs 30 min to 1 hour after meal
client experiences pain upon palpation of the epigastric region
A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? select all that apply
take 1 hour before meal
limit NSAIDS while taking
expect skin flushing while taking
increase fiber intake while taking
chew medication thoroughly before swallowing
A nurse is reviewing the laboratory data of a client who has an acute exacerbation of Crohn's Disease. Which of the following blood laboratory results should the nurse expect to be elevated? select all that apply
Hematocrit
ESR
WBC
Folic Acid
Albumin
A nurse is assessing a client who has been taking prednisone following an exacerbation of IBD. The nurse should recognize which of the following findings as the priority?
client reports difficulty sleeping
urine is positve for glucose
client reports having elevated body temp
client reports gaining 4lb in the last 6 months
A nurse is completing discharge teaching to a client who has Crohn's disease. Which of the following should the nurse include in the teaching?
decrease intake of calorie dense foods
drink canned protein supplements
increase intake of high fiber foods
eat high-residue foods
A nurse is teaching a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?
take 2 hours after eating
discontinue if skin turns yellow-orange
notify provider if you experience sore throat
expect your stool to turn black
A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching?
i will plan to limit fiber in my diet
i will restrict fluid intake during meals
i will switch to black tea instead of drinking coffee
i will try to eat cold foods rather then warm when my stomach is upset
A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the teaching? select all that apply
take baths rather than showers
resume diet of choice
cleanse the puncture site using mild soap and water
remove adhesive strips from puncture site in 24 hours
Report N/V to surgeon
A nurse is reviewing risk factors with a client who has cholecystitis. The nurse should identify that which of the following is a risk factor of cholecystitis?
obesity
rapid wt gain
decreased blood triglyceride level
male
A nurse is completing preoperative teaching for a client who is scheduled for a laparoscopic cholecystectomy. Which of the following should the nurse include in the teaching?
the scope will be passed through your rectum
you may have shoulder pain after surgery
you will have a JPdrain placed after surgery
you should limit walking for the next 2 weeks
A nurse is reviewing a new prescription for chenodiol with a client who has cholelithiasis. Which of the following should the nurse include in the teaching?
the medication is used to decrease acute biliary pain
this medication requires thyroid function monitoring every 6 months
this medication is not recommended for clients with diabetes melluitus
this medication dissolves gallstones gradually for a period of up to 2 years
A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding?
blood amylase 80 units/L
WBC 9,000
direct bilirubin 2.1mg/dL
alkaline phosphatase 25 units/L
