A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000
mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory
results?
1. Report the abnormally low count.
2. Report the abnormally high count.
3. Place the client on bleeding precautions.
4. Place the normal report in the client's medical record.
The nurse is teaching a client who has iron deficiency anemia about foods she should
include in the diet. The nurse determines that the client understands the dietary
modifications if which items are selected from the menu?
1. Nuts and milk
2. Coffee and tea
3. Cooked rolled oats and fish
4. Oranges and dark green leafy vegetables
The nurse is planning to teach a client with malabsorption syndrome about the
necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid
and should include which food items on the list? Select all that apply.
1. Oranges
2. Broccoli
3. Margarine
4. Cream cheese
5. Luncheon meats
6. Broiled haddock
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the
operative consent form because of sedation from opioid analgesics that have been
administered. The nurse should take which most appropriate action in the care of this
client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately.
3. Send the client to surgery without the consent form being signed.
,4. Obtain a telephone consent from a family member, following agency
policy.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the
nurse would be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin
A gastrectomy is performed on a client with gastric cancer. In the immediate
postoperative period, the nurse notes bloody drainage from the nasogastric tube. The
nurse should take which most appropriate action?
1. Measure abdominal girth.
2. Irrigate the nasogastric tube.
3. Continue to monitor the drainage.
4. Notify the primary health care provider (PHCP).
The nurse is teaching a client about the risk factors associated with colorectal cancer.
The nurse determines that further teaching is necessary related to colorectal cancer
if the client identifies which item as an associated risk factor?
1. Age younger than 50 years
2. History of colorectal polyps
3. Family history of colorectal cancer
4. Chronic inflammatory bowel disease
The nurse is assessing the perineal wound in a client who has returned from the
operating room following an abdominal perineal resection and notes serosanguineous
drainage from the wound. Which nursing intervention is most appropriate?
1. Clamp the surgical drain.
2. Change the dressing as prescribed.
3. Notify the surgeon.
4. Remove and replace the perineal packing.
,A client is diagnosed as having a intestinal tumor. The nurse should monitor the client
for which complications of this type of tumor? Select all that apply.
1. Flatulence
2. Peritonitis
3. Hemorrhage
4. Fistula formation
5. Bowel perforation
6. Lactose intolerance
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis.
The nurse instructs the client to include which foods rich in vitamin B12 in the
diet? Select all that apply.
1. Nuts
2. Corn
3. Liver
4. Apples
5. Lentils
6. Bananas
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis
who is scheduled for surgery in 2 hours. The client begins to complain of increased
abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen
is distended and bowel sounds are diminished. Which is the most appropriate nursing
intervention?
1. Administer the prescribed pain medication.
2. Notify the primary health care provider (PHCP).
3. Call and ask the operating room team to perform surgery as soon as
possible.
4. Reposition the client and apply a heating pad on the warm setting to the
client's abdomen.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with acute
pancreatitis? Select all that apply.
1. Diarrhea
, 2. Black, tarry stools
3. Hyperactive bowel sounds
4. Gray-blue color at the flank
5. Abdominal guarding and tenderness
6. Left upper quadrant pain with radiation to the back
The nurse is assessing a client who is experiencing an acute episode of cholecystitis.
Which of these clinical manifestations support this diagnosis? Select all that apply.
1. Fever
2. Positive Cullen's sign
3. Complaints of indigestion
4. Palpable mass in the left upper quadrant
5. Pain in the upper right quadrant after a fatty meal
6. Vague lower right quadrant abdominal discomfort
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my
taste for food." What instruction should the nurse give the client to provide adequate
nutrition?
1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only 3 large meals daily.
A client has developed hepatitis A after eating contaminated oysters. The nurse
assesses the client for which expected assessment finding?
1. Malaise
2. Dark stools
3. Weight gain
4. Left upper quadrant discomfort
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate
for this client? Select all that apply.