- The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory
results of these patients. Which patient’s PSA result is most important to report to the health care
a. A 38-year-old who is being treated for acute prostatitis
b. A 48-year-old whose father died of metastatic prostate cancer
c. A 52-year-old who goes on long bicycle rides every weekend
d. A 75-year-old who uses saw palmetto to treat benign prostatic hyperplasia (BPH)
The family history of prostate cancer and elevation of PSA indicate that further evaluation of the
patient for prostate cancer is needed. Elevations in PSA for the other patients are not unusual.
- A 22-year-old man tells the nurse at the health clinic that he has recently had some
problems with erectile dysfunction. Which question should the nurse ask first to assess for
possible etiologic factors?
a. “Do you experience an unusual amount of stress?”
b. “Do you use any recreational drugs or drink alcohol?”
c. “Do you have chronic cardiovascular or peripheral vascular disease?”
d. “Do you have a history of an erection that lasted for 6 hours or more?”
A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational
drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are
not common etiologic factors in younger men.
- The nurse in a health clinic receives requests for appointments from several patients. Which
patient should be seen by the health care provider first?
a. A 48-year-old man who has perineal pain and a temperature of 100.4° F
b. A 58-year-old man who has a painful erection that has lasted over 6 hours
c. A 38-year-old man who states he had difficulty maintaining an erection last night
d. A 68-year-old man who has pink urine after a transurethral resection of the prostate
(TURP) 3 days ago
Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be
treated immediately. The other patients do not require immediate action to prevent serious
- Which assessment information is most important for the nurse to report to the health care
provider when a patient asks for a prescription for testosterone replacement therapy (TRT)?
a. The patient has noticed a decrease in energy level for a few years.
b. The patient’s symptoms have increased steadily over the last few years.
c. The patient has been using sildenafil (Viagra) several times every week.
d. The patient has had a gradual decrease in the force of his urinary stream.
The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate
cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The
other patient data indicate that TRT may be a helpful therapy for the patient.
- A 76-year-old patient who has been diagnosed with stage 2 prostate cancer chooses the
option of active surveillance. The nurse will plan to
a. vaccinate the patient with sipuleucel-T ( Provenge).
b. provide the patient with information about cryotherapy.
c. teach the patient about placement of intraurethral stents.
d. schedule the patient for annual prostate-specific antigen testing.
Patients who opt for active surveillance need to have annual digital rectal exams and prostatespecific antigen testing. Vaccination with sipuleucel-T, cryotherapy, and stent placement are
options for patients who choose to have active treatment for prostate cancer.
- Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder
fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in
the initial plan for an effective bladder training program?
a. Limit fluid intake to 1200 mL daily to reduce urine volume.
b. Assist the patient onto the bedside commode every 2 hours.
c. Perform intermittent catheterization after each voiding to check for residual urine.
d. Use an external “condom” catheter to protect the skin and prevent embarrassment.
Developing a regular voiding schedule will prevent incontinence and may increase patient
awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent
catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but
should not be considered solutions for long-term management because of the risks for urinary
tract infection (UTI) and skin breakdown.
- Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis
(MS) who has urinary retention caused by a flaccid bladder?
a. Decrease the patient’s evening fluid intake.
b. Teach the patient how to use the Credé method.
c. Suggest the use of adult incontinence briefs for nighttime only.
d. Assist the patient to the commode every 2 hours during the day.
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not
improve bladder emptying and may increase risk for urinary tract infection (UTI) and
dehydration. The use of incontinence briefs and frequent toileting will not improve bladder
- A client is scheduled for a mastectomy. As she is about to receive the preoperative medication,
she tells the nurse that she does not want to have her breast removed but wants a lumpectomy.
Which response indicates that the nurse is acting as a client advocate?
a. Telling the client her surgeon is excellent and knows what is best for her condition
b. Calling the surgeon to come and explain all treatment options to the client
c. Holding the client’s hand and offering to pray with her for a good outcome
d. Arranging for a postoperative visit from a cancer survivor
Clients have the right to be fully informed about their treatment plans and to change their minds.
A client who expresses doubt, uncertainty, or a change of feeling about a treatment plan should
be supported by the nurse and heard by the health care provider, and should serve as an active
participant in treatment planning. The nurse would be functioning best as a client advocate by
notifying the surgeon that the client wants a different treatment option. The nurse would not be
acting as a client advocate by providing vague reassurance, arranging for a cancer survivor to
come meet with the client, or offering to pray with the client because none of these options
would address the client’s desire for a different treatment option. Calling the surgeon to come
and explain all treatment options also promotes communication and client advocacy.
- A client with cholecystitis has pain in the right shoulder area and asks, “What is happening to
me? What did I do to my shoulder?” What is the nurse’s best response?
a. “You are weak from staying in bed.”
b. “Does your other arm hurt too?”
c. “Sometimes pain from a certain organ is referred elsewhere in the body.”
d. “I am going to hold your medication until we can determine what is happening.”
Many types of visceral pain can be felt in body areas other than the originating site. This is
known as referred pain. Pain originating in the gallbladder can be referred to the right posterior
shoulder. The client should be reassured that this is normal and should be medicated
- The client, who has been found to have a mutation in the BRCA1 gene allele and
to be at increased risk for breast and ovarian cancer, has asked the nurse to be present when she
discloses this information to her adult daughter. What is the nurse’s role in this situation?
a. To act as the primary health care provider
b. To function as a genetic counselor
c. To serve as a client advocate
d. To provide client support
The nurse should be supporting the client emotionally while the client tells her daughter the
information she has learned about the test results. The nurse should not interpret the results nor
counsel the client or her daughter. The nurse should refer the client for counseling or support, if
- A client recently underwent genetic testing that revealed that she has a BRCA1 gene mutation
for breast cancer. What are the best actions of the nurse? (Select all that apply.)
a. Encourage genetic counseling for self and family.
b. Disclose the information to the medical insurance company.
c. Recommend self–breast examination every week.
d. Assess the client’s response to the test results.
e. Aid in making a plan for prevention and risk reduction.
ANS: A, D, E
The medical-surgical nurse can assess the client’s response to the test results and encourage
genetic counseling for self and family. For some positive genetic test results, such as having a
BRCA1 gene mutation, the risk for developing breast cancer is high but is not a certainty.
Because the risk is high, the client should have a plan for prevention and risk reduction. One
form of prevention is early detection. Self–breast examinations are helpful when performed
monthly, but those performed every week may not be useful, especially around the time of
menses. A client who tests positive for a BRCA1 mutation should have at least yearly
mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily
cured. Owing to confidentiality, the nurse would never reveal any information about a client to
an insurance company without the client’s permission.
- A client in the emergency department has potassium of 2.9 mEq/L. For which disease
process or condition does the nurse assess the client?
a. Diabetes mellitus
b. Addison’s disease
d. Diabetes insipidus
- A client has a history of hypothyroidism. Which laboratory value is the nurse most
c. Ca2+ 8.2 mg/dL
d. Mg2+ 1.1 mEq/L
- A client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of
the client’s previous or concurrent health problems is most likely to increase the client’s risk for
a. Chronic alcoholic pancreatitis
b. 50–pack-year smoking history
c. Prostate cancer history
d. Heart surgery 8 years ago
- A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess
for which manifestation consistent with this condition?
b. Kussmaul respirations
d. Positive Chvostek’s sign
- The nurse has sustained a needle stick injury and received a dose of hepatitis B immune
globulin. Which statement indicates that the nurse understands this intervention?
a. “I don’t need to receive the hepatitis B vaccine because I already had the immune
b. “I will need to receive only two doses of the hepatitis B vaccine because I had one
dose of the immune globulin.”
c. “I need to start the hepatitis B vaccination series as soon as possible.”
d. “I will make an appointment to start the hepatitis B vaccination series in 6 weeks.”
The hepatitis B immune globulin will provide only temporary protection against hepatitis B; the
student should begin the vaccination series as soon as possible to ensure long-lasting protection
against the virus.
- Which comment made by a client with breast cancer indicates a need for clarification
regarding cancer causes and prevention?
a. “I will eat a low-fat, high-fiber diet from now on.”
b. “Probably nothing I did or didn’t do caused this cancer.”
c. “I hope my daughter doesn’t develop breast cancer.”
d. “Regular mammograms on my other breast will prevent cancer.”
Regular mammography can help detect breast cancer at an early stage, but it does not prevent
breast cancer. For the most part, the specific cause of many cancers is unknown. Some
associations have been noted with dietary habits. High fat, low fiber, high intake of red meat, and
eating food with preservatives and other additives all have been suspected to contribute to
carcinogenesis. Breast cancer has familial and hereditary forms.
- An adult client who has a suspicious mammogram says that her mother died of bone
cancer when she was around the same age. Which is the most important question for the nurse to
ask this client?
a. “Have any other members of your family had bone cancer?”
b. “Did your mother ever have any other type of cancer?”
c. “How old were you when you started your periods?”
d. “Did your mother have regular mammograms?”
Breast cancer often spreads to the bone. Many laypersons do not understand that breast cancer in
the bone is still breast cancer. It would be very important to know whether this client’s mother
had breast cancer because a genetic component is associated with it. Asking about other family
members who have had bone cancer may give the nurse useful information but would not be as
important as finding out about other cancers. Menstrual cycle and mammogram information also
would not provide as relevant information as inquiring about other types of cancer, specifically
- In preparing a community teaching program, which information does the nurse plan to
present to address secondary cancer prevention?
a. Receiving cancer treatment with chemotherapy
b. Annual measurement of prostate-specific antigen levels
c. Avoiding known cancer-causing substances or conditions
d. Having adolescent children receive the Gardasil vaccination
Secondary prevention focuses on screening and early diagnosis. Annual prostate-specific antigen
(PSA) levels are a screening tool for prostate cancer. Chemotherapy is tertiary prevention
(treatment and rehabilitation). Both avoiding carcinogens and receiving the Gardasil vaccination
are primary preventions.
- The nurse counsels a woman who has a BRCA1 gene that she has what chance for developing
breast cancer during her lifetime?
a. None; this gene has a protective effect
b. Same as the general population
c. Lower than the general population
d. Higher than the general population
BRAC1 is a genetic mutation that increases risk for both breast and ovarian cancer.
3.A client who has just had a mastectomy is crying. When the nurse asks about her crying, the
client responds, “I know I shouldn’t cry because this surgery may well save my life.” What is the
nurse’s best response?
a. “It is all right to cry. Mourning this loss will help make you stronger.”
b. “I know this is hard, but your chances of survival are better now.”
c. “I can arrange for someone who had a mastectomy to come visit if you like.”
d. “How have you coped with difficult situations in the past?”
Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or
grieving for a body image alteration is a healthy part of adapting or adjusting to a new image.
Visiting with someone who has experienced the same situation as the client is very helpful in
showing the client that many aspects of life can be the same afterward. If the opportunity to
arrange this type of visit is available, this would be the nurse’s best response. The other options
do not provide any assistance to the client in coping with her new body image and grieving for
- The nurse works in a long-term care facility. Which resident does the nurse assess most
carefully for manifestations of infection?
a. Resident who has long-standing dementia
b. Resident with incontinence
c. Resident who eats a lot of sweets and little protein
d. Resident whose family won’t allow an influenza vaccination
All older clients are at increased risk for infection owing to age-related decreased immune
function. Each of these clients has special reasons for being at increased risk. However, the one
at highest risk is the client with incontinence because this is a chronic condition that is a daily
problem, leaving his or her skin vulnerable to breakdown and bacterial entry. Poor perineal care
also increases the risk for urinary tract infection.
- A client is recovering from cataract surgery and needs medication to prevent a potential eye
infection. Which drug does the nurse question administering to the client?
a. Tobramycin (Tobrex)
b. Apraclonidine (Iopidine)
c. Gentamicin (Genoptic)
d. Ciprofloxacin (Ciloxan)
- The nurse assesses several clients. Which one is most likely to have secondary open-angle
a. Client with gradual onset of blurred vision
b. Client who has recently had eye surgery
c. Client who sees halos around lights
d. Client with reactive pupils and clear sclera
Secondary open-angle glaucoma results from another condition that interferes with drainage of
the aqueous humor such as recent eye surgery. Cataracts usually start with a slow onset of
blurred vision but do not lead to secondary open-angle glaucoma. A late manifestation of primary
open-angle glaucoma is seeing halos around lights; this is not considered secondary open-angle
glaucoma. The client with reactive pupils and clear sclera has normal assessment findings, not
related to secondary open-angle glaucoma
- The nurse is providing discharge teaching for a client with posterior uveitis. Which is the
most important precaution for the nurse to teach the client?
a. Correct technique for eyedrop instillation
b. Clinical manifestations of retinal hemorrhage
c. Correct technique for insertion of contact lenses
d. Proper timing of opioid analgesics
Treatment of posterior uveitis is symptomatic, with eyedrops used to dilate the pupil and
decrease the inflammatory response. The client may have to instill eyedrops as frequently as
every hour. This condition consists of inflammation of the retina—not a hemorrhage. Opioids are
not prescribed to lessen the pain, but cool or warm compresses may be used for ocular pain.
- A client comes to the emergency department with periorbital ecchymosis of the right eye.
Which is the nurse’s priority action?
a. Apply an ice pack to the affected eye.
b. Patch the eye to prevent eye movement.
c. Assess the client’s vision in both eyes.
d. Irrigate the affected eye with normal saline.
Ice will cause capillary vasoconstriction, thereby decreasing swelling and capillary oozing.
Treatment with ice begins at the time of injury. Whenever the eye or surrounding tissue is
injured, visual acuity is assessed next.
- A client with acute-angle glaucoma has several medications ordered. Which medications does
the nurse question? (Select all that apply.)
a. Acetazolamide (Diamox)
b. Pilocarpine (Pilocar)
c. Atropine (Isopto Atropine)
d. Latanoprost (Xalatan)
e. Timolol (Timoptic)
ANS: C, F
Atropine and epinephrine are mydriatics, which decrease the outflow of aqueous humor,
resulting in increased intraocular pressure (IOP). Diamox is a carbonic anhydrase inhibitor that
decreases the formation of aqueous humor. Pilocar is a miotic that enhances outflow of aqueous
humor. Xalatan is a prostaglandin agonist that improves outflow, and Timoptic is a beta blocker
that decreases the formation of aqueous humor. All these help decrease IOP.
- The nurse is teaching a postoperative client who had a keratoplasty. Which responses by the
client require further teaching about safety in the home? (Select all that apply.)
a. “We use throw rugs in the bathroom.”
b. “Our neighbors will be bringing food for a week.”
c. “We may have two extension cords in the living room.”
d. “Most of the furniture is placed against the wall, except for one rocking chair.”
e. “Every room has at least one window.”
f. “The hallway has low lighting.”
ANS: A, C, D, F
Throw rugs pose a danger of slipping or tripping. The client cannot see if the rug is flat or
elevated. Extension cords should be placed under or behind the furniture to decrease the
possibility of tripping. Furniture should be out of the normal walking pathway. Low lighting in
the hallway may pose a problem when the client has a patch and shield over the operated eye.
Lighting from a window should not be a problem. When neighbors bring food, the chance of
burns occurring while cooking with limited vision is reduced.
- A blind client is admitted to the hospital unit. Orientation to the unit includes which
information? (Select all that apply.)
a. Introduce the staff to the client.
b. Describe the room to the client using one reference point.
c. Walk the client to the bathroom and describe it.
d. Tell the client to use the call light if he or she wants to go to the bathroom.
e. Explain the routine of the unit and how to operate the bed controls.
f. Assist in putting the client’s belongings away.
ANS: B, C, E, F
The client needs to know where everything is located to be independent and safe from falls.
Clients need to be shown where things are and how to do things such as turn on the call light and
raise the head of the bed. The client should be introduced to the staff, not the reverse, and should
first be shown how to use the call light.
- Which of the nurse’s assessment findings will require collaboration with the client’s primary
health care provider? (Select all that apply.)
a. Purulent drainage from the ear canal
b. Hearing loss with nausea and vertigo
c. Ringing in the ears after attending a loud rock concert
d. Presence of cerumen blocking 50% of the ear canal
e. Increasing hearing loss since starting furosemide (Lasix)
f. Temperature of 101.7° F following a stapedectomy 3 days ago
ANS: A, B, E, F
Purulent drainage in the ear canal indicates a middle ear infection with a ruptured tympanic
membrane. Hearing loss with vertigo and nausea indicates labyrinthitis. Furosemide is ototoxic.
Fever following stapedectomy is most likely caused by infection inside the ear. Ringing in the
ears following exposure to loud noise is a common symptom, which should resolve
spontaneously. Nonimpactedcerumen may be left alone if it is not impairing the client’s hearing.
- Which client statement indicates that the client understands teaching about stapedectomy
surgery? (Select all that apply.)
a. “My hearing will get worse before it gets better.”
b. “I will have to miss 6 weeks of swim team practice.”
c. “I will see the doctor 1 week after surgery to have my stitches removed.”
d. “Foods may taste funny for a short time after surgery.”
e. “I may get dizzy and feel like the room is spinning after surgery.”
f. “I can blow my nose to relieve the feeling of fullness in my ear after surgery.”
ANS: A, B, D, E
Postoperative swelling and packing in the ear will result in reduced hearing ability for the first
few weeks after surgery. When the swelling subsides and the packing is removed, hearing will
improve. The client should not get water in the ear for the first 6 weeks after surgery. Damage to
or swelling of the facial nerve may result in postoperative loss of taste sensation. Vertigo is
common after stapedectomy because of close proximity to inner ear structures. Blowing the nose
should be avoided to prevent increased pressure within the ear.
- A client has mastoiditis. The nurse assesses most carefully for which manifestations? (Select
all that apply.)
a. Red and bulging eardrum
b. A crackling sound upon yawning
c. Enlarged lymph nodes behind the ear
d. Low-grade fever and malaise
e. Diminished hearing
f. Loss of appetite
ANS: C, D, E, F
Common signs and symptoms of mastoiditis include enlarged lymph nodes behind the ear, lowgrade fever, malaise, loss of hearing, and loss of appetite. When the eardrum is red and bulging
and a crackling sound is heard upon yawning, the client is usually diagnosed with otitis media.
- The nurse reviews the health history of a client with acute osteomyelitis. Which findings might
have contributed to the diagnosis? (Select all that apply.)
a. Recent dental work
b. Urinary tract infection
f. Gastrointestinal infection
ANS: B, E, F
Poor dental hygiene and gum infection (not necessarily recent dental work), urinary tract
infection, hemodialysis, and Salmonella infection of the gastrointestinal tract can be sources of
infection and, consequently, osteomyelitis. Pregnancy and advancing age are not necessarily
precursors to osteomyelitis, even though urinary tract infection leading to osteomyelitis is
common in older men.
- The nurse is performing a medical history and physical assessment for a client. Which
assessment findings lead the nurse to conclude that the client is at risk for development of
osteoporosis? (Select all that apply.)
a. Client is a white woman with a body mass index (BMI) of 19.4.
b. Client fractured her wrist badly in a fall last year.
c. Client drinks at least four cans of diet cola every day.
d. Client does tai chi exercises for 45 minutes every morning.
e. Client has smoked two packs of cigarettes a day for 40 years.
f. Client has taken estrogen (Premarin) 0.625 mg daily since menopause.
ANS: A, B, C, E
Risk factors for osteoporosis include white race, female gender, small body frame, large intake of
caffeinated carbonated drinks, and smoking cigarettes. Recent fracture after a fall indicates that
the client’s bones may be soft and/or thin. Hormone replacement therapy, late onset of
menopause, and regular exercise help reduce the risk of osteoporosis.
- A client has a fractured tibia and is asking the nurse about external fixation. What are some
advantages for the use of external fixation for the immobilization of fractures? (Select all that
a. Leads to minimal blood loss
b. Allows for early ambulation
c. Decreases the risk of infection
d. Increases blood supply to tissues
e. Provides visualization of bone ends
f. Promotes healing
ANS: A, B, F
Blood loss is less. The device allows early ambulation and exercise, maintains alignment,
stabilizes the fracture site, and promotes healing. The device does place the client at risk for
infection and does not increase the blood supply to tissues, nor does it provide visualization of
the ends of the bone.
- An older woman is admitted after falling down the stairs. Which assessment findings require
immediate intervention? (Select all that apply.)
a. Blood pressure, 80/50 mm Hg
b. Potassium, 6.0 mEq/L
c. Dark brown urine
d. Heart rate, 90 beats/min
e. Urine output, 50 mL/hr
ANS: A, B, C
Low blood pressure could indicate hypovolemia, which occurs with crush syndrome.
Hyperkalemia and dark brown urine also may indicate crush syndrome. A heart rate of 90
beats/min is within normal limits; urine output of 50 mL/hr is also a normal finding.
- A client with a new fracture reports pain in the site of the fracture. An opioid pain medication
was administered 20 minutes ago. Which is the nurse’s best intervention? (Select all that apply.)
a. Administration of additional opioids
b. Elevation of the extremity
c. Application of ice
d. Application of heat
e. Keeping the extremity in a dependent position
ANS: A, B, C
The client with a new fracture likely has edema; elevating the extremity and applying ice
probably will help in decreasing pain. Heat will increase edema and may increase pain.
Dependent positioning will also increase edema. Administration of an additional opioid within
the dosage guidelines may be ordered.
- The nurse is preparing to perform an abdominal assessment on a client with suspected
cholecystitis. In what sequence does the nurse palpate the client’s abdomen?
a. Palpate the lower quadrants only.
b. Palpate the upper quadrants last.
c. Palpate the upper quadrants only.
d. Defer palpation and use percussion only.
The client with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender
or painful areas should be palpated last to prevent the client from tensing his or her abdominal
muscles because of pain, thereby making the examination more difficult. All quadrants should be
palpated. Palpation is an important assessment tool that should not be deferred for this client.
- The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to
talk with someone who had a similar experience. Which is the nurse’s best response?
a. “Most people who have had a colostomy are reluctant to talk about it.”
b. “I will make a referral to the United Ostomy Associations of America.”
c. “You can get all the information you need from the enterostomal therapist.”
d. “I do not think that we have any other clients with colostomies on the unit right
Nurses need to become familiar with community-based resources to assist clients better. The
local chapter of the United Ostomy Associations of America has resources for clients and their
families, including Ostomates (specially trained visitors who also have ostomies). Although the
enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as
talking with someone who actually has had a colostomy. Many people are willing to share their
ostomy experience in the hope of helping others. The nurse should not brush aside the client’s
request by saying that no colostomy clients are present on the unit at the time.
- A client tells the nurse that her husband is repulsed by her colostomy and refuses to be
intimate with her after surgery. Which is the nurse’s best response?
a. “Let’s talk to the ostomy nurse to help you and your husband work through this.”
b. “You could try to wear longer lingerie that will better hide the ostomy appliance.”
c. “You should empty the pouch first so it will be less noticeable for your husband.”
d. “If you are not careful, you can hurt the stoma if you engage in sexual activity.”
The nurse should collaborate with the ostomy nurse to help the client and her husband work
through intimacy issues. The nurse should not minimize the client’s concern about her husband
with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her
- The nurse is caring for a client who just had colon resection surgery with a new colostomy.
Which teaching objective does the nurse include in the client’s plan of care?
a. Understanding colostomy care and lifestyle implications
b. Learning how to change the appliance independently
c. Demonstrating the correct way to change the appliance by discharge
d. Not being afraid to handle the ostomy appliance tomorrow
Client learning goals must be measurable and objective with a time frame, so the nurse can
determine whether they have been met. When the goal is to have the client demonstrate a
particular skill, the nurse can easily determine whether the goal was met. The specific time frame
of “by discharge” is easily measurable also. The other goals are all subjective and cannot be
measured objectively. The first two options do not have time frames. “Tomorrow” is a vague
- The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which
assessment finding leads the nurse to conclude that the obstruction is in the small bowel?
a. Potassium of 2.8 mEq/L, with a sodium value of 121 mEq/L
b. Losing 15 pounds over the last month without dieting
c. Reports of crampy abdominal pain across the lower quadrants
d. High-pitched, hyperactive bowel sounds in all quadrants
Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is
hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145
mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the
probable development of colon cancer. High-pitched, hyperactive bowel sounds may be noted
with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is
associated with large bowel obstruction.
- A client who has had a colostomy placed in the ascending colon expresses concern that the
effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is
the nurse’s best response?
a. “This is normal for your type of colostomy.”
b. “I will let the health care provider know, so that it can be assessed.”
c. “You should add extra fiber to your diet to stop the diarrhea.”
d. “Your stool will become firmer over the next few weeks.”
The stool from an ascending colostomy can be expected to remain liquid because little large
bowel is available to reabsorb the liquid from the stool. The provider may be notified, but this is
not the best response from the nurse. Liquid stool from an ascending colostomy will not become
firmer with the addition of fiber to the client’s diet or with the passage of time.
- The nurse is providing discharge teaching for a client who has undergone colon resection
surgery with a colostomy. Which statements by the client indicate that the instruction was
understood? (Select all that apply.)
a. “I will change the ostomy appliance daily and as needed.”
b. “I will use warm water and a soft washcloth to clean around the stoma.”
c. “I will start bicycling and swimming again once my incision has healed.”
d. “I will notify the doctor right away if any bleeding from the stoma occurs.”
e. “I will check the stoma regularly to make sure that it stays a deep red color.”
f. “I will avoid dairy products to reduce gas and odor in the pouch.”
g. “I will cut the flange so it fits snugly around the stoma to avoid skin breakdown.”
ANS: B, C, G
The client should avoid using soap to clean around the stoma because it might prevent effective
adhesive of the ostomy appliance. The client should use warm water and a soft washcloth
instead. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia
and should be reported to the surgeon right away. The tissue of the stoma is very fragile, and
scant bleeding may occur when the stoma is cleaned. Yogurt and buttermilk can help reduce gas
in the pouch, so the client need not avoid dairy products. Exercise (other than some contact
sports) is important for clients with an ostomy.
- A female client is admitted with an exacerbation of ulcerative colitis. Which laboratory value
does the nurse correlate with this condition?
a. Potassium, 5.5 mEq/L
b. Hemoglobin, 14.2 g/dL
c. Sodium, 144 mEq/L
d. Erythrocyte sedimentation rate (ESR), 55 mm/hr
The erythrocyte sedimentation rate (ESR) is an indicator of inflammation, which is elevated
during an exacerbation of ulcerative colitis. The normal range for the ESR is 0 to 33 mm/hr.
Diarrhea caused by ulcerative colitis will result in loss of potassium and hypokalemia with levels
lower than 3.5 mEq/L. Bloody diarrhea will lead to anemia, with hemoglobin levels lower than
12 g/dL in females. The sodium level is normal.
- The nurse is teaching a client how to care for a new ileostomy. Which client statement
indicates that additional teaching is needed?
a. “I will consult the pharmacist before filling any new prescriptions.”
b. “I will empty the ostomy pouch when it is half-filled with stool or gas.”
c. “I will wash my hands with antibacterial soap before and after ostomy care.”
d. “I will call my health care provider if I have not had ostomy drainage for 3 hours.”
A client with an ileostomy should call the provider if no drainage has come from the ostomy in 6
to 12 hours. The other statements indicate good understanding of self-management.
- The nurse is caring for a teenage girl with a new ileostomy. She tells the nurse tearfully that
she cannot go to the prom with an ostomy. Which is the nurse’s best response?
a. “You should get your prom dress one size larger to hide the ostomy appliance.”
b. “You should avoid broccoli and carbonated drinks so that the pouch won’t fill with
air under your dress.”
c. “Let’s talk to the enterostomal therapist (ET) about options for ostomy supplies
and dress styles so that you can look beautiful for the prom.”
d. “You can remove the pouch from your ostomy appliance when you are at the prom
so that it is less noticeable.”
The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and
methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy
appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client.
Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not
- The nurse is caring for a client who had ileostomy surgery 10 days ago. The client verbalizes
concerns that the effluent has not become formed and is still liquid green. Which is the nurse’s
a. “I will call your health care provider right away because the stool should be semi-solid by now.”
b. “Your stools will firm up in a few weeks as your body gets used to the ileostomy.”
c. “You should eat a high-fiber diet to help make the stool bulkier and more solid.”
d. “You can add buttermilk or yogurt to your diet and avoid carbonated soft drinks.”
Effluent from an ileostomy will become less liquid (but not solid) over time as the body adapts to
loss of the large bowel. This process takes time and the client should be reassured of this. Clients
with a new ileostomy should avoid high-fiber diets for the first few weeks because blockage of
the bowel may occur. Buttermilk, yogurt, and carbonated drinks will not affect this process
- The nurse is caring for a client with severe ulcerative colitis who has been prescribed
adalimumab (Humira). Which client statement indicates that additional teaching about the
medication is needed?
a. “I will avoid large crowds and people who are sick.”
b. “I will take this medication with food or milk.”
c. “Nausea and vomiting are common side effects.”
d. “I will wash my hands after I play with my dog.”
Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It
does not need to be given with food or milk. Nausea and vomiting are two common side effects.
Adalimumab can cause immune suppression, so clients receiving the medication should avoid
large crowds and people who are sick, and should practice good handwashing.
- The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing
assessment is the highest priority?
a. Skin integrity
b. Blood pressure
c. Heart rate and rhythm
d. Abdominal percussion
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the
client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from
severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte
replacement may be necessary. Abdominal percussion is an important part of physical
assessment but has lower priority for this client than heart rate and rhythm.
- The nurse is preparing to begin teaching the client about how to care for a new ileostomy.
Which consideration is the highest priority for the nurse when planning teaching for this client?
a. Informing the client about what to expect with basic ostomy care
b. Starting the teaching after the client has received pain medication
c. Starting the teaching when the client is ready to look at the stoma
d. Making sure that all needed supplies are ready at the client’s bedside
The nurse should wait until the client is ready to look at the ostomy and stoma before initiating
teaching about ostomy care. The nurse should monitor clues from the client and encourage him
or her to start taking an active role in management. Effective learning will occur only when the
learner is ready. The other considerations are of lower priority for the client and nurse.
- The nurse is caring for a client with Crohn’s disease who has developed a fistula. Which
nursing intervention is the highest priority?
a. Monitor the client’s hematocrit and hemoglobin.
b. Position the client to allow gravity drainage of the fistula.
c. Check and record blood glucose levels every 6 hours.
d. Encourage the client to consume a diet high in protein and calories.
The client with Crohn’s disease is already at risk for malabsorption and malnutrition.
Malnutrition impairs healing of the fistula and immune responses. Therefore, maintaining
adequate nutrition is a priority for this client. The client will require 3000 calories per day to
promote healing of the fistula. Monitoring the client’s blood sugar and hemoglobin levels is
important, but less so than encouraging nutritional intake. The client need not be positioned to
facilitate gravity drainage of the fistula, because fistulas often are found in the abdominal cavity.
- The nurse reviews a health teaching for a client with Crohn’s disease. Which instruction does
the nurse provide for the client?
a. “You should have a colonoscopy every few years.”
b. “You should eat a diet that is high in protein and fiber.”
c. “You should avoid heavy lifting and tight-fitting clothes.”
d. “You should take the Asacol whenever you have loose stools.”
Long-term inflammatory bowel disease increases the risk of colon cancer, so regular
colonoscopies are recommended. A high-fiber diet is not recommended for clients with Crohn’s
disease because fiber can further irritate the inner lining of the bowel. Asacol (mesalamine [5-
aminosalicylic acid]) should be taken daily, not as needed. Avoiding heavy lifting and tightfitting clothes is not necessary.
- The nurse is preparing a client with diverticulitis for discharge from the hospital. Which
statement by the client indicates that additional teaching is needed?
a. “I will ride my bike or take a long walk at least three times a week.”
b. “I will try to include at least 25 g of fiber in my diet every day.”
c. “I will take a senna laxative at bedtime to avoid becoming constipated.”
d. “I will use my legs rather than my back muscles when I lift heavy objects.”
Laxatives are not recommended for clients with diverticulitis because they can increase pressure
in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are
recommended for clients with diverticulitis because they promote regular bowel function. Using
the leg muscles rather than the back for lifting prevents abdominal straining.
- The nurse is assessing health fair participants for risks for hepatitis. The nurse recognizes
which client as being at greatest risk for developing hepatitis B?
a. College student who has had several sexual partners
b. Woman who takes acetaminophen daily for headaches
c. Businessman who travels frequently
d. Older woman who has eaten raw shellfish
Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood
transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple
sexual partners has more opportunities to contract the infection.
- A client is admitted with jaundice and suspected hepatitis B. Which intervention does the
nurse add to the client’s care plan?
a. Encourage rest during this period.
b. Assist the client with ambulation.
c. Place the client on a clear liquid diet.
d. Administer PRN prochlorperazine maleate (Compazine).
During the icteric phase, the client is encouraged to rest. Rest reduces the metabolic demands of
the liver and promotes hepatic cell regeneration. The client may or may not need assistance with
ambulation. The diet should be high in carbohydrates and calories for energy; clear liquids may
be needed if the client is nauseated. The client may or may not need antiemetics.
- The nurse monitors for which serologic marker in the client who is a carrier of chronic
a. Anti-hepatitis C virus (HCV) antibodies
b. Anti-hepatitis B (HBs) antibodies
c. Hepatitis B surface antigen (HBsAg) antibodies
d. Hepatitis A virus (HAV) antibodies
Persistent presence of the serologic marker HBsAg after 6 months indicates a carrier state or
chronic hepatitis. The other markers are not indicative of a carrier state.
- A client is diagnosed with hepatitis B. Which information does the nurse include in the
teaching plan as a priority?
a. “Avoid drinking any alcohol until the doctor says you can.”
b. “You will need aggressive control of your serum lipids.”
c. “Once your lab work returns to normal, you can donate blood again.”
d. “Wash your hands well after handling meat and shellfish.”
Alcohol has a hepatotoxic effect, and clients with any liver disease should not drink it. Serum
lipids need control in clients with fatty liver. Once a client has hepatitis B, he or she should not
donate blood or organs. Handling contaminated shellfish is a cause of hepatitis A infection.
- The nurse is caring for a client with cholecystitis. Which assessment finding indicates to the
nurse that the condition is chronic rather than acute?
a. Abdomen that is hyperresonant to percussion
b. Hyperactive bowel sounds and diarrhea
c. Clay-colored stools and dark amber urine
d. Rebound tenderness in the right upper quadrant
In chronic cholecystitis, bile duct obstruction results in the absence of urobilinogen to color the
stool. Excess circulating bilirubin turns the urine dark and foamy. The other assessment findings
do not correlate with chronic cholecystitis.
- A client is admitted for suspected cholecystitis. On reviewing laboratory results, the nurse
notes that the client’s amylase is elevated. Which action by the nurse is best?
a. Document the finding in the chart.
b. Ask the client about drinking habits.
c. Notify the health care provider.
d. Place the client on clear liquids.
Serum and urine amylase levels are elevated when the pancreas becomes inflamed. One cause of
pancreatitis is gallbladder disease; another causative factor is alcohol intake. The nurse should
tactfully explore this subject with the client before documenting the findings and notifying the
provider. The client may need to be NPO or on clear liquids, but the nurse does not have enough
information yet to determine this.
- The nurse is providing discharge teaching for a client who has just undergone laparoscopic
cholecystectomy surgery. Which statement by the client indicates understanding of the
a. “I will drink at least 2 liters of fluid a day.”
b. “I need a diet without a lot of fatty foods.”
c. “I should drink fluids between meals rather than with meals.”
d. “I will avoid concentrated sweets and simple carbohydrates.”
After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a
special diet is not recommended for most clients. Good fluid intake is healthy for all people but
is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which
is not seen with this operation. Restriction of sweets is not required.
- The nurse is caring for a postoperative client who reports pain in the shoulder blades following
laparoscopic cholecystectomy surgery. Which direction does the nurse give to the nursing
assistant to help relieve the client’s pain?
a. “Ambulate the client in the hallway.”
b. “Apply a cold compress to the client’s back.”
c. “Encourage the client to take sips of hot tea or broth.”
d. “Remind the client to cough and deep breathe every hour.”
The client who has undergone a laparoscopic cholecystectomy may report free air pain because
of retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation
to promote absorption of the carbon dioxide. Coughing and deep breathing are important
postoperative activities, but they are not related to discomfort from carbon dioxide. Cold
compresses and drinking tea would not be helpful.
- The nurse is caring for a client with acute pancreatitis. During the physical assessment, the
nurse notes a grayish-blue discoloration of the client’s flanks. Which is the nurse’s priority
a. Prepare the client for emergency surgery.
b. Place the client in high Fowler’s position.
c. Insert a nasogastric (NG) tube to low intermittent suction.
d. Ensure that the client has a patent large-bore IV site.
Grayish-blue discoloration on the flanks (Turner’s sign) indicates pancreatic enzyme leakage into
the peritoneal cavity. This presents a risk of shock for the client, so IV access should be
maintained with at least one large-bore patent IV catheter. The client may or may not need
surgery; usually a fetal position helps with pain, and having an NG tube would not take priority
over IV access.
- The nurse is caring for a client with acute pancreatitis. Which nursing intervention best
reduces discomfort for the client?
a. Administering morphine sulfate IV every 4 to 6 hours as needed
b. Maintaining NPO status for the client with IV fluids
c. Providing small, frequent feedings, with no concentrated sweets
d. Placing the client in semi-Fowler’s position at elevation of 30 degrees
The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production.
IV fluids should be used to prevent dehydration. The client may need a nasogastric (NG) tube.
Pain medications should be given around the clock and more frequently than every 4 to 6 hours.
A fetal position with legs drawn up to the chest will promote comfort.
- The nurse is caring for a client with chronic pancreatitis. Which instruction by the nurse is
a. “You will need to limit your protein intake.”
b. “We need to call the dietitian to get help in planning your diet.”
c. “You cannot eat concentrated sweets any longer.”
d. “Try to eat less red meat and more chicken and fish.”
A client with chronic pancreatitis needs 4000 to 6000 calories per day for optimum nutrition and
healing. The client may have additional restrictions if he or she has other health problems such as
diabetes. The nurse should collaborate with the registered dietitian to help the client plan
- The nurse is teaching a community group about pancreatic cancer. Which risk factor does
the nurse instruct is known for development of this type of cancer?
c. BRCA2 gene mutation
d. African-American ethnicity
Mutations in both BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a
small number of cases. The other factors do not appear to be linked to increased risk.