Quiz #6 Rationales

Question 1

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply.

a. Coffee
b. Chocolate
c. Peppermint
d. Nonfat milk
e. Fried chicken
f. Scrambled eggs

Answer 1

a. Coffee
b. Chocolate
c. Peppermint
e. Fried chicken

Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options d and f do not promote this effect.

Question 2

New prescription for esomeprazole to manage GERD. what statement indicates an understanding of the teaching?

a. “I won’t pass gas as often now that I am taking this medication.”
b. “I will take this medication each morning with my breakfast.”
c. “I have an increased risk of getting pneumonia while taking this medication.”
d. “I will need to take a daily stool softener while taking this medication.”

Answer 2

c. “I have an increased risk of getting pneumonia while taking this medication.”

The client taking esomeprazole is at a greater risk for developing pneumonia due to an elevation of gastric pH, especially during the first few days of treatment. The nurse should instruct the client about manifestations of a respiratory infection and to report these findings to the provider if they occur.

Question 3

A client is prescribed lansoprazole 15 mg PO once a day. At which of the following times should the nurse administer the medication?

A. Thirty minutes after lunch
B. With a bedtime snack
C. Thirty minutes before breakfast
D. During the evening meal

Answer 3

C. Thirty minutes before breakfast

Lansoprazole should be given thirty minutes before breakfast for best absorption because food diminishes the effectiveness of the medication

Question 4

A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times?

1.With meals and at bedtime
2.Every 6 hours around the clock
3.One hour after meals and at bedtime
4.One hour before meals and at bedtime

Answer 4

One hour before meals and at bedtime

Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.

Question 5

Sucralfate is prescribed for a client. The nurse determines that the client understands the instructions for medication administration if the client states to take the medication at what time?

1.At bedtime
2.One hour after meals
3.At noontime with a meal
4.One hour before meals and again at bedtime

Answer 5

One hour before meals and again at bedtime

Rationale: Sucralfate is an antiulcer medication that forms a barrier over the ulcer and protects against acid and pepsin. The medication should be taken 1 hour before meals and at bedtime to allow it to form a protective coating over the ulcer to prevent irritation from food, gastric acid, and mechanical movement. The other time frames are incorrect.

Question 6

A nurse is teaching a client who has a new prescription for aluminum hydroxide to treat heartburn. The nurse should instruct the client to monitor for and report which of the following adverse reactions?

Answer 6

Constipation

Aluminum hydroxide can cause constipation. The nurse should tell the client to increase fluid and fiber intake to reduce the risk for constipation.

Question 7

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

Hyperactive bowel sounds
Sudden abdominal pain
Increased blood pressure
Bradycardia

Answer 7

Sudden abdominal pain

Classic indications of gastrointestinal perforation include sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock.

Question 8

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

a. Epigastric discomfort
b. Dyspepsia
c. Epigastric discomfort
d. Hematemesis

Answer 8

D. Hematemesis
rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority is hematemesis, which indicates massive bleeding

Question 9

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

a. Assess orthostatic blood pressure
b. Explain the procedure for an upper gastrointestinal series
c. Administer pain medication
d. Test the client’s emesis for blood

Answer 9

A. Assess orthostatic blood pressure
rational: During the nursing process, the first action the nurse should take is to assess the client by measuring the clients’ orthostatic blood pressure. This action determines if the client is hypovolemic and establishes a baseline for further measurements

Question 10

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client’s blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?

A. Graham crackers
B. 1 tsp sugar
C. 4 oz diet soda
D. 4 oz skim milk

Answer 10

A. Graham crackers

After establishing that the client has hypoglycemia, the nurse should give the client about 15 g of a rapid-acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk, 3 tsp of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. The nurse should recheck the client’s blood glucose level in 15 minutes.

Question 11

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?

a) 6.3%
b) 7.8%
c) 8.5%
d) 10%

Answer 11

a) 6.3%

The client who has diabetes mellitus needs to manage activity and diet while monitoring blood glucose levels. High levels of blood glucose cause damage to the macro and microcirculation, affecting such things as eyesight and kidney function. The goal for a client who has diabetes mellitus is to keep the HbA1c values at 6.5% or less.

Question 12

A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include?

A. Discard the NPH solution if it appears cloudy.
B. Shake the insulin vigorously before loading the syringe.
C. Expect the NPH insulin to peak in 6 to 14 hr.
D. Freeze unopened insulin vials.

Answer 12

C. Expect the NPH insulin to peak in 6 to 14 hr.

NPH insulin is an intermediate-acting insulin. Its onset of action is 1 to 2 hr, peaking at 6 to 14 hr. Its duration of action is 16 to 24 hr. The client is at risk for hypoglycemia during the peak time.

Question 13

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

A. “Have an eye examination once per year.”
B. “Examine your feet carefully every day.”
C. “Wear compression stockings daily.”
D. “Maintain stable blood glucose levels.”

Answer 13

D. “Maintain stable blood glucose levels.”

Keeping blood glucose under control is the client’s best protection against long-term complications of diabetes, since increased blood sugar contributes to neuropathic disease, and microvascular complications such as retinopathy and nephropathy, as well as to macrovascular complications.

Question 14

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A. “I’ll wear sandals in warm weather.”
B. “I’ll put lotion between my toes after drying my feet.”
C. “I’ll check my feet every day for sores and bruises.”
D. “I’ll soak my feet in cool water every night before I go to bed.”

Answer 14

C. “I’ll check my feet every day for sores and bruises.”

The client should check his feet daily to monitor for any problems and observe any other changes before they become serious. He can use a hand mirror to examine areas that are difficult for him to see.

Question 15

A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A. “ I should soak my feet before trimming my nails.”
B. “I should buy new shoes late in the day.”
C. “I should wear a clean pair of nylon socks every day.”
D. “I should use a heating pad at night when my feet feel cold.”

Answer 15

B. “I should buy new shoes late in the day.”

The client’s feet are larger later in the day. Therefore, this is the best time to buy new shoes.

Question 16

A nurse is evaluating teaching with a client who is receiving continuous subcutaneous insulin via an external insulin pump. which of the following statements by the client indicates a need for further teaching?

Answer 16

“I will use insulin glargine in my insulin pump.”

The client should use a short-acting insulin in the pump. The pump is designed to administer rapid-acting or short acting insulin 24 hours a da. Glargine is classified as a long-acting insulin and is administered at the same time each day to maintain stable blood glucose concentration for a 24 hours period.

Question 17

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include?

A. Perform vigorous exercise when blood glucose is less than 100 mg/dL.
B. Do not exercise if ketones are present in your urine.
C. Avoid eating for 2 hr before exercise.
D. Examine your feet weekly.

Answer 17

B. Do not exercise if ketones are present in your urine.

The nurse should instruct the client not exercise if ketones are present in her urine because this is an indication of inadequate insulin and increases the risk for hyperglycemia.

Question 18

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?

a) Place a bed cradle on the client’s bed.
b) Inspect the client’s feet once weekly.
c) Apply graduated compression stockings to the client’s lower extremities.
d) Put a heating pad on the client’s feet.

Answer 18

a) Place a bed cradle on the client’s bed.

A bed cradle can reduce pain for a client who has diabetic neuropathy by preventing sheets from touching hypersensitive skin.

Question 19

A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

“Take the medication with a meal.”

“You may crush or chew the medication.”

“This medication may cause an increase in perspiration.”

“This medication may turn your urine orange.”

Answer 19

“Take the medication with a meal.”

The client should take metformin with a meal to avoid hypoglycemia and GI upset, and to provide the most absorption of the medication.

Question 20

A female client who has a blood pressure greater than 130 mm Hg systolic and 85 mm Hg diastolic is at risk for type 2 diabetes.

Question 21

A nurse observes mild hand tremors in a client who has diabetes mellitus. Which of the following actions should the nurse take after obtaining a glucose meter reading of 60 mg/dL?

A. Administer 15 g of carbohydrates
B. retest the blood glucose
C. Administer 1 mg of glucagon
D. Administer IV dextarose

Answer 21

A. Administer 15 g of carbohydrates

The first step in preventing the client’s blood glucose level from dropping further is to administer 15 to 20 g of carbohydrates. A client who is awake and can swallow can consume carbohydrates, such as glucose tablets or glucose gel, 120 mL (4 oz) of orange juice, 240 mL (8 oz) of skim milk, 6 saltine crackers, 3 graham crackers, or 6 to 10 hard candies.

Question 22

A nurse in a provider’s office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following findings is the nurse’s priority?

a. The client is experiencing shakiness.
b. The client reports having difficulty checking their blood glucose.
c. The client reports burning and tingling in their feet.
d. The client has a small foot wound.

Answer 22

a. The client is experiencing shakiness.

Using the urgent vs. nonurgent priority-setting framework, the nurse should determine that the client experiencing shakiness is the priority. The client might be experiencing hypoglycemia and requires an intake of glucose. The nurse should check the client’s capillary blood glucose level and provide a carbohydrate if needed.

Question 23

Use of NSAIDs is associated with damage to the gastric mucosa, which can result in acute gastritis.

Question 24

24. A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next?

a. Irrigate the NG tube.
b. Obtain the vital signs.
c. Listen for bowel sounds.
d. Give the ordered antacid.

Answer 24

ANS: B

The patient’s symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken.

Question 25

A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective?

Hct 43%
WBC 8,000/uL
Albumin 4.2 g/dL
Calcium 9.4 mg/dL

Answer 25

Albumin 4.2 g/dL

Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein.

Question 26

A nurse is preparing a client for placement of a catheter for TPN. Which of the following access sites should the nurse plan to prepare for catheter insertion?

A. Left antecubital vein
B. Right subclavian vein
C. Right femoral artery
D. Left arm radial artery

Answer 26

Right subclavian vein

The right subclavian vein is the most common access site for total parenteral nutrition.

Question 27

A nurse is caring for a client who is receiving TPN. The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available?

A. 10% dextrose in water (D10W)
B. 0.45% sodium chloride (0.45% NaCl)
C. Lactated Ringer’s solution
D. 5% dextrose in lactated Ringer’s solution (D5LR)

Answer 27

10% dextrose in water (D10W)

TPN solution has a high concentration of glucose and protein and is hyperosmotic; therefore, the nurse should administer D10W or 20% dextrose in water if there is not another bag of TPN solution available. This will ensure that the client receives the adequate amount of glucose and a solution with the appropriate osmolarity until another TPN solution is available.

Question 28

A nurse is assessing a client who is receiving intermittent enteral nutrition through a nasogastric tube. Which of the following assessments is the nurse’s priority?

a. The client is experiencing abdominal cramping.
b. The client is reporting constipation.
c. The client reports being thirsty.
d. The client is regurgitating the enteral formula.

Answer 28

d. The client is regurgitating the enteral formula.

Using the safety and risk reduction framework, the nurse should identify that the client regurgitating the enteral formula is the priority. This can be an indication of a displaced feeding tube that can result in pulmonary aspiration. The nurse should immediately report this finding to the provider.

Question 29

A nurse is assessing a client and discovers the infusion pump with the client’s total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

A. Excessive thirst and urination
B. Shakiness and diaphoresis
C. Fever and chills
D. Hypertension and crackles

Answer 29

B. Shakiness and diaphoresis

When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.

Question 30

A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syrine. Which of the following instructions should the nurse include?

Answer 30

Discard regular insulin that appears cloudy.

*The nurse should teach the client to discard any regular insulin that appears cloudy, as regular insulin should be clear. NPH insulin has a cloudy appearance.