Medsurg Exam #3

Which drug does the nurse expect to administer to a client in order to decreased hydrochloric acid secretion in the stomach? A. Famotidine B. Gaviscon C. Mylanta D. Antibiotic

ANS: A Rationale: Famotidine is a histamine receptor antagonist (histamine blocker). This drug works by inhibiting gastric acid secretion, which relieves the dyspepsia and other symptoms of GERD.

What is the nurse's best first action when a client with a gastric ulcer is found lying in the knee-chest (fetal) position with a rigid, tender, and painful abdomen? A. Notify the primary health care provider B. Administer opioid pain medication C. Reposition the client supine D. Measure the abdominal circumference

ANS: A Rationale: When the client's abdomen is tender, rigid, and board-like, this is likely an infection (peritonitis). The client often assumes a "fetal" position to decrease the tension on the abdominal muscles. He or she can become severely ill within hours. Bacterial septicemia and hypovolemic shock can follow. Peristalsis diminishes, and paralytic ileum develops. Peptic ulcer perforation is a surgical emergency and can be life threatening. The nurse's best first action is to notify the HCP or the Rapid Response Team.

Which actions will the nurse teach a client with GERD to use to prevent harm? Select all that apply. A. Do not consume caffeinated or carbonated beverages B. Avoid peppermint, chocolate, and fried foods C. Eat slowly and chew food thoroughly D. Consume four to six small meals each day E. Do not eat 3 hours before going to bed F. Sleep on your side to prevent regurgitation

ANS: A, B, C, D, E Rationale: All of these are appropriate for the nurse to teach a client to avoid the harmful effects of GERD, except option F. The client is taught to sleep propped up to promote gas exchange and prevent regurgitation. This can be done by placing blocks under the head of bed or by using a large, wedge-style pillow instead of a standard pillow.

Which signs and symptoms will the nurse expect to see in a client who is diagnosed with advanced pancreatic cancer? Select all that apply. A. Light-colored urine and dark-colored stools B. Anorexia and weight loss C. Splenomegaly D. Ascites E. Leg or calf pain F. Weakness and fatigue

ANS: A, B, C, D, E, F Rationale: All the signs and symptoms listed are associated with pancreatic cancer.

Which conditions or actions will the nurse expect to worsen the presence and symptoms of a client's hemorrhoids? Select all that apply. A. Pregnancy B. Straining with constipation C. Weight lifting D. Prolonged bedrest E. Strenuous exercise F. Obesity

ANS: A, B, C, E, F Rationale: All of these actions or conditions can cause worsening of hemorrhoids except option D. Prolonged sitting or standing may worsen hemorrhoids, but bedrest does not.

Which action will the nurse teach a client to take to prevent the spread of gastroenteritis? Select all that apply. A. Washing hands well for at least 30 seconds B. Using easily accessible hand sanitizers C. Taking broad-spectrum antibiotics prophylactically D. Testing all food preparation employees E. Sanitizing all surfaces that may be contaminated F. Properly preparing food and beverages

ANS: A, B, E Rationale: The nurse teaches the client and family to prevent the spread of gastroenteritis by using the strategies: washing hands well for at least 30 seconds with an antibacterial soap, especially after a bowel movement, and maintaining good personal hygiene; restricting the use of glasses, dishes, eating utensils, and tubes of toothpaste for his or her own use (in severe cases, disposable utensils may be used); maintaining clean, bathroom facilities to avoid exposure to stool; informing the primary healthcare provider, if symptoms persist beyond 3 days; and not preparing or handling food, that will be consumed by others.

Which signs and symptoms in an older client admitted for a medical problem indicate to the nurse the possibility of "failure to thrive?" Select all that apply. A. Weakness B. Exhaustion C. Poor skin turgor D. Reduced hearing E. Stress incontinence F. Slow walking speed G. Low physical activity H. Unintentional weight loss

ANS: A, B, F, G, H Rationale: "Failure to thrive" in older clients is a combination of any three of these five symptoms: Weakness, slow walking speed, Low physical activity, unintentional weight loss, and exhaustion.

Which signs and symptoms will the nurse expect to find on assessment of a client who is admitted with obstructive jaundice? Select all that apply. A. Pruritus B. Hypertension C. Pale, clay-colored stools D. Dark, coffee-colored urine E. Pink discoloration of sclera F. Bright red bleeding from the gums

ANS: A, C, D Rationale: Jaundice is a yellow discoloration of the skin and mucous membranes from excessive bilirubin in these structures and blood. Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning it dark and coffee-colored. The obstruction prevents bilirubin from reaching the intestinal system, where it is broken down and gives stool it's dark brown color. Because the biliubin does not reach the G.I. tract, stools are light with a gray or clay color.

Which nonsurgical treatment options for cancer of the esophagus will the nurse discuss with the client? Select all that apply. A. Swallowing therapy B. Smoking cessation programs C. Nutritional therapy D. Chemoradiation E. Photodynamic therapy F. Esophageal dilation

ANS: A, C, D, E, F Rationale: All of these options are nonsurgical treatment options except option B.

Which actions will the nurse teach a client with severe GERD that causes pain after each meal, lasts for at least 45 minutes, and worsen when he or she lies down? Select all that apply. A. "Drink fluids right away." B. "When you lie down, try lying on your side." C. "Take an antacid as prescribed by the HCP." D. "Eating something bland such as a slice of white bread." E. "Maintain an upright position for at least an hour after you eat." F. "Try pressing over your abdomen to mobilize the food in your stomach."

ANS: A, C, E Rationale: When a client experiences GERD, drinking fluids, taking antacids as prescribed, or maintaining an upright posture usually provides prompt relief.

Which teaching points will the nurse include when instructing a client about preparation for a colonoscopy? Select all that apply. A. "Avoid taking aspirin, NSAIDS, or anticoagulants for several days before the test." B. "Drink lots of red, orange, or purple beverages the day before the test." C. "Do not eat or drink for 4 to 5 hours before the test." D. "After the bowel-cleansing solutions, you may develop constipation for 1 to 2 days." E. "Drink only clear liquids the day before the colonoscopy." F. "An IV will be placed to give medication to help you relax during the procedure."

ANS: A, C, E, F Rationale: Clients are instructed to avoid aspirin, anticoagulants, and anti platelet drugs for several days before the procedure. The HCP will prescribe the specific method of preparation of the bowel which begins the night before procedure. Drinkable solutions can be chilled to improve taste. Teach the client to have a clear liquid diet the day before colonoscopy. The nurse instructs him/her to avoid red, orange, or purple beverages or gelatin. The client should be NPO for several hours before the procedure, based on the HCP's instructions. Watery diarrhea usually begins an hour after starting the bowel preparation process. In some cases, the client may also require laxatives, suppositories, or one or more small-volume cleansing enemas. Intravenous access is necessary for the administration of moderate sedation. The HCP prescribes drugs to aid in relaxation during the procedure.

Which drugs will the nurse expect the HCP to prescribe for a client after esophageal trauma? Select all that apply A. Broad-spectrum antibiotics B. Loop diuretics C. Corticosteroids D. Antacids E. Pain medications F. Viscous lidocaine

ANS: A, C, E, F Rationale: To prevent sepsis, the HCP prescribes broad-spectrum antibiotics. High-dose corticosteroids may be administered to suppress inflammation and prevent strictures (esophageal narrowing). Opioid and nonopioid analgesics may be prescribed for pain management. When caustic burns involve the mouth, topical agents such as viscous lidocaine may be used.

Which actions will the nurse assign to the assistive personnel (AP) who will be helping to care for a client with stomatitis? Select all that apply. A. Providing oral care every 2 hours or more if stomatitis is not controlled B. Teaching the client to use a soft toothbrush or gauze, and to avoid commercial mouthwashes and lemon-glycerin swabs which can irritate mucosa C. Encouraging frequent rinsing of the mouth with warm saline, sodium bicarbonate (baking soda) solution, or a combination of these solutions D. Applying a topical analgesics or anesthetics as prescribed and documenting effectiveness E. Instructing the client on how select soft, bland, and nonacidic foods F. Removing dentures if the client has severe stomatitis or oral pain

ANS: A, C, F Rationale: Administering medications is appropriate to the nurse, but application of topical drugs could be assigned to an LPN/LVN. Lemon-glycerin swabs and commercial mouthwashes with alcohol can cause more damage and are avoided.

Which activities are most important for the nurse to teach a client with esophageal varices to prevent harm from bleeding or hemorrhage? Select all that apply. A. Avoid alcoholic beverages B. Eat soft foods and cool liquids C. Do not engage in strenuous exercise or heavy lifting D. Try to eat six smaller meals daily instead of three larger ones E. Be sure to keep your mouth open when sneezing or coughing F. Cross your legs only at the ankles, when sitting, rather than the knees.

ANS: B, C Rationale: Esophageal varices are thin-walled blood vessels that bleed easily with mechanical irritation or any increase in pressure within the portal system. Clients must avoid any activity that increases intra-abdominal pressure, such as strenuous exercise and heavy lifting. Hard or rough foods can mechanically open the varices and cause bleeding. Avoiding alcohol, may prevent worsening of the liver problems, but does not directly prevent bleeding or hemorrhage. None of the other activities, altar, intra-abdominal pressure or prevent direct injury to the varices.

In collaboration with the registered dietitian nutritionist, which nutrients and substances will the nurse instruct a client with ulcerative colitis (UC) to avoid to reduce symptoms? Select all that apply. A. Eggs B. Corn C. Caffeine D. Vitamin C E. Dried fruits F. Carbohydrates G. Dairy products H. Pepper-based spices

ANS: B, C, E, G, H Rationale: Although each client with UC may have different foods that trigger diarrhea, common nutrients and substances that cause problems in most clients with UC include caffeine, alcohol, raw vegetables, dried fruits, dairy products, pepper, corn, nuts, carbonated beverages, and any high-fiber foods. The client is instructed to reduce or eliminate the intake of these items, and any other that are known to increase his or her symptoms. Carbohydrates, proteins, and vitamin C are needed in the diet.

What liver problem does the nurse suspect in a client whose liver is hard with a nodular texture and the hepatic enzymes remain normal? A. Prenecrotic inflammation B. Postnecrotic inflammation C. Compensated cirrhosis D. Decompensated cirrhosis

ANS: C Rationale: In compensated cirrhosis, the liver is scarred with physical changes and cellular regulation is impaired, but the organ can still perform essential functions, including maintaining normal liver enzyme levels without causing major symptoms. In decompensated, cirrhosis, liver function is impaired with obvious signs and symptoms of liver failure, including elevated liver enzymes.

Which change in electrolyte values will the nurse expect in a client with acute pancreatitis who reports numbness around the mouth and leg muscle twitching? A. Hyponatremia B. Hypokalemia C. Hypocalcemia D. Hypochloremia

ANS: C Rationale: The free or unbound serum calcium level is usually low in clients who have acute pancreatitis as a result of fat necrosis and the inability of the body to use protein-bound calcium.

Which are the most common symptoms of gastroesophageal reflux disease (GERD) reported to the nurse by a client? Select all that apply. A. Eructation B. Water brash C. Dyspepsia D. Regurgitation E. Odynophagia F. Flatulence

ANS: C, D Rationale: Dyspepsia, also known as indigestion, and regurgitation are the main symptoms of GERD, although symptoms may vary in severity. With severe GERD, these sensations generally occur after each meal and last for 20 minutes to 2 hours.

What procedural teaching will the nurse provide for a client scheduled for an abdominal CT scan with contrast? Select all that apply. A. The test will take about 30 to 45 minutes B. An IV line will be placed for injection of the contrast C. You may experience loud and gurgling sounds from your belly D. The CT technician may ask you to hold your breath while images are taken E. You may feel warm and flushed, and may experience a metallic taste with injection F. If you are claustrophobic, you can be given a mild sedative before the procedure

ANS: B, D, E, F Rationale: The nurse instructs the client that an IV access is required for injection of the contrast medium. Advise the client that he/she may feel warm and flushed, or experience a metallic tastes, on or after the injection. A client who has claustrophobia may require a mild sedative to tolerate the study. The CT technician will instruct the client to lie still and to hold his/her breath when asked, as a series of images are taken. The test takes about 10 minutes and the client is not likely to experience gurgling bowel sounds.

Which sign and symptoms will the nurse expect to assess when a client is diagnosed with a paraesophageal hernia? Select all that apply. A. Regurgitation B. Feeling of fullness (after eating) C. Dyspepsia D. Breathlessness (after eating) E. Dysphagia F. Chest pain that mimics angina

ANS: B, D, F Rationale: Signs and symptoms of paraesophageal hernia include: Feeling of fullness (after eating), breathlessness (after eating), and chest pain that mimics angina. Regurgitation, dyspepsia, and dysphagia are symptoms of sliding hiatal hernias.

Which signs and symptoms does the nurse expect to assess when a client has early gastric cancer? Select all that apply. A. Nausea and vomiting B. Feeling of fullness C. Weakness and fatigue D. Epigastric, back, or retrosternal pain E. Palpable gastric mass F. Abdominal discomfort initially relieved with antacids

ANS: B, D, F Rationale: Although clients with early gastric cancer may be asymptomatic, dyspepsia and abdominal discomfort are common symptoms. A feeling of fullness and epigastric, back, or retrosternal pain are also early symptoms. Nausea and vomiting, waking and fatigue, and a palpable gastric mass are LATE symptoms of gastric cancer.

Which assessment findings on a client with peritonitis indicate to the nurse the probability that the fluid shift into the peritoneal cavity is continuing? Select all that apply. A. Weight loss B. Tachycardia C. Hypertension D. Decreasing urine output E. Hyperactive bowel sounds F. Skin tenting over the forehead and sternum

ANS: B, D, F Rationale: When fluid shifts from the vascular space into the peritoneal cavity, the client experiences, central dehydration with hypo bulimia. Symptoms include tachycardia and hypotension (not hypertension). Weight is not lost because the fluid has changed places in the body but it is not lost from the body. With hypotension, urine output decreases and skin turgor is poor. Bowel motility decreases further.

For which abnormal laboratory findings will the nurse monitor when providing care for a client with acute pancreatitis? Select all that apply A. Increased prothrombin time B. Increased serum lipase C. Increased unconjugated bilirubin D. Increased aspartate transaminase E. Increased serum amylase F. Increased serum ammonia

ANS: B, E Rationale: Elevations in serum amylase and lipase may indicate acute pancreatitis, a serious inflammation of the pancreas characterized by a sudden onset of abdominal pain, nausea, and vomiting. Serum amylase levels begin to elevate within 24 hours of onset and remain elevated for up to 5 days. The values listed in options A, C, D, and F are more commonly seen with liver disease.

Which question will the nurse be sure to ask a client suspected of having leukoplakia? A. "Do you smoke, dip, or chew tobacco products?" B. "How much alcohol do you drink each day?" C. "Do you consume many of fast food meals?" D. "How often do you have dental checkups?"

ANS: A Rationale: Tobacco use increases the chance of development of leukoplakia. The nurse asks the client about current or historical tobacco use.

Which foods will the nurse expect the client who follows a lacto-ovo-vegetarian diet to select as menu items for breakfast? Select all that apply A. Milk B. Toast C. Cereal D. Sausage E. Tuna fish F. Scrambled eggs

ANS: A, B, C, F Rationale: An adult who follows a lacto-ovo vegetarian diet eats a primarily plant-based diet that also includes eggs and dairy products. Meat, poultry, and fish are avoided.

Which advantages of minimally invasive surgery (MIS) laparoscopic cholecystectomy will the nurse reinforce to a client after the surgeon has provided information for informed consent? Select all that apply. A. Bile duct injuries are rare B. Complications are uncommon C. Postoperative pain is less severe D. Mortality is about equal to that of traditional cholecystectomy E. IV antibiotics are not needed because infection is not occur F. Depending on the nature of the job, some clients can return to work within 1-2 weeks

ANS: A, B, C, F Rationale: Injuries and complications are much lower than with traditional cholecystectomy and the postoperative pain is less severe. Many clients can resume their normal activities within 1 week. The mortality rate is very low, much lower than traditional cholecystectomy. Although the infection rate is low, there is still an infection risk. Any time in incision is made.

Which clients will the nurse suggest to be immunized against hepatitis B (HBV)? Select all that apply A. People who have unprotected sex with more than one partner B. Men who have sex with men C. Any clients scheduled for a surgical procedure D. Firefighters E. Healthcare providers F. Client prescribed immunosuppressant drugs

ANS: A, B, D, E, F Rationale: HBV can be spread by both the parenteral and sexual routes. Exposures are more likely to result in infection in clients who are immunosuppressed for any reason. Individuals who are exposed to blood or other bodily fluids in the workplace are at risk for exposure.

Which signs and symptoms does the nurse expect to assess when a client experiences an upper GI bleed? Select all that apply. A. Decreased blood pressure B. Decreased heart rate C. Dizziness or light-headedness D. Melena (tarry or dark sticky) stools E. Weak peripheral pulses F. Increased hemoglobin and hematocrit levels

ANS: A, C, D, E Rationale: Option B is not correct because heart rate is increased, and option F is not correct because hemoglobin and hematocrit levels are decreased when upper GI bleed occurs.

Which signs and symptoms will the nurse assess when a client is diagnosed with oral cancer? Select all that apply. A. Bleeding from the mouth B. Painful oral lesions that are red, raised, or eroded C. Difficulty chewing or swallowing D. Unplanned weight gain E. Thick or absent saliva F. Thickening or lump in cheek

ANS: A, C, E, F Rationale: Signs and symptoms that the nurse will monitor for when a client has oral cancer include: Bleeding from mouth, poor appetite, compromised nutrition status, difficulty chewing or swallowing, unplanned weight loss, thick or absent saliva, painless oral lesions that are red, raised or eroded, and thickening or lump in the cheek.

Which client's previous health history will the nurse most associate with a risk for developing postnecrotic cirrhosis of the liver? A. 28-year-old woman who had gallstones 1 year ago and has recently lost 20 lb on a low-calorie, low-fat diet B. 45-year-old man with hepatitis C infection and chronic use of acetaminophen C. 50-year-old man who has many years of excessive alcohol consumption D. 55-year-old woman who has chronic biliary obstruction

ANS: B Rationale: Postnecrotic cirrhosis of the liver is caused by viral hepatitis, especially hepatitis, C, and drugs that are liver, toxic, such as acetaminophen. Cirrhosis caused by chronic alcoholism is Laennec cirrhosis. Chronic biliary obstruction can result in biliary cirrhosis. Gallstones are not associated with cirrhosis unless chronic biliary obstruction is also present.

Which assessment with the nurse use as the most reliable indicator of a clients fluid status? A. Intake and output B. Trends in weight C. Changes in skin turgor D. Presence of dependent edema

ANS: B Rationale: Weight change is the most reliable indicator of fluid status. A liter of water weight 1 kg (2.2 lb). An actual weight gain or loss can account for a daily change of only about half a lb. More than that indicates increased fluid and less than that indicates fluid loss.

Which types of ulcers does the nurse teach a client about when discussing peptic ulcer disease (PUD)? Select all that apply. A. Pressure ulcers B. Gastric ulcers C. Duodenal ulcers D. Stress ulcers E. Esophageal ulcers F. Colon ulcers

ANS: B, C, D Rationale: Three types of peptic ulcers may occur in PUD: Gastric ulcers, Duodenal ulcers, and Stress ulcers (less common). Duodenal ulcers are most common, gastric ulcers occur in the antrum of the stomach, and stress ulcers are acute gastric mucosal lesions occurring after an acute medical crisis or trauma, such as sepsis or a head injury.

What nutritional deficiency does the nurse suspect when a client reports recent onset of alopecia? A. Zinc B. Vitamin A C. Riboflavin D. Vitamin C

ANS: Rationale: A Hair loss is one of the first indicators of a zinc deficiency

What is the nurses best first action when the stoma of a client who had a permanent ileostomy placed 2 days ago now has a dark bluish-purple appearance? A. Notifying the surgeon immediately B. Applying oxygen by nasal cannula C. Placing the client in a high fowler position D. Documenting the finding as the only action

ANS: A Rationale: A healthy stoma has a pink to bright red color. A dark bluish-purple appearance indicates inadequate blood flow to the stoma and the intestine behind it. The nurse notified the surgeon immediately to take action to restore circulation to the area and prevent necrosis.

Which neuromuscular assessment change indicates to the nurse that a client who has late stage liver cirrhosis now has encephalopathy? A. Asterixis B. Positive Chvostek sign C. Increased deep tendon reflex responses D. Decreased deep tendon reflex responses

ANS: A Rationale: A late finding in clients who have late-stage liver cirrhosis, and encephalopathy is Asterixis, which is a course tremor that is characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

Which activity of a nutritional screening will the nurse assigned to an assistive personnel (AP)? A. Obtaining an accurate height and weight B. Asking about the client's usual food intake C. Reviewing the client's laboratory results D. Performing a psychosocial assessment

ANS: A Rationale: Accurately measuring height and weight are within the AP's scope of practice. Collecting information about a client's nutrition history, reviewing laboratory findings and performing a psychosocial assessment require greater knowledge and skill and are not within an AP's scope of practice.

In which position will the nurse place the client after an open Whipple procedure for treatment of pancreatic cancer? A. Semi-Fowler position to reduce tension on the suture line B. prone position to prevent acute respiratory distress syndrome C. Left lateral Sims' position with knees drawn up to the chest to reduce pain D. Right lateral Sims' position with knees drawn up to the chest to reduce pain

ANS: A Rationale: After a radical pancreatectomy, the client is kept in a semi fowler position to reduce tension on the suture line and anastomosis site.

Which precaution is most important for the nurse to instruct clients with hepatitis C (HCV) who are receiving drug therapy with any second-generation protease inhibitor? A. Avoid crowds and people who are ill B. Do not touch these drugs with your bare hands C. Alternate periods of activity with periods of rest D. Be sure to take vitamin K supplements with this drug

ANS: A Rationale: All of these drugs, cause some degree of immunosuppression and increase the clients risk for infection.

Which precaution is most important for the nurse to instruct the client with cirrhosis and his or her family about continuing care in the home? A. Avoid taking acetaminophen or drinking alcohol B. Maintain one-floor living to prevent excessive fatigue C. Use cool baths to reduce the sensation of itching D. Report any change in cognition to the HCP

ANS: A Rationale: Although all of the listed precautions are important, the most important is the avoidance of acetaminophen and alcohol. These substances are toxic to the liver and will worsen the clients liver disease.

What is the nurse's best action when assessment of a client 2 hours after abdominal surgery reveals hypoactive bowel sounds? A. Documenting the finding and continue to monitor B. Notifying the surgeon immediately C. Putting a nasogastric (NG) tube in place D. Obtaining an immediate abdominal x-ray

ANS: A Rationale: Bowel sounds are characterized as normal, hypoactive, or hyperactive. They are diminished (hypoactive) or absent after abdominal surgery. The most reliable way of knowing that peristalsis has returned is when the client passes flatus or stool. After surgery this may take a few hours. The nurse's best action is to document the finding and continue to monitor for flatus or stool.

Which lunch food selection made by a client with diverticulosis indicates to the nurse the correct understanding of the necessary dietary modifications for management of the problem? A. A turkey sandwich on whole wheat, bread, steamed carrots, and a raw apple B. Roasted chicken, potato salad, and a glass of milk C. Chicken salad, sandwich, on white bread, creamed, soup, and hot tea D. Fried shrimp, lettuce, and tomato salad, and a dinner roll

ANS: A Rationale: Dietary recommendations to prevent problems in a client with diverticulosis, include a high fiber diet with protein, root vegetables, whole grain, breads, and cereals, and fruit with the skin on.

Which action will the nurse take first when an 80-year-old client with acute pancreatitis has no breath sounds in the left lower lung lobe? A. Apply oxygen B. Assess the breath sounds on the right C. Notify the primary healthcare provider D. Document the findings as the only action

ANS: A Rationale: Left lower lung effusions, atelectasis, and pneumonia often develop in clients with acute pancreatitis, especially in older adults, and can lead to pulmonary failure and death. The nurse would first apply oxygen and then immediately notify the primary healthcare provider.

What is the nurse's priority assessment when a client is given IV Midazolam hydrochloride before a colonoscopy? A. Monitoring the rate and depth of respirations B. Auscultating for bowel sounds in all four quadrants C. Monitoring the client for cardiac dysrhythmias D. Suctioning secretions as needed to prevent aspiration

ANS: A Rationale: Midazolam is commonly used for sedation with procedures such as colonoscopy. These drugs can depress the rate and depth of respirations. Thus, the nurse's priority assessment is checking the client's rate and depth of respirations. If the client's respiratory rate is below 10 breaths/min or the exhaled carbon dioxide levels falls below 20%, the nurse uses a stimulus such as a sternal rub to encourage deeper and faster respirations.

Which client will the nurse recognize as having the greatest risk for non-alcoholic fatty liver disease (NAFLD)? A. 45-year-old Latino man who is 30 lb overweight and has type 2 diabetes B. 50-year-old white woman who drinks one glass of wine daily and has breast cancer C. 60-year-old back woman who is hypertensive and takes a diuretic daily D. 70-year-old Asian man who has gastroesophageal reflux disease (GERD)

ANS: A Rationale: Obesity and type 2 diabetes with metabolic syndrome are risk factors for NAFLD. In addition, a genetic variation in the PNPLA3 gene increases the risk. This variation is much more common among Latinos.

Which condition will the nurse most likely suspect as the cause of a client's symptoms of obstipation and failure to pass flatus? A. Complete obstruction B. Partial obstruction C. Colorectal cancer D. Singultus

ANS: A Rationale: Obstipation (no passage of stool) and failure to pass flatus are associated with complete obstruction. Singultus is hiccups

Which priority teaching will the nurse provide to an older client with GERD who is prescribed Omeprazole for symptom relief? A. "Older adults taking this drug may be at increased risk for hip fracture because it interferes with calcium absorption." B. "Because of this drug's side effect of decreasing potassium, you may be prescribed a potassium supplement." C. "This drug causes sodium retention, so you may be prescribed a dietary sodium restriction." D. "A pacemaker may be necessary because this drug changes magnesium levels which can lead to life-threatening dysrhythmias."

ANS: A Rationale: Omeprazole is a proton pump inhibitor (PPI). These drugs may increase the risk for hip fracture, especially in older adults. PPIs can interfere with calcium absorption and protein digestion and therefore, reduce available calcium to bone tissue. Decreased calcium makes bones more brittle and likely to fracture, especially as adults get older.

What is the most common symptom the nurse expects clients with esophageal cancer to report? A. Difficulty with swallowing B. Shortness of breath C. Reflux especially at night D. Productive cough

ANS: A Rationale: One of the most common symptoms - Dysphagia (difficulty swallowing). This symptom may not be present until the esophageal opening has narrowed significantly.

Which precaution to prevent harm is most important for the nurse to teach an overweight client who is prescribed Orlistat? A. "Take a multivitamin daily because this drug prevents absorption of some vitamins." B. "Notify your primary healthcare provider if you have any thoughts about hurting yourself." C. "Be sure to use a reliable method of contraception because this drug can cause birth defects." D. "Watch for feelings of lightheadedness and jitteriness because this drug can cause hypoglycemia."

ANS: A Rationale: Orilstat inhibits lipase so that fats are only partially digested and absorbed. The non digested fats and many fat-soluble nutrients are eliminated in the stool, potentially leading to vitamin deficiency

What will the nurse recognize as the cause of splenomegaly in a client who has cirrhosis? A. Increased pressure in the portal vein causing backflow of blood into the spleen B. The loss of cellular regulation in the liver spreading to the spleen and causing extensive scarring C. Chronic inflammation and infection, increasing the spleen's maturation and release of white blood cells D. Direct destruction of spleen cells from alcohol or other toxins, causing replacement with scar tissue formation

ANS: A Rationale: Portal hypertension caused by stiffened liver tissue results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. This increased portal vein pressure causes backflow of blood into the spleen, resulting in splenomegaly.

Which action will the nurse take first to promote adequate intake in a client who is malnourished? A. Asking the client about his or her food preferences B. Providing the client with high-calorie, high-protein food C. Offering frequent snacks or proteins shakes between meals D. Obtaining serial weights on a weekly basis to monitor progress

ANS: A Rationale: Regardless of a dietary intervention for malnutrition, if the client does not eat the food provided or recommended, malnutrition will continue. Incorporating the client's food preferences increases the likelihood of the intervention's success.

For which client will the nurse expect extracorporeal shock wave lithotripsy (ESWL) as treatment of gallstones to be contraindicated? A. 30-year-old who is 70 inches tall and weighs 325 lbs B. 35-year-old who has cholesterol-based stones C. 45-year-old who has a shellfish allergy D. 55-year-old who has bilateral total knee replacements

ANS: A Rationale: Some clients who have small, cholesterol based stones and good gallbladder function may undergo extracorporeal shockwave lithotripsy (ESWL) to break up the stones. This procedure can be used only for patients who have a normal weight.

What is the nurses priority action when caring for a client with a cute cholecystitis who now has severe abdominal pain, diaphoresis, heart rate of 118 beats/min, BP 95/70, respirations 32 breaths/min, and temperature 101°F (38.3°C)? A. Initiating the Rapid Response Team B. Assisting the client to a semi-fowler position C. Administering the prescribed opioid analgesic D. Auscultating the clients abdomen in all four quadrants

ANS: A Rationale: The client is exhibiting the symptoms associated with biliary colic and possible shock. This is an emergency, and if the clients primary healthcare provider is not immediately available, initiating the rapid response team is a priority.

In which position will the nurse place the client with peritonitis to promote comfort and prevent harm from potential complications? A. Semi-Fowler B. Left side-lying with knees to chest C. Right side-lying with knees to chest D. Supine flat with hips and knees flexed

ANS: A Rationale: The client with peritonitis is placed in a semi-fowler position to promote drainage to the lower abdominal region. Also, this position prevents abscess formation under the diaphragm and promote lung expansion. Most clients also find this position comfortable.

What is the nurse's best response when a client asks which kind of stool to expect from a colostomy in the descending colon? A. "Your stool will be solid and similar to what you expelled from your rectum." B. "It will be very water and similar to diarrhea stool." C. "You should expect your stool to be somewhat thin and gelatin-like." D. "Most likely your stool will have the consistency of paste and be thick."

ANS: A Rationale: The colostomy should start functioning in 2 to 3 days after surgery. Stool is liquid immediately after surgery, but becomes more solid, depending on where in the colon the stoma was placed. For example, stool from an ascending colon colostomy continues to be liquid, stool from a transverse colon colostomy, becomes pasty, and stool from a descending colon colostomy becomes more solid (similar to stool expelled from the rectum).

Which finding does the nurse understand is an early pathologic manifestation when a client is diagnosed with acute gastritis? A. Thickened, reddened mucous membrane with prominent rugae B. Patchy, diffuse inflammation C. H.pylori infection D. Thin, trophied wall and lining of the stomach

ANS: A Rationale: The early pathologic manifestation of acute gastritis is a thickened, reddened mucous membrane with prominent rug, or folds, in the stomach. Options B, C, and D are signs and symptoms of chronic gastritis.

What instructions will the nurse provide to a client with a gastrointestinal problem who is scheduled for an abdominal x-ray? A. "Wear a hospital gown and remove any jewelry or belts." B. "You will have nothing to eat or drink until after the procedure." C. "A nasogastric tube will be placed to decompress your stomach." D. "You will receive a laxative to clear stool out of your bowel."

ANS: A Rationale: The nurse reached the client that no preparation is required except to wear a hospital gown and remove any jewelry or belts, which may interfere with the film.

To prevent harm after a surgical procedure for peritonitis, which action will the nurse teach the client to avoid? A. Taking additional acetaminophen to prevent liver toxicity B. Lifting for at least six months after an open surgical procedure C. Resuming normal activities for at least 3 to 4 days after the procedure D. Using stool softeners and laxatives to prevent diarrhea

ANS: A Rationale: The nurse teaches the client to avoid taking additional acetaminophen to prevent liver toxicity. Clients are instructed to refrain from any lifting for at least 6 weeks (not months) after an open surgical procedure. Other activity limitations are based on individual need, and the primary healthcare providers recommendation. Patients who have laparoscopic surgery can resume activities within a week or two and may not have any major restrictions. Stool softeners are often prescribed to prevent constipation.

Which priority teaching will the nurse provide to prevent harm when a client with an oral problem is prescribed viscous lidocaine? A. "Lidocaine causes an anesthetic effect so you may not feel burns from hot liquids." B. "You should avoid drinking either cool or cold liquids which can damage the tongue." C. "When you take viscous lidocaine, you should swish it around your mouth then spit it out." D. "Viscous lidocaine will decrease the pain in your mouth when you usterm-25e it regularly."

ANS: A Rationale: The nurse teaches the client to use viscous lidocaine with extreme caution. Lidocaine causes a topical anesthetic effect so the client may not easily feel burns from hot liquids. As sensation in the mouth and throat decrease, the risk for aspiration increases.

Which client with symptoms of chronic abdominal pain and frequent bowel movements will the nurse consider at highest risk for a diagnosis of ulcerative colitis (UC)? A. 26-year-old, white woman of Jewish ancestry, who has an identical, twin sister with the disorder B. 40-year-old black man who has just returned home from a business trip to South East Asia C. 50-year-old Latino man with liver cirrhosis, whose uncle died of colon cancer D. 65-year-old obese Asian woman who has chronic inflammatory cystitis

ANS: A Rationale: UC is most common among younger white woman. The disorder has a higher prevalence in adults with Ashkenazi Jewish heritage and has some degree of genetic predisposition. Thus, presence in an identical twin or other first-degree relative increases the risk.

How will the nurse know that the drug alvimo-pan, given to a client with postoperative ileus, is working and providing its intended action? A. Gastrointestinal (GI) motility is increased B. The client has a large, formed bowel movement C. Indications of infection are gone D. Nausea and vomiting are no longer present

ANS: A Rationale: When administered to a client with a postoperative ileum (POI), alvimopan is given short-term. This drug is an oral, peripherally acting mu opioid receptor antagonist that increases GI motility. The nurse expects to auscultate increased bowel sounds.

For which finding does the nurse alert the health care provider immediately after assessing a client's abdomen? A. Bulging, pulsating mass B. Borborygmus C. Unintentional weight loss D. Reflux with dyspepsia

ANS: A Rationale: If a bulging, pulsating mass is present during assessment of abdomen, the nurse does not touch the area because the client may have an abdominal aortic aneurysm which is a life-threatening problem. The nurse notifies the HCP of this finding immediately!!

Which actions will the nurse include when providing care for a client after a colonoscopy? Select all that apply. A. Checking vital signs every 15 to 30 minutes until the client is alert B. Keeping client in left lateral position to promote passing of flatus C. Assessing for signs and symptoms of bowel perforation, including severe abdominal pain and guarding D. Preventing the client from taking anything by mouth until sedation wears off E. Keeping the top side rails up until the client is alert F. Holding the client 6 to 8 hours before allowing him or her to drive home

ANS: A, B, C, D, E Rationale: All of these options must be included in the care provided to the client after colonoscopy except option F. If the procedure is performed in an ambulatory care setting, another person must drive the client home because of the action of IV drugs given to help with relaxation during the procedure.

Which actions will the nurse take when caring for a client after bariatric surgery to prevent harm from complication? Select all that apply. A. Monitoring oxygen saturation B. Applying an abdominal binder C. Placing the client in semi-Fowler position D. Applying sequential compression stockings E. Assessing skinfolds for redness and excoriation F. Maintaining the client on bedrest for 24 to 48 hours

ANS: A, B, C, D, E Rationale: With the exception of maintaining the client on bedrest for 24 to 48 hours, all of the above actions are recommended as best practices to prevent the many potential complications associated with bariatric surgeries.

Which actions are most effective for the nurses and other healthcare workers to prevent occupational transmission of viral hepatitis? Select all that apply. A. Washing hands before and after contact with all clients B. Using needleless systems for parenteral therapy C. Using standard precautions with all clients, regardless of age or sexual orientation D. Obtaining an immunoglobulin injection after exposure to hepatitis A E. Being fully vaccinated with the hepatitis B vaccine F. Wearing gloves during direct contact with all clients

ANS: A, B, C, D, E Rationale: With the exception of F, all actions are effective in preventing or reducing transmission of infectious hepatitis among healthcare workers, as a result of occupational exposure. Wearing gloves during direct contact with all patients may give a false sense of security, and does not prevent transmission if gloves are contaminated and then come into contact with another person. Gloves are not needed for all client contact.

Which common signs and symptoms will the nurse expect to find on assessment of a 60 year old client who has had gastroenteritis for the past 2 days? Select all that apply. A. Weight loss B. Elevated temperature C. Dry mucous membranes D. Hypotension E. Oliguria F. Poor skin turgor

ANS: A, B, C, D, E, F Rationale: After 2 days of vomiting and diarrhea with Gastroenteritis, the client would have some degree of dehydration with all of the signs and symptoms listed.

Which risk factors will the nurse assess for when taking a history of a client suspected of having gastritis? Select all that apply. A. Use of alcohol B. Excessive caffeine intake C. Smoking cigarettes D. Life stressors E. Prescribed steroids F. Ingestion of corrosive substances

ANS: A, B, C, D, E, F Rationale: All of these options are potential factors that increase the risk for a client to develop gastritis.

Which actions will the nurse take to enhance an older client's desire to eat? Select all that apply. A. Assisting the client to make menu selections and substitutions to match his or her food preferences B. Removing any items from sight that reduce appetite such as emesis basins, urinals, and bedpans C. Eliminating distractions, such as turning down the volume of the television D. Offering the client the opportunity to toilet before the meal arrives E. Opening cartons and condiment packages for the client F. Bringing the client's medications to take with the meal G. Ensuring the food served is at appropriate temperature H. Asking all of the client's visitors to leave

ANS: A, B, C, D, E, G Rationale: Although it is not possible to increase a client's appetite, actions that make the client more comfortable, reduce unpleasant thoughts, and make food more appetizing.

Which priority actions will the nurse take to manage a client's active upper GI bleeding? Select all that apply. A. Administering oxygen B. Starting two large-bore IV lines C. Infusing 0.9% normal saline solution as prescribed D. Collecting a urine sample for urinalysis E. Inserting a nasogastric (NG) tube F. Monitoring serum electrolytes

ANS: A, B, C, E Rationale: The nurse understands that a client with an active GI bleed has a life-threatening emergency and needs supportive therapy to prevent hypovolemic shock and possible death. The priority for care of this client is to maintain airway, breathing and circulation (ABCs). Collecting urine for urinalysis is not a priority at this time, nor is monitoring serum electrolytes.

Which interventions will the nurse include when care of a client with peritonitis is focused on restoring fluid volume balance? Select all that apply. A. administering IV isotonic fluids and broad spectrum antibiotics B. Assigning the assistive personnel to weigh the client daily and record intake and output C. Providing nasogastric tube (NGT) care and keeping the stomach decompressed D. Administering opioid pain medication as prescribed by the primary healthcare provider E. Maintaining the client on NPO status while the NGT is in place to low suction F. Assessing whether the client retains fluid used for irrigation by comparing and recording the amount of fluid returns with the amount of fluid installed

ANS: A, B, C, E, F Rationale: All of these options are important in the care of a client with peritonitis with a focus on restoring fluid, volume balance, except option D. administering opioid pain drugs would be part of the care focused on eliminating pain for this client.

Which potential causes will the nurse be sure to ask about when taking a history from an older client suspected of having a mechanical obstruc-tion? Select all that apply. A. Fecal impaction B. Strictures from previous radiation therapy C. Fibrosis related to endometriosis D. Recent bowel surgery E. Benign tumor F. Diverticulitis

ANS: A, B, C, E, F Rationale: In people aged 60 years or older, the nurse asks about diverticulitis, tumors, and fecal impaction, which are the most common causes of obstruction. Causes of mechanical obstruction also include: Adhesions (scar tissue from surgeries or pathology); benign or malignant tumors; complications of appendicitis; hernias; fecal complications (especially in older adults); strictures due to Crohn disease (a chronic inflammatory bowel disease) or previous radiation therapy; intussusception (telescoping of a segment of the intestine within itself); volvulus (twisting of the intestine); and fibrosis due to disorders such as endometriosis. Option D is incorrect because surgery that involves handling the bowel causes a nonmechanical obstruction.

Which are the major risk factors for development of colorectal cancer that the nurse will be sure to ask about when taking a client's history? Select all that apply. A. Age older than 50 years B. Personal or family history of cancer C. History of intestinal blockage D. Crohn disease E. Ulcerative colitis F. Duodenal ulcers

ANS: A, B, D, E Rationale: Major risk factors for development of colorectal cancer include: Being older than 50 years, genetic predisposition, personal or family history of cancer, and/or disease that predispose the client to cancer such as familial adenomatous polyposis (FAP), Crohn disease, and ulcerative colitis.

What priority teaching points will the nurse include when teaching a group of older adults about prevention of fecal impaction? Select all that apply. A. "Eat high-fiber foods including raw fruits and vegetables." B. "Consume adequate fluids, especially water." C. "Use a laxative daily as needed to foster bowel regularity." D. "Walking every day is an excellent exercise for promoting intestinal motility." E. "Use natural foods to stimulate peristalsis, such as warm beverages and prune juice." F. "Avoid bulk-forming products to ease bowel elimination."

ANS: A, B, D, E Rationale: Preventing fecal impaction includes: Teaching the client to eat high-fiber foods, including plenty of raw fruits and vegetables and whole-grain products; encouraging the client to drink adequate amounts of fluids, especially water; avoiding routinely taking a laxative; teaching the client that laxative abuse decreases abdominal muscle tone and contributes to an atonic colon; encouraging the client to exercise regularly, if possible; walking every day is an excellent exercise for promoting intestinal motility; using natural foods to stimulate peristalsis, such as warm beverages and prune juice; and taking bulk-forming products to provide fiber and stool softeners to ease bowel elimination.

Which assessment findings with the nurse expect in a client with late stage liver cirrhosis who is total serum album level is low? Select all that apply. A. Ascites B. Hypotension C. Hyperkalemia D. Hyponatremia E. Dependent edema F. Decreased serum ammonia levels

ANS: A, B, D, E Rationale: Serum, albumin, maintains plasma oncotic pressure and sodium levels in the normal range. When albumin levels are low, plasma, volume decreases as fluid leaks into the abdomen and dependent areas, forming ascites and dependent edema. Sodium follows the albumin, making serum sodium levels low. The decreased plasma volume results in hypotension..

Which actions will the nurse perform when caring for a client with acute appendicitis before surgical management? Select all that apply. A. Maintaining the client on NPO status B. Administering IV fluids as prescribed C. Providing laxatives and enemas to clear the bowel D. Advising the client to maintain semi fowler position E. giving adequate medication's to control the clients pain F. Applying hot compresses to the right lower quadrant

ANS: A, B, D, E Rationale: The client with suspected or known appendicitis is kept NPO to prepare for the probability of surgery. IV fluids are administered to maintain fluid and electrolyte balance and replace fluid volume. The client is instructed to maintain a semi fowler position so abdominal drainage can be contained in the lower abdomen. Once the diagnosis of appendicitis is confirmed, and surgery is scheduled, opioid, analgesics, and antibiotics are administered as prescribed. The client with suspected or confirmed appendicitis must not receive laxatives or enemas, which can cause perforation of the appendix. Heat is not applied to the abdomen, because this may increase circulation to the appendix and result in increased inflammation and perforation.

Which dietary change suggestions will the nurse make to a client to decrease the risk of colorectal cancer (CRC)? Select all that apply. A. Decrease fat intake B. Increase fiber foods C. Decrease proteins D. Decreased refined carbohydrates E. Increase brassica vegetables F. Increase intake of red meat

ANS: A, B, D, E Rationale: The nurse teaches adults at risk for colorectal cancer to modify their diets as needed to decrease fat, refined carbohydrates, and low fiber foods. Encourage baked or broiled foods, especially those high in fiber and low and animal fat. Remind adults to eat, increased amounts of brassica vegetables, including broccoli, cabbage, cauliflower, and sprouts.

Which actions will the nurse take to manage a client's dumping syndrome? Select all that apply. A. Providing smaller, more frequent meals B. Eliminating ingestions of fluids with meals C. Providing a high-carbohydrate diet D. Administering acarbose as prescribed E. Increasing fat and protein in the diet F. Administering subcutaneous octreotide three times a day before meals

ANS: A, B, D, E, F Rationale: All of these actions will help with management of client's dumping syndrome, except option C. The nurse teaches the client to eat a high-protein, high-fat, low-to-moderate-carbohydrate diet.

Which signs and symptoms will the nurse expect to find on assessment of a client with chronic liver disease who has an elevated serum Bilirubin level? Select all that apply. A. Pruritus B. Icterus C. Hypertension D. Jaundice E. Pale, clay-colored stools F. Dark, coffee-colored urine

ANS: A, B, D, E, F Rationale: Bilirubin is a bile pigment. Elevated serum, bilirubin levels stain the skin yellow (jaundice) and the eyes yellow (icterus). Jaundice is accompanied by intense itching. The excess bilirubin is excreted in the urine, turning at dark and coffee-colored. With liver disease and reduced function, the bilirubin does not reach the intestinal system where it is normally broken down to give stool its dark brown color. Because the bilirubin does not reach the G.I. tract, stools are light with a gray or clay color

Which signs or symptoms will the nurse assess for in a client who is suspected of having cholecystitis? Select all that apply. A. Anorexia B. Jaundice C. Ascites D. Streatorrhea E. Eructation F. Rebound tenderness

ANS: A, B, D, E, F Rationale: Characteristics signs and symptoms of Coley. Cystitis include episodic or vague, upper abdominal pain or discomfort that can radiate to the right shoulder, pain, triggered by a high-fat or high-value meal, anorexia, nausea, and/or vomiting, dyspepsia, eructation, flatulence, feeling of abdominal fullness, rebound tenderness (Blumberg's sign), and fever. Additional symptoms include jaundice and fatty stools (steatorrhea).

A client has postcholecystectomy syndrome (PCS) with persistent, abdominal pain, accompanied by vomiting for several weeks after removal of the gallbladder. Which possible causes or complications will the nurse remain alert for in this client? Select all that apply. A. Pseudocyst B. Common bile duct leak C. Dumping syndrome D. Diverticular compression E. Ductal structure or obstruction F. Sphincter of Odds dysfunction G. primary sclerosis cholangitis H. Retained or new gallstones

ANS: A, B, D, E, F, G, H Rationale: PCS most commonly indicates possible problems in the biliary tract, such as pseudo cyst, common bile duct leak, diverticular compression, ductile stricture or obstruction, sphincter of Oddi dysfunction, primary sclerosis cholangitis, and routines or new gallstones. Dumping syndrome is not part of the problems associated with PCS. Further testing is needed to identify the cause and provide interventions to prevent even more serious complications.

Which new-onset assessment findings in a client with Laennec cirrhosis indicates to the nurse that the client may be starting to have Delerium tremens (DTs) from alcohol withdrawal? Select all that apply. A. Anxiety B. Tachycardia C. Hypotension D. Hypertension E. Cool, clammy skin F. Psychotic behavior

ANS: A, B, D, F Rationale: Alcohol withdrawal occurs sometimes as soon as 6 to 8 hours after stopping alcohol intake after heavy and prolonged use and can lead to DTs. Cognitive, behavioral, and autonomic changes that occur may include acute confusion, anxiety, and psychotic behaviors, such as delusions and hallucinations, along with autonomic changes of tachycardia, elevated blood pressure, and diaphoresis.

Which care actions does the nurse expect to perform when caring for a client who had an appendectomy with an abscess? Select all that apply. A. Providing care for wound drains inserted during the surgery B. Administering IV antibiotics as prescribed by the surgeon C. Providing the client with a clear liquid diet D. Assessing the nasogastric tube (NGT) position and drainage E. Providing nonsteroidal, anti-inflammatory drugs (NSAIDs) for pain control F. Helping the patient out of bed on the evening of surgery

ANS: A, B, D, F Rationale: If complications such as peritonitis or abscesses are found during open traditional surgery, the nursing care is more complex and includes caring for wound drains and a nasogastric tube that may be placed to decompress the stomach and prevent abdominal distention. The nurse administers, IV antibiotics and opioid analgesics as prescribed. The client is helped out of bed on the evening of surgery to help prevent respiratory complications, such as atelectasis.

What priority teaching points does the nurse include when instructing a client and family about how to prevent gastritis? Select all that apply. A. Eat a well-balanced diet and exercise regularly B. Do not take large doses of aspirin, other NSAIDs (Ibuprofen), and corticosteroids C. Decrease the amount of smoking and/or use of other forms of tobacco D. Manage stress levels using complementary and integrative therapies such as relaxation and meditation techniques E. Use over-the-counter (OTC) proton pump inhibitors (PPIs) if you experience symptoms of esophageal reflux F. Protect yourself against exposure to toxic substances in the workplace such as lead and nickel

ANS: A, B, D, F Rationale: Option C is not correct because the client should stop smoking and using tobacco products completely. Option E is not correct because the client should seek medical care for symptoms of reflux and not use OTC drugs.

Which important information will the nurse include when teaching a client about Peritonitis? Select all that apply. A. Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals. B. Respiratory problems associated with peritonitis are related to increased abdominal pressure against the diaphragm. C. White blood cell counts are often decreased when a client is diagnosed with peritonitis. D. Chemical peritonitis is caused by leakage of pancreatic enzymes or gastric acids. E. Fairly common causes of peritonitis include invasive tumors and continuous ambulatory peritoneal dialysis (CAPD). F. When the peritoneal cavity is contaminated by bacteria, the body begins an inflammatory reaction, walling off a localized area to fight the infection.

ANS: A, B, D, F Rationale: Options A, B, D, and F are correct statements about peritonitis. Option C is not correct because white blood cell counts increase (not decrease) with peritonitis. Option E is not correct because tumors and CAPD are not common causes of peritonitis

Which potential causes will the nurse monitor for when a client is suspected of having irritable bowel syndrome? Select all that apply. A. Stress B. Caffeinated beverages C. Sugary deserts D. Anxiety E. Red meats F. Dairy products

ANS: A, B, D, F Rationale: The cause of IBS remains unclear. Research suggests that a combination of environmental, immunologic, genetic, hormonal, and stress factors plays a role in the development and course of the disorder. Examples of environmental factors include foods and fluids, such as caffeinated or carbonated, beverages and dairy products. Considerable evidence relates the role of stress and mental or behavioral illness, especially anxiety and depression, to IBS.

Which serum laboratory values will the nurse expect to be elevated in a client who has acute pancreatitis? Select all that apply. A. Amylase B. Bilirubin C. Calcium D. Lipase E. Magnesium F. Glucose

ANS: A, B, D, F Rationale: With acute pancreatitis, the pancreatic enzymes amylase and lipase are elevated. Bilirubin also is usually elevated as a result of biliary dysfunction or obstruction. Blood glucose levels are often elevated because pancreatic secretion of insulin is reduced. Most often, magnesium and calcium levels are decreased.

Which actions and precautions will the nurse educate a client with chronic pancreatitis about when starting pancreatic enzyme replacement therapy (PERT)? Select all that apply A. Do not crush or chew the capsules B. Take these drugs with all meals and snacks C. Sit in an upright position for at least 30 minutes after taking the drug D. Wear sunscreen and protective clothing outdoors to prevent severe sunburn E. Check your stools for amounts and presence of fat to assess whether the drugs are working F. If you are too nauseated to eat, or to take the drug, go to an emergency department for an injectable form of the drug.

ANS: A, B, E Rationale: PERT is used to assist in the digestion of foods. Thus, it must be taken orally only whenever the client eats a meal or snack. Capsules are not to be opened, crushed or chewed for maximum benefit. The amount of fat in the stools, as well as the amount and consistency of stools, are used to evaluate PERT effectiveness. It is not necessary to remain upright, and the drugs is not caused or increase photo sensitivity.

Which actions are appropriate for the nurse to perform to prevent harm in a client with cirrhosis and ascites who has just undergone an esophagogastroduodenoscopy (EGD)? Select all that apply A. Measuring oxygen saturation B. Checking for leakage from the site C. Assessing for return of the gag reflex D. Monitoring heart rate and blood pressure E. Auscultating bowel sounds in all four quadrants F. Comparing weight with that obtained before the procedure

ANS: A, C, D Rationale: A client with cirrhosis and ascites is at risk for bleeding and hemorrhage as a result of reduced blood clotting factor synthesis. The endoscope placement for an EGD can irritate or rupture any varices in the esophagus, stomach, or duodenum, and lead to hemorrhage. The client must be closely monitored for indications of bleeding and hemorrhage by examining for changes in oxygen saturation, heart rate, and blood pressure. In addition, the procedure is performed under local anesthesia or light sedation, and the clients gag reflex is affected.

Which actions will the nurse teach a client to avoid to prevent harm after Nissen fundoplication surgery when gas bloat syndrome occurs? A. Drinking carbonated beverages B. Passing flatus or belching C. Eating gas-producing foods D. Chewing gum E. Drinking through a straw F. Changing positions frequently

ANS: A, C, D, E Rationale: After Nissen fundoplication surgery, some clients develop gas bloat syndrome, in which they cannot voluntarily eructate (belch). Teach the client to avoid drinking carbonate beverages and eating gas-producing foods (especially high-fat foods), chewing gum, and drinking through a straw. Frequent position changes and ambulation are often effective interventions for eliminating air from the GI tract. If gas pain is still present, clients may be recommended to take simethicone, which relieves gas pressure.

Which alternative or complimentary therapies will the nurse teach a client that may be helpful in managing irritable bowel syndrome (IBS)? Select all that apply. A. "Probiotics can help decrease bacteria and IBS symptoms." B. "Gingko can be used for abdominal discomfort and to expel gas." C. "Meditation may help decrease stress and help eliminate IBS symptoms." D. ""Regular exercise will help decrease stress and lead to regular lower movements." E. "Peppermint oil has been used to expel gas and relax spastic intestinal muscles." F. "Hydrotherapy may help decrease IBS symptoms."

ANS: A, C, D, E Rationale: Probiotics have been shown to be effective for reducing bacteria and successfully alleviating G.I. symptoms of IBS. There is also evidence that peppermint oil capsules may be effective in reducing symptoms for clients with IBS. Relaxation techniques, meditation, and/or yoga may help the client decrease G.I. symptoms. The nurse teaches the client that regular exercise is important for managing stress and promoting regular bowel elimination.

Which actions will the nurse take to prevent harm when caring for a client receiving continuous enteral tube feeding? Select all that apply. A. Checking the residual volume at least every 6 hours B. Changing the feeding bag and tubing every 12 hours C. Keeping the head of the bed elevated at least 30 degrees D. Using clean technique when changing the feeding system E. Discarding unused open enteral products after 24 hours F. Warming the enteral products before infusion

ANS: A, C, D, E Rationale: Residual volume must be assessed at least every 6 hours to prevent reflux and aspiration, as well as other complications. Keeping the head of the bed elevated to at least 30 degrees also helps prevent reflux and aspiration. Clean technique is required to prevent GI infections, as is discarding any unused enteral products that have been open for 24 hours. The feeding bag and tubing are changed every 24 to 48 hours as needed and in accordance with agency policy. Warming of the enteral product is not required or recommended.

Which findings will the nurse be sure to document after inspecting a client's abdomen during assessment? Select all that apply. A. Overall asymmetry of the abdomen B. Size of percussed abdominal organs C. Discoloration or scarring D. Abdominal distention and skin folds E. High-pitched musical sounds F. Location and size of pressure injuries

ANS: A, C, D, F Rationale: After inspecting a client's abdomen, the nurse documents these findings: overall asymmetry of the abdomen; discoloration or scarring; abdominal distention; bulging flanks; taut, glistening skin; skin folds; subcutaneous fat; and location, size, and description of any pressure injuries. Percussion and auscultation are not parts of abdominal inspection.

Which clients will the nurse expect to be prescribed total enteral nutrition (TEN) to help attain or maintain an adequate nutrition status? Select all that apply. A. 28-year-old who remains comatose 10 days after a head injury B. 38-year-old with esophageal strictures and an intestinal blockage C. 48-year-old who eats all meals but remains 22 lb underweight D. 58-year-old who has lung cancer and cachexia E. 68-year-old with no teeth or dentures F. 78-year-old who cannot swallow after a stroke

ANS: A, C, D, F Rationale: As long as the stomach and lower GI system are functioning, clients can receive TEN to provide all or part of their nutritional needs regardless of their LOC, if they are unable to meet these needs by eating (clients in options C and F). The client with an intestinal blockage should be NPO and may require parenteral nutrition. The client who has no teeth or dentures can use liquids, semisolids, soft foods, and chopped or minced foods that require no chewing. The client with lung caner and cachexia can receive TEN if he or she chooses to do so.

Which important information will the nurse gather when a client reports a change in bowel habits? Select all that apply. A. Presence of abdominal distention or gas B. Intentional weight gain C. Occurrence of diarrhea or constipation D. Color and consistency of feces E. Occurrence of heartburn or reflux F. Presence of bloody or tarry stools

ANS: A, C, D, F Rationale: Changes in bowel habits are commonly reported by clients. Important information for the nurse to gather from the client includes: -Pattern of bowel movements -Color and consistency of the feces -Occurrence of diarrhea or constipation -Effective action(s) taken to relieve diarrhea or constipation -Presence of frank blood or tarry stools -Presence of abdominal distention or gas

Which postoperative instructions will the nurse provide for a client after laparoscopic Nissen fundoplication (LNF)? Select all that apply A. Consume a soft diet for about a week; avoid carbonated beverages, tough foods and raw vegetables that are difficult to swallow B. You will no longer need to take antireflux medications after your surgery is over C. You must not drive for a week after surgery; especially do not drive after D. Walk every day but do not do any heavy lifting E. Remove the small dressings and closure strips 2 days after surgery and then you may shower F. Report fever above 101°F (38.3°C), nausea, vomiting, or uncontrollable bloating or pain

ANS: A, C, D, F Rationale: Option B is not correct because the client may take anti reflux medications for a month after surgery. Option E is not correct because the closure strips are kept in place for 10 days after surgery.

Which clients will the nurse carefully assess for high risk of oral cavity disorders? Select all that apply. A. Clients who are homeless or live in institutions B. Clients with sexually transmitted infections C. Clients who are developmentally disabled D. Clients who consume an unhealthy diet E. Clients who work in coal mines F. Clients who regularly use tobacco or alcohol

ANS: A, C, D, F Rationale: The nurse would carefully assess clients for increased risk of oral cavity disorders with: Having developmental delays or mental health disorders, Having limited access to care due to homelessness, Residing in institutions, Using tobacco and/or alcohol, consuming an unhealthy diet, having a type of oral cancer, and consuming dietary excess.

Which simple, noninvasive tests will the nurse expect to be ordered to detect H. pylori in a client with PUD? Select all that apply. A. Serologic testing for antibodies B. Abdominal ultrasound C. Urea breath test D. Computerized tomography scan E. Stool antigen test F. Magnetic resonance imaging

ANS: A, C, E Rationale: There are three simple, noninvasive tests to detect H. pylori in the client's blood, breath, or stool. Although the breath and stool tests are considered more accurate, serologic testing for H. pylori antibodies is the most common method used to confirm H. pylori infection.

When the nurse is teaching a client about bowel obstructions, which conditions will be described as mechanical bowel obstructions? Select all that apply. A. Adhesions B. Paralytic ileum C. Tumors D. Functional obstruction E. Crohn disease F. Absent peristalsis

ANS: A, C, E Rationale: When the nurse describes mechanical bowel obstructions, they include conditions where the bowel is physically blocked by problems outside the intestine (adhesions), in the bowel wall (Crohn disease), or in the intestinal lumen (tumors).

When providing discharge teaching, for which symptoms will the nurse teach a client with peptic ulcer disease (PUD) to seek immediate medical attention? Select all that apply. A. Bloody or back stools B. Dyspepsia or reflux C. Bloody vomit or vomit that looks like coffee grounds D. Odynophagia with nausea E. Sharp, sudden, persistent, and severe epigastric or abdominal pain F. Loss of appetite with dysphagia

ANS: A, C, E Rationale: The nurse teaches a client with PUD to seek immediate medical attention for these symptoms (Options A, C, E)

Which action will the nurse take to help relieve the severe pain in a client with acute pancreatitis? Select all that apply. A. Maintaining the client on NPO status B. Administering oral NSAIDs around the clock C. Inserting a nasogastric (NG) tube to low suction D. Providing opioids by patient-controlled analgesia E. Administering pancreatic enzyme replacement therapy F. Assisting the client to a side-lying position with knees drawn up to the chest

ANS: A, D, F Rationale: Pain can be reduced by preventing pancreatic stimulation by keeping the client NPO. Opioids are needed for severe pain, and our best provided by PCA. Clients may obtain some pain relief from a sideline position with the knees, John closely to the chest. NSAIDs are not used and pancreatic enzyme replacement therapy would only make the pancreatitis worse at this time. NG tube placement is reserved for only those clients who have continuous vomiting or biliary obstruction.

Which symptoms in a client with cirrhosis and encephalopathy indicate to the nurse that the prescribed lactulose therapy is effective? Select all that apply. A. Decreased confusion B. Increased urine output C. Musty odor to the breath D. Two to three soft stools daily E. Lower serum bilirubin levels F. Lower serum ammonia levels

ANS: A, D, F Rationale: Lactulose helps reduce encephalopathy by increasing stools, which causes the loss of some nitrogen-producing bacteria in the intestinal tract. This loss reduces ammonia levels and helps decrease confusion. Lactulose does not affect serum bilirubin levels or increase urine output. A musty odor of the breath (fetter hepatics) is an indication of worsening encephalopathy.

For clients with which types of hepatitis will the nurse teach about prevention of infection spread through the oral-fecal contamination route? Select all that apply. A. Hepatitis A (HAV) B. Hepatitis B (HBV) C. Hepatitis C (HCV) D. Hepatitis D (HDV) E. Hepatitis E (HEV) F. Toxic hepatitis

ANS: A, E Rationale: HAV and HEV are spread by the oral-fecal route from contaminated food and water sources. HBV, HCV, and HDV are spread primarily by the parental route, although sexual contact can also result in infection spread. Toxic hepatitis is not infectious and it's caused by exposure to hepatotoxic chemicals.

Which drugs will the nurse expect to administer to a client with PUD, caused by an H. pylori infection, who is prescribed PPI - triple therapy? A. A proton pump inhibitor, two antibiotics, and bismuth B. A proton pump inhibitor and two antibiotics C. An opioid drug, proton pump inhibitor, and an antibiotic D. An H2 histamine blocker, an antibiotic, and a proton pump inhibitor

ANS: B Rationale: A common drug regimen for H. pylori infection is PPI - triple therapy, which includes a PPI, such as lansoprazole, plus two antibiotics such as metronidazole and tetracycline or clarithromycin and amoxicillin for 10 to 14 days.

What type of hernia does the nurse suspect when assessing a client and discovering these findings: Abdominal pain, nausea, vomiting, pain, heart rate 118 beats/min, and temperature 101°F (38.3°C)? A. Incisional B. Strangulated C. Incarcerated D. Umbilical

ANS: B Rationale: A hernia is strangulated when the blood supply to the herniated segment of the bow is cut off by pressure from the hernial ring (the band of muscle around the hernia). If a hernia is strangulated, there is ischemia and obstruction of the bowel loop. This can lead to necrosis of the bowel, sepsis, and possibly bowel perforation. Signs of strangulation or abdominal distention, nausea, vomiting, pain, fever, and tachycardia..

Indications of which vitamin deficiency will the nurse be sure to assess for in a client who follows a strict vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D3

ANS: B Rationale: A strict vegan diet is plant-based only. All animal sources of protein, such as meat, poultry, fish, seafood, eggs, and dairy products are avoided as are any complex foods that contain these products. Vitamin B12 is highest in red meats.

Which complication in a client with a cute necrotizing pancreatitis who develops a temperature spiked to 104°F will the nurse suspect? A. pancreatic pseudocyst B. Pancreatic abscess C. Chronic pancreatitis D. Pancreatic cancer

ANS: B Rationale: A sudden temperature elevation in a client with a cute necrotizing pancreatitis is a strong indicator of pancreatic abscess that develops as a secondary bacterial infection with suppuration and pus formation of the necrotic pancreatic tissue. This condition can lead to sepsis and multiple organ dysfunction syndrome (MODS)

What is the most important assessment for the nurse to perform before administering the first dose of sulfasalazine to a client diagnosed with ulcerative colitis? A. Obtaining an accurate weight B. Asking whether he or she has an allergy to sulfa drugs C. Measuring heart and respiratory rate and blood pressure D. Determining the number of times the client has had a stool today

ANS: B Rationale: Although all assessment information is appropriate and important, the most important data to obtain is determining whether the client has a sulfa allergy. The drug sulfasalazine contains significant amounts of sulfa, and if the client has a sulfa allergy, he or she is likely to have an allergic reaction to this drug.

Which assessment is the priority for the nurse to make in the immediate postoperative period for a client after bariatric surgery? A. Asking the client to rate his or her pain B. Checking oxygen saturation and respiratory effort C. Examining the wound for indications of infections or dehiscence D. Monitoring skinfold areas for cleanliness and indications of breakdown

ANS: B Rationale: Although all the listed assessments are important, airway management is the priority in the immediate postoperative period after bariatric surgery. Obese clients often have short, thick necks and compromised airways. These clients are more likely to need mechanical ventilation or other types of respiratory support to ensure adequate gas exhchange.

Which serum electrolyte value in a client with early-stage ascites from chronic liver disease who is taking spironolactone will the nurse report immediately to the primary healthcare provider? A. Sodium 133 mEq/L (mmol/L) B. Potassium 6.4 mEq/L (mmol/L) C. Chloride 101 mEq/L (mmol/L) D. Calcium 8.9 mg/dL (mmol/L)

ANS: B Rationale: Although the sodium and calcium levels are slightly low, they do not pose a significant risk at this time. The serum potassium level is well above normal, which may be related to the Spironolactone therapy because it causes sodium excretion and potassium retention, and must be reported to the HCP immediately. The serum chloride level is normal.

With which client will the nurse avoid relying on body, mass index (BMI) as an indicator of nutrition status? A. 25-year-old female with anorexia B. 35-year-old male weight-lifter who works out daily C. 55-year-old female runner who is post menopausal D. 65-year-old male who plays golf twice a week and walks 5 miles daily

ANS: B Rationale: BMI is an unreliable indicate of over nutrition or under nutrition in adults who are very athletic and muscular. When muscle mass is significantly greater than average, the client will weigh more even though the percentage of body fat is low.

Which fluid and electrolyte balance assessment action will the nurse perform most often for a client with pancreatic cancer after surgery with a traditional Whipple procedure? A. Using a reflex hammer to check deep tendon reflexes B. Pinching up skin over the sternum and checking for tenting C. Applying a blood pressure cuff and assessing for Trousseau sign D. Asking the client whether he or she has noticed tingling or numbness around the mouth

ANS: B Rationale: Clients are at extreme risk for dehydration during and after a traditional Whipple surgical procedure for pancreatic cancer because of variety of factors. These factors include exposure of the bowel during surgery, extensive NPO status, the presence of drainage tubes, and protein malnutrition resulting in poor osmotic/oncotic pressure.

Which nonsurgical treatment will the nurse expect the client with esophageal cancer to receive for immediate relief of dysphagia? A. Photodynamic therapy B. Esophageal dilation C. Radiation therapy D. Swallowing therapy

ANS: B Rationale: Esophageal dilation may be performed as necessary throughout the course of the disease to achieve temporary but immediate relief of dysphagia. It is usually performed in the ambulatory care setting. Dilators are used to tear soft tissue, thereby widening the esophageal lumen (opening).

Which complication does the nurse suspect when a client with PUD suddenly develops sharp epigastric pain that spreads over the entire abdomen? A. Gastric erosion B. Perforation C. Hemorrhage D. Gastric cancer

ANS: B Rationale: Gastric and duodenal ulcers can perforate and bleed. Perforation occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is worn away. The stomach or duodenal contents can then leak untie the peritoneal cavity. Sudden, sharp pain begins in the mid-epigastric region and spreads over the entire abdomen.

The nurse reviews a client's laboratory values and discovers a serum potassium level of 3.1 mEq/L. Which gastrointestinal condition could cause this value? A. Malabsorption B. Gastric suctioning C. Acute pancreatitis D. Liver disease

ANS: B Rationale: Gastrointestinal causes of decreased potassium include vomiting, gastric suctioning, diarrhea, and drainage from intestinal fistulas.

How will a nurse interpret a clients laboratory finding of the presence of immunoglobulin G antibodies directed against hepatitis A (HAV)? A. Active, infectious HAV is present B. Permanent immunity to HAV is present C. This is the client's first infection to HAV D. The risk for infection if exposed to HAV is high

ANS: B Rationale: Immunoglobulin G (IgG) directed against HAV are antibodies that indicate the client was previously exposed to HIV and developed immunity against it.

For which client with gastric cancer does the nurse expect that minimal invasive surgery (MIS) plus radiation therapy or chemotherapy may be curative? A. 45-year-old with advanced disease B. 50-year-old with early disease C. 60-year-old with liver metastases D. 65-year-old with invasion of the stomach muscle

ANS: B Rationale: In early stage of gastric cancer, laparoscopic surgery (minimally invasive surgery - MIS) plus adjuvant chemotherapy and radiation may be curative.

How does the nurse expect a client's nasogastric (NG) tube drainage to appear immediately after Nissen fundoplication surgery? A. Bright red mixed with brown B. Dark brown C. Yellowish to green D. Green to clear

ANS: B Rationale: Initially the nurse expects the NG drainage to be dark brown with old blood. The drainage should become normal yellowish green within the first 8 hours after surgery.

Which statement by a client with gastroenteritis due to infection with the norovirus indicates that the nurse is teaching about this illness has been successful? A. "I got this infection from being around my grandchildren when they had respiratory illnesses." B. "it is most likely that I got this infectious illness from either contaminated food or water." C. "I may have gotten sick when I was traveling last month to Florida." D. "It's really important that I don't go to restaurants for at least a month after I am well."

ANS: B Rationale: Norovirus is transmitted through the fecal-oral route from person to person and from contaminated food and water. Infected individuals can also contaminate surfaces and objects in the environment. Vomiting may cause the virus to become airborne.

What is the next best action for the nurse to take after assessing a client who returned to the care unit with a colostomy by minimally invasive surgery (MIS) that is covered by a petrolatum gauze dressing under a dry sterile dressing? A. Reinforcing the dressing and leave it in place until the surgeon changes it the next morning B. Collaborating with the certified wound, stony, continence nurse (CWOCN) to place a pouch system as soon as possible C. Teaching the client how to use the patient-controlled anesthesia (PCA) machine to control his or her pain D. Notifying the surgeon that the colostomy stoma is pink, moist, slightly edematous, and protrudes 2 cm from the abdominal wall

ANS: B Rationale: Option A is not correct because the nurse collaborates with the certified wound, ostomy, continence nurse (CWOCN) to place a pouch system as soon as possible (option B). The colostomy pouch system, also called an appliance, allows more convenient and suitable collection of stools than a dressing does. Option C is not correct because a client who has an open colon resection may need PCA for 24 to 36 hrs posteroperative, but a client who undergoes MIS has less pain and usually does not require PCA. Option D is not correct because it describes a healthy stoma. This must be documented, but not be reported to the surgeon.

Which action is appropriate for the nurse to take to prevent harm when caring for a client with ulcerative colitis who has undergone a total proctocolectomy with placement of a permanent ileostomy? A. Irrigating the ileostomy to maintain patency B. Using a skin barrier to prevent excoriation C. Monitoring the client for nausea due to decreased intestinal motility D. Giving small, frequent feedings to compensate for malnutrition from short-gut syndrome

ANS: B Rationale: Prevention of harm from skin problems (irritation, excoriation) is a nursing priority for these clients. The contents of the small intestine contain proteolytic enzymes and bile salts that are very irritating to the skin. Therefore, the priority action is to use a skin barrier.

Which new-onset assessment finding in a client with Crohn disease (CD) indicates to the nurse the possibility of a fistula development? A. Anorexia B. Pyuria with fever C. Smooth, beefy red tongue D. Decreased serum albumin

ANS: B Rationale: Pyuria, white blood cells or pus in the urine, is a strong indicator of an enterovesical fistula between the bowel and bladder. Anorexia is nonspecific and can be a chronic problem because of the discomfort associated with Crohn's disease. A smooth, beefy red tongue is common with vitamin B12 deficiency. Decreased albumin levels can indicate worsening of the disorder, but it's not specific to fistula development.

Which food will the nurse recommend a client to avoid when he or she reports fear of stomach cancer? A. Foods that cause reflux B. Pickled or processed foods C. Large, heavy meals D. Spicy foods that cause gas

ANS: B Rationale: Stomach cancer seems to be positively correlated with eating excessive pickled foods, nitrates from processed foods, and salt added to food. Indigestion of these foods over a long period can lead to atrophic gastritis, which is a precancerous condition.

Which action will the nurse take to prevent harm when a client's total parenteral nutrition (TPN) bag has only 20 mL left ini it and the next bag will not be delivered for at least 1 hour? A. Capping the TPN line until the next TPN solution is available B. Infusing 10% dextrose/water until the TPN solution is available C. Preparing to treat the client for hypoglycemia D. Notifying the HCP

ANS: B Rationale: The TPN infusion line cannot be capped and must remain patent. The nurse infuses a 10% glucose infusion to keep the line open and prevent changes in blood glucose levels.

Which nursing assessment has the highest priority for the nurse to perform on a client admitted in severe pain with acute pancreatitis? A. Asking the client to rate the level of pain B. Measuring heart rate, blood pressure, and oxygen saturation C. Auscultating bowel sounds in all four abdominal quadrants D. Determining the amount of alcoholic beverages the client consumes daily

ANS: B Rationale: The client with acute pancreatitis is at high risk for death from hemorrhage and shock as a result of necrotic blood vessels destroyed by enzymatic digestion. Although all of the above assessments are appropriate, the priority is to determine whether any indications of internal hemorrhage and shock or present.

Which are the most common symptoms of colorectal cancer that clients are likely to report to nurses? A. Constipation and fatigue B. Rectal bleeding and change in stool consistency C. Weight loss and abdominal fullness D. Abdominal pain and diarrhea

ANS: B Rationale: The most common signs of CRC are rectal bleeding, anemia, and a change in stool consistency or shape. Stools may contain microscopic amounts of blood that are occult (hidden), or the client may have mahogany-colored (dark), or bright red stools.

What complication does the nurse suspect when a client who had a gastrectomy develops tachycardia, syncope, and a desire to lie down 30 minutes after eating? A. Fluid overload B. Early dumping syndrome C. Late dumping syndrome D. Vitamin b12 deficiency

ANS: B Rationale: These are early manifestations of dumping syndrome, which typically occur within 30 minutes of eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse reports these manifestations to the surgeon and encourages the client to lie down.

Which oral disorder does the nurse suspect when assessment findings reveal white plaquelike lesions that when wiped away show an underlying red and sore surface? A. Leukoplakia B. Candidiasis C. Erythroplakia D. Kaposi's sarcoma

ANS: B Rationale: When a client develops oral candidiasis, white plaquelike lesions appear on the tongue, palate, pharynx (throat), and buccal mucosa (inside the cheeks). When these patches are wiped away, underlying surface is red, sore, and painful, and tissue integrity is compromised.

Which action is the priority for the nurse to take when caring for clients with oral cancers? A. Providing pain control B. Maintaining the airway C. Promoting tissue integrity D. Enhancing nutrition

ANS: B Rationale: While all these concerns are important, air-way maintenance to facilitate gas exchange is the priority of care for clients with oral cancer.

Which condition or symptom does the nurse associated with a client who has chronic gastritis? A. Hematemesis B. Pernicious Anemia C. Dyspepsia D. Epigastric burning

ANS: B Rationale: With chronic gastritis, progressive gastric atrophy from chronic mucosal injury occurs. The function of the parietal (acid-secreting) cells decrease, and the source of intrinsic factor is lost. Intrinsic factor is critical for absorption of vitamin b12. When body stores of vitamin b12 are eventually depleted, pernicious anemia results.

Based on the nurse's knowledge of gastrointestinal (GI) changes that occur with age, for which disorder in an older client will the nurse vigilantly monitor related to decreased peristalsis? A. Loss of appetite for favorite foods B. Constipation with possible impaction C. Vomiting that occurs after eating D. Indigestion related to consuming spicy foods

ANS: B Rationale: As clients age, peristalsis decreases and GI nerve impulses are dulled. This leads to decreased sensation for defecation and can result in postponement of bowel movements, which can lead to constipation and impaction.

Which gastrointestinal condition does the nurse suspect a client is at risk for, when she reports emotional distress about her family situation and whether she will be able to return to work? A. Hiatal hernia B. Exacerbation of irritable bowel syndrome C. Nausea accompanied by vomiting and diarrhea D. Esophageal ulcers

ANS: B Rationale: The nurse must ask a client about experiencing stressful events because stress has been associated with the development or exacerbation (flare-up) of irritable bowel syndrome (IBS).

Which clients will the nurse recognize as having a higher risk for development of acute pancreatitis? Select all that apply. A. 26-year-old woman who is a marathon runner B. 34-year-old man with Stage II HIV disease C. 40-year-old woman who has had cholelithiasis for 3 years D. 56-year-old man who drinks alcohol heavily and is underweight E. 62-year-old woman with gastroesophageal reflux disease F. 70-year-old man who has type 2 diabetes

ANS: B, C, D Rationale: Although the cause of acute pancreatitis is often unknown, risk factors include viral infection with HIV, long-term cholelithiasis that can lead to obstruction, and alcoholism. Being thin and active is not directly associated with pancreatitis. Neither gastroesophageal reflux disease, nor type 2 diabetes increase the risk for acute pancreatitis.

When the nurse is providing discharge instructions for a client recovering from peritonitis, which is essential findings will the client and family be instructed to report immediately to the primary healthcare provider? Select all that apply. A. Completion of broad-spectrum antibiotics as prescribed B. Unusual or foul-smelling drainage C. Signs of wound dehiscence or ileus D. Swelling, redness, warmth, or bleeding from the incision site E. A temperature higher than 101°F (38.3°C) F. Abdominal pain or board-like stiffness in the abdomen

ANS: B, C, D, E, F Rationale: Before being discharged home, the nurse assesses the clients ability for self management and provides the client and family with written and oral instructions to report the following problems to the primary healthcare provider immediately: unusual or foul-smelling drainage; swelling, redness, warmth, or bleeding from the incision site; a temperature higher than 101°F; abdominal pain; and signs of wound dehiscence or ileum.

Which assessment findings will the nurse expect to find when a client is experiencing early mechanical small bowel obstruction? Select all that apply. A. Absence of bowel sounds B. Abdominal distention C. Visible peristaltic waves D. High-pitched bowel sounds E. Abdominal rigidity F. Cramping

ANS: B, C, D, F Rationale: On examination of the abdomen, the nurse observes for abdominal distention which is common in all forms of intestinal obstruction. Peristaltic waves may also be visible. The nurse auscultates for proximal (above the obstruction) high-pitched bowel sounds (borborygmi), which are associated with cramping early in the obstructive process as the intestine tries to push the mechanical obstruction forward. Absent bowel sounds and abdominal rigidity occur in later stages of the obstruction.

Which important information will the nurse include when teaching clients how to maintain healthy oral cavities? Select all that apply. A. Perform a monthly self-examination of the mouth looking for changes B. Eat a well-balanced diet and stay hydrated by drinking water C. If you wear dentures, make sure that they are in good repair and fit properly D. Thoroughly brush and floss your teeth (or brush dentures) consistently twice daily. E. Use mouthwashes that contain alcohol to destroy organisms that live in the mouth F. See the dentist regularly and have dental problems repaired as soon as possible

ANS: B, C, D, F Rationale: Option A is not correct - the nurse teaches client to examine the mouth weekly and report any changes to HCP. Option E is not correct - Mouthwashes containing alcohol are avoided because they can cause tissue damage

Which changes in a 60-year-old clients assessment findings over the past 4 weeks indicate to the nurse the need for a nutrition status evaluation? Select all that apply. A. Sprained a wrist two weeks ago B. Initiation of a strict vegan diet C. Unintentional weight loss of 6% D. Initiation of a regular exercise program E. Reports starting counseling for depression F. Reduced cigarette smoking from 2 packs/day to 1 pack/day

ANS: B, C, E Rationale: The changes that could alter nutrition status the most for this 60-year-old client are the start of a strict vegan diet, unintentional weight loss greater than 5% in a month, and the presence of depression. Many people who decide to begin a strict vegan diet are unaware of what types of plant-based foods will be needed to maintain an adequate intake of micronutrients and protein. Many, but not all, people with depression often lose interest in maintaining an adequate nutritional intake.

Which priority points will the nurse include when providing discharge teaching for a client who had a minimally invasive inguinal hernia repair (MIIHR)? A. "Limit your oral fluid intake to between 1000 to 1200 mL per day." B. "Avoid strenuous activity for several days before returning to work a normal activities." C. "Take your prescribed stool softener regularly to prevent the occurrence of constipation." D. "You will need to learn how to insert a straight urinary catheter for the first week after your surgery." E. "Observe your incisions and report any signs of infection to your surgeon immediately." F. "This procedure is fairly painless, so you will not need a prescription for pain medications."

ANS: B, C, E Rationale: The nurse teaches the client to avoid strenuous activity for several days before returning to work and a normal routine. A stool softener may be needed to prevent constipation. Clients who are taking oral opioids for pain management or cautioned not to drive or operate, heavy machinery. Clients are instructed to observe their incisions for redness, swelling, heat, drainage, and increased pain and promptly report these occurrences to the surgeon. The nurse reminds clients that soreness and discomfort (rather than severe, acute pain) are common after MIIHR.

Which gastrointestinal (GI) changes will the nurse expect to see in an older client with a GI problem? Select all that apply. A. Increased hydrochloric acid secretion B. Decreased absorption of iron and Vitamin b12 C. Decreased peristalsis with constipation D. Increased cholesterol synthesis E. Decreased lipase with decreased fat digestion F. Decreased drug metabolism with risk of toxicities

ANS: B, C, E, F Rationale: The nurse understands that as people age, and after 65 years of age, physiologic changes can occur in the GI system.

For which reasons will the nurse insert a large-bore nasogastric tube (NGT) in a client with upper GI bleeding or possible obstruction? Select all that apply. A. To provide nutritional supplements B. To determine the presence or absence of blood in the stomach C. To assess the rate of bleeding D. To administer medications E. To prevent gastric dilation F. To administer gastric lavage

ANS: B, C, E, F Rationale: Upper GI bleeding or obstruction often requires the HCP or nurse to insert a large-bore NGT in order to: Determine the presence or absence of blood in the stomach, assess the rate of bleeding, prevent gastric dilation, and administer gastric lavage.

Which actions will the nurse include when providing care for a client with a nasogastric tube (NGT) in place? Select all that apply. A. Assessing for NGT placement every 8 hours B. Keeping the client in a semi-Fowler position C. If the NGT is repositioned, confirming placement with an x-ray D. Instructing the client that feeling nausea is due to the NGT placement E. Monitoring the contents and drainage from the NGT F. Irrigating the NGT with 30 mL of normal saline as prescribed

ANS: B, C, E, F Rationale: When managing a client who has a nasogastric tube (NGT) in place, these nursing care actions are included: Monitoring drainage, ensuring tube patency, checking tube placement evert 4 hours; irrigating tube as prescribed (usually 30 mL normal saline), maintaining the client on NPO status, providing frequent mouth and nares care, and maintaining the client in a semi-fowler position. If the NGT is repositioned or replaced, confirmation of proper placement is obtained by x-ray before using it.

Which common factors will the nurse recognize as contributing to or worsening of hepatic encephalopathy in clients with liver cirrhosis? Select all that apply. A. Anorexia B. Infection C. Opioids D. Diarrhea E. GI bleeding F. High-protein diet G. Diabetes mellitus H. Chronic confusion

ANS: B, C, E, F Rationale: Factors that may contribute to or worsen hepatic encephalopathy in patients with cirrhosis include: High-protein diet, infection, hypovolemia (decreased fluid volume), hypokalemia (decreased serum potassium), constipation, G.I. bleeding (causes a large protein load in the intestines), and some drugs, especially hypnotics, opioids, sedatives, analgesics, diuretics, illicit drugs.

Which techniques will the nurse instruct the family who will be caring for an 88-year-old female client who has severe osteoarthritis, muscle weakness, and dementia to use to improve nutrition and prevent harm? Select all that apply. A. "Be sure to keep her in bed while eating to prevent her from becoming over tired." B. "Let her feed herself as much as possible even if she uses her fingers." C. "Always include some foods that you know she likes for every meal." D. "Withhold her pain medications before meals to prevent nausea." E. "If she doesn't finish a meal in 20 minutes, take the food away." F. "During meals, be sure she has her glasses and hearing aid on."

ANS: B, C, F Rationale: Clients are more likely to eat when they enjoy the experience and have some control over the process. Wearing prescribed glasses and hearing aids increase sensory perception, which can help hold the client's interest in eating. Having the client up in a chair, rather than in bed for meals, improved movement through the GI tract, reduces the risk for aspiration, and helps keep the client awake. Clients are more likely to eat if they're not in pain. Giving prescribed pain medication an hour to 30 minutes before meals can increase the comfort. The family is instructed to let the client eat at her own pace. Hurrying the client can result in an increased risk for aspiration, as well as make the experience less pleasant.

Which disease features will the nurse commonly associate with a client who has Crohn disease (CD) that are rare or absent in a client with ulcerative colitis (UC)? Select all that apply. A. The problem first appears in the rectum and proceeds in a continuous manner toward the cecum B. Fistulas commonly develop C. Clients have 5 to 6 soft, loose, non-bloody stools per day D. there is a greatly increased risk for colon cancer E. Many clients have one or more extraintestinal problems such as arthritis, ankylosing spondylitis, and erythema nodosum. F. The appearance of the affected intestine areas resemble "cobblestone."

ANS: B, C, F Rationale: The affected intestinal areas in CD are not continuous and usually have normal tissue in between lesions ("skip lesions") that often have a cobblestone appearance. Fistula development is very common and serious. Although colon cancer can occur in clients with CD, it is much more common in clients with ulcerative colitis. Extraintestinal symptoms, bloody stools, and development from the rectum toward the cecum are characteristics of ulcerative colitis, not Crohn disease.

Which drugs will the nurse expect to give a client with acute gastritis that are anti secretory agents? Select all that apply. A. Famotidine B. Omeprazole C. Sucralfate D. Pantoprazole E. Nizatidine F. Calcium carbonate

ANS: B, D Rationale: H2 receptor antagonists, such as Famotidine and Nizatidine, are typically used to block gastric secretions. Sucralfate, a mucosal barrier fortifier, may also be prescribed. Antisecretory agents (PPIs), such as Omeprazole and Pantoprazole, are prescribed to suppress gastric acid. Calcium carbonate (chewable or liquid) is also a potent antacid.

Which laboratory assessment findings will the nurse expect in a client who is diagnosed with ulcerative colitis? A. Increased albumin B. Decreased hemoglobin C. Increased sodium D. Decreased potassium E. Elevated white blood cell (WBC) count F. Elevated erythrocyte sedimentation rate

ANS: B, D, E, F Rationale: Hematocrit and hemoglobin are often low from chronic blood loss. The inflammatory nature of the disease results in an increased WBC count and erythrocyte sedimentation rate. Sodium, potassium, and albumin levels are low from loss of these substances in the frequent diarrheal stools and malabsorption through the diseased bowel.

Which diagnostic test will the nurse prepare a client for to confirm the diagnosis of colorectal cancer (CRC)? A. Fecal occult blood test (FOBT) B. Carcinoembryonic antigen (CEA) C. Colonoscopy with biopsy D. CT-guided virtual colonoscopy

ANS: C Rationale: A colonoscopy provides views of the entire large bowel from the rectum to the ileocecal valve. As with sigmoidoscopy, polyps can be seen and removed, and tissue samples can be taken for biopsy. Colonoscopy with biopsy is the definitive test for the diagnosis of colorectal cancer.

Which symptom reported by client after eating eggs indicates to the nurse a possible allergy to eggs rather than an egg intolerance? A. Diarrhea B. Excessive flatulence C. Throat itching and swelling D. Nausea when smelling eggs

ANS: C Rationale: A true food allergy is an immune and inflammatory response that can occur as a systemic response, as well as in tissues that came into direct contact with the allergen in the food. A food intolerance is seen as a physiologic change in gastrointestinal responses that indicate a problem with digesting the food item.

Which assessment findings will the nurse expect in a client with chronic vitamin D deficiency? A. Swollen, bleeding gums B. Reddened and dry conjunctiva C. Osteomalacia, bone pain, and rickets D. Enlargement of the liver and spleen

ANS: C Rationale: Activated vitamin D is needed to absorb and use calcium, an element that contributes to bone density. When a client is chronically deficient in vitamin D, bones become soft (osteomalacia), bend (rickets), and bone pain increases.

What is the nurse's first priority when providing care for a client after an esophagogastroduodenoscopy (EGD)? A. Monitoring the client's vital signs every 15 minutes B. Auscultating the client's breath sounds for crackles C. Keeping the client NPO until the gag reflex returns D. Recording accurate intake and output

ANS: C Rationale: After an EGD, the nurse's priority of care is to prevent aspiration. The client is kept NPO until the gag reflex returns (usually in 30 to 60 minutes) because an absent gag reflex increases the risk for aspiration. Clients must not be offered fluids or food by mouth until the gag reflex is intact!

Which most accurate diagnostic test will the nurse expect to be ordered for a client to verify the diagnosis of GERD? A. Esophagogastroduodenoscopy (EGD) B. Esophageal manometry C. Ambulatory esophageal pH monitoring D. Motility testing

ANS: C Rationale: Ambulatory esophageal pH monitoring is the most accurate method of diagnosing GERD. With this procedure, a transnasally placed catheter or wireless, capsule-like device is affixed to the distal esophageal mucosa. The client is asked to keep a diary of activities and symptoms over 24-48 hours, and the pH is continuously monitored and recorded.

What is the nurses best first action when a client who just had a liver transplant develops using around two IV sites as well as has some new bruising? A. Applying pressure to the IV sites B. Checking the clients platelet levels C. Notifying the surgeon immediately D. Documenting the findings as the only action

ANS: C Rationale: Bleeding around the IV sites is a strong indicator of clotting problems. Such problems are an indicator of impaired function of the transplanted liver and may be an early sign of transplant rejection. Immediate action is needed to prevent harm in the form of graft loss. Do

Which action will the nurse instructs a client with celiac disease to perform to reduce symptoms? A. Limiting caffeine B. Drinking more liquids C. Reading labels on prepared foods D. Avoiding raw fruits and vegetables

ANS: C Rationale: Celiac disease results in inflammatory intestinal responses, when gluten, especially wheat, is eaten. Clients are instructed to avoid obvious gluten sources, such as breads, cereals, and food made with most types of flour. Many prepared or packaged foods contain some wheat or other gluten as a minor ingredient that can still cause symptoms. Clients are taught to read, packaged food labels carefully for possible "hidden" gluten content.

What advice will the nurse give when a client expresses concern about gas and odor from a colostomy? A. "Place an aspirin in the colostomy bag once a day to help eliminate gas." B. "Empty the bag often, especially when it is about half full." C. "Adding a breath mint to the pouch can help to eliminate odors." D. "Cutting a small hole in the top of the bag will allow for the release of excess gas."

ANS: C Rationale: Charcoal, filters, pouch, deodorizers, or placement of a breath, mint in the pouch helps eliminate odors. The client should be cautioned to not put aspirin tablet in the pouch because they may cause ulceration of the stoma. Pouches with vents that allow release of gas from the ostomy bag through a deodorizing filter are available and may decrease the clients level of self-consciousness about odor.

Which client will the nurse recognize as having the most risk factors for Cholelithiasis? A. 25-year-old white female athlete who is 10 lb underweight and had an appendicitis 2 months ago B. 35-year-old African-American male who is 10 lb overweight and is hypertensive C. 50-year-old Mexican-American female who has three children and takes hormone replacement therapy D. 60-year-old Asian-American male who had coronary artery bypass graft surgery 4 weeks ago

ANS: C Rationale: Cholelithiasis has a higher incidence among Mexican-Americans, especially women who have had multiple pregnancies, and among those who are taking estrogen/progesterone hormone replacement therapy.

What does the nurse suspect when a client comes into the emergency department with right lower quadrant cramping pain, nausea, vomiting, and guarding with rigidity of the abdomen? A. Gastroenteritis B. Ulcerative colitis C. Appendicitis D. Crohn disease

ANS: C Rationale: Cramping abdominal pain followed by nausea and vomiting can indicate appendicitis. When the nurse or emergency healthcare provider find muscle rigidly and guarding on palpation of the abdomen, peritonitis is suspected..

Which diagnostic test does the nurse expect will be ordered for a client with suspected gastritis? A. Computed tomography (CT) scan B. Upper gastrointestinal (GI) series C. Esophagogastroduodenoscopy (EGD) D. Barium swallow

ANS: C Rationale: EGD via an endoscope with biopsy is the gold standard for diagnosing gastritis. The HCP performs a biopsy to establish a definitive diagnosis of the type of gastritis.

Which diagnostic procedure does the nurse expect will be ordered by the HCP to view a client's liver, gallbladder, bile ducts, and pancreas for identification of the location of an obstruction? A. Upper gastrointestinal radiographic series B. Percutaneous transhepatic cholangiography C. Endoscopic retrograde cholangiopancreatography D. Esophagogastroduodenoscopy

ANS: C Rationale: Endoscopic Retrograde Cholangiopancreatography (ERCP) includes visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas to identify the cause and location of obstruction. After a cannula is inserted into the common bile duct, a radiopaque dye is instilled, and several x-ray images are obtained. The HCP may perform a papillotomy (a small incision in the sphincter around the ampulla of Vater) to remove gallstones. If a biliary duct stricture is found, plastic or metal stents may be inserted to keep the ducts open. Biopsies of tissue are also frequently taken during this test.

What does the nurse suspect when assessing a client's mouth and finding an oral cavity tumor that appears as a red, velvety lesion on the tongue, palpate, floor of the mouth, or mandibular mucosa? A. Kaposi's sarcoma B. Basal cell carcinoma C. Erythroplakia D. Leukoplakia

ANS: C Rationale: Erythroplakia, which is considered precancerous, appear as red, velvety mucosal lesions on the floor of the mouth, tongue, palate, and mandibular mucosa.

Which serum laboratory value is most important for the nurse to monitor when caring for an older client with gastroenteritis who has an irregular heart rate and reports "feeling weak?" A. Albumin B. Sodium C. Potassium D. Leukocyte count

ANS: C Rationale: In clients who are older, the diarrhea of gastroenteritis can cause significant potassium loss, along with fluid loss, which can cause cardiac dysrhythmias and skeletal muscle weakness.

What type of bowel sounds will the nurse expect to auscultate when a client reports having diarrhea for the past 2 days? A. Decreased or diminished sounds B. Increased sounds in the left lower quadrant only C. Increased loud and gurgling sounds D. Decreased sounds in the right upper quadrant only

ANS: C Rationale: Increased bowel sounds, especially loud, gurgling sounds (borborygmus), result from increased motility of the bowel. These sounds are usually heard when a client has diarrhea, gastroenteritis, or a complete intestinal obstruction (sounds will be heard above the obstruction).

What is the nurses priority action when a client with ascites reports increased abdominal pain and chills? A. Applying oxygen and making the client NPO B. Notifying the primary healthcare provider immediately C. Assessing for abdominal rigidity and taking the clients temperature D. Applying a heating blanket, and raising the head of the bed to a 45-degree angle

ANS: C Rationale: Increasing abdominal pain and the presence of chills in a client who has ascites indicate possible spontaneous bacterial peritonitis. The nurse would perform a complete abdominal assessment and assess for a temperature elevation before notifying the health care provider.

Which client will the nurse identify as most as risk for the marasmic-kwashiorkor form of protein-energy malnutrition (PEM)? A. 48-year-old with rheumatoid arthritis who has worn dentures for 6 years B. 58-year-old who suffered a traumatic amputation of the left arm 15 years ago C. 68-year-old vegan who is 10 lbs underweight and has bacterial pneumonia with a high fever D. 78-year-old who has type 2 diabetes mellitus and lives with his 50 year old daughter

ANS: C Rationale: Marasmus is an energy (caloric) malnutrition with some degree of starvation in which body fat and muscle proteins are wasted although serum proteins may be normal. The client appears thin. Kwashiorkor malnutrition occurs with a severe protein deficiency although overall caloric intake may be adequate to maintain a normal weight, but serum proteins are low. Marasmic-Kwashirokor is a more severe malnutrition in which both protein and caloric intake are inadequate and the client is seriously underweight. It is common when a client is already malnourished and develops a health problem that greatly increases the metabolic need for nutrients.

For which reason will the nurse carefully examine the mouth of an older adult for candidiasis? A. Older clients are more likely to wear dentures which increase the risk for candidiasis B. Older adults on fixed incomes consume fewer fresh vegetables and fruits C. Older adults' immune systems decline with aging increasing their risk for candidiasis D. Older clients are less likely to see a dentist and have healthy oral hygiene

ANS: C Rationale: Older adults are at high risk for candidiasis because the immune system naturally declines as people age

Which complication will the nurse suspect when a client with peritonitis reports increased pain in the upper left abdominal quadrant, and in the left shoulder, especially during inhalation? A. Sepsis B. Pneumonia C. Localized abscess D. Bacterial hepatitis

ANS: C Rationale: Peritonitis can cause a localized abscess to form. Indications of this problem are more pain in one area of the abdomen than in the rest of the abdomen. An abscess in the upper right abdomen often causes referred pain to the right shoulder.

Which client does the nurse assess as at highest risk for development of esophageal cancer? A. 45-year-old on a high-fiber diet B. 50-year-old with a sedentary lifestyle C. 55-year-old who smokes and is 25 lb overweight D. 60-year-old who is prescribed famotidine for reflux

ANS: C Rationale: Primary risk factors associated with the development of esophageal cancer include: Alcohol intake, diets cholerically deficient in fresh fruits and vegetables, diets high in nitrates and nitrosamines (found in pickled and fermented foods), malnutrition, obesity (especially with increased abdominal pressure), smoking and untreated GERD

What is the nurses best response to a client who fears he may have been exposed to hepatitis A while attending a banquet last week, after which three restaurant workers were diagnosed with hepatitis A? A. "Which types of food did you eat at the banquet?" B. "If you have no symptoms at this time, you are probably safe." C. "You can receive an immunoglobulin injection to prevent the infection." D. "Contact your primary healthcare provider about receiving the hepatitis A vaccine."

ANS: C Rationale: Receiving immunoglobulin with a high concentration of antihepatitis A antibodies within 2 weeks of exposure can prevent an exposed person from developing the infection. Receiving the vaccination at this time takes too long to develop sufficient immunity to prevent an infection from this exposure.

After esohphagectomy for esophageal cancer, what is the nurse's priority for client care? A. Wound care B. Nutrition management C. Respiratory care D. Hydration status

ANS: C Rationale: Respiratory care is the highest post-op priority for clients having an esohphagectomy. For those who undergo traditional surgery, intubation with mechanical ventilation is necessary for at least the first 16-24 hours. Pulmonary complications include atelectasis and pneumonia. The risk for postoperative pulmonary complications is increased in the client who has received preoperative radiation. Once the client is extubated, the nurse supports deep breathing, turning, and coughing every 1 to 2 hours. The nurse assess the client for decreased breath sounds and shortness of breath every 1 to 2 hours. Incisional support is provided along with adequate analgesia to enhance effective coughing.

What action will the nurse take when, 12 hours after a traditional cholecystectomy, a clients Jackson-Pratt drain shows serosanguineous drainage stained with bile? A. Placing the client to the left lateral Sims position B. Clamping the drain intermittently for 30 minutes every hour C. Measuring the drainage and documenting the findings D. Disconnecting thterm-162e suction device and gently irrigating the drain with sterile saline

ANS: C Rationale: Serosanguineous drainage stained with bile is expected and normal during the first 24 hours after traditional cholecystectomy. The drain is not to be clamped or irrigated. Placing the client and left lateral Sims position can be done, but is not related to drainage from the JP..

Which statement by a client indicates to the nurse that teaching about the action of sucralfate has been successful? A. "The main side effect of sucralfate is diarrhea." B. "I will take my sucralfate with each meal." C. "Sucralfate will work to heal my ulcer." D. "I will take my sucralfate with my antacid."

ANS: C Rationale: Sucralfate is a mucosal barrier fortifier. It helps ulcers to heal by coating and protecting the inner lining of the stomach. It should be given 1 hour before and 2 hours after meals and at bedtime because food may interfere with drug's adherence to mucosa. Sucralfate is not given with 30 minutes of giving antacids or other drugs because antacids may interfere with its effects.

Which is the most effective action for the nurse to take to assess adequate bowel function in a client with acute pancreatitis who is at risk for the development of paralytic (adynamic) ileus? A. Observing contents of the nasogastric drainage B. Listening for bowel sounds in all four abdominal quadrants C. Asking the client if he or she has passed flatus or had a stool D. Interpreting the report of a CT scan of the abdomen with contrast medium

ANS: C Rationale: The best indicator of bowel function and adequate motility is the actual passage of flatus or stool. Bowel sounds may still be present in the presence of an adynamic ileus. A CT scan is static and does not indicate motility. Gastric contents cannot indicate bowel motility.

Which priority teaching will the nurse provide to a client who is prescribed bismuth for peptic ulcer disease (PUD)? A. "Take this drug with an aspirin." B. "You may experience dyspepsia between doses." C. "Bismuth may cause your tongue and stool to appear black." D. "Be sure to take this drug before each meal and snack."

ANS: C Rationale: The nurse teaches the client that bismuth may cause the stools and/or tongue to turn back. This discoloration is temporary and harmless.

Which statement by a client to the nurse indicates correct understanding of the management of hemorrhoids after surgical removal? A. "It will take 10 to 14 days for the rubber band used on the hemorrhoid to fall off." B. "After surgery, I will need to consume a low-fiber, low-fluid diet." C. "My first bowel movement after the surgery may be very painful." D. "Stool softeners and laxatives are avoided after hemorrhoid surgery."

ANS: C Rationale: The nurse tells the client who has had a surgical intervention for hemorrhoids that the first posteroperative bowel movement may be very painful. The client is also instructed to be sure that someone is with or nearby when this happens, because some clients become light-headed and diaphoretic, and may have syncope (temporary loss of consciousness) related to a vasovagal response.

Which electrolyte imbalance will the nurse assess for most frequently in a client who is receiving total parenteral nutrition with a solution that contains both glucose and insulin? A. Hypochloremia B. Hyperchloremia C. Hypokalemia D. Hyperkalemia

ANS: C Rationale: The presence of insulin in the TPN solution activates the sodium-potassium ATPase pump on cell membranes and moves potassium from the extracellular fluid across the membranes into the cells, resulting in hypokalemia. Because the potassium is not present in the blood in high concentrations, any movement out of the blood can result in hypokalemia and serious physiologic changes.

Which health problem will the nurse assess for in an obese client who has a 40-inch waist circumference and a waist-to-hip ratio of 0.90? A. Rheumatoid arthritits B. Chronic kidney disease C. Cardiovascular disease D. Type 1 diabetes mellitus

ANS: C Rationale: Waist circumference is a strong predictor of coronary artery disease, and WC greater than 35 inches in women and greater than 40 inches in men indicates central obesity.A waist-to-hip ratio of 0.95 or greater in men (0.8 or greater in women) indicates android obesity with excess fat at the waist and abdomen, which is also a strong predictor of CAD.

What does the nurse suspect has occurred when a client with a bowel obstruction starts passing flatus and has a small bowel movement? A. Blockage is complete B. Peritonitis has occurred C. Peristalsis has returned D. Client is rehydrated

ANS: C Rationale: When a client with a bowel obstruction has been treated and begins to pass flatus and have bowel movements, these signs indicate a return of peristalsis and that the bowel is no longer blocked.

Which laboratory finding will the nurse expect to see in a client who is suspected of having an acute, uncomplicated appendicitis? A. Decreased serum potassium level B. Increased international normalized ratio (INR) C. Increased white blood cell (WBC) count D. decreased erythrocyte sedimentation rate

ANS: C Rationale: With an acute uncomplicated appendicitis, the white blood cell count is usually elevated above normal, but remains below 20,000/mm3. The potassium level and INR are unaffected. The inflammation associated with the infection may or may not cause an elevation of the erythrocyte sedimentation rate, but would not cause it to decrease.

Which statements about eating habits and diet therapy indicate to the nurse that the client recovering from acute pancreatitis understands the recommendations made in collaboration with the registered dietitian nutritionist? Select all that apply. A. "Now I can go back to my usual three meals a day." B. "Replacing carbohydrates with protein will speed my recovery." C. "Although they do not contain fat, I will avoid chocolate and caffeine." D. "If vomiting or diarrhea occur, I will call my primary healthcare provider." E. "I can't wait to have some good, spicy Mexican food after all this hospital food." F. "I am planning on joining Alcoholics Anonymous (AA) and giving up drinking all together."

ANS: C, D, F Rationale: Recommendations for diet therapy during recovery from acute pancreatitis includes small, frequent, moderate-to-high carbohydrate, high-protein, low-fat meals with bland, non spicy food; avoidance of alcohol; and avoidance of GI stimulants such as caffeine-containing food (tea, coffee, cola, and chocolate). If clients start to have nausea, vomiting or diarrhea after eating he or she is instructed to notify the primary healthcare provider

Which actions will the nurse perform when preparing a client for paracentesis? Select all that apply. A. Obtaining informed consent B. Maintaining the client on NPO status C. Asking the client to avoid before the procedure D. Placing the client in the flat supine position E. Weighing the client before the procedure F. Assessing the respiratory rate and blood pressure

ANS: C, E, F Rationale: Vital signs, including weight are taken before the procedure to use as a baseline for changes after the procedure. Weight is important because it can help determine the volume of fluid removed (clients are expected to weigh less after a paracentesis). Having the client void before procedure helps prevent injury to the bladder. The healthcare provider performing the paracentesis is responsible for obtaining informed consent, not the nurse. The client does not need to be NPO before the procedure. The client is positioned with the head of the bed elevated.

Which assessment findings in an older client indicates that the nurse that this client is at increased risk for developing under nutrition? Select all that apply. A. Male B. Is of Jewish ethnicity C. Reports chronic diarrhea D. Receiving oxygen after surgery E. Does not consume pork products F. Has chronic obstructive pulmonary disease G. Presence of chronic draining pressure injury H. Presence of swollen gums and many missing teeth

ANS: C, F, G, H Rationale: The risk for malnutrition is not particularly associated with ethnicity or gender. Conditions that increase nutrient loss, such as chronic wounds and chronic diarrhea contribute to undernutrition risk. Poor dentition interferes with a client's ability to consume adequate nutrients.

For which client assessment finding will the nurse withhold the scheduled monthly dose of a prescribed parenteral biologic for management of ulcerative colitis (UC)? A. 5 lb (2.3 kg) weight gain B. Increased number of diarrhea stools per day C. Presence of occult blood in today's stool sample D. Cough and fever of 102°F (38.9°C)

ANS: D Rationale: "Biologics" (Biological response modifiers) all cause some degree of immunosuppression and are not given when a client has indications of an infection. The weight gain would indicate a positive response to the drug. The presence of diarrhea stools and occult blood in the stool are the reasons why the drug is given.

Which surgical client will the nurse recognize as having the highest risk for development of peritonitis? A. 35-year-old having a laparoscopic appendectomy B. 45-year-old having a vaginal hysterectomy C. 60 year olds, having a traditional cholecystectomy for cholelithiasis D. 72 year old having a bowel resection for colon cancer

ANS: D Rationale: A client of any age having open bowel surgery is always at greater risk for peritonitis, because the bowel is difficult to disinfect. This client is older and likely to have reduced immunity, placing him or her at even higher risk for peritonitis following bowel resection surgery.

What does the nurse suspect when assessment of a client after gastric resection reveals a tongue that is smooth, shiny, and appears "beefy?" A. Inadequate nutrition B. Hypovolemia C. Anemia D. Atrophic glossitis

ANS: D Rationale: After gastrectomy the nurse assesses for the development of atrophic glossitis secondary to vitamin b12 deficiency. In atrophic glossitis, the tongue takes on a shiny, smooth, and "beefy" appearance.

Which assessment technique will the nurse use to most accurately determine increasing ascites in a client with advanced liver cirrhosis and portal hypertension? A. Interpreting the serum albumin value B. Measuring the clients abdominal girth C. Testing stool for the presence of occult blood D. Weighing the client daily at the same time of the day

ANS: D Rationale: Although measuring abdominal girth can show increases in growth that can be interpreted as more ascites, weighing the client provides more accurate information of water retention in the abdominal and dependent areas.

Which client will the nurse recognize as having the highest risk for pancreatic cancer? A. 27-year-old man who is underweight and has opioid use disorder B. 35-year-old woman who is overweight and uses oral contraceptives C. 50-year-old woman who has ductal breast cancer, and receiving radiotherapy D. 60-year-old man who smokes two packs of cigarettes daily, and has liver cirrhosis

ANS: D Rationale: Although the exact cause of pancreatic cancer is not known, the older man who smokes and has liver cirrhosis, has four risk factors.

Which acid-base imbalance does the nurse expect when a client experiences a bowel obstruction high in the small intestine? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

ANS: D Rationale: An obstruction high in the small intestine causes a loss of gastric hydrochloric acid, which can lead to metabolic alkalosis.

What instruction will the nurse provide to a client to prepare him or her to undergo ultrasonography of the right upper abdominal quadrant to diagnose gallstones? A. Do not eat or drink for at least 6 hours before the test B. Shower with an antibacterial soap the morning before the test C. Be sure to have someone come with you who can drive you home D. A small instrument will be rolled over your upper abdomen and there will be no pain

ANS: D Rationale: An ultrasound is performed with an electronic probe lubricated and rolled on the skin over the area to be examined. It causes no pain, does not require the client to be NPO, or to be sedated, and special cleansing of the area is not needed.

Which cause does the nurse recognize as a potential intentional cause for a client's esophageal trauma? A. Nasogastric (NG) tube B. Esophageal ulcers C. Struck by a foreign object D. Chemical injury

ANS: D Rationale: Chemical injury is usually a result of the accidental or intentional ingestion of caustic substances. The damage to the mouth and esophagus is rapid and severe. Acid burns tend to affect the superficial mucosal lining, whereas alkaline substances cause deeper penetrating injuries. Strong alkalis can cause full perforation of the esophagus within 1 minute. Additional complications may include aspiration pneumonia and hemorrhage. Esophageal strictures may develop as scar tissue forms

Which statement indicates to the nurse that a client who is experiencing frequent episodes of "indigestion" and flatulence may have cholecystitis? A. "My stools are sometimes very dark and tarry looking." B. "Sometimes at night I have bad-tasting fluid in my mouth." C. "Usually about a half hour after I eat, I become sweaty and nauseated." D. "My right arm and shoulder always seem to hurt after I eat fried foods."

ANS: D Rationale: Cholecystitis and cholelithiasis can cause referred pain to the right shoulder area, including under the right shoulder blade. Dark, tarry stools are associated with G.I. bleeding. Bad-tasting fluid or vomitus in the mouth at night is related to gastroesophageal reflux disease. Becoming sweaty and nauseated after a meal is associated with dumping syndrome, not gallbladder disease.

Which essential nutrient will the nurse expect to be deficient in a client who has liver cirrhosis and ascites? A. Sodium B. Potassium C. Vitamin C D. Vitamin K

ANS: D Rationale: Clients with advanced liver disease, such as cirrhosis with ascites, are unable to metabolize fats and absorb fat-soluble vitamins from the G.I. tract. As a result, vitamin K is deficient. (Vitamin C is water-soluble)

Which drug will the nurse be sure to question to prevent harm when prescribed for an older adult with gastroenteritis? A. Azithromycin B. Protective skin barrier cream C. Ciprofloxacin D. Diphenoxylate hydrochloride with atropine sulfate

ANS: D Rationale: Diphenoxylate hydrochloride with atropine sulfate reduces G.I. motility, but is used sparingly because if it's habit-forming ability. The drug is not recommended for older adults because it also causes drowsiness and could contribute to falls.

Which problem does the nurse suspect in a client who is 4 weeks postoperative from gastric bypass surgery and reports that after a meal her heart races, she is nauseated, and has abdominal cramping with diarrhea? A. Hyperglycemia B. Intestinal obstruction C. Possible peritonitis D. Dumping syndrome

ANS: D Rationale: Dumping syndrome occurs when food enters the small intestine rather than the stomach after gastric bypass surgery, which results in increased blood flow to that site with decreased blood flow eslewhere. This causes hypotension and tachycardia from reduced central circulation and increased intestinal peristalsis with abdominal cramping and diarrhea from the stimulation caused by the sudden expansion of intestinal lumen.

Which set of energy balance factors leads to body weight loss? A. Energy intake and energy use our balanced B. Energy use an energy intake or both zero C. Energy intake exceeds energy use D. Energy use exceeds energy intake

ANS: D Rationale: Energy balance relationship between energy use and energy intake. When energy used is greater than energy taken in or stored, weight loss occurs.

What priority teaching will the nurse provide to prevent harm when a client with gastritis reports taking Ibuprofen regularly for discomfort related to arthritis? A. "Do not take ibuprofen more than twice a day." B. "Ibuprofen can interfere with the action of the drugs you take for gastritis." C. "This drug is excellent for pain relief related to arthritis." D. "Avoid taking ibuprofen because it can cause gastritis."

ANS: D Rationale: Ibuprofen is a non steroidal anti-inflammatory drug (NSAID). The nurse teaches the client that long-term NSAID use creates a high risk for acute gastritis. NSAIDs inhibit prostaglandin production in the mucosal barrier. Use of this drug may have caused the gastritis and continued use will cause it to worsen.

What is the nurse's best action to prevent harm for a client who is receiving enteral feedings by nasogastric (NG) tube when stomach contents cannot be aspirated and the client is coughing continuously? A. Notify the HCP to request an order for a chest x-ray B. Use piston-style syringe and gentle pressure to instill 30 mL of water C. Reposition the client on his or her right side and apply oxygen D. Remove the tube

ANS: D Rationale: If the position of the NG tube is in doubt or questionable, remove the tube. The fact that the client is continuously coughing is an indication that the tube may no longer be in the esophagus. Although a chest x-ray could establish tube placement, removal is warranted to prevent respiratory distress.

What action does the nurse expect to occur after administration of the drug Linaclotide to a client with irritable bowel syndrome (IBS)? A. Control of symptoms of diarrhea B. Elimination of pain associated with bowel movement C. Reduction of anxiety and stress D. Increased fluid in the intestines to promote bowel elimination

ANS: D Rationale: Linaclotide is a drug for IBS-C (IBS constipation). It works by simulating receptors in the intestines to increase fluid absorption and promote bow transit time. The drug also helps relieve pain and cramping that are associated with IBS. The nurse teaches a client to take this drug once a day about 30 minutes before breakfast.

What manifestation of esophageal cancer does the nurse recognize when a client describes experiencing a dull and steady substernal pain after drinking cold liquids? A. Angina B. Aspiration C. Dysphagia D. Odynophagia

ANS: D Rationale: Odynophagia is defined as painful swallowing. This occurs with the original cancer and may recur because of stricture, reflux, or cancer recurrence. It should be reported to the HCP promptly.

What does the nurse expect when a client's parietal cells do not produce enough intrinsic factor? A. Reflux of GI contents B. Poor regulation of metabolism C. Buildup of harmful substances D. Development of pernicious anemia

ANS: D Rationale: Parietal cells produce intrinsic factor, a substance that aids in the absorption of vitamin b12. Absence of the intrinsic factor leads to decreased absorption of vitamin b12 and caused pernicious anemia.

Which complication does the nurse suspect when a client in a starvation state receiving enteral feedings has shallow respirations, weakness, acute confusion, and oozing from the IV site? A. Sepsis B. Aspiration C. Hypoglycemia D. Refeeding syndrome

ANS: D Rationale: Refeeding syndrome is a life-threatening complication of aggressive enteral feeding in a severely malnourished client that is caused by fluid and electrolyte shifts. This condition can lead to heart failure, muscle breakdown, seizures, or hemolysis. Main electrolyte imbalances are hypokalemia and hypophosphatemia. The hypokalemia causes shallow respiration, as does heart failure. Bleeding around the IV site can be caused by the accompanying hemolysis and poor clotting.

Which diagnostic test will the nurse expect the client to undergo to best identify a hiatal hernia? A. Esophagogastroduodenoscopy (EGD) B. 24-hour ambulatory pH monitoring C. Esophageal manometry D. Barium swallow with fluoroscopy

ANS: D Rationale: The Barium swallow study with fluoroscopy is the most specific diagnostic test for identifying a hiatal hernia. Rolling hernias are usually clearly visible, and sliding hernias can often be observed when the client moves through a series of positions that increase intra-abdominal pressure.

What is the nurse's best response when a client asks which diagnostic test will determine if an oral tumor is cancerous? A. "MRI is the only test that you will need at this time." B. "No single test will make the diagnosis on its own." C. "Aqueous toluidine blue will be absorbed by malignancies." D. "Biopsy is the definitive method for diagnosing oral cancer."

ANS: D Rationale: The best diagnostic test for oral cancer is a biopsy. A needle-biopsy specimen, or an incisional biopsy, of the abnormal tissue will be obtained by the HCP to assess for malignant or premalignant changes. In very small lesions, an excision biopsy can permit complete tumor removal.

For what priority information will the nurse ask next after a client reports decreased appetite, decreased nutritional intake, and episodes of nausea over the past 2 months? A. Usual bowel pattern B. Baseline blood pressure C. Preferred favorite foods D. Usual weight and weight loss

ANS: D Rationale: The next important information the nurse asks about is the client's usual weight and whether he or she has experienced a weight loss (especially unintentional). It is important to inquire about unintentional weight loss because some GI cancers may present in this matter.

Which cardinal signs will the nurse expect to assess in a client diagnosed with peritonitis? A. Fever with headache and confusion B. Dizziness with nausea and vomiting C. Loss of appetite with nausea and weight loss D. Abdominal pain with distention and tenderness

ANS: D Rationale: The nurse expect to assess these cardinal signs of peritonitis: abdominal pain, tenderness, and distention. In the client with localized peritonitis, the abdomen is tender on palpation in a well-defined area with rebound tenderness in this area. With generalized peritonitis, tenderness is widespread.

For which gastrointestinal diagnostic test does the nurse teach a client to expect mild gas pain, flatulence, and a small amount of bleeding after the procedure if a biopsy was obtained? A. Endoscopic retrograde cholangiopancreatography B. Esophagogastroduodenoscopy C. Barium swallow D. Proctosigmoidoscopy

ANS: D Rationale: The nurse informs the client that after proctosigmoidoscopy, mild gas pain and flatulence may be experienced from air instilled into the rectum during the examination. If a biopsy was obtained, a small amount of bleeding may be observed. The client is instructed to report excessive bleeding to the HCP immediately!

What is the nurse's best first action when assessment findings on a client after gastric bypass surgery reveal increased back pain, restlessness, heart rate of 126 beats/min, and a urine output of only 15 mL for the past 2 hours? A. Increasing the IV infusion rate B. Inserting a fresh nasogastric tube C. Listening for bowel sounds in all abdominal quadrants D. Notifying the surgeon or Rapid Response Team immediately

ANS: D Rationale: These assessment findings strongly suggest an anastomotic leak, which is an emergency and can lead to peritonitis, sepsis and death

Which nursing care action will the nurse assign to the assistive personnel (AP) when caring for a client with a bowel obstruction? A. Discussing surgical procedures with the client B. Checking the client's abdomen for distention C. Assessing the client's level of discomfort D. Providing mouth care every 2 hours as needed

ANS: D Rationale: To choose the best response to this question, the nurse must be familiar with the scope of practice for an AP. AP's are assigned care tasks that are within their scope of practice such as assisting clients with ADLs and personal care such as mouth care. Discussing surgical procedures, checking for abdominal distentions, and assessing a client's level of comfort are skills that require the additional training of the professional RN.

Which location of a tumor in the colon does the nurse suspect when a client presents with passage of red blood via the rectum? A. Transverse colon B. Ascending colon C. Descending colon D. Rectosigmoid colon

ANS: D Rationale: Tumors in the transverse and descending colon result in symptoms of obstruction as growth of the tumor blocks the passage of stool. The client may report "gas pains," cramping, or incomplete evacuation. Tumors in the rectosigmoid colon are associated with hematochezia (the passage of red blood via the rectum), straining to pass stools, and narrowing of stools.

From where does the nurse suspect a client with PUD is bleeding when massive coffee-ground emesis occurs? A. Colon B. Rectum C. Small intestine D. Upper GI system

ANS: D Rationale: With massive bleeding, the client vomits bright red or coffee-ground blood (hematemesis). Gastric acid digestion of blood typically results in the coffee-ground appearance. Hematemesis usually indicates bleeding at or above the duodenojejunal junction (upper GI bleeding)

About which pancreatic functions will the nurse teach a client with a gastrointestinal disorder? Select all that apply A. Breaking down amino acids B. Producing glucagon from the endocrine part of the organ C. Detoxifying potentially harmful compounds D. Secreting enzymes for digestion from the exocrine part of the organ E. Producing enzymes that digest carbohydrates, fats, and proteins F. Beta cells producing insulin

Ans: B, D, E, F Rationale: The nurse teaches the client about two major cellular bodies (exocrine and endocrine) within the pancreas that have separate functions. The exocrine part consists of cells that secrete enzymes needed for digestion of carbohydrates, fats, and proteins (proteases, amylase, and lipase). The endocrine part of the pancreas is made up of the islets of Langerhans, with alpha cells producing glucagon and beta cells producing insulin.