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Flashcards in Exam 2 - ATI Questions Deck (21)
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1

A nurse is caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following lab reports should the nurse monitor?

A. Urine specific gravity
B. Blood glucose
C. Serum amylase
D. D-dimer

B. Blood glucose

Blood glucose should be monitored d/t decreased production of glucose and stress to the liver from the surgery

2

A nurse is reviewing the serum lab data of a client who has an acute exacerbation of Crohn's disease. Which of the following lab tests should the nurse expect to be elevated? (Select all that apply)

A. Hematocrit
B. ESR
C. WBC
D. Folic acid
E. Albumin

B. ESR
C. WBC

Decreased serum albumin
Decreased folic acid
Decreased hematocrit

3

A nurse is collecting data from a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should identify which of the following findings as the priority?

A. Client reports difficulty sleeping
B. The client's urine is positive for glucose
C. Client reports having an elevated body temperature
D. Client reports gaining 4 lb in the last 6 months

C. Client reports having an elevated body temperature

4

A nurse is reinforcing teaching with a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching?

A. Take the medication 2 hr after eating.
B. Discontinue this medication if your skin turns yellow-orange.
C. Notify the provider if you experience a sore throat.
D. Expect your stools to turn black.

C. Notify the provider if you experience a sore throat.

5

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching?

A. Decrease intake of calorie-dense foods.
B. Drink canned protein supplements.
C. Increase intake of high fiber foods.
D. Take a bulk-forming laxative daily.

B. Drink canned protein supplements.

High-protein diet is recommended.

6

A nurse in a clinic is reinforcing teaching with a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching?

A. I will plan to limit fiber in my diet.
B. I will restrict fluid intake during meals.
C. I will switch to black tea instead of drinking coffee.
D. I will try to eat three moderate to large meals a day.

A. I will plan to limit fiber in my diet.

A low-fiber diet is recommended for ulcerative colitis.

7

A nurse is collecting data from a client who has acute pancreatitis. Which of the following findings is the priority to report?

A. History of cholelithiasis
B. Elevated serum amylase level
C. Decrease in bowel sounds upon auscultation
D. Hand spasms when blood pressure is checked

D. Hand spasms when blood pressure is checked

Hand spasms when taking blood pressure is an indication of hypocalcemia.

8

A nurse is preparing to administer pancrelipase to a client who has pancreatitis. Which of the following actions should the nurse take?

A. Instruct the client to chew the medication before swallowing.
B. Offer 8 oz. water following medication administration.
C. Administer the medication 30 min before meals.
D. Sprinkle the contents on peanut butter.

B. Offer 8 oz. water following medication administration.

9

A nurse is collecting data from a newly admitted client who has pancreatitis. Which of the following findings should the nurse expect?

A. Pain in RUQ radiating to right shoulder
B. Pain that is worse when sitting upright
C. Pain that is worse when in a fetal position
D. Epigastric pain radiating to the left shoulder

D. Epigastric pain radiating to the left shoulder

10

A nurse is collecting data from a client who has pancreatitis. Which of the following actions should the nurse take to check for presence of Cullen's sign?

A. Tap lightly at the costovertebral margin on the client's back.
B. Palpate the RLQ
C. Inspect the skin around the umbilicus
D. Auscultate the area below the scapula

C. Inspect the skin around the umbilicus

Cullen's sign is indicated by a bluish-gray discoloration in the periumbilical area.

11

A nurse is reinforcing nutrition teaching with a client who has pancreatitis. Which of the following statements by the client indicates understanding. (Select all that apply)

A. I plan to eat small, frequent meals.
B. I will eat easy-to-digest foods with limited spice.
C. I will use skim milk when cooking.
D. I plan to drink regular cola.
E. I will limit alcohol intake to two drinks per day.

A. I plan to eat small, frequent meals.
B. I will eat easy-to-digest foods with limited spice.
C. I will use skim milk when cooking.

12

A nurse is contributing to the plan of care for a client who has hepatitis B with ascites. Which of the following interventions should the nurse recommend?

A. Initiate contact precautions
B. Weigh the client weekly
C.. Measure abdominal girth every 48 hr
D. Provide a high-calorie, high-carbohydrate diet

D. Provide a high-calorie, high-carbohydrate diet

Promotes healing of the liver tissue

13

A nurse is collecting data from a client who has advanced cirrhosis. Which of the following findings indicates the client is experiencing hepatic encephalopathy? (Select all that apply)

A. Anorexia
B. Change in orientation
C. Asterixis
D. Ascites
E. Fetor hepaticus

B. Change in orientation
C. Asterixis
E. Fetor hepaticus

Asterixis - a coarse tremor of the wrists and fingers

Fetor hepaticus - fruity breath odor

14

A nurse is caring for a client who has cirrhosis. Which of the following medications should the nurse expect to administer to this client? (Select all that apply)

A. Diuretic
B. Beta-blocking agent
C. Opioid analgesic
D. Lactulose
E. Sedative

A. Diuretic
B. Beta-blocking agent
D. Lactulose

15

A nurse is reinforcing teaching with a client who has hepatitis B about home care. Which of the following instructions should the nurse include? (Select all that apply)

A. Limit physical activity
B. Avoid alcohol
C. Take acetaminophen for comfort
D. Wear a mask when in public places
E. Eat small frequent meals

A. Limit physical activity
B. Avoid alcohol
E. Eat small frequent meals

16

A nurse is reviewing the medical record of a client who has a new diagnosis of hepatitis C. Which of the following lab tests should the nurse expect to be elevated?

A. Prothrombin time 8 sec
B. Total bilirubin 4.5 mg/dL
C. Aspartate aminotransferase (AST) 35 units/L
D. Alanine aminotransferase (ALT) 15 IU/L

B. Total bilirubin 4.5 mg/dL

AST and ALT would be elevated as well

17

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take?

A. Check blood glucose immediately after breakfast.
B. Administer insulin when breakfast arrives
C. Hold breakfast for 1 hr after insulin administration
D. Clarify the prescription because insulin should not be administered at this time.

B. Administer insulin when breakfast arrives

Prevents hypoglycemic episode

18

A nurse is assisting with a presentation about nutrition habits that prevent type 2 diabetes mellitus for a group of clients. Which of the following should the nurse include? (Select all that apply)

A. Eat less meat and processed foods.
B. Decrease intake of saturated fats.
C. Increase daily fiber intake.
D. Limit unsaturated fat intake to 15% of daily caloric intake.
E. Include omega-3 fatty acids in the diet.

A. Eat less meat and processed foods.
B. Decrease intake of saturated fats.
C. Increase daily fiber intake.
E. Include omega-3 fatty acids in the diet.

19

A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply)

A. Remove calluses using OTC remedies
B. Apply lotion between toes
C. Perform nail care after bathing
D. Trim toenails straight across
E. Wear closed-toe shoes

C. Perform nail care after bathing
D. Trim toenails straight across
E. Wear closed-toe shoes

20

A nurse is reviewing the health record of a client who has hyperglycemic-hyperosmolar state (HHS). Which of the following factors can cause HHS? (Select all that apply)

A. Evidence of recent MI
B. BUN 35 mg/dL
C. Takes a calcium channel blocker
D. Age 77 years
E. Fluid volume excess

A. Evidence of recent MI
B. BUN 35 mg/dL
C. Takes a calcium channel blocker
D. Age 77 years

21

A nurse is collecting data from a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply)

A. Weight gain
B. Fruity odor of breath
C. Abdominal pain
D. Kussmaul respirations
E. Metabolic acidosis

B. Fruity odor of breath
C. Abdominal pain
D. Kussmaul respirations
E. Metabolic acidosis