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A nurse is assessing a client who has appendicitis. Which of the following findings
should the nurse report to the provider immediately?
WBC 16,000/mm³
Board-like abdomen
Nausea and vomiting
Temperature of 38° C (100.4° F) - ANSWERS-Board-like abdomen
When using the urgent vs. nonurgent approach to client care, the nurse should identify
that a board-like abdomen is the priority finding indicating peritonitis. The nurse should
notify the provider immediately.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to
prevent reflux. Which of the following information should the nurse include in the
teaching?
Drink tomato juice with the breakfast meal.
Suck on peppermint when having indigestion.
Elevate the head of the bed 10 cm (4 in) using wooden blocks.
Plan to finish eating at least 3 hr before bedtime. - ANSWERS-Plan to finish eating at
least 3 hr before bedtime.
The nurse should encourage the client not to eat anything at least 3 hr before bedtime
to prevent reflux.
,A nurse is teaching a client who has a deep-vein thrombosis about a new prescription
for warfarin. Which of the following client statements indicates an understanding of the
teaching?
"I will stop taking the medication immediately if I experience nausea."
"I should contact my provider if I notice a pink-tinged color to my urine."
"I will increase my dietary intake of spinach."
"I will not be able to use an electric razor while I am taking this medication." -
ANSWERS-"I should contact my provider if I notice a pink-tinged color to my urine."
The nurse should instruct the client to monitor for blood in the urine. The client should
report a pink-tinged urine color to the provider.
A nurse is reviewing the urinalysis results of a client who has completed a 14-day
course of ciprofloxacin to treat pyelonephritis. Which of the following values should
indicate to the nurse that the client has a continuing infection?
Negative nitrites
RBCs < 2
Positive leukocyte esterase
Amber-colored urine - ANSWERS-Positive leukocyte esterase
The nurse should identify that a positive leukocyte esterase test is an indication of the
presence of WBCs in the urine and the presence of continued infection.
A nurse is assessing a client for manifestations of grief after having a colostomy for
removal of colon cancer. Which of the following findings indicates to the nurse that the
client has accepted the loss?
Becomes angry when it is time to perform colostomy care
Touches the colostomy stoma when the bag is changed
Looks away as the nurse empties the colostomy bag
Tells others that it will be nice to have a normal bowel movement again - ANSWERS-
Touches the colostomy stoma when the bag is changed
,The client touching the colostomy stoma when the bag is changed should indicate to the
nurse that the client is accepting and coping with the alteration of body image and has
gone through the stages of grief.
A nurse is assessing a school-age child who has appendicitis with possible perforation.
Which of the following findings should the nurse identify as a manifestation of
peritonitis?
Abdominal distention
Bradycardia
Hyperactive bowel sounds
Slow, deep breathing - ANSWERS-Abdominal distention
The nurse should identify that peritonitis is an inflammation of the lining of the
abdominal wall. This inflammation, along with the ileus that develops, causes abdominal
distention; therefore, the nurse should identify this as a manifestation of peritonitis.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the
following findings is a priority to report to the provider?
Melena stools
Hemoglobin 7.6 mg/dL
Weight gain of 1.4 kg (3 lb) in 2 weeks
Dyspepsia during the day - ANSWERS-Hemoglobin 7.6 mg/dL
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding to report to the provider is the hemoglobin below the
expected reference range, which in an indication of a peptic ulcer that is chronically
bleeding.
A nurse in an emergency department is assessing a client who has hyperthermia.
Which of the following findings should the nurse identify as an indication that the client
has heat exhaustion?
, Hallucinations
Vomiting
Bradycardia
Seizures - ANSWERS-Vomiting
The nurse should identify that heat exhaustion is usually the result of excess sweating,
leading to dehydration. Manifestations include nausea, vomiting, headache, dizziness,
fainting, and a temperature typically between 38.3º C and 38.9º C (101º F and 102º F).
A nurse is providing teaching to a client who is experiencing malabsorption related to
lactose intolerance. Which of the following foods should the nurse recommend to the
client as the best nondairy source of calcium?
Ground beef
Collard greens
Cauliflower
Walnuts - ANSWERS-Collard greens
The nurse should determine that collard greens are the best food source to recommend
because 1 cup contains 268 mg of calcium per serving.
A nurse is planning care for a client who has renal calculi. Which of the following
interventions should the nurse include to promote elimination of the calculi?
Maintain bedrest until calculi are expelled.
Withhold thiazide diuretics.
Encourage intake of at least 3 L of fluid each day.
Collect all urine for 24 hr in a collection container. - ANSWERS-Encourage intake of at
least 3 L of fluid each day.
The nurse should encourage the client to consume at least 3 L of fluid each day.
Increased fluid intake increases urine production, promotes eliminiation of calculi, and
helps prevent recurrence.