practice test
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?
Increase the amount of fluids Explanation: The client, returning from an upper gastrointestinal series, needs to increase fluids in an effort to eliminate the barium from the body through a bowel movement. General anesthesia is not used. The client typically does not have nausea and vomiting following the procedure. If the client is able to ambulate independently prior to the procedure, the client will be able to ambulate independently following.
A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the:
Left lower quadrant. Explanation: Rovsing's sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant.
The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?
Rovsing sign Explanation: When an examiner deeply palpates the left lower abdominal quadrant and the client feels pain in the right lower quadrant, this is referred to as a positive Rovsing sign and suggests acute appendicitis. Referred pain indicates pain in another area but is not necessarily manipulated by the examiner. Rebound pain is indicated when the pain of palpation is worse when the pressure is off of the site. The cremasteric reflex is a superficial reflex that is present in male clients.
The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?
30 minutes Explanation: Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer.
A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer?
Actinic cheilitis Explanation: Actinic cheilitis is a type of premalignant squamous cell skin cancer that presents as scaling, crusty fissures or a white overgrowth of the horny layer of the epidermis. Herpes simplex 1 is an opportunistic infection frequently seen in immunosuppressed clients. Chancres are reddened circumscribed lesions that ulcerate and become crusted and are the primary lesions of syphilis. Krythoplakia is a red patch on the oral mucous membrane that is frequently seen in the elderly.
The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?
Diuretics Explanation: Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the client's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?
Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon.
The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction?
Resume regular diet. Explanation: The nurse includes resumption of regular diet in the client's discharge instructions as the client is able to resume activities and diet after an endoscopic exam. There is no need to adhere to a clear liquid diet or to increase fluid intake. As sedation is not usually involved for endoscopic examinations, the client does not need to avoid driving.
A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction?
Dyspepsia Explanation: Dyspepsia is a condition that usually involves a combination of symptoms: abdominal pain, bloating, distention, nausea, and belching.
The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be
Fecal incontinence Explanation: The nurse should anticipate fecal incontinence as one of the assessment findings. Other possible assessment findings include constipation and abdominal distention.
A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland?
Parotid Explanation: The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.
A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?
Potassium-rich foods Explanation: The nurse should encourage the client with diarrhea to consume potassium-rich foods. Excessive diarrhea causes severe loss of potassium. The nurse should also instruct the client to avoid high-fiber or fatty foods because these foods stimulate gastrointestinal motility. The intake of protein foods may or may not be appropriate depending on the client's status.
A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding?
Rapid gastric dumping Explanation: Rapid gastric dumping may lead to steatorrhea, excessive fat in the feces. The primary cause of this finding is rapid gastric dumping. Excessive fat intake can make the problem worse; however, this is not the primary cause of the symptoms. Steatorrhea results from increased motility, not decreased and the size of the stomach does not contribute to this finding.
A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems?
Reduced or absent bile as a result of obstruction impacts digestion. Explanation: Digestion is impacted by cholecystitis because an obstruction of the gallbladder results in reduced or absent bile. Contractile spasms and inflammation of the gallbladder leads to pain, not problems with digestion.
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.
Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances Explanation: Gastrointestinal intubation is used to decompress the stomach and remove gas and fluids, lavage the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. Because gastrointestinal intubation involves the insertion of a tube into the stomach, beyond the pylorus into the duodenum or jejunum, it could not be used to evaluate for masses in the large colon.
The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention
Wear a face mask during dressing changes. Explanation: The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves.
A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is:
acute cholecystitis Explanation: Gallstones are more frequent in women, particularly women who are middle-aged and obese. With acute cholecystitis, clients usually are very sick with fever, vomiting, tenderness over the liver, and severe pain that may radiate to the back and shoulders. The patient profile and symptoms are suggestive of acute cholecystitis.
A client has symptoms suggestive of peritonitis. Nursing management would not include:
limiting analgesics to avoid the formation of paralytic ileus. Explanation: Analgesics such as meperidine or IV morphine sulfate are ordered to relieve pain and promote rest. Because hypovolemia can occur from fluids leaking into the peritoneal cavity, input and output are monitored closely to assist in determining fluid replacement. A nasogastric tube is used to relieve abdominal distention by suctioning the accumulated gas and stagnant upper GI fluids. If hypovolemia is present, renal perfusion can become decreased, requiring close monitoring.
The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of:
total gastrectomy. Explanation: If a total gastrectomy is performed, injection of vitamin B12 will be required for life, because intrinsic factor, secreted by parietal cells in the stomach, binds to vitamin B12 so that it may be absorbed in the ileum. Bariatric surgery, diverticulitis and GERD do not necessitate total gastrectomy and subsequent vitamin B12 supplementation.
