Chapter 27 med surge
During a morning assessment, the nurse observes that a patient displays bulging flanks when supine with the knees flexed. Which action should the nurse take next? a. Measure the patient's abdominal girth. b. Auscultate each quadrant of the abdomen for 5 minutes. c. Document the finding. d. Notify the charge nurse.
A
The nurse is talking with a patient who has been experiencing nausea and vomiting. The patient indicates an interest in using alternative therapies for the condition. Which product may aid in nausea management? a. Ginger b. Ginseng c. Chamomile d. Soy
A
The nurse is caring for a patient who complains, "I don't see why I can't have a CT scan instead of the expensive MRI!" Which response is most appropriate for the nurse to make? a. "The MRI provides better contrast between normal and pathologic tissue." b. "The MRI requires less analysis and is easier to read." c. "The MRI produces a digital image that can be transmitted via e-mail." d. "The MRI exposes the patient to less radiation.
A
The nurse is caring for a patient who is complaining of postoperative gas pain. What intervention should nurse implement? a. Assist the patient with ambulation. b. Apply a cold compress on the abdomen. c. Offer a cup of coffee or tea. d. Offer chilled vegetable juice
A
The nurse is caring for a patient who returns to the floor at lunch time after undergoing an upper GI (UGI series). Which action is most important for the nurse to perform first? a. Administer a laxative. b. Educate the patient about the possibility of white stools. c. Offer the patient a small snack. d. Provide oral care.
A
The nurse is percussing a patient's abdomen and hears a dull thud in the right upper quadrant. This sound indicates that nurse is percussing over which location? a. The liver b. The small intestine c. The stomach d. The lungs
A
The nurse is reviewing the laboratory results of an assigned patient. The serum bilirubin is 2.8 mg/dL. The nurse anticipates that the patient's urine will display which finding? a. Dark color b. Low specific gravity c. Very scant amount d. Foul odor
A
When assessing a patient's bowel sounds, nurse auscultates loud bowel sounds in each quadrant every 3 seconds. The nurse understands that these findings could indicate that the patient is experiencing which condition? a. Diarrhea b. Paralytic ileus c. Vomiting d. Constipation
A
Which action(s) should the nurse recommend to promote a patient's bowel health? (select all that apply.) a. Exercise regularly. b. Include adequate bulk in the diet. c. Drink adequate water. d. Defecate at approximately the same time every day. e. Take a laxative to maintain a regular defecation pattern.
A, B, C, D
The nurse explains that the older adult is prone to digestive disorders related to which age-related change(s)? (select all that apply.) a. Decreased hydrochloric acid b. Increased enzyme levels c. Inadequate chewing d. Diminished intestinal motility e. Gastroesophageal sphincter incompetence
A, C, D, E
The nurse is caring for a patient immediately following a liver biopsy. Which actions are appropriate for the nurse to take? (select all that apply.) a. Position the patient on the right side. b. Assess the patient's pain. c. Monitor vital signs every 15 minutes for the first hour. d. Instruct patient to cough and deep-breathe. e. Assess for hematoma at puncture site.
ABCE
Which factor(s) increase the risk for developing pancreatic cancer? (select all that apply.) a. Obesity b. Jewish ethnicity c. Diabetes mellitus (DM) d. Hepatitis A e. Smoking
ACE
The nurse caring for an 80-year-old woman who is undergoing the extensive bowel preparation for a colonoscopy. The nurse should most closely monitor the patient for which potential complication? a. Diarrhea b. Metabolic acidosis c. Fatigue d. Dyspnea
B
The home health nurse is caring for the patient with tuberculosis who is taking rifampin and isoniazid (INH). The nurse should carefully monitor the patient for which potential side effect? a. Gallstones b. Liver disorders c. Bleeding ulcers d. Esophagitis
B
The nurse is assessing a patient's bowel sounds. After auscultating each quadrant for 30 seconds, the nurse fails to hear any sounds. How should the nurse document this finding? a. Absent bowel sounds b. Hypoactive bowel sounds c. Active bowel sounds d. Hyperactive bowel sounds
B
The nurse is planning care for a patient who has experienced moderate diarrhea for 3 days. Which collaborative intervention is most important to include in the plan of care? a. Place the patient on NPO status. b. Limit the patient's diet to clear liquids. c. Administer parenteral nutrition. d. Restrict the patient's diet to soft foods only.
B
The nurse is caring for a patient scheduled to have an MRI study. Which instruction(s) should the nurse include in the teaching? (select all that apply.) a. Radiation exposure is extremely minimal. b. All metal objects, including dental bridges, jewelry, and body piercings, must be removed. c. Do not eat or drink for 4 hours before the procedure. d. A radiopaque medium may be injected during the procedure. e. There may be a tingling sensation in metal alloy filling of the teeth.
B, D, E
Before a nurse can document the presence of diarrhea, which criteria must be met? (select all that apply.) a. One loose stool in a 24-hour period b. Multiple liquid or semiliquid stools in a 24-hour period c. Hyperactive bowel sounds d. Cramping e. Fever
BCD
The nurse is caring for a patient with anorexia nervosa. Which intervention(s) might the nurse use to stimulate appetite? (select all that apply.) a. Offer oral care after meals. b. Arrange for preferred foods to be served. c. Encourage family members to bring food from home. d. Suggest that family members or friends come and socialize during the meal. e. Allow ample time to eat and enjoy the meal.
BCDE
The nurse is caring for a patient who has been experiencing severe diarrhea and can now resume solid foods. The nurse educates the patient about appropriate food choices. Which food choice indicates that the nurse's teaching has been successful? a. Whole-grain rice b. Wheat toast c. Applesauce d. Grapes
C
The nurse is caring for multiple patients. The nurse determines that which patient has the highest risk for developing gallstones? a. A 37-year-old white man of normal weight on long-term corticosteroids for asthma. b. A 42-year-old African American man of normal weight who has smoked for 25 years. c. A 46-year-old Indonesian woman who is under normal weight and has recently had radiation treatments. d. A 50-year-old obese Mexican American woman who has type 1 diabetes.
D
The nurse is obtaining a history of a patient with hepatitis A. Which question is most appropriate for the nurse to ask? a. "If using drugs, do you share needles?" b. "Do you always practice safe sex?" c. "Have you traveled to Canada in the last month?" d. "Do you eat shellfish or oysters often?"
D
The nurse is performing preprocedure teaching for a patient scheduled to undergo a liver biopsy. After listening to the information, the patient states, "I am so scared. I just don't know if I can do this procedure." Which response is best? a. "The procedure will only last about 15 minutes." b. "Most patients say it feels similar to a punch in the shoulder." c. "You do not have to have the procedure." d. "I understand that you are afraid. Tell me more about your concerns."
D
The nurse is preparing to administer liquid laxative to a patient in preparation for a colonoscopy. Which action should the nurse take? a. Offer a small snack. b. Take the patient's temperature. c. Mix the laxative with orange juice. d. Chill the laxative and pour it over ic
D
The nurse is reviewing a student nurse's charting and notes that the student has documented absent bowel sounds. The nurse reminds the student that in order to document absent bowel sounds, one must auscultate each quadrant at what period of time? a. 30 seconds b. 1 minute c. 2 minutes d. 5 minutes
D
The nurse caring for the patient who has diarrhea from taking a protocol of oral amoxicillin will use __________ Precautions in the care.
STANDARD
The nurse cautions that constant stress can cause which alteration to the gastrointestinal (GI) system? a. Slowed GI mobility resulting in constipation b. Reversed peristalsis resulting in projectile vomiting c. Increased digestive juices resulting in a gastric ulcer d. Decreased digestive juices resulting in ineffective metabolism
c. Increased digestive juices resulting in a gastric ulcer
