Med Surg
The major carbohydrate that tissue cells use as fuel is A chyme. B proteins. C fats. D glucose.
glucose. Explanation: Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.
The nurse determines one or two bowel sounds in 2 minutes should be documented as A Hypoactive B Hyperactive C Absent D Normal
hypoactive. Explanation: Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Normal bowel sounds are heard every 5 to 20 seconds. Hyperactive bowel sounds occur when 5 or 6 sounds are heard in less than 30 seconds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.
Which client requires immediate nursing intervention? The client who: A presents with ribbonlike stools. B complains of anorexia and periumbilical pain. C presents with a rigid, board-like abdomen. D complains of epigastric pain after eating.
presents with a rigid, board-like abdomen. Explanation: A rigid, board-like abdomen is a sign of peritonitis, a possibly life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating indicates a duodenal ulcer. Anorexia and periumbilical pain are characteristic of appendicitis. Risk of rupture is minimal within the first 24 hours, but increases significantly after 48 hours. A client with a large-bowel obstruction may have ribbonlike stools
What happens to a patient when there is a lack of intrinsic factor?
vitamin B12 cannot be absorbed, and pernicious anemia results
Which of the following digestive enzymes aids in the digesting of starch? A Trypsin B Bile C Amylase D Lipase
Amylase Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme
Which of the following is a function of the stomach? Select all that apply. A Secretion of digestive fluids B Propels partially digested food into small intestine C Secretion of bile D Food storage E Secretion of digestive enzymes
Food storage Secretion of digestive fluids Propels partially digested food into small intestine Explanation: The stomach stores food during eating, secretes digestive fluids, and propels the partially digested foods into the small intestine. Secretion of digestive enzymes is completed by the pancreas. The liver secretes bile.
When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first? A Percussion B Auscultation C Palpation D Inspection
Inspection Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
A client has had a gastrostomy tube inserted. What does the nurse anticipate the initial fluid nourishment will be after the insertion of the gastrostomy tube? A Sterile water at 30 mL/h B Formula feeding at 50 mL/h C Distilled water at 60 mL/h D High-calorie liquids at 50 mL/h
Sterile water at 30 mL/h Explanation: The first fluid nourishment is administered soon after tube insertion and can consist of a sterile water or normal saline flush of at least 30 mL. Distilled water is not used for initial start of feeding. Formula feeding and high-calorie liquids are not used initially.
The nurse is collecting a stool specimen from a patient . What characteristic of the stool indicates to the nurse that the patient may have an upper GI bleed?
Tarry and black
Which of the following is the most successful treatment for gastric cancer? A Radiation B Chemotherapy C Palliation D Removal of the tumor
Removal of the tumor Explanation: There is no successful treatment for gastric carcinoma except removal of the tumor. If the tumor can be removed while it is still localized to the stomach, the patient may be cured. If the tumor has spread beyond the area that can be excised, cure is less likely.
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? A Six small meals daily with 120 mL fluid between meals B Three meals and three snacks and 120 mL fluid daily C Three meals and 120 ml fluid daily D Six small meals and 120 mL fluid daily
Six small meals daily with 120 mL fluid between meals Explanation: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals
The nurse determines that teaching for the client with peptic ulcer disease has been effective when the client makes which statement? A "I should stop all my medications if I develop any side effects." B "I can buy whatever antacids are on sale because they all have the same effect." C "I should continue my treatment regimen as long as I have pain." D "I have learned some relaxation strategies that decrease my stress."
"I have learned some relaxation strategies that decrease my stress." Explanation: The nurse assists the client to identify stressful or exhausting situations. A hectic lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings along with the regular administration of medications. The client may benefit from regular rest periods during the day, at least during the acute phase of the disease. Biofeedback, hypnosis, behavior modification, massage, or acupuncture may be helpful.
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccupping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? A Duodenal ulcer B Gastric ulcer C Acute gastritis D Gastric cancer
Acute gastritis Explanation: A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. A client with a duodenal ulcer will present with heartburn, nausea, excessive gas and vomiting. A client with gastric cancer will have persistent symptoms of nausea and vomiting, not sudden symptoms. A client with a gastric ulcer will have bloating, nausea, and vomiting, but not necessarily hiccups.
The nurse is caring for a group of clients. Which client(s) would be a candidate for total parenteral nutrition (TPN)? Select all that apply. A Young adult with gastroenteritis B Woman with superficial burns C Middle-aged man with acute pancreatitis D Child with short bowel syndrome E Man with two-thirds of his colon removed
Child with short bowel syndrome Middle-aged man with acute pancreatitis Man with two-thirds of his colon removed Explanation: Indications for parenteral nutrition include short bowel syndrome, acute pancreatitis, and extensive bowel surgery. Gastroenteritis and superficial burns would not be indications for parenteral nutrition.
Which medication classification represents a proton (gastric acid) pump inhibitor? A Famotidine B Metronidazole C Omeprazole D Sucralfate
Omeprazole Explanation: Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: A "It indicates if a cancer is present." B "It detects a protein normally found in the blood." C "It determines functionality of the liver." D "It tells the physician what type of cancer is present."
"It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.
A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? A10 p.m. to 12 a.m. B 8 p.m. to 10 p.m. C 4 p.m. to 6 p.m. D 6 p.m. to 8 p.m.
6 p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.
During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring? A Infection B Colonic polyp C Bowel perforation D Rectal fissure
Bowel perforation Explanation: Immediately after the test, the patient is monitored for signs and symptoms of bowel perforation (e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs)
A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event? A Bile reflux B Celiac disease C Dumping syndrome D Gastric outlet obstruction
Dumping syndrome Explanation: Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that occur in up to 76% of patients who have had bariatric surgery. Early symptoms include a sensation of fullness, weakness, faintness, dizziness, palpitations, diaphoresis, cramping pains, and diarrhea. These symptoms resolve once the intestine has been evacuated (i.e., with defecation)
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? A Histamine B Intrinsic factor C Liver enzyme D Hydrochloric acid
Intrinsic factor Explanation: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.
Clinical manifestations of common bile duct obstruction include all of the following except: A Jaundice B Pruritus C Light-colored urine D Clay-colored feces
Light-colored urine Explanation: The excretion of the bile pigments by the kidneys gives the urine a very dark color. The feces, no longer colored with bile pigments, are grayish, like putty, or clay-colored. The symptoms may be acute or chronic. Epigastric distress, such as fullness, abdominal distention, and vague pain in the right upper quadrant of the abdomen, may occur. If it goes untreated jaundice and pruritus can occur.
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color? A Red B Black C Yellow D Milky white
Red Explanation: Carrots or beets will tend to change the stool color to red. Black stools are associated with iron, licorice, and charcoal. Senna is associated with yellow stools. A milky white stool is associated with administration of barium
A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times? A Side-lying with the head slightly lower than the chest B Semi-Fowler's with the head of the bed elevated 30 to 45 degrees C Supine with a small pillow under the patient's head D High Fowler's with the patient sitting erect
Semi-Fowler's with the head of the bed elevated 30 to 45 degrees Explanation: For the patient receiving continuous enteral feedings, the nurse would position the patient in the semi-Fowler's position with the head of the bed elevated 30 to 45 degrees at all times to reduce the risk of reflux and aspiration. This is the only appropriate patient position
A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? A Use incentive spirometry every hour. B Monitor pulse oximetry every hour. C Withhold analgesics unless necessary. D Instruct the client to cough only when necessary.
Use incentive spirometry every hour. Explanation: The nurse instructs the client in techniques of coughing and deep breathing and in the use of incentive spirometry to improve respiratory function. The nurse assists the client to perform these activities every hour. Repositioning the client every 2 hours minimizes the risk of atelectasis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring pulse oximetry helps show changes in respiratory status and promotes early intervention, but it would do little to minimize the risk of atelectasis. Withholding analgesics is not an appropriate intervention due to the severe pain associated with pancreatitis
A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? A "I'll avoid eating or drinking anything 6 to 8 hours before the test." B "I'll take a laxative to clear my bowels before the test." C "I'll drink full liquids the day before the test." D "There is no need for special preparation before the test."
"I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.
A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. A Ensure availability of an infusion pump B Place a 1.5-micron filter on the tubing C Assess for patency of the peripheral intravenous site D Administer the intravenous antibiotic in the same tubing as the parenteral nutrition E Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel
Ensure availability of an infusion pump Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Place a 1.5-micron filter on the tubing Explanation: Parenteral nutrition with dextrose concentrations of greater than 10% should not be administered through peripheral veins. An infusion pump should always be used for the administration of parenteral nutrition. Standing orders are initiated that include monitoring of CBC and chemistry panel prior to the start of parenteral nutrition. Medications should not be administered in the same IV line as the parenteral nutrition because of potential incompatibilities with the components of the nutritional solution. A special filter (1.5-micron filter) is used with parenteral nutrition.
A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? A Serum calcium B Serum potassium C Serum bilirubin D Serum amylase
Serum amylase Explanation: Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: A alcohol abuse and a history of acute renal failure. B a sedentary lifestyle and smoking. C a history of hemorrhoids and smoking. D alcohol abuse and smoking.
alcohol abuse and smoking. Explanation: The nurse should mention that risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren't risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.
The nurse on an evidence-based practice council makes recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which situation? A before drawing blood B when the line is discontinued C daily when not in use D with continuous infusions
daily when not in use Explanation: Daily instillation of normal saline and dilute heparin flush when a nontunneled central catheter is not in use will maintain the line's patency. Continuous infusion maintains the patency of the line. Normal saline and heparin flushes should be used after each time blood is drawn to prevent clotting of blood within the line. Normal saline and heparin flush are not needed when a line is being discontinued
When the patient is to perform a Hemoccult II test, name some things the patent mustavoid ingesting in order to prevent a false-positive result?
red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish should be avoided for 72 hours prior to the study
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should: A turn the client on his left side and place the bed in Trendelenburg's position. B place the client in a supine position and prepare to perform cardiopulmonary resuscitation. C position the client in the shock position with his legs elevated. D place the client in high-Fowler's position and administer supplemental oxygen.
turn the client on his left side and place the bed in Trendelenburg's position. Explanation: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.
A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? A Deficient fluid volume B Excess fluid volume C Risk for imbalanced nutrition, more than body requirements D Impaired urinary elimination
Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.
The nurse is performing a community screening for colorectal cancer. Which characteristic should the nurse include in the screening? A Low-fat, low-protein, high-fiber diet B Age younger than 40 years C Familial polyposis D History of skin cancer
Familial polyposis Explanation: Family history of colon cancer or familial polyposis is a risk factor for colorectal cancer. Age older than 40 years and a high-fat, high-protein, low-fiber diet are risk factors for colorectal cancer. A history of skin cancer is not a recognized risk factor for colorectal cancer
A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate? A Gastric penetration B Ineffective treatment for the peptic ulcer C Perforation of the peptic ulcer D A reaction to the medication given for the ulcer
Perforation of the peptic ulcer Explanation: Signs and symptoms of perforation include the following: Sudden, severe upper abdominal pain (persisting and increasing in intensity), which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock.
After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method? A pH measurement of aspirate B Measurement of exposed tubing C X-ray visualization D Air auscultation
X-ray visualization Explanation: X-ray visualization of the tube tip is the most accurate method to verify placement; however, it is also the most expensive method and exposes the patient to radiation doses. Measuring the length of the exposed tubing only provides information about the position, not the location, of the tip. Testing the pH of the aspirate helps to distinguish between gastric and intestinal placement. This method also can be affected by interventions such as the use of antacids or continuous tube feedings. Air auscultation is highly variable, and normal bowel and bronchial sounds may interfere with interpretation.