A.
Hiccups and diarrhea
B.
Fatigue and abdominal pain
C.
Constipation and fever
D.
Diaphoresis and diarrhea
1. D
Dumping syndrome occurs after gastric surgery because food is not held as long in the stomach and is dumped into the intestine as hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms typically can include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distension, hyperactive bowel sounds, and diarrhea. Options 1, 2, and 3 are incorrect and are not signs of dumping syndrome.
2.
A nurse is providing instructions to a client who will collect a stool
specimen for occult blood. The nurse instructs the client to avoid which of the
following for 3 days before the collection of the stool specimen?
A.
Milk products
B.
Hard cheese
C.
Turnips
D.
Cottage cheese
2. C
The nurse would instruct the client to avoid red meat, poultry, fish, turnips, horseradish, and foods such as fruits and vegetables for 3 days before and during testing. These products may alter test results.
3.
Which of the following nursing interventions should have the highest
priority during the first hour after the admission of a client with
cholecystitis who is experiencing pain, nausea, and vomiting?
A.
Administering pain medication.
B.
Completing the admission history.
C.
Maintaining hydration.
D.
Teaching about planned diagnostic tests.
3. A
1: Administering pain medication would have the highest priority during the first hour after the client's admission. 2: Completing the admission history can be done after the client's pain is controlled. 3: Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief. 4: It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.
4.
The client with Crohn’s disease has a nursing diagnosis of Acute Pain.
The nurse would teach the client to avoid which of the following in managing
this problem?
A.
Lying supine with the legs straight
B.
Massaging the abdomen
C.
Using antispasmodic medication
D.
Using relaxation techniques
4. A
Pain associated with Crohn’s disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.
5.
A client with viral hepatitis is discussing with the nurse the need to
avoid alcohol and states, “I’m not sure I can avoid alcohol.” The most
appropriate response is
A.
“Everything will be alright.”
B.
“I think you should talk more with the doctor about this.”
C.
“I don’t believe that.”
D.
“I’m not sure that I don’t understand. Would you please explain?”
5. D
Explaining what is vague or clarifying the meaning of what has been said increases the understanding for the client and the nurse. False reassurance devalues the client’s feelings. Refusing to consider the client’s ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. Placing the client’s feelings on hold by referring the client to the doctor for further information is a block to communication.
6.
A nurse is reviewing the orders of a client admitted to the hospital
with a diagnosis of acute pancreatitis. Select the interventions that the nurse
would expect be prescribed for the client.
A.
Small, frequent high calorie feedings.
B.
Meperidine (Demerol) as prescribed for pain.
C.
Maintain the client in a supine and flat position.
D.
Encourage coughing and deep breathing.
E.
Administer antacids as prescribed.
6. B+D+E
The client with acute pancreatitis normally is placed on an NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as meperidine will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45-degrees decreases tension on the abdomen and also may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.
7.
A nurse is performing an assessment on a client with a suspected
diagnosis of acute pancreatitis. The nurse assesses the client, knowing that
which of the following is a hallmark sign of this disorder?
A.
Severe abdominal pain relieved by vomiting
B.
Severe abdominal pain that is unrelieved by vomiting
C.
Hypothermia
D.
Epigastric pain radiating to the neck area
7. B
Nausea and vomiting are common presenting symptoms of acute pancreatitis. A hallmark sign is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever is also a common symptom but is usually less than 38 degrees centigrade. Epigastric pain radiating to the neck area is not a characteristic sign.
8.
A 30-year-old woman is admitted to the hospital with complaints of
severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness
of the patient's intravenous therapy. Which of the following laboratory tests
BEST reflects hydration status?
A.
Erythrocyte sedimentation rate.
B.
White blood cell count.
C.
Hematocrit.
D.
Serum glucose.
8. C
STRATEGY: Think about what each value measures. How does it relate to hydration? CORRECT ANSWER: (3) relative vol of plasma to RBCs; increased with dehydration, reduced fluid vol excess; normal: men 42 - 50%, women 40 - 48%; other tests that indicate hydration: BP, urine specific gravity (normal: 1.010 - 1.030), CVP (normal 3 - 11 cm/H2O) (1) ESR: rate at which RBCs settle out of unclotted blood in 1 hr; indicates inflammation/necrosis; normal: men 0 - 15 mm/h, women 0 - 20 mm/h (2) WBC: indicates infection (normal 5,000 - 10,000); reduced: leukopenia, elevated: leukocytosis (4) indicates insulin production (normal 60 - 110 mg/dL)
9.
The nurse provides discharge instructions to a patient with hepatitis B.
Which of the following statements, if made by the patient, would indicate the
need for further instruction?
A.
"I can never donate blood."
B.
"I can never have unprotected sex."
C.
"I cannot share needles."
D.
"I should avoid drugs and alcohol."
9. D
(4)Hepatitis B is an inflammation of the liver by a virus that results in degeneration and necrosis of liver cells. This patient statement indicates need for further teaching. The patient should be instructed that, in order to avoid complications, alcohol should be avoided for six months to one year. Illicit drugs and toxic chemicals should be avoided Acetaminophe may be taken only when necessary and not beyond the recommended dosage. (1)Hepatitis B is transmitted by the serum of infected people. Because all blood and blood products are potential sources of contamination, the patient should not donate blood. (2)The major source of transmission is via infected serum. It is also transmitted by body fluids sue as saliva and semen. The patient should avoid sexual contact until antigen-antibody tests are negative. When sex is allowed to resume, a condom should be worn and sexual contact should be refrained from during menstruation. (3)All blood and blood products and any instruments that pierce the skin and enter the vascular system are potential sources of contamination. Patients are told not to share needles and to d~ pose of them properly after single use.
10. Which nursing
measure would be most effective in helping the client cough and deep breathe
after a cholecystectomy?
A.
Having the client take rapid, shallow breaths to decrease pain.
B.
Having the client lay on the left side while coughing and deep
breathing.
C.
Teaching the client to use a folded blanket or pillow to splint the
incision.
D.
Withholding pain medication so the client can be alert enough to follow
the nurse's instructions.
10. C
3: A folded bath blanket or pillow placed over the incision will be most effective in helping the client cough and deep breathe after a cholecystectomy. 1: Taking rapid, shallow breaths would not be effective in decreasing pain. 2: Lying on the left side would cause decreased lung expansion. When possible, the client should be positioned in semi-Fowler's or Fowler's position to promote maximum lung expansion.. 4: Withholding pain medication will make the client less likely to cough and deep breathe owing to the discomfort.
11. A client had an
abdominal perineal resection with a colostomy 4 days ago and is ready for
discharge. Which of the following would be an appropriate expected outcome at
this point?
A.
The client maintains a high-fiber diet.
B.
The client discusses concerns about his sexual functioning.
C.
The client maintains bedrestbed rest.
D.
The client limits fluid intake to 1000 ml/day.
11. B
2: Clients often have concerns about their sexuality after a fecal diversion. The nurse should encourage the client to discuss any questions about sexual functioning. 1: The client will not need to maintain a high-fiber diet but will be encouraged to avoid any foods that cause odor and flatulence. 3: The client should be able to ambulate and sit out of bed for several hours at a time at this point. 4: Fluid intake will be encouraged, not restricted.
12. Before
administering an intermitted tube feeding through a nasogastric tube, the nurse
assesses for gastric residual. The nurse understands that this procedure is
important to
A.
Confirm proper nasogastric tube placement.
B.
Observe gastric contents.
C.
Assess fluid and electrolyte status.
D.
Evaluate absorption of the last feeding.
12. D
All the stomach contents are aspirated and measure before administering a tube feeding. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains and thereby evaluates absorption of the last feeding. Assessment of gastric residual is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. Options 1, 2, and 3 do not relate to the purpose of assessing residual.
13. Which of the
following expected outcomes would be appropriate for the client who has
ulcerative colitis?
A.
The client maintains a daily record of intake and output.
B.
The client verbalizes the importance of small, frequent feedings.
C.
The client uses a heating pad to decrease abdominal cramping.
D.
The client accepts that a colostomy is inevitable at some time in his
life.
13. B
2: Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation. 1: The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs. 3: A heating pad should not be applied to the intestine as it is inflamed. 4: It is not inevitable that the client will require surgery to treat the ulcerative colitis as about 85% respond favorably to conservative therapy. If the severity of the disease mandates surgery, the colon will be removed, resulting in an ileostomy.
14. The home care
nurse is visiting a client with a diagnosis of pernicious anemia that developed
as a result of gastric surgery. The nurse instructs the client that because the
stomach lining produces a decreased amount of intrinsic factor in this
disorder, the client will need
A.
Vitamin B12 injections
B.
Vitamin B6 injections
C.
An antibiotic
D.
An antacid
14. A
A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.
15. When assessing the
client with celiac disease, the nurse can expect to find which of the
following?
A.
Steatorrhea
B.
Jaundiced sclerae
C.
Clay-colored stools
D.
Widened pulse pressure
15. A
Because celiac disease destroys the absorbing surface of the intestine, fat isn't absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesn't cause a widened pulse pressure.
16. A client with
viral hepatitis states, “I am so yellow.” The nurse most appropriately would
A.
Assist the client in expressing feelings.
B.
Do most of the activities of daily living for the client.
C.
Provide information to the client only when the client requests it.
D.
Restrict visitors until the jaundice subsides.
16. A
To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. The nurse should explore the client’s feelings to discover how that client feels about the disease process and appearance so as to plan appropriate interventions. Restricting visitors will reinforce the client’s negative self-esteem.
17. A client has been
diagnosed with gastroesophageal reflux disease. The nurse interprets that the
client has dysfunction of which of the following parts of the digestive system?
A.
Chief cells of the stomach
B.
Parietal cells of the stomach
C.
Lower esophageal sphincter
D.
Upper esophageal sphincter
17. C
The lower esophageal sphincter is a functional sphincter that normally remains close except when food or fluids are swallowed. If relaxation of this sphincter occurs, the client could experience symptoms of gastroesophageal reflux disease. The chief cells of the stomach secrete pepsinogen, a precursor to pepsin, which helps to digest proteins. The parietal cells of the stomach secrete hydrochloric acid (gastric acid) and intrinsic factor. The upper esophageal sphincter is formed by the cricopharyngeus muscle attached to the cricoid cartilage.
18. The nurse is
caring for a client on the first postoperative day following a surgical repair
of an abdominal aortic aneurysm. Which nursing diagnosis is the most important
for this client?
A.
Risk for infection
B.
Deficient knowledge
C.
Ineffecitve peripheral tissue perfusion
D.
Activity intolerance
18. C
Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, Deficient knowledge, and Activity intolerance are all important nursing diagnoses in the postoperative client after the nurse has assessed graft patency and peripheral circulation. Generally, wound infections don't occur until 4 to 7 days after surgery.
19. The client with
cirrhosis has ascites and excess fluid volume. Which measure will the nurse
include in the plan of care for this client?
A.
Increase the amount of sodium in the diet.
B.
Limit the amount of fluids consumed.
C.
Encourage frequent ambulation.
D.
Administer magnesium antacids.
19. B
Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess. Options 3 and 4 will not assist in reducing excess fluid volume.
20. The client has had
a new colostomy created 2 days earlier. The client is beginning to pass
malodorous flatus from the stoma. The nurse interprets that
A.
This indicates inadequate preoperative bowel preparation.
B.
This is a normal, expected event.
C.
The client is experiencing early signs of ischemic bowel.
D.
The client should not have the nasogastric tube removed.
20. B
As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 74 hours of surgery, the client should begin passing stool via the colostomy. Options 1, 3, and 4 are incorrect.
21. The nurse is
assessing a 71-year-old female client with ulcerative colitis. Which assessment
finding related to the family will have the greatest impact on the client's
rehabilitation after discharge?
A.
The family's ability to take care of the client's special diet needs
B.
The family's expectation that the client will resume responsibilities
and role-related activities
C.
Emotional support from the family
D.
The family's ability to understand the ups and downs of the illness
21. C
Emotional support from the family is the main need. A special diet doesn't focus on emotional needs. Role expectations don't address the main issue, but emotional support while the client is fulfilling these roles is important. The family's ability to understand the ups and downs of the illness will help them but not the client.
22. The nurse is
performing an assessment on a client with acute pancreatitis who was admitted
to the hospital. Which of the following assessment questions most specifically
would elicit information regarding the pain that is associated with acute
pancreatitis?
A.
“Does the pain in your abdomen radiate to your groin.”
B.
“Does the pain in your stomach radiate to the back?”
C.
“Does the pain in your stomach radiate to your lower middle abdomen?”
D.
“Does the pain in your lower abdomen radiate to the hip?”
22. B
The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis.
23. The nurse has
given instructions to the client with an ileostomy about foods to eat to
thicken the stool. The nurse determines that the client needs further
instructions if the client stated to eat which of the following foods to make
the stool less watery?
A.
Pasta
B.
Boiled rice
C.
Bran
D.
Low-fat cheese
23. C
Foods that help to thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help to thicken or loosen this liquid drainage.
24. The nurse is
caring for a client with an exacerbation of ulcerative colitis. Which of the
following nursing measures should be included in the client's plan of care?
A.
Encourage regular use of antidiarrheal medications.
B.
Incorporate frequent rest periods into the client's schedule.
C.
Have the client maintain a high-fiber diet.
D.
Wear a gown when providing direct client care.
24. B
2: It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be ordered. 1: Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended for regular use as they can lead to colonic dilation. 3: The client should maintain a low-residue, high-calorie, caffeine-free diet. 4: The nurse does not need to wear a gown when providing direct client care because an infectious organism is not present.
25. A nurse orientee
is preparing to insert a nasogastric tube, and a nurse educator is observing
the procedure. Which of the following supplies if obtained by the nurse
orientee would indicate a need foe further education regarding this procedure?
A.
Half-inch or one-inch tape
B.
Oil-soluble lubricant
C.
A glass of tap water with a straw
D.
A 50-mL catheter tip syringe
25. B
Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after the correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.
26. Which of the
following expected outcomes would be most appropriate for a client with peptic
ulcer disease? The client will:
A.
verbalize absence of epigastric pain.
B.
accept the need to inject himself with vitamin B12 for the rest of his
life.
C.
understand the need to increase his exercise activity.
D.
eliminate stress from his life.
26. A
1: A realistic goal for this client would be to gain relief from epigastric pain. 2: There is no need for vitamin B12 injections because this client has not had any gastric surgery that would lead to vitamin B12 deficiency. 3: Exercise should be modified, not increased, because it can stimulate further production of gastric acid. 4: It is not possible to eliminate stress from a client's life. Instead, the client should be assisted to develop effective coping and problem-solving strategies as necessary.
27. A nurse is
developing a teaching plan for the client with viral hepatitis. The nurse plans
to tell the client which of the following in the teaching session?
A.
Activity should be limited to prevent fatigue
B.
The diet should be low in calories
C.
Meals should be large to conserve energy
D.
Alcohol intake should be limited to 2 oz. per day.
27. A
The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden.
28. After gastric
resection surgery, which of the following signs and symptoms would alert the
nurse to the development of a leaking anastomosis?
A.
Pain, fever, and abdominal rigidity.
B.
Diarrhea with fat in the stool.
C.
Palpitations, pallor, and diaphoresis after eating.
D.
Feelings of fullness and nausea after eating.
28. A
1: Pain, fever, and abdominal rigidity are signs and symptoms of inflammation or peritonitis caused by the leaking anastomosis. 2: Diarrhea with fat in the stool is steatorrhea and is not present in peritonitis. 3: Palpitations, pallor, and diaphoresis after eating are vasomotor symptoms of gastric retention. 4: Feelings of fullness and nausea after eating are not present in peritonitis.
29. A home care nurse
is visiting a client with a diagnosis of pernicious anemia that developed as a
result of gastric surgery. The nurse instructs the client that because the
stomach lining produces a decreased amount of intrinsic factor in this
disorder, the client will need
A.
Vitamin B12 injections.
B.
Vitamin B6 injections.
C.
An antibiotic.
D.
An antacid.
29. A
A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.
30. The nurse assesses
the client's understanding of the relationship between body position and
gastroesophageal reflux. Which response would indicate that the client
understands measures to avoid problems with reflux while sleeping?
A.
"I can elevate the foot of the bed 4 to 6 inches."
B.
"I can sleep on my stomach with my head turned to the left."
C.
"I can sleep on my back without a pillow under my head."
D.
"I can elevate the head of the bed 4 to 6 inches."
30. D
4: Sleeping with the head of the bed elevated encourages movement of food through the esophagus by gravity. By fostering esophageal acid clearance, gravity helps keep the acidic pepsin and alkaline biliary secretions from contacting the esophagus. 1: Elevating the foot of the bed does not affect clearance of esophageal acid. 2: This position will not decrease reflux incidence. 3: Sleeping flat without a pillow under the head does not enhance clearance.
31. A client with
ulcerative colitis is diagnosed with a mild case of the disease. The nurse
doing dietary teaching gives the client examples of foods to eat that represent
which of the following therapeutic diets?
A.
High-fat with milk
B.
High-protein without milk
C.
Low-roughage without milk
D.
Low-roughage with milk
31. C
The client with a mild to moderate case of ulcerative colitis often is prescribed a diet that is low in roughage and does not include milk. This will help to reduce the frequency of diarrhea for this client. Options A, B, and D are correct.
32. A nurse is
inserting a nasogastric tube in an adult client. During the procedure, the
client begins to cough and has difficulty breathing. Which of the following is
the most appropriate nursing action?
A.
Remove the tube and reinsert when the respiratory distress subsides.
B.
Pull back on the tube and wait until the respiratory distress subsides.
C.
Quickly insert the tube.
D.
Notify the physician immediately.
32. B
During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 1 and 4 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.
33. A client who has
had gastrectomy is not producing sufficient intrinsic factor. The nurse
interprets that the client has loss the ability to absorb cyanocobalamin
(vitamin B12) in the
A.
Stomach.
B.
Small intestine.
C.
Large intestine.
D.
Colon.
33. B
Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. Vitamin B12 is not absorbed in the large intestine (options 3 and 4).
34. The nurse
aspirates 40 mL of undigested formula from the client’s nasogastric tube.
Before administering an intermittent tube feeding, the nurse understands that
the 40 mL of gastric aspirate should be
A.
Discarded properly and recorded as output on the client’s intake and
output record.
B.
Poured into the nasogastric tube through a syringe with the plunger
removed.
C.
Mixed with the formula and poured into the nasogastric tube through a
syringe with the plunger removed.
D.
Diluted with water and injected into the nasogastric tube by putting
pressure on the plunger.
34. B
After checking the residual feeding contents, the gastric contents are reinstalled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstalled to maintain the client’s electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by putting pressure on the plunger. Gastric contents do not need to be mixed with water or should the contents be discarded.
35. A nurse is
preparing to remove a nasogastric tube from a client. The nurse would instruct
the client to do which of the following just before the nurse removes the tube?
A.
To perform Valsalva’s maneuver
B.
To take hold and hold a deep breath
C.
To exhale
D.
To inhale and exhale quickly
35. B
When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.
36. The nurse is
planning to teach the client with gastroesophageal reflux disease about
substances that will increase the lower esophageal sphincter pressure. Which of
the following items would the nurse include on this list?
A.
Fatty foods
B.
Nonfat milk
C.
Chocolate
D.
Coffee
36. B
Foods that increase the lower esophageal sphincter (LES) pressure will decrease reflux, and lessen the symptoms of gastroesophageal reflux disease (GERD). The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods and alcohol.
37. Lactulose
(Chronulac) is prescribed for a client with a diagnosis of hepatic
encephalopathy. The nurse would determine that this medication has had a
therapeutic effect if which of following is noted?
A.
Increased red blood cell count
B.
Decreased serum ammonia level
C.
Increased protein level
D.
Decreased white blood cell level
37. B
Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.
38. A nurse has been
caring for a client with a Sengstaken-Blakemore tube. The physician arrives on
the nursing unit and deflates the esophageal balloon. The nurse should monitor
the client most closely for which of the following?
A.
Swelling of the abdomen
B.
Bloody diarrhea
C.
Vomiting blood
D.
An elevated temperature and arise in blood pressure
38. C
A Sengstaken-.Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the may begin to bleed again from the esophageal varices, noted by vomiting of blood.
39. A client is
scheduled for an abdominal perineal resection with permanent colostomy. Which
of the following measures would most likely be included in the plan for the
client's preoperative preparation?
A.
Keep the client NPO for 2 days before surgery.
B.
Administer kanamycin (Kantrex) the night before surgery.
C.
Inform the client that chest tubes will be in place after surgery.
D.
Advise the client to limit activity.
39. B
2: Antibiotics are administered preoperatively to reduce the bacterial count in the colon. 1: The client will be placed on a low residue diet to help cleanse the bowel before surgery but typically is not placed on NPO status until 8 to 12 hours before surgery. Laxatives and enemas may also be administered. 3: Chest tubes would not be expected postoperatively. 4: There is no need to limit the client's activity before surgery.
40. The client with
chronic pancreatitis needs information on dietary modification to manage the
health problem. The nurse teaches the client to limit which of the following
items in the diet?
A.
Carbohydrate
B.
Protein
C.
Fat
D.
Water-soluble vitamins
40. C
The client should limit fat in the diet. The client also should take in small meals, which also will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.
41. The nurse is
preparing a discharge teaching plan for the client who had an umbilical hernia
repair. Which of the following would the nurse include in the plan?
A.
Restricting pain medication
B.
Maintaining bedrest
C.
Avoiding coughing
D.
Irrigating the drain
41. C
Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Coughing is avoided to prevent disruption of the tissue integrity, which can occur because of the location of this surgical procedure.
42. A client has a
nasogastric tube inserted at the time of abdominal perineal resection with
permanent colostomy. This tube will most likely be removed when the client
demonstrates:
A.
Absence of nausea and vomiting.
B.
Passage of mucus from the rectum.
C.
Passage of flatus and feces from the colostomy.
D.
Absence of stomach drainage for 24 hours.
42. C
3: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. 1: Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. 2: Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. 4: Absence of stomach drainage is not a criterion for judging whether or not gastric suction should be continued.
43. A nurse is
performing an abdominal assessment on a client. The nurse determines that which
of the following findings that which of the following findings should be
reported to the physician?
A.
Concave, midline umbilicus
B.
Pulsation between the umbilicus and pubis
C.
Bowel sound frequency of 15 sounds per minute
D.
Absence of a bruit
43. B
The umbilicus should be in the midline, with a concave appearance. The presence of pulsation between the umbilicus and the pubis could indicate abdominal aortic aneurysm and should be reported to the physician. Bowel sounds vary according to the timing of the last meal, and usually range in frequency from 5 to 35 per minute. Bruits are not normally present.
44. The nurse is doing
preoperative teaching with the client who is about to undergo creation of a
Kock pouch. The nurse interprets that the client has the best understanding of
the nature of the surgery if the client makes which of the following
statements?
A.
“I will need to drain the pouch regularly with a catheter.”
B.
“I will need to wear a drainage bag for the rest of my life.”
C.
“The drainage from this type of ostomy will be formed.”
D.
“I will be able to pass stool from the rectum eventually.”
44. A
A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.
45. A nurse is caring
for a client who has just returned from the operating room following the
creation of a colostomy. The nurse is assessing the drainage in the pouch
attached to the site where the colostomy was formed and notes serosanguineous
drainage. Which nursing action is most appropriate based on this assessment?
A.
Notify the physician
B.
Document the amount and characteristics of the drainage
C.
Apply ice to the stoma site
D.
Apply pressure to the site
45. D
During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Options 2 and 3 are inappropriate actions. The nurse does not need to notify the physician because this is an expected finding
46. Cholestyramine
resin (Questran Light) is prescribed for the client with an elevated serum
cholesterol level. The nurse would instruct the client to take the medication
A.
After meals.
B.
Mixed with fruit juice.
C.
Via rectal suppository.
D.
At least 3 hours before meals.
46. B
Cholestyramine resin binds with bile salts in the intestines to form a compound that is excreted in the feces. The client should be instructed to mix the medication with 3 to 6 oz of water, milk, fruit juice, or soup. The medication should be administered before meals. The medication is not administered via rectal suppository.
47. A client is
admitted with a diagnosis of ulcerative colitis. Which of the following
symptoms should the nurse expect the client to report when responding to
questions about his bowel elimination pattern?
A.
Constipation.
B.
Bloody, diarrheal stools.
C.
Steatorrhea.
D.
Alternating periods of constipation and diarrhea.
47. B
2: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. 1: Constipation is not a sign or symptom of ulcerative colitis. 3: Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. 4: Alternating diarrhea and constipation is associated with irritable bowel syndrome.
48. The nurse is
caring for a client following a Billroth II procedure. On review of the
postoperative orders, which of the following if prescribed, should the nurse
question and verify?
A.
Irrigating the nasogastric tube
B.
Coughing and deep breathing exercises
C.
Leg exercises
D.
Early ambulation
48. A
In a Billroth II procedure the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation the nurse should clarify the order. Options B,C, and D are appropriate postoperative interventions.
49. The nurse is
caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome,
the nurse should advise the client to:
A.
restrict fluid intake to 1 qt (1,000 ml)/day.
B.
drink liquids only with meals.
C.
don't drink liquids 2 hours before meals.
D.
drink liquids only between meals.
49. D
A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.
50. The nurse is
irrigating a client's colostomy when she complains of abdominal cramping after
receiving about 100 mL of the irrigating solution. What should the nurse's
first response be in this situation?
A.
Stop the flow of solution temporarily.
B.
Reposition the client on to her right side.
C.
Remove the irrigation tube.
D.
Massage the abdomen gently.
50. A
1: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. 2: Repositioning the client to the right side will not alleviate the cramping. 3: Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. 4: Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.
51. A nurse teaches a
preoperative client about the nasogastric tube that will be inserted in
preparation for surgery. The nurse determines that the client understands when
the tube will be removed in the postoperative period when the client states
A.
“When my gastrointestinal system is healed enough.”
B.
“When I can tolerate food without vomiting.”
C.
“When my bowels begin to function again, and I begin to pass gas.”
D.
“When the doctor says so.”
51. C
Nasogastric tubes are discontinues when normal function returns to the gastrointestinal tract. The tube will be removed before gastrointestinal healing. Food would not be administered unless bowel function returns. Although the physician determines when the nasogastric tube will be removed, option 4 does not determine effectiveness of teaching.
52. A Penrose drain is
in place on the first postoperative day following a cholecystectomy.
Serosanguineous drainage is noted on the dressing covering the drain. Which
nursing intervention is most appropriate?
A.
Notify the physician.
B.
Change the dressing.
C.
Circle the amount on the dressing with a pen.
D.
Continue to monitor the drainage.
52. B
Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.
53. The nurse is
monitoring a client for the early signs and symptoms for dumping syndrome.
Which symptom indicates this occurrence?
A.
Abdominal cramping and pain
B.
Bradycardia and indigestion
C.
Sweating and pallor
D.
Double vision and chest pain
53. C
Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
54. Which of the
following nursing measures would be inappropriate when caring for a client with
a Cantor tube?
A.
Injecting 10 mL of air into the tube to facilitate drainage.
B.
Applying a water-soluble lubricant to the client's nares.
C.
Coiling extra tubing on the client's bed.
D.
Irrigating the tube with 50 mL of normal saline solution.
54. D
4: Intestinal tubes are not irrigated. 1: This nursing measure is appropriate. 2: This nursing measure is appropriate. 3: This nursing measure is appropriate.
55. Of the following
signs and symptoms of bowel obstruction, which is related primarily to small
bowel obstruction rather than large bowel obstruction?
A.
Profuse vomiting.
B.
Cramping abdominal pain.
C.
Abdominal distention.
D.
High-pitched bowel sounds above the obstruction.
55. A
1: Profuse vomiting is the classic sign of small bowel obstruction and rarely occurs with large bowel obstruction. 2: Abdominal discomfort is present in both small and large bowel obstructions. 3: Abdominal distention occurs with both small and large bowel obstruction but is more common in large bowel obstruction. 4: High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.
56. A nurse is
assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis.
The nurse reviews the laboratory result, anticipating a laboratory report that
indicates a serum amylase level of
A.
45 units/L
B.
100 units/L
C.
300 units/L
D.
500 units/L
56. C
The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 3 is an extremely elevated level seen in acute pancreatitis.
57. The client is
admitted to the hospital with viral hepatitis, complaining of “no appetite” and
“losing my taste for food.” To provide adequate nutrition, the nurse would
instruct the client to
A.
Eat a good supper when anorexia is not as severe.
B.
Eat less often, preferably only three large meals daily.
C.
Increase intake of fluids including juices.
D.
Select foods high in fat.
57. C
Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.
58. Which of the
following techniques would the nurse use first to determine if a nasogastric
tube is positioned in the stomach?
A.
Aspirating with a syringe and observing for the return of gastric
contents.
B.
Irrigating with normal saline and observing for the return of solution.
C.
Placing the tube's free end in water and observing for air bubbles.
D.
Instilling air and auscultating over the epigastric area for the
presence of the tube.
58. A
1: The initial way to determine if a nasogastric tube is in the stomach is to apply suction to the tube with a syringe and observe for the return of stomach contents. Then the pH of the aspirate can be measured. This is the method of choice. 2: One would not irrigate until tube placement is confirmed. Irrigation is not associated with placement confirmation techniques. 3: Observing for air bubbles when the free end of the tube is placed under water is an unacceptable, unsafe method of determining tube placement. 4: Another method is to instill air into the tube with a syringe while auscultating over the epigastric area. Hearing the air enter the stomach helps ensure proper placement, but the method is not foolproof and is no longer considered an effective or preferred way to determine placement. (SR 3114)
59. Vasopressin
(Pitressin) therapy is prescribed for a client with a diagnosis of bleeding
esophageal varices. The nurse is preparing to administer the medication to the
client. Which of the following essential items is needed during the
administration of this medication?
A.
A cardiac monitor
B.
An intubation set
C.
A suction setup
D.
A tracheotomy set
59. A
The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring is essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.
60. When preparing the
client with hepatitis A for extended convalescence, the nurse teaches the
client about problems that may occur. The nurse knows that the client has
understood the teaching when he says that he is most likely to have difficulty:
A.
Controlling abdominal pain.
B.
Maintaining a regular bowel elimination pattern.
C.
Preventing respiratory complications.
D.
Maintaining a positive, optimistic outlook.
60. 4
4: Convalescence after hepatitis A may take weeks or even months. Boredom and depression are common problems that the client should anticipate. 1: Abdominal pain is not usually a symptom of hepatitis A. 2: Maintaining a regular bowel elimination pattern is not usually a problem with hepatitis. 3: Problems preventing respiratory complications are unlikely. To support healing, activity is strictly limited but bed rest is not prescribed.
61. The nurse is
reviewing the record of a client with a diagnosis of cirrhosis and notes that
there is documentation of the presence of asterixis. To assess for the presence
of this sign, the nurse would do which of the following?
A.
Ask the client to extend the arms.
B.
Assess for the client the presence of Homans’ sign.
C.
Instruct the client to lean forward.
D.
Measurement the abdominal girth.
61. A
Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options B,C, and D are incorrect.
62. A client with a
history of gastric ulcer suddenly complains of a sharp-severe pain in the mid
epigastric area, which then spreads over the entire abdomen. The client’s
abdomen is rigid and board-like to palpation, and the client obtains most
comfort from lying in the knee-chest position. The nurse calls the physician
immediately suspecting that the client is experiencing which of the following
complications of peptic ulcer disease?
A.
Perforation
B.
Obstruction
C.
Hemorrhage
D.
Intractability
62. A
The signs and symptoms described in the question are consistent with perforation of the ulcer, which then progresses to peritonitis if the perforation is large enough. The client with intestinal obstruction most likely would complain of abdominal pain, distension, and nausea and vomiting. The client with hemorrhage would be vomiting blood or coffee-ground-like material or would be expelling black, tarry, or bloody stools. Intractability is a term that refers to continued symptoms of a disease process, despite ongoing medical treatment. (SR 7794)
63. The nurse is
caring for a client admitted to the hospital with a suspected diagnosis of
acute appendicitis. Which of the following laboratory results would the nurse
expect to note if the client indeed has appendicitis?
A.
Leukopenia with a shift to the right
B.
Leukocytosis with a shift to the right
C.
Leukocytosis with a shift to the left
D.
Leukopenia with a shift to the left
63. C
Laboratory findings do not establish the diagnosis of appendicitis, but often moderate elevation of the white blood cell count (leukocytosis) to 10,000 to 18,000 cells/mm3 occurs with a “shift to the left” (an increased number of immature white blood cells.).
64. To prevent
gastroesophageal reflux in a client with hiatal hernia, the nurse should
provide which discharge instructions?
A.
Lie down after meals to promote digestion.
B.
Avoid coffee and alcoholic beverages.
C.
Take antacids before meals.
D.
Limit fluids with meals.
64. B
To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that tend to increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client doesn't need to limit fluids with meals as long as the fluids aren't gastric irritants.
65. Which of the
following activities should the nurse encourage the client with a peptic ulcer
to avoid?
A.
Chewing gum.
B.
Smoking cigarettes.
C.
Eating chocolate.
D.
Taking acetaminophen (Tylenol).
65. B
2: Cigarette smoking should be avoided because of its stimulatory effect on gastric secretions. Nicotine also increases the release of epinephrine, which leads to vasoconstriction. 1: The client may chew gum if desired. 3: The client may eat chocolate if desired. 4: A client with a peptic ulcer should check with the physician before taking any over-the-counter drug, but acetaminophen does not typically cause gastric irritation.
66. A client returns
from surgery with a sigmoid colostomy. An ostomy appliance is attached. The
priority nursing diagnosis for daily observation and care is:
A.
Diarrhea related to alteration in bowel elimination.
B.
Impaired skin integrity related to seepage.
C.
Impaired nutrition: More than body requirements related to high-fat
diet.
D.
Impaired physical mobility related to surgical procedure.
66. B
Impaired skin integrity would be the priority nursing diagnosis for daily care of the colostomy because the effluent from the colostomy can be irritating to the skin. Diarrhea isn't a concern at this point. The client will be allowed nothing by mouth until peristalsis returns. The client should get out of bed on the first postoperative day, so mobility shouldn't be a problem.
67. The nurse provides
medication instructions to a client with peptic ulcer disease. Which statement,
if made by the client, indicates best understanding of the medication therapy?
A.
“The cimetidine (Tagamet) will cause me to produce less stomach acid.”
B.
“Sucralfate (Carafate) will change the fluid in my stomach.”
C.
“Antacids will coat my stomach.”
D.
“Omeprazole (Prilosec) will coat the ulcer and help it heal.”
67. A
Cimetidine (Tagamet) a Histamine H2 receptor antagonist, will decrease the secretion of gastric acid. Sucralfate (Carafate) promotes healing by coating the ulcer. Antacids neutralize acid in the stomach. Omeprazole (Prilosec) inhibits gastric acid secretion. (SR 7870)
68. A nurse is
developing a plan of care for a client who will be returning to a nursing unit
following a percutaneous transhephatic cholangiogram. The nurse includes which
intervention in the postprocedure plan of care?
A.
Place a sandbag over the insertion site.
B.
Allow the client bathroom privileges only.
C.
Encourage fluid intake.
D.
Allow the client to sit in a chair for meals.
68. A
Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.
69. The client with a
new colostomy is concerned about the odor from stool from the ostomy drainage
bag. The nurse teaches the client to include which of the following foods in
the diet to reduce odor?
A.
Yogurt
B.
Broccoli
C.
Cucumbers
D.
Eggs
69. A
The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumber, and eggs are gas-forming foods.
70. The nurse has
inserted a nasogastric tube to the level of the oropharynx and has repositioned
the client’s head in a flexed-forward position. The client has been asked to
begin swallowing. The nurse starts slowly to advance the nasogastric tube with
each swallow. The client begins to cough, gag, and choke. Which nursing action
would least likely result in proper tube insertion and promote client relaxation?
A.
Continuing to advance the tube to the desired distance
B.
Pulling the tube back slightly
C.
Checking the back of the pharynx using a tongue blade and flashlight.
D.
Instructing the client to breathe slowly and take sips of water.
70. A
As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.
71. A nurse is giving
dietary instructions to a client who has a new colostomy. The nurse encourages
the client to eat foods representing which of the following diets for the first
4 to 6 weeks postoperatively?
A.
High-protein
B.
High-carbohydrate
C.
Low-calorie
D.
Low-residue
71. D
For the first 4 to 6 weeks following colostomy formation, the client should take in a low-residue diet. Following this period, the client should eat a high-carbohydrate, high-protein diet. The nurse also instructs the client to add new foods, one at a time, to determine tolerance to that food.
72. The nurse is
preparing to discontinue a client’s nasogastric tube. The client is positioned
properly, and the tube has been flushed with 15 mL of air to clear secretions.
Before removing the tube, the nurse makes which statement to the client?
A.
“Take a deep breath when I tell you and breathe normally while I remove
the tube.”
B.
“Take a deep breath when I tell you and bear down while I remove the
tube.”
C.
“Take a deep breath when I tell you and slowly exhale while I remove the
tube.”
D.
“Take a deep breath when I tell you and hold it while I remove the
tube.”
72. C
The client should take a deep breath because the client’s airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.
73. The client with a
colostomy has an order for irrigation of the colostomy. The nurse uses which
solution for the irrigation?
A.
Distilled water
B.
Tap water
C.
Sterile water
D.
Lactated Ringer’s
73. B
Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used. Options 1, 3, and 4 are incorrect solutions.
74. A client is
suspected of having hepatitis. Which diagnostic test results will assist in
confirming this diagnosis?
A.
Decreased erythrocyte sedimentation rate
B.
Elevated serum bilirubin
C.
Elevated hemoglobin
D.
Elevated blood urea nitrogen
74. B
Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leucopenia. An elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
75. A nurse is
providing the client with biliary obstruction a simple overview of the anatomy
of the liver and gallbladder. The nurse tells the client that normally the
liver stores bile in the gallbladder, which is connected to the liver by the?
A.
Liver canaliculi
B.
Common bile duct
C.
Cystic duct
D.
Right hepatic duct.
75. C
The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi. Bile then flows into the common hepatic duct. From the common hepatic duct, the bile can be stored in the gallbladder through the cystic duct. Otherwise, the bile can flow directly into the duodenum by way of the common bile duct.
76. A nurse is
reviewing the results of serum laboratory studies drawn on a client who is
suspected of having hepatitis. The nurse interprets that an elevation in which
of the following studies is the most specific indicator of the disease?
A.
Erythrocyte sedimentation rate
B.
Serum bilirubin
C.
Hemoglobin
D.
Blood urea nitrogen
76. C
Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and erythrocyte sedimentation rate is nonspecific test that indicates the presence of inflammation somewhere in the body. Elevated blood urea nitrogen may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
77. The nurse develops
a plan of care for a client with a T tube. Which one of the following nursing
interventions should be included?
A.
Inspect skin around the T tube daily for irritation.
B.
Irrigate the T tube every 4 hours to maintain patency.
C.
Maintain client in a supine position while T tube is in place.
D.
Keep T tube clamped except for during mealtimes.
77. A
1: Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the T tube be kept clean and dry. 2: T tubes are not routinely irrigated; they are irrigated only on order of the physician. 3: There is no need to maintain the client in a supine position; assist the client into a position of comfort. 4: T tubes are never clamped without a physician's order. If ordered to be clamped, however, this typically is done 1 to 2 hours before and after meals.
78. A client with peptic
ulcer is scheduled for a Vagotomy. The client asks the nurse about the purpose
of this procedure. The nurse tells the client that the procedure
A.
Decreases food absorption in the stomach.
B.
Heals the gastric mucosa.
C.
Halts stress reactions.
D.
Reduces the stimulus to acid secretions.
78. D
A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options 1, 2, and 3 are incorrect descriptions of vagotomy.
79. A client is
providing instructions to a client who is scheduled for an oral cholecystogram.
The nurse tells the client to
A.
Eat a high-fat meal on the evening before the procedure.
B.
Maintain strict NPO status on the day of the procedure.
C.
Avoid oral except for water on the day of the procedure.
D.
Eat a high-fat meal for breakfast on the day of the procedure.
79. C
The nurse instructs the client to eat a fat-free meal the evening before the procedure and then to avoid oral intake except for water on the day of the procedure. The client may be given a high-fat meal or drink during the test to stimulate the emptying of the gallbladder.
80. The nurse is
scheduling diagnostic tests for a client. If all of the following diagnostic
tests are ordered, which would be performed last?
A.
Gallbladder series
B.
Barium enema
C.
Barium swallow
D.
Oral cholecystogram
80. C
A barium swallow should be done after a barium enema or gallbladder series to prevent the contrast used in the barium swallow from obstructing the view of other organs. It takes several days for swallowed barium to pass completely out of the gastrointestinal tract.
81. A client with
liver dysfunction has low serum levels of thrombin. The nurse provides care,
anticipating that this client is most at risk of
A.
Dehydration
B.
Malnutrition
C.
Bleeding
D.
Infection
81. C
Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding.
82. The hospitalized
client with gastroesophageal reflux disease is complaining of chest discomfort that
feels like heartburn following a meal. After administering an ordered antacid,
the nurse encourages the client to lie on which of the following positions?
A.
Supine with the head of bed flat
B.
On the stomach with the head flat
C.
On the left side with the head of bed elevated 30 degrees
D.
On the right side with the head of bed elevated 30 degrees
82. C
The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. These include lying flat on the back or on the stomach after a meal or lying on the right side. The left side-lying position with the head of bed elevated is most likely to give relief to the client.
83. To accurately
assess for jaundice in a patient with dark skin pigmentation, the nurse should
examine which body areas?
A.
Nail beds
B.
Skin on back of the hand
C.
Hard palate of the mouth
D.
Soles of the feet
83. C
(3) Jaundice is best assessed in the sclera. However, the dark-skinned patient may have normal yellow pigmentation present in the sclera. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. (1) Cyanosis is best observed in the nail beds. (2) Skin on the palm of the hand can indicate jaundice, but not skin on the back of the hand. (4) Jaundice can be assessed on the soles of the feet in a patient with dark skin. However, it is better assessed in the hard palate
84. A client is
recovering from an ileostomy that was performed to treat inflammatory bowel
disease. During discharge teaching for this client, the nurse should stress:
A.
increasing fluid intake to prevent dehydration.
B.
wearing an appliance pouch only at bedtime.
C.
consuming a low-protein, high fiber diet.
D.
taking only enteric-coated medications.
84. A
Because stool is formed in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse also should instruct the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they can cause intestinal irritation, and to avoid enteric-coated medications because they can't be absorbed by the body after an ileostomy.
85. The nurse is
reviewing the record of a client with Crohn’s disease. Which of the following
stool characteristics would the nurse expect to note documented in the client’s
record?
A.
Chronic constipation
B.
Diarrhea
C.
Constipation alternating with diarrhea
D.
Stool constantly oozing from the rectum
85. B
Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 1, 3, and 4 are not characteristics of Crohn’s disease.
86. A nurse is caring
for a client with cirrhosis of the liver. To minimize the effects of the
disorder, the nurse teaches the client about foods that are high in thiamine.
The nurse determines that the client has best understanding of the dietary
measures to follow of the client states an intention to increase intake of:
A.
Pork
B.
Milk
C.
Chicken
D.
Broccoli
86. A
The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Broccoli contains vitamins C, E, and K and folic acid.
87. The nurse is
reviewing the medication record of a client with acute gastritis. Which
medication if noted on the client’s record, would the nurse question?
A.
Digoxin (Lanoxin)
B.
Indomethacin (Indocin)
C.
Furosemide (Lasix)
D.
Propranolol hydrochloride (Inderal)
87. B
Indomethacin (Indocin) is a Nonsteroidal antiinflammatory drug and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol (Inderal) is a B- adnergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.
88. The nurse is
evaluating the plan of care for a client with peptic ulcer disease with a
nursing diagnosis of Acute Pain. The nurse would determine that the client has
not met the expected outcomes if the client states
A.
That pain is relieved with histamine H2 receptor antagonists.
B.
That irritating foods have been eliminated from the diet.
C.
The client is being awakened at 2 AM with heartburn.
D.
The client has absence of pain before meals.
88. C
Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.
89. The client being
seen in a physician’s office has just been scheduled for a barium swallow the
next day. The nurse writes down which of the following instructions for the
client to follow before the test?
A.
Fast for 8 hours before the test.
B.
Eat a regular supper and breakfast.
C.
Continue to take all oral medications as scheduled.
D.
Monitor own bowel movement pattern for constipation
89. A
A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract.
90. The nurse is
caring for a client with cirrhosis. Which manifestations indicate deficient
vitamin K absorption caused by this liver disease?
A.
Dyspnea and fatigue
B.
Ascites and orthopnea
C.
Purpura and petechiae
D.
Gynecomastia and testicular atrophy
90. C
A liver disorder, such as cirrhosis, can disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Because of this, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
91. A client is scheduled
for oral cholecystography. Which one of the following actions would the nurse
plan to implement before the test?
A.
Have the client drink 1000 mL of water.
B.
Ask the client about possible allergies to iodine or shellfish.
C.
Administer an intravenous contrast agent the evening before the test.
D.
Administer tap-water enemas until clear.
91. B
1: Drinking large amounts of water is indicated for certain kidney or urinary bladder studies, not gall bladder studies. 2: Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur. 3: The contrast agent is administered orally 10 to 12 hours before the test. The client is NPO after administration of the contrast agent. 4: Enemas are not required for cholecystography.
92. A client with
liver dysfunction is having difficulty with protein metabolism. The nurse
anticipates that the results of which of the following serum laboratory studies
will be elevated?
A.
Lactic acid
B.
Ammonia
C.
Albumin
D.
Lactase
92. B
During deamination of proteins, the liver splits the amino group from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result.
93. A client with
viral hepatitis has no appetite, and food makes the client nauseated. Which of
the following interventions would be most appropriate?
A.
Explain that high-fat diets usually are tolerated better.
B.
Encourage intake of foods high in protein.
C.
Explain that the majority of calories need to be consumed in the evening
hours.
D.
Monitor for fluid and electrolyte imbalance.
93. D
If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.
94. The client with
ascites is scheduled for a paracentesis. The nurse is assisting the physician
in performing the procedure. Which of the following positions will the nurse
assist the client to assume for this procedure?
A.
Supine
B.
Left side-lying
C.
Right side-lying
D.
Upright position.
94. D
An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.
95. The nurse is
caring for a client with a diagnosis of cirrhosis and is monitoring the client
for signs of portal hypertension. Which initial sign, if noted in the client,
indicates the presence of portal hypertension?
A.
Flat neck veins
B.
Hypotension
C.
Weak pulse
D.
Crackles on auscultation of the lungs
95. D
Clinical signs and symptoms or portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse.
96. A client is
admitted to the hospital with acute viral hepatitis. Which of the following
signs or symptoms would the nurse expect to note based on this diagnosis?
A.
Spider angiomas
B.
Fatigue
C.
Pale urine
D.
Weight gain
96. B
Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas small, dilated blood vessels are common in cirrhosis of the liver.
97. The nurse is
monitoring a client admitted to the hospital with a diagnosis of appendicitis.
The client is scheduled for surgery for 2 hours. The client begins to complain
of increases abdominal pain and begins to vomit. On assessment the nurse notes
that the abdomen distended and bowel sounds are diminished. Which of the
following is the most appropriate nursing intervention?
A.
Administer the prescribed pain medication.
B.
Notify the physician.
C.
Call and ask the operating room team to perform the surgery as soon as
possible.
D.
Reposition the client and apply a heating pad on warm setting to the
client’s abdomen.
97. B
Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
98. A nurse is caring
for a client diagnose with pancreatitis. The nurse anticipates that the client
would not experience an elevation of which of the following enzymes?
A.
Lipase
B.
Lactase
C.
Amylase
D.
Trypsin
98. B
Lactase is produced in the small intestine and aids in splitting neural fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.
99. The client is
admitted to the hospital for treatment of acute hepatitis B. Which activity
order would the nurse expect to be prescribed?
A.
Bedrest
B.
Encourage ambulation
C.
Out of bed in a chair
D.
No activity restrictions
99. A
Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce the metabolic demands on the liver and its blood supply.
100. The physician
orders a Salem sump tube for gastrointestinal intubation. The nurse prepares
for the insertion and obtains which of the following items from the supply
room?
A.
A tube with a single lumen that connects to suction
B.
A tube with a large lumen and an air vent
C.
A Sengstaken-Blakemore tube
D.
A Dobbhoff weighted tube
100. B
A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levin’s tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings.
For practice test please click the link below:
GASTROINTESTINAL SYSTEM Practice Exam
http://zipansion.com/as5S
GASTROINTESTINAL SYSTEM Practice Exam
http://zipansion.com/as5S
http://zipansion.com/as5S
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