UNIT TWO HIGHLIGHTED

48. A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action?

) Report possible signs of aspiration pneumonia to the primary care provider.

34. A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply.

A) Acute Pain Related to Increased Peristalsis and GI Inflammation B) Activity Intolerance Related to Generalized Weakness D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea

51. A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

A) Confirm placement of the tube prior to each medication administration.

16. A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer?

A) Does your pain resolve when you have something to eat?

21. A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having trouble swallowing for the past few days. What recommendation should the nurse make?

A) Eating more slowly and chewing food more thoroughly

40. A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy?

A) Premature removal of the G tube

9. A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care?

A) Risk for Aspiration Related to Inhalation of Gastric Contents

56. nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply.

A) To remove gas from the stomach C) To remove toxins from the stomach E) To diagnose GI motility disorders

33. The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). Which statement(s) by the client indicates effective knowledge of the procedure? Select all that apply.

A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." C. "One of my nerves, the vagus nerve, may be cut during the surgery."

7. A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client?

A. "Take no NSAIDs within 72 hours of the test."

34. A client has come to the clinic reporting pain just above her umbilicus. When assessing the client, the nurse notes Sister Mary Joseph nodules. The nurse should refer the client to the primary provider to be assessed for what health problem?

A. A GI malignancy

21. The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen?

A. Antidiarrheal medications 30 minutes before a meal

32. An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply.

A. Avoid drinking alcohol C. Avoid nonsteroidal anti-inflammatories.

32. The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?

A. Checking the client's capillary blood glucose levels regularly

8. A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?

A. Infection with Helicobacter pylori

27. A nurse is caring for a client in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristic(s) of this stage of the disease? Select all that apply.

A. Perforation into the mediastinum C. Erosion into the great vessels E. Obstruction of the esophagus

2. A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care?

A. The client will be monitored closely to detect malignant changes.

6. A patient who had a hemi glossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patients priority need at this time?

B) An effective means of communicating with the nurse

22. A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurses assessment should be planned in light of the possibility of what potential complications? Select all that apply.

B) Atelectasis C) Pneumonia D) Metabolic imbalances F) Hemorrhage

18. A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patients discharge. Which of the following is essential to include?

B) Eat several small meals daily spaced at equal intervals.

61. A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patients plan of care, which of the following nursing diagnoses should be included?

B) Ineffective Role Performance Related to Parenteral Nutrition

43. A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions?

B) Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance

38. A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?

B) Keep the vent lumen above the patients waist.

15. Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage?

B) Keeping the head of the bed slightly elevated

8. The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

B) Presence of a painless sore with raised edges

41. A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action?

B) Prevent aspiration

54. A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?

B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube

45. A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize?

B) Risk for Infection Related to the Presence of a Subclavian Catheter

35. A client has come to the clinic reporting blood in the stool. A fecal occult blood test is performed but is negative. Based on the client's history, the health care provider suggests a colonoscopy, but the client refuses, citing a strong aversion to the invasive nature of the test. What other test might the provider order to check for blood in the stool?

B. A fecal immunochemical test (FIT)

27. The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

B. Avoiding taking aspirin to treat pain or fever

38. A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply.

B. Clotted or displaced catheter. C. PneumothoraxD. Hyperglycemia E. Line sepsis

3. A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

B. Contact the primary care provider promptly and report these signs of perforation.

17. An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.

B. Increased fiber intake D. Reduced fat intake.

6. A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client?

B. Infection typically occurs due to ingestion of contaminated food and water.

26. A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education?

B. The client can resume a normal routine immediately.

30. A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer?

B. The client has a rigid, "board-like" abdomen that is tender.

10. A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?

B. Upper GI tract

13. A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis?

C) An older adult whose medication regimen includes an anticholinergic

10. A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement?

C) Avoid carbonated drinks.

39. A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?

C) Dilute the concentration of the feeding solution.

47. A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding?

C) Frequent lung auscultation

22. A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation?

C. "You'll need to have enemas the day before the test."

10. A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer?

C. Early diagnosis and treatment of gastroesophageal reflux disease

4. An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

C. Fluids must be increased to facilitate the evacuation of the stool.

9. A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for post procedure recovery?

C. Increase fluid intake to evacuate the barium.

29. A client is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the client to first seek care?

C. Intermittent pain and bloody stool

20. A client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. What should the nurse include in the client's immediate postoperative plan of care?

C. Positioning the client to prevent gastric reflux

4. A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem?

C. Smokes one pack of cigarettes daily.

7. A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem?

C. The client's polyps constitute a risk factor for cancer.

30. A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?

Colonoscopy

57. A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurses best response?

D) An internal retention disc secures the tube against the stomach wall.

12. A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis?

D) Imbalanced Nutrition: Less Than Body Requirements

24. A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

D. "Instead of eating three meals a day, try eating smaller amounts more often."

11. A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate?

D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

14. A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider?

D. Streaks of blood present in the stool

2. A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis?

D. The early symptoms of gastric cancer are usually not alarming or highly unusual.

17. A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe?

D. The test is noninvasive.

19. A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying?

Fowlers

11. An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body?

Glucagon

32. A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT?

Hemorrhoids

21. A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client?

Notify the health care provider